ACLS and Anesthesia Emergencies Flashcards
Asystole
CPR: 100-120 compression/min 2” deep
Allow complete chest recoil
Minimize breaks in CPR
Rotate compressors q2min
Assess CPR, improve if EtCO2 <10mmHg or arterial line diastolic <20mmHg
Call for help. Call for Code Cart. Inform team
IMMEDIATE
Turn off vasodilating volatile and IV drips; increase to 100% O2, high flow
Ventilate 10 breaths/min, do not over ventilate
Ensure IV access (or consider IO)
Epinephrine 1mg IV push q3-5 mins
If rhythm changes to VF/VT (shockable rhythm) - immediate defibrillation
Common perioperative DDx asystole
- Hemorrhage
- Anesthetic overdose
- Septic or other shock states
- Auto-PEEP
- Anaphylaxis
- Medication error
- High spinal
- Pneumothorax
- Local anesthetic toxicity
- Vagal stimulus
- Pulmonary embolus
H’s and T’s
- Hypovolemia
- Hypoxemia
- Tension pneumothorax
- Thrombosis- coronary
- Thrombosis- pulmonary
- Toxins
- Tamponade- cardiac
- Hypothermia
- Hyperthermia
- Obtain ABG to rule out: hyperkalemia, hypokalemia, hypoglycemia, H+ acidosis, hypocalcemia
Unstable Bradycardia
CHECK FOR PULSE
- If no pulse, go to PEA: CPR
- If pulse present but hypotensive, proceed with treatment
Call for help. Call for code cart. Halt surgical stimulation.
IMMEDIATE
1. 100% O2
2. Confirm ventilation and oxygenation
3. Turn off anesthetics
4. Atropine 0.5 to 1mg IV, may repeat up to 3mg
5. Consider transcutaneous pacing (rate at least 80bpm, increase current until capture achieved, confirm patient has a pulse with capture)
OR
6. Consider infusions (Dopamine 2-20ug/kg/min; Epinephrine 0-0.1ug/kg/min)
SECONDARY
1. Arterial line
2. Labs: ABG, hemoglobin, electrolytes
3. R/out ischemia: EKG, troponins
Pulseless Electrical Activity
CPR: 100-120 compression/min 2” deep
Allow complete chest recoil
Minimize breaks in CPR
Rotate compressors q2min
Assess CPR, improve if EtCO2 <10mmHg or arterial line diastolic <20mmHg
Call for help. Call for Code Cart. Inform team
IMMEDIATE
Turn off vasodilating volatile and IV drips; increase to 100% O2, high flow
Ventilate 10 breaths/min, do not over ventilate
Ensure IV access (or consider IO)
Epinephrine 1mg IV push q3-5 mins
If rhythm changes to VF/VT (shockable rhythm) - immediate defibrillation
More likely sinus tachycardia than SVT if:
- Rate >150
- Irregular
- Sudden onset
Supraventricular tachycardia - stable
Narrow complex and regular
- Adenosine 6mg IV push with flush. May give 2nd dose at 12mg IV (avoid adenosine if asthma or WPW).
- If NOT converted, may rate control.
- Beta blocker or calcium channel blocker
- Esmolol (0.5 mg/kg IV over 1 minute… may start infusion at 50 mcg/kg/min)
- Metoprolol (1-2.5 mg IV… may repeat after 2.5 mins)
- Diltiazem (5-10 mg IV over 2 minutes… may repeat after 5 mins).
Supraventricular tachycardia - stable
Narrow complex and irregular
- Beta blocker or calcium channel
- Esmolol (0.5 mg/kg IV over 1 minute… may start infusion at 50 mcg/kg/min)
- Metoprolol (1-2.5 mg IV… may repeat after 2.5 mins)
- Diltiazem (5-10 mg IV over 2 minutes… may repeat after 5 mins). - Amiodarone: 150 mg IV SLOWLY over 10 mins, may repeat once. Start infusion 1mg/min for first 6 hours.
Supraventricular tachycardia - stable
Wide complex and regular
- Adenosine 6mg IV push with flush. May give 2nd dose at 12mg IV (avoid adenosine if asthma or WPW).
- Amiodarone: 150 mg IV SLOWLY over 10 mins, may repeat once. Start infusion 1mg/min for first 6 hours
What differentiates unstable supraventricular tachycardia from stable SVT?
Sudden and/or continuing sharp decrease in BP; acute ischemia, SBP <75
Supraventricular tachycardia - unstable
Immediate synchronized cardioversion (biphasic doses)
- Narrow complex, regular: 50-100J
- Narrow complex, irregular: 120-200J
- Wide complex, regular: 100J
- Wide complex, irregular: Unsynchronized defibrillation at 200J
If unsuccessful cardioversion, Re-SYNC and increase Joules incrementally for synchronized cardioversion.
While preparing to cardiovert (DO NOT DELAY), if narrow complex and regular, consider adenosine 6mg rapid IV push with flush; may give 2nd dose of 12mg IV.
Ventricular fibrillation
Pulseless ventricular tachycardia
- Call for help
- Call for code cart
- Inform team
- Difibrillate 120-200 J Biphasic, per manufacturer
- Resume CPR immediately
- Repeat shock Q 2 mins, reasonable to increase energy with subsequent shocks, resume CPR
- After 2nd shot, epinephrine 1mg IV push q 3-5 mins
- Consider antiarrhythmics
- If pulseless, amiodarone 300mg IV push or lidocaine 100mg IV push
- If hypoMg or torsades + prolonged QT: magnesium sulfate 2g IV
- If hyperK: calcium, insulin + glucose, sodium bicarbonate
Anaphylaxis signs (some may be absent in anesthetized patient)
- Hypoxemia, difficulty breathing, tachypnea
- Rash/hives
- Hypotension (may be severe)
- Tachycardia
- Bronchospasm/wheezing
- Increase in peak inspiratory pressure (PIP)
- Angioedema (potential airway swelling)
Anaphylaxis: consider and rule-out other causes such as:
- Pulmonary embolus
- Myocardial infarction
- Anesthetic overdose
- Pneumothorax
- Hemorrhage
- Aspiration
Anaphylaxis treatment
- Call for help, call for code cart, inform team
- Discontinue potential allergens (muscle relaxants, latex, antibiotics, colloids, protamine, blood, contrast, chlorhexidine)
- Discontinue volatile anesthetic if hypotensive. Consider amnestic agent. Increase to 100% O2, high flow.
- Give IV fluid bolus (may require many liters!)
- Give epinephrine IV in escalating doses every 2 minutes. Start at 10-100 mcg IV and increase dose every 2 minutes until clinical improvement is noted. Start early epinephrine infusion. May require large doses >1mg.
- If no improvement, continue treatment, but consider other causes (hypotension, hypoxemia)
- Consider vasopressin bolus IV or norepinephrine infusion.
- Treat bronchospasm with albuterol and epinephrine if severe
- Consider additional IV access and invasive monitors (a-line)
- If signs of angioedema, consider early intubation
- After stable, consider H1 antagonist (diphenhydramine 25-50 mg IV), H2 antagonist (Famotidine 20mg IV) and corticosteroids (methylprednisolone 125mg IV).
