CRISIS

Question 1

A 60 year old male for rigid cystoscopy has bile stained fluid in his classic LMA . Describe management

Answer 1

Classic LMA - no gastric port
- regurgitation, may have aspirated

Tell surgeon to stop
Patient is head down already
If anaesthetic assistant not in OT get a staff member to call them
Remove LMA
Paralyse with suxamethonium 1mg/kg
Laryngoscopy and suction oropharynx , look for evidence of aspiration eg bile down vocal cords
Intubate and suction bronchial tree with suction catheter
Ventilate with 100% O2 and titrate to normal SpO2
- if SpO2 falls I would positive pressure ventilate earlier

If SpO2 normal on minimal FiO2 - continue
If difficult oxygenation / ventilation - finish operation

Before extubation - NGT and empty stomach
Extubate awake sitting upright

If significant oxygen requirement consider HDU/ICU
-large particulate matter

Once in recovery - observe for 2 hours , if no symptoms , CXR is clear and SpO2 is normal - no need for HDU

No role for antibiotics or steriods in short term management

Open disclosure with patient
Present at M&M

Question 2

A 60 year old scheduled for ORIF of fractured ankle arrests on induction . ECG shows VF

Outline immediate management of arrest - reference to new guidelines

Answer 2

Medical emergency - emergency buzzer, get defibrillator, assign roles - team leader, defib, CPR, Airway, Scribe

Turn off anaesthetic
Airway/Breathing - Intubate and ventilate 100% FiO2 , RR8 bpm, 500ml VCV
Circulation - CPR @100-120 bpm , aim ETCO2 >20mmHg for adequacy of compressions
2min cycles

Defibrillator - on ASAP and early rhythm check
Shockable = VF/VT - 200J 
1) Shock
2) Shock + 1mg Adrenaline
3) Shock + 300mg Amiodarone

If develops NON shockable (PEA/asystole)
- dump charge + 1mg adrenaline
then adrenaline every 2nd loop

Assess for Cause
Hypothermia - check temp
Hypoglycaemia
Hyperkalaemia - send ABG
Hypovaemia ?anaphylaxis
Toxins - ? regional /LAST
Thrombus  -PE or MI ?ECG evidence of STEMI prior to VF
Tamponade - TTE to exclude effusion
Tension Pneumo - JVP, high airway pressures

If cause identified treat
Ongoing talk to cardiology + ICU
Consider E-CPR

IF ROSC - Post resus cares as per ALS guidelines