Crisis

Question 1

30yo NKDA open appendicetomy

1 min BP drops to 60, diff to vent, Vt 100mL

Question 2

CRM principles

Answer 2

1. Call for help early
2. Anticipate and plan
3. Set priorities
4. Leadership
5. Teamwork
6. Comm
7. Info
8. Attn
9. Distribute
10. Mobilse

Question 3

RESUSC, TRAUMA, CRISIS – Damage control resuscitation in severe trauma

[21B14] Discuss the principles of damage control resuscitation in severe trauma.

Question 4

Anaphylaxis

Answer 4

150 microg - 7.5-20kg 5yo
300 microg - >20kg 6-12yp
500 microg - 12yo+

Community vs periop

graded approach to (2022)
volume resus
IV adrenaline

Severity grading
Mild 1- skin (46% none - NAP6)
2 - CVS comp
- 10-20mcg, 500mL
3 - severe hypotension/hypoxaemia
- sBP <60, SpO2 <90
- 50-100 microg, 1L
4 - Arrest 2L
- mostly PEA
- CPR start at sBP <50 in anaes pt

DDx

MCT
imm/ASAP, 1, 4, 24hrs

• Low output state –> worth continuing CPR

Skin testing
- provoke IgE reaction - wheal/flare
- wheal expansion = pos rxn

MR
Sux 1:2000
Roc 1:2500

1:20000 all grades anaphylaxis (CVN)

H2 extend H1 blockade

D Hill M&M

Question 5

ANAESTHETIC CRISIS / COMPLICATIONS– Anaphylaxis

[15B08] A 20 year old patient has been successfully resuscitated from suspected anaphylaxis.

Describe your immediate and longer term post crisis management. [18B02] xx (also 13A06, 05B07, 03B01)

Answer 5

ANZCA BP 2022
**IMMEDIATE mx post resus

**Post crisis mx

1. Steroids
   - 2nd mx post acute mx and pt stable
2. TRYPTASE
   - peak 15-120min post onset
   - t1/2 2hr
   - declines 3-6 hrs post onset
   - 24 hrs = reliable baseline
   - ASAP onset sx, 1, 4, 24
3. Monitor/environ
   - Grade 2-3 –> HDU/ICU
   - Grade 1/2 settled –> 6hr close mon
4. ## Referral

Question 6

RESUSC, TRAUMA, CRISIS – Damage control resuscitation in severe trauma

[21B14] Discuss the principles of damage control resuscitation in severe trauma.

Answer 6

• maintenance of normothermia
• avoidance of excessive crystalloid administration
• permissive hypotension
• early MTP (massive transfusion protocol) and coagulation products
• early surgery and airway control
• administration of antifibrinolytic - tranexamic acid
• performance of tests to guide management including point of care (ROTEM/TEG/blood gas) and formal tests of coagulation and PLT counts.

PreHosp –> ED –> OT –> ICU

Triad
1. Permissive hypotension
2. Haemostatic resus
3. DCS

Aims
1. Cir vol
2. Cont haemorrhage
3. Correct lethal triad (hypothermia/coagulopathy/acidosis)

PHT
- Perm Hypo (sbp 80-90, map 50-60)
** bal perf and exsang **
- RESTRICT fluid (CSL>NS), pressors PRN
- blood product PAMPer

ED
- early transfusion (1:1:1) PROMMTT
- Antifibrinolytic (only if < 3hrs) - TXA
CRASH-2 MATTERs
- routine bloods + fibrinogen + ROTEM
- coag target
- Hb 70-90
- Fib conc 3-4g or cryo 50mL/kg
- Plt >50
- iCa 1.1-1.3
- FFP 10-15mL/kg if PT > 1.5
- Novoseven not first line
- normothermia
- AW - RSI
- - Reversal of antithrom
- –Warf –> PTX + vit K
- – dabigatran - idarucizumab + diluted TT
- – rivaroxaban / apixaban - anti-Xa, PTX
- –anti plt (PLT conc, desmopressin)

Question 7

ANAESTHETIC CRISIS / COMPLICATIONS– Malignant Hyperthermia

[21A10] List the signs of malignant hyperthermia. (30%)

Outline the immediate management of a patient where malignant hyperthermia is suspected. (70%)

(also 16B08, 09A03)

Answer 7

MH
1. Early
a) EtCO2 / tachy
b) masseter spasm
c) arrhythmia

2. Developing
   a) TEMP
   b) acidosis
   c) HIGH K
3. Late
   a) Dark urine
   b) CK high
   c) Arrest

Imm Mx:
1. Dec Emergency
2. S F H
3. Delegate
4. MH box
5. Cease cause
a) off VA
b) remove vaporiser
c) change soda lime
d) hypervent

DAS - dant/anaes/supportive

DANTROLENE
2.5mg/kg q10-15min (10mg/kg max)

20mg amp + 60mL WATER

Anaesthesia
PROPOFOL TIVA

Supportive

Question 8

LAST

MH

drug dose

Answer 8

LAST
Intralipid
1. 1.5mL/kg
2. 15ml/kg/hr
up to 30

MH
Dantrolene
2.5mg/kg

Question 9

ANAESTHETIC CRISIS / COMPLICATIONS– Failure to wake

[19B15] A 16-year-old girl has failed to wake from anaesthesia following posterior instrumentation for severe idiopathic scoliosis.

Discuss the potential causes and management of her failure to wake. (also 15A09, 05A07)

Answer 9

Potential cause
Anaes/pt/surg

Mx
1. Switch off agents
2. ABCDE
3. Review hx
4. Reversal
- BZD - flumazenil 200 –> 1000microg
- Opioids - naloxone 80 –> 800

Question 10

ANAESTHETIC CRISIS / COMPLICATIONS– OT Fire

[19B08] Your patient is midway through a laparoscopic cholecystectomy. You smell smoke and can see flames in the room adjacent to your theatre. Describe your management of this situation.

Answer 10

Triangle

1. Fuel
   - drapes/etoh sol/ETT
2. Ignition
   - Diathermy/Laser/Defib in O2
3. Oxidant
   - O2/N2O

Imm
- early recog
- comm
- remove fuel
- remove ox
- ext fire

Subs
- further pt care - bronch/burns
-failure to ext fire = RACE protocol
Rescue
Alert
Confine
Extinguish

More on fire:

PREVENTION
1. Low O2
2. Saline near site/ign source
3. TIVA
4. Laser ET

MAK95
OHST

Question 11

ANAESTHETIC CRISIS / COMPLICATIONS– Anaphylaxis

[15B08] A 20 year old patient has been successfully resuscitated from suspected anaphylaxis.

Describe your immediate and longer term post crisis management. [18B02] xx (also 13A06, 05B07, 03B01)

Answer 11

Imm mx post resus of anaphylaxis
1. early ix
2. Monitor at ICU - biphasic rxn
3. Discussion with pt

LT mx
- referral to allergy testing/letter to GP/M&M / bracelet

Suspected anaphylaxis