Crisis Scenarios Flashcards

Question

Airway Fire Prevention

Answer 1

PREVENTION Silverstein fire risk assessment Laser proof vs. resistant ETT cuff filled w/ saline or methylene blue Fire extinguishing materials available Sterile saline & saline-moistened cotton gauze Minimum oxygen Avoid N2O during high risk procedures Allow preparation solutions adequate drying time Bipolar ESU not monopolar

Answer 2

1. Remove ETT/LMA, turn off gases, remove flammable material, & pour saline into airway 2. Extinguish burning ETT/LMA in sterile saline basin 3. Resume ventilation w/ 21% 4. Ventilate w/ 100% FiO2 via face mask only when fire extinguished 5. Examine airway & remove residual debris w/ rigid bronchoscope 6. Consider lavage w/ normal saline 7. Re-intubate w/ smaller ETT when indicated 8. Assess thermal trauma extent Post airway fire - 24hr observation - Monitor delayed laryngeal-tracheal edema - Severe airway burns remain intubated & receive humidified FiO2 - Monthly laryngoscopy or bronchoscopy indicated up to 6mos (tracheal stenosis occur months later) - All materials involved should be retained for further investigation - Report to the Joint Commission as sentinel event

Answer 3

RYR1 gene located on 19q13.1 chromosome CACNA1S gene Dihydropyridine & ryanodine VGCa2+ channels ↓receptor threshold to release Ca2+ Resistance to feedback mechanisms ↓Ca2+ ion conductance

Answer 4

Exposure to volatile anesthetic agents Succinylcholine Stress?

Answer 5

``` ↑ETCO2 not responsive to hyperventilation Tachycardia or arrhythmias Rigidity Tachypnea Labile blood pressure ↑temperature Myoglobinuria Skin mottling or cyanosis SaO2 desaturation Metabolic & respiratory acidosis Hyperkalemia ↑creatinine kinase ↑serum & urine myoglobin ```

Answer 6

Discontinue volatile anesthetic or Succinylcholine HELP! Admin Dantrolene 2.5mg/kg Hyperventilate w/ 100% FiO2 Cooling Activated charcoal filters on AGM circuit Antidysrhythmic Monitor & treat ABGs, blood glucose, coags, CK, serum & urine myoglobin, & liver enzymes Maintain adequate urine output

Answer 7

Liquid or particulate matter enter tracheobronchial tree R bronchus more susceptible d/t lesser angle & wider 1. Direct chemical damage to epithelium 2. Inflammatory cascade 3. Infectious fluid consolidation in alveoli 4. V/Q mismatch → shunting

Answer 8

Anesthesia ↓lower esophageal sphincter tone & loss protective reflexes

Answer 9

``` Uncontrolled GERD Stroke → dysphagia Diabetes (gastroparesis) Morbid obesity ↑abdominal pressure (ascites/edema) Bowel obstruction Pregnancy >13wks Trauma - SNS response impairs gastric emptying (blood diverts to vital organs) ```

Answer 10

Oral secretions - Cough - Mild tracheal irritation - Transient laryngospasm Acidic gastric contents - Arterial hypoxemia - Bronchospasm - Dyspnea - Abnormal breath sounds - ARDS

Answer 11

``` PREVENTION Preop assessment to identify at risk patients NPO guidelines Pharmacologic prophylaxis Gastric U/S RSI ``` Vigilance Trendelenburg Suction mouth & pharynx Intubate & oxygenate ``` Post-aspiration Monitor S/S Cough or wheeze Maintain SpO2 CXR Extended LOS ICU admission ```

Answer 12

``` Atherosclerotic disease NSTEMI vs. STEMI Demand ischemia (supply vs. demand) Supply: - CorrPP - ADBP - LVEDP - HR (diastole time) - Coronary artery resistance Demand: - HR - Preload - Afterload - Contractility/inotropy ```

Answer 13

Supply/demand mismatch

Answer 14

``` Sustained tachycardia or bradycardia Hypertension or hypotension Arterial hypoxemia ST depression or elevation Troponin levels ↑PAOP TEE ventricular wall changes ``` Presentation/sensation potentially masked by anesthetics & other drugs

Answer 15

PREVENTION = key STEMI - TPA fibrinolytic therapy - Percutaneous coronary intervention - Coronary artery bypass graft Goal re-establish blocked coronary blood flow ↓MVO2 Bed rest, analgesia, supplemental oxygen, β blocker therapy, IV nitroglycerin (short-acting vasodilator), antiplatelets/anticoagulants, ACE inhibitors, ANG II receptor blockers, Ca2+ channel blockers

Answer 16

Excessive blood loss ↓CO → baroreflex SNS response ↑HR ↑renin, ANG II, vasopressin RAAS activation

Answer 17

Risk factors include anticoagulants, coagulopathies, certain surgeries, tissue/collagen disorders Incompetent surgeons

Answer 18

``` Hypotension Acute blood loss & hemodynamic instability Tachycardia ↑HR RAAS activation Na+/H2O retention MAP <50mmHg → CNS ischemic response "Oh shit" "Call vascular surgery" *Suction* ```

Answer 19

Phase I - immediate life-threatening & uncontrolled hemorrhage → activate MTP Massive transfusion protocol Phase II - ongoing hemorrhage → tailored management Phase III - controlled hemorrhage → restore physiology

Answer 20

``` 10 units PRBCs in 24hr Goal = maintain end organ perfusion Control airway 100% FiO2 Large bore IVs Blood warmer & rapid infuser Send type & screen IV fluids, Trendelenburg, vasopressors Ideal ratio PRBC:FFP:Platelets 1:1:1 Minimize lethal triad - metabolic acidosis, hypothermia, & coagulopathy ```

Answer 21

Thyroid gland hyperactivity = hyperthyroidism Thyroid hormones directly excite the heart ↑HR/inotropy Heart muscle strength impaired d/t protein catabolism ↑β adrenergic receptor Upregulation - exaggerated response to circulating catecholamines

Answer 22

Grave's disease - Autoimmune disorder antibodies bind to TSH receptor & stimulate the thyroid Toxic nodular hyperthyroidism Thyroiditis - release stored thyroid hormones Thyroid cancer

Answer 23

``` Weight loss Anxiety Fatigue Heat intolerance ↑oxygen consumption ↑SBP 10-15mmHg ↓DBP Vasodilation Sinus tachycardia Cardiac dysrhythmias ↑CO Muscle weakness Hand tremor Difficulty sleeping ```

Answer 24

Thyroid gland ablation w/ radioactive iodine Thyroidectomy Anti-thyroid drugs - Thionamides (Methimazole, Carbimazole, Propylthiouracil) β adrenergic blockade - Propranolol, Metoprolol, Atenolol High relapse rate in patients treated only w/ medications

Answer 25

Precipitating event rapid ↑thyroid hormone & SNS activity Hypothesized Acute stress or infection causes ↑SNS response & ↑thyroid hormone sensitivity → cytokine release & other immune dysfunction (immunological disturbances)

Answer 26

Surgery Abrupt anti-thyroid medication discontinue Trauma Acute illness Parturition Recent use iodinated contrast or radio-iodine therapy Burns Medication SE (amiodarone, anesthetics, salicylates)

Answer 27

``` Fever >38.5°C Tachycardia/dysrhythmias Heart failure Hypertension N/V Confusion/agitation Weakness Tremor ```

Answer 28

Identification β adrenergics blunt response Anti-thyroid medications inhibit thyroid hormone synthesis Supportive measures - IVF replacement, electrolyte imbalance correction, reverse any acid-base imbalance, ensure adequate oxygenation ↑FiO2 demand Manage hyperthermia Vasoactive medications & advanced monitoring often necessary

Answer 29

Inadequate neuromuscular blocker reversal | nAChR antagonist

Answer 30

Incomplete relaxant reversal or failure to reverse NMB post-procedure

Answer 31

``` Long-acting NMB Improper dose or timing r/t paralytic or reversal dose Deeper block = higher risk Inhalational agents ↑risk Elderly Longer surgeries Medical conditions: - Renal or liver dysfunction/failure - Neuromuscular disorders - Sepsis or trauma - Adrenocortical dysfunction - Cholinesterase deficiency or genetic variation - Metabolic disturbances - Electrolyte abnormalities - Obesity Medications: - Antibiotics - Antidysrhythmics - Antihypertensives ```

Answer 32

``` Postop pulmonary complications - Hypoxemia - Upper airway muscle weakness or obstruction - Aspiration risk Generalized muscle weakness - Facial weakness - Numbness - Difficulty speaking, coughing, drinking - Inability to perform deep breathing - ↓ventilatory response to hypoxia Awareness during emergence ```

Answer 33

Peripheral nerve stimulator - Ensure proper placement (stimulate the nerve NOT the muscle) - Avoid monitoring facial muscles (overestimates recovery) Quantitative TOF <0.9 objective measurement

Answer 34

IV concentration 1:10,000 or 0.1mg/mL = 1mg/10mL IM concentration 1:1,000 or 1mg/mL Bronchospasm 10-100mcg Anaphylaxis 10-100mcg IV Q2min → Epi infusion (stabilizes the mast cells) Code dose = 1mg Pediatrics 1-10mcg/kg

Answer 35

``` Call for help! 100% FiO2 Discontinue anesthetics Verbalize differentials Notify the surgical team DELEGATE ```

Answer 36

Displacement Obstruction ↑peak airway pressures d/t secretions or kinked ETT/tubing Pneumothorax Equipment failure

Answer 37

- Epi 10-20mcg - Terbutaline 0.25mg - Intubate - Methylprednisolone 125mg - Inhaled muscarinic antagonist (Ipratropium) - Magnesium sulfate 2g over 15-20min

Answer 38

<15% blood volume | - No significant vital sign changes

Answer 39

15-30% - Tachycardia, tachypnea, ↑pulse pressure - Loss 20% ↓BP

Answer 40

30-40% | - Tachycardia, tachypnea, systolic hypotension, oliguria, mental status changes

Answer 41

>40% - Immediately life-threatening - Severe sustained hypotension, tachycardia, narrow pulse pressure, no UOP, cold & pale skin, ↓mental status

Answer 42

- Hyperkalemia → arrhythmias or sudden cardiac arrest - Hypocalcemia → muscle weakness, tetany, myocardial dysfunction, coagulopathy - Hypothermia → coagulopathy, arrhythmias, hepatic dysfunction, myocardial depression, ↓drug metabolism