Emergencies Flashcards
Airway Fire
Management
Prevention
Airway Fire
Management
Inform team & call for help
Simultaneously remove the endotracheal tube (ETT) & stop gases/disconnect circuit
Pour saline or water into airway
Remove airway foreign bodies (ie: ETT pieces, sponges)
When fire is extinguished: re-establish ventilation; avoid supplemental oxygen if possible
Consider prompt reintubation prior to swelling & coordinated with bronchoscopy
Examine entire airway (including bronchoscopy) to assess injury & remove residual debris
Prevention
For high risk procedures:
Discuss fire prevention & management with team during time-out
Avoid FiO2 > 0.3 & avoid N2O
For laser surgery of vocal cord or larynx:
Use laser resistant ETT (single or double cuff)
Assure ETT cuff sufficiently deep below vocal cords
Fill proximal ETT cuff with methylene blue-tinted saline (acts as a marker if cuff perforated by laser)
Ensure laser in STANDBY when not in active use
Surgeon protects ETT cuff with wet gauze
Surgeon confirms FiO2 < 0.3 & no N2O prior to laser use (may require several minutes to dilute FiO2 & FeO2 to <0.3 depending on fresh gas flow & initial FiO2)
For non-laser surgery in oropharynx:
Regular PVC ETT may be used
Consider packing wet gauze around ETT to minimize O2 leakage
Consider continuous suctioning of the operating field inside oropharynx
Anaphylaxis
Signs
Management
Anaphylaxis
Signs
Rash/hives
Angioedema
Hypotension
Tachycardia
Hypoxemia
Bronchospasm/wheezing
↑ peak inspiratory pressure
Management
Stop offending agent
Inform surgeon, call for help
Discontinue or ↓ all anesthetic agents
Airway:
100% O2
Secure airway
Administer epinephrine IV in escalating doses:
Start at 10-100 mcg & ↑ as necessary until clinical improvement
Consider early epinephrine infusion (start at 2-20mcg/min)
Aggressive fluid resuscitation (may require several litres)
Bronchospasm: salbutamol PRN
Give secondary medications:
H1 antagonist: diphenhydramine 25-50mg IV
H2 antagonist: ranitidine 50mg IV
Methylprednisolone 1-2mg/kg IV per day OR dexamethasone 20mg IV
Start invasive lines: arterial line, central line
Refractory hypotension despite epinephrine:
Vasopressin 1-40 unit bolus, 0.01-0.04 units/min infusion
Glucagon 1-2 mg over 5 min IV then 5-15 mcg/min IV infusion (especially for patients taking beta blockers; inotropic & chronotropic effects not mediated through beta receptors)
Methylene blue 1-2mg/kg IV (inhibits nitric oxide synthase & guanylate cyclase)
Consider bicarbonate (0.5-1 mEq/kg) with acidosis
Consider transesophageal echocardiography (TEE) & entertain other differential diagnosis
Post-event care:
Laboratory tests to support diagnosis:
Serum tryptase levels 15 minutes and 3 hours after onset of symptoms
Serum histamine levels peak 5 - 15 minutes after onset of symptoms; return to baseline at 60 minutes
Discharge to ICU intubated & ventilated
Due to biphasic nature, monitor at least 24 hours
Consult allergist
Aspiration Event
Background
Considerations
Prevention
Management
Aspiration Event
Background
Definition: inhalation of gastric contents into the lung via passive regurgitation or active vomiting
Common patients:
“Full stomach”: Not NPO, bowel obstruction, pregnant, gastroparesis, intoxicated
Incompetent LES: hiatal hernia, previous esophageal/gastric surgery, obese
Can’t protect airway: ↓ LOC, residual NMB, neurologic disease
Considerations
Signs/symptoms: Severe hypoxemia, ↑ peak insp. pressure, bronchospasm, ↑ tracheal/oropharyngeal secretions, chest retractions, dyspnea, coughing, laryngospasm, pulmonary edema
↑ morbidity/mortality: pneumonia, ARDS, sepsis, barotrauma
CXR: infiltrates and atelectasis, but can be unremarkable
Prevention
Avoid GA & excessive sedation if possible
Consider awake intubation
Ensure NPO status, if elective
Medications prior to induction:
Non-particulate antacide: Sodium citrate PO
H2 Antagonists: Ranitidine IV
Metoclopramide IV
Suction through NGT before inducing
Remove NGT when inducing
Suction on
Cricoid pressure
Management
Suction oropharynx
Intubate & inflate cuff
Suction through ETT
PPV with 100% and adequate PEEP
Bronchoscopy to:
Assess level of contamination
Remove particulate matter
Cancel elective surgery & minimize emergency surgery
Supportive care
Crystalloids better than colloid, H2 blockers, intermittent pulmonary toilet
Consider antibiotics
Consider ECMO if unable to oxygenate
Bronchospasm
Signs
DDx
Management
Bronchospasm
Signs
Wheezing on lung auscultation
Slow or incomplete expiration
Change in EtCO2:
Upsloping waveform
Severe ↓ or absent waveform
↓ tidal volume
↓ oxygen saturation
↑ peak airway pressure
Differential Diagnosis
↑ resistance:
Bronchial asthma
COPD with reversible component
Laryngospasm (if supraglottic airway)
Anaphylaxis
↓ compliance:
Aspiration
Pulmonary edema
Pulmonary embolism/fat embolism/amniotic fluid embolism
Pneumothorax
Opioid-induced chest wall rigidity
Inadequate muscle relaxation
Circuit/machine problems
ETT/supraglottic airway:
Kinked
Malposition
Endobronchial/esophageal/submucosal
Herniated cuff
Foreign body/secretions
Management
Adjust FiO2 as necessary, remove irritants, deepen anesthesia
Disconnect & hand-ventilate to assess compliance, rule out other possibilities
Beta 2 agonists are first line treatment:
Salbutamol 4-8 puffs via ETT OR 2.5-5mg via nebulizer q20min PRN
Epinephrine infusion 0.5-2mcg/min in severe, refractory cases
Anticholinergics: ipratropium 4-8 puffs via ETT OR 0.5 mg via nebulizer q20min PRN
Steroids: methylprednisolone 125mg IV OR dexamethasone 8mg IV
Appropriate ventilation to avoid dynamic hyperinflation:
Longer expiratory time (I:E 1:3-1:5)
Low/normal respiratory rates (8-12/min)
Permissive hypercapnia
Adjuncts:
Bronchodilating anesthetics: volatiles > ketamine > propofol
Magnesium sulfate 2g IV over 20min
Heliox (does not reverse bronchospasm, but can be used as a temporizing measure)
Neuromuscular blocking drugs (may improve mechanics of ventilation & lower peak inspiratory pressures)
Extracorporeal membrane oxygenation (ECMO) if severe & refractory to all other treatments
Compartment Syndrome
Background
Considerations
Compartment Syndrome
Background
Fascial membranes in the human body combine to surround muscle groups in the human body
Compartment syndrome: increased pressure in fascial compartments compromises circulation and function of tissue within these compartments
Positive feedback: ischemia —> necrosis —> edema —> further increase in compartment pressure
Epidemiology:
Occurs most commonly after trauma, esp long bone #
Incidence 7.3/100k in men and 0.7/100k in women
Most common sites are the:
Fibular and extensor compartments in lower leg
Extensor compartment in forearm
Risk factors:
Sustained fracture or soft-tissue injury
Tibial diaphyseal, distal radius & diaphyseal forearm #’s
↑ Age
↑ Comminuted #
High-energy mechanism
Considerations
Have a ↑ degree of suspicion in at-risk patients
3 P’s (low sensitivity to & high specificity):
Pain - main clinical sign, classically pain “out of proportion” to injury
Paresthesia - late clinical sign
Paresis - even later clinical sign
Diagnosis:
Clinical signs/symptoms (3 P’s)
Measure compartment pressure, where normal compartment pressure ~ 8mmHg
Calculate Critical Δ Tissue pressure = Diastolic BP - compartment pressure
> 30mmHg = normal
< 30mmHg = indication for fasciotomy (100% sens & 100% specif)
Achieve adequate pain control with the lowest possible dose
In effort to avoid delayed diagnosis of compartment syndrome
Sudden increase in pain should be compartment syndrome until proven otherwise
Avoid epidurals in patients at ↑ risk
Theoretical, ↑ risk of delayed diagnosis of compartment syndrome
If using epidural, use low-concentration solution
Peripheral regional anesthesia is safe & does not delay diagnosis of compartment syndrome
But opt to use dilute concentrations & minimal adequate dose
Liberal indication for fasciotomy
Delayed Emergence
Differential Diagnosis (“DIMS”)
Management
Delayed Emergence
Differential Diagnosis (“DIMS”)
Drugs
Anesthesia related:
Sedatives & narcotics
Residual paralysis, pseudocholinesterase deficiency
Drug error
Non-anesthesia related:
Street drugs, alcohol
Herbal medicines (valerian root, St. John’s wort)
Infection:
Encephalitis, meningitis
Sepsis
Metabolic:
Hypoxia
Hypercarbia
Electrolyte abnormalities
Hypoglycemia or hyperglycemia (DKA or HONK)
Hypothermia
Uremia
Hepatic encephalopathy
Osmolality problems
Myxedema coma
Structural:
Stroke (ischemic or hemorrhagic)
Hydrocephalus
Diffuse anoxic injury
Cerebral edema
Seizure or post-ictal
Pneumocephalus
Cerebral hyperperfusion syndrome (post carotid endarterectomy)
Management
Scan monitors: HR, ECG, rhythm, EtCO2, SpO2, BP, temp
Ensure stability of ABC’s
Confirm reversal of paralysis
Review all drugs administered & syringes for drug error
Focused physical exam:
Neurological: GCS, pupils, gag/cough, symmetric motor movement, focal signs
Cardiorespiratory: adequacy of perfusion
Blood work:
CBC, lytes, urea, creatinine, glucometer, osmolality, ABG with lactate & ionized calcium
Liver enzymes, bilirubin
Toxicology screen
TSH, FT4
Consider: Neurology / ICU consultation, CT head, EEG, lumbar puncture
Empiric therapy:
Glucose: 25-50 cc of D50 or 250 cc of D10
Thiamine 100 mg IV
Opioid reversal: naloxone 0.04 mg IV q 2 mins, up to 2mg
Benzodiazepine reversal: flumazenil 0.2-1 mg IV q 1 min, up to 1mg
Physostigmine (0.5 to 1 mg IV) counteracts but does not reverse sedation caused by inhalation anesthetics, other sedatives, & anticholinergics
Dental Injury
Considerations
Management
Prevention
Dental Injury
Considerations
Upper central incisors are most frequently injured
Need to inform patient of risk of dental damage whenever manipulating airway
Can be caused by:
Intubation
LMA placement
Suctioning
Extubation
After extubation (i.e. biting down on OPA)
Risk factors:
Difficult intubation
Poor dentition
Previous dental work
Major morbidity if tooth fragments aspirated into airway
Management
Dislodged teeth should be put in saline
Ensure all tooth fragments are found and removed
Consult dentistry
Prevention
Careful technique
Choose VL over DL
Consider use of mouth guard during DL/VL
Use muscle relaxants
Use bite block
Extravasation Injuries
Management of Vasopressor Extravasation
Prevention
Extravasation Injuries
Management of Vasopressor Extravasation
Stop injection/infusion immediately; leave the catheter in place
Place immediate substitute IV access; resume vasopressors
Slowly aspirate as much of the drug as possible
Elevate the area & apply warm compresses for 48 hours
Consult plastic surgery & vascular surgery for opinion & ongoing management
Reversal:
First line: phentolamine subcutaneously
Dilute phentolamine 5 mg in 10 mL 0.9% sodium chloride
A dose of 0.1-0.2 mg/kg (up to a maximum of 10 mg) should then be injected through the catheter & subcutaneously around the site
Use 25 g or smaller needle
Additional injections may be required if blanching returns
Systemic hypotension may occur
Other options:
Topical nitroglycerin 2% 1-inch strip applied to the site of ischemia (redose q8h PRN)
Terbulatine subcutaneously 1mg in 10ml NS, inject locally across symptomatic sites
Consider sympathetic block, e.g. stellate ganglion (case reports of success)
Consider a saline-wash out method or liposuction:
Saline wash out:
Probably the most effective way of removing drug from the site of extravasation & has been shown to reduce tissue injury
Under sterile conditions with local or general anaesthesia, four to six stab incisions are made around the area of extravasation
A blunt-ended cannula is inserted through one of the incisions & a large volume of saline flushed through the subcutanous tissues
The saline exits through the other incisions
Liposuction:
Blunt-ended liposuction cannula is inserted into the area of extravasation & used to aspirate fat & extravasated material
Less effective than saline washout
Prevention
Avoid IVs in the hand/wrist
Avoid unreassuring IVs
Perform protocolized extremity checks
Keep antidotes & worksheet in the room with the patient
10 mg of phentolamine mesylate can be added to each liter of solution containing norepinephrine (the vasopressor effect of norepinephrine is not affected)
Increased Airway Pressure
Differential diagnosis
Management
Increased Airway Pressure
Differential diagnosis
Circuit or machine problem:
Ventilator/bag switch in wrong position
Stuck valve (inspiratory/expiratory/APL)
Oxygen flush valve stuck in “on” position
Kinked/misconnected hose in circuit/scavenge limb
Failure of check valves/regulators in machine, allowing high-pressure gas into low-pressure circuit
PEEP valve accidentally placed in inspiratory limb
ETT/supraglottic airway problem:
Kinked tube
Malpositioned supraglottic airway
Endobronchial, esophageal, submucosal intubation
Herniated cuff obstructing end of tube
Dissection of interior surface of tube leading to airway narrowing
↓ pulmonary compliance:
↑ intra-abdominal pressure
Pulmonary aspiration
Bronchospasm
↓ chest wall compliance
Pulmonary edema
Pneumothorax
Drug-induced problem:
Opioid-induced chest wall rigidity
Inadequate muscle relaxation
Malignant hyperthermia
Laryngospasm (if using supraglottic airway)
Management
↑ FiO2 to 100%
Verify the peak inspiratory pressure
Switch to manually using reservoir bag; assess pulmonary & circuit compliance
Disconnect circuit from ETT & squeeze bag:
If PIP still high, obstruction in circuit; ventilate using BVM connected to 100% FiO2
Get help to replace/repair circuit
Auscultate chest & neck:
Listen for symmetry (endobronchial, tension, or simple pneumothorax) & for adventitious sounds (pulmonary edema, bronchospasm)
Listen for stridorous sound of laryngospasm
Examine trachea for deviation, check HR & BP
Exclude ETT obstruction:
Pass suction catheter down ETT & apply suction to clear secretions
If ETT obstructed, deflate cuff & repeat
Consider fiberoptic bronchoscopy to elucidate problem
Remove & reintubate if necessary
Check for other causes of ↓ chest compliance:
Malignant hyperthermia
Aspiration
Inadequate muscle relaxation
Opiates
Excessive surgical retraction
Abnormal anatomy (ie: scoliosis)
Fat Embolism
Signs
Management
Fat Embolism
Signs
Hypoxemia (most common early sign)
Neurological abnormalities (majority of patients)
Petechial rash (only 20-50% of patients; usually on conjuctiva, oral mucosa, skin folds of neck & axillae)
Management
Supportive treatment:
Respiratory support: intubation/ventilation, treat as ARDS (lung protective strategy)
Hemodynamic support: fluid resuscitation, vasopressors, invasive monitors, TEE
Steroids: no strong evidence but consider in refractory cases
Reduce incidence/severity:
Early immobilization of fractures
Operative correction rather than traction alone
Limitation of the intraosseus pressure during orthopedic procedures
Hypertension
Differential Diagnosis
Management
Complications
Hypertension
Differential Diagnosis
Hypoxemia, hypercarbia
Drugs:
Vasopressors, cocaine, MAOIs, stimulants
Drug errors
Acute withdrawal: EtOH, benzodiazepines, opioids, clonidine, beta-blockers
Pain, inadequate anesthesia:
Laryngoscopy/intubation
Surgical stimulation, laparoscopy
Remote (distended bladder)
Awareness
Patient factors:
Pre-existing hypertension
Pre-eclampsia
High ICP (Cushing reflex)
Autonomic dysreflexia
Endocrine:
Hyperthyroidism
Pheochromocytoma
Carcinoid
Malignant hyperthermia
Serotonin syndrome
Hyperaldosteronism
Cushing syndrome
Equipment error (falsely high reading)
Management
Inform surgeon, request cessation of surgical stimulation
Cycle BP, scan monitors for HR, ECG rhythm, EtCO2, temperature
Provided the patient is adequately oxygenated & ventilated, deepen anesthetic
Examine patient:
Pupils (high ICP)
Diaphoresis & flushing (carcinoid, pheochromocytoma, hyperthyroidism)
Rigidity (malignant hyperthermia, serotonin syndrome)
Bladder distension
Hot (thyroid storm, malignant hyperthermia, serotonin syndrome)
Examine drugs & equipment:
Potential drug error
Possible TIVA or circuit disconnect (awareness)
Tourniquet (pain)
Equipment error (falsely high reading)
Temporize:
Labetalol 5-20mg IV q10 min (max total 300mg)
Esmolol 0.5mg/kg IV over 1 minute; start infusion at 50mcg/kg/min
Hydralazine 5-20mg IV (max 30mg) slow IV push every 20 minutes
Nitroglycerin 50-100mcg IV; start infusion at 10mcg/min
Treat underlying cause
Complications
CVS: MI, arrhythmia, CHF/pulmonary edema, dissection
CNS: intracranial hemorrhage
↑ surgical bleeding
Hypoxemia
Differential Diagnosis
Management
Hypoxemia
Differential Diagnosis
Low FiO2:
Oxygen failure or pipeline crossover of gases
Hypoventilation:
Low TV or RR
Ventilator dyssynchrony
Circuit leak
Obstructed ETT
V/Q mismatch or shunt:
Airway:
Bronchospasm
Mainstem intubation
Mucous plug
Alveolar:
Pulmonary edema
Aspiration
Atelectasis
Pleura:
Pneumothorax
Pleural effusion
Deadspace:
Pulmonary embolism
Low cardiac output state
↑ metabolic O2 demand:
Malignant hyperthermia, thyrotoxicosis, sepsis, hyperthermia, neuroleptic malignant syndrome
Diffusion abnormality:
Chronic lung disease
Artifacts:
Confirm by ABG
Poor waveform (probe malposition, cold extremity, light interference, cautery)
Dyes (methylene blue, indigo carmine, blue nail polish)
Management
↑ FiO2 to 100%, high flow
Check gas analyzer to rule out low FiO2 or high N2O
Check other vitals, cycle NIBP, check peak inspiratory pressure, feel for pulse
Check ETCO2 (?extubated/disconnected/low BP)
Hand ventilate (check compliance, rule out leaks & machine factors)
Listen for breath sounds
Check position of ETT
Soft suction via ETT (to clear secretions & check for obstructions)
Consider code cart if severe
Depending on likely diagnosis, consider:
Large recruitment breaths, consider PEEP
Bronchodilators
Additional neuromuscular blockade
↑ FRC (head up, desufflate abdomen)
Fiberoptic scope to rule out mainstem intubation or ETT obstruction
ABG, CXR
Consider terminating surgery for refractory hypoxemia
Plan for post-op care
Malignant Hyperthermia (MH)
Signs (early and later)
DDx
Management
Malignant Hyperthermia (MH)
Signs (early)
↑ EtCO2
Tachycardia
Tachypnea
Mixed acidosis
Masseter spasm/trismus
Sudden cardiac arrest due to hyperkalemia
Signs (may be later)
Hyperthermia
Muscle rigidity
Myoglobinuria
Arrhythmias
Cardiac arrest
Differential Diagnosis
Neuroleptic malignant syndrome: similar presentation to MH but associated with use of antipsychotic neuroleptic medications (also treated with dantrolene)
Thyroid storm: fever, tachycardia, altered mental status
Anaphylaxis: cardiovascular collapse without hypermetabolic features
Pheochromocytoma: significant hypertension
Drug toxicity: consider clinical context, screen urine/plasma
Management
Alert surgeon & call for help
Stop anesthetic triggers (volatiles & succinylcholine), ↑ fresh gas flow to 10L/min; do not change machine or circuit
If available, insert activated charcoal filters into the inspiratory & expiratory limbs of the breathing circuit
↑ to 100% FiO2 & ↑ minute ventilation
Halt surgery; if emergent, continue with non-triggering anesthetic
Call MH hotline:
MHAUS (Malignant Hyperthermia Association of the United States)
1 800 644 9737 (within USA); 00 1 209 417 3722 (outside USA)
Assign several people to prepare dantrolene 2.5 mg/kg IV bolus:
Dilute each 20 mg dantrolene vial in 60 mL preservative-free sterile water
For 70 kg person, give 175 mg (prepare 9 vials of 20 mg dantrolene)
Rapidly administer dantrolene & continue giving until patient stable
May need > 10 mg/kg
Cool patient: IV fluids, ice packs, gastric / peritoneal lavage
Treat arrhythmias:
Usually secondary to hyperkalemia
Treat in standard fashion, however avoid calcium channel blockers
Treat metabolic acidosis:
Sodium bicarbonate 1 to 2mEq/kg PRN for base excess greater than -8
Treat hyperkalemia:
Hyperventilation
Calcium chloride 10mg/kg (max dose 2g) or calcium gluconate 30mg/kg (max 3g)
D50 1 amp IV (25g dextrose) + regular insulin 10 units IV → monitor glucose
Sodium bicarbonate 1 amp
Furosemide 0.5-1mg/kg once
For refractory hyperkalemia, consider beta-agonist, kayexalate, dialysis, or ECMO if in cardiac arrest
Monitor temperature, electrolytes, arterial/venous blood gases, creatine kinase, urine output, coagulation studies, lactic acid
Place foley catheter, monitor urine output
When stable, transfer to post anesthesia care unit or intensive care unit for at least 24 hours
Monitor for recurrence & continue dantrolene 1 mg/kg q 4-6 hours x 24 to 48 hours
Refer for genetic counseling/in-vitro muscle contracture testing
Increased Intracranial Pressure
Background incl signs
Management
Increased Intracranial Pressure
Background
Etiology:
trauma, CNS tumors, hydrocephalus, hepatic encephalopathy, impaired venous outflow
Normal ICP ≤ 15mmHg in adults
Increased ICP ≥ 20 mmHg
Intracranial components = 1400 - 1700mL total
Brain parenchyma = 80%, usually fixed in adults
CSF = 10%, can vary greatly,
Blood 10%, can vary greatly
Pathologic structures = masses, abscesses, hematomas etc.
Monro-Kellie doctrine:
Cranial compartment is a fixed volume
∴ increased in one component (blood, brain, CSF) means:
displacement of other components or;
increased ICP or;
both 1 & 2
Main compensatory mechanisms for rising ICP:
Displacement of CSF into thecal sac
Displacement of venous blood from cranial vault
Major causes of increased ICP:
Intracranial masses (i.e. tumor, hematoma)
Cerebral edema (i.e. severe infarcts, severe TBI)
Increased CSF production
Decreased CSF absorption
Obstructive hydrocephalus
Obstructed venous outflow
Idiopathic ICH
Signs:
CN VI palsies, papilledema
Decreasing GCS
Decorticate or decerebrate posturing
Cushing triad: bradycardia, respiratory depression, hypertension
Herniation syndromes
Management
Search for underlying treatable cause, for example:
Evacuating blood clot
Resection of mass
CSF drainage
R/o alternate causes of decreased GCS
hypotension, hypothermia, intoxication
ABCs
A: secure airway to allow for sedation and monitoring/controlling respiration
B: aim for hypocapnia, avoid hypoxemia
C: avoid hypotension, goal CPP 60-120mmHg with ICP monitor in-situ
Determine urgent/emergent patients:
GCS < 8
Worrisome history (i.e. head trauma or sudden thunder-clap headache)
Worrisome physical exam: Dilated & fixed pupils, decorticate/decerebrate posturing
Cushing’s triad
If true emergency patients (i.e. impending herniation):
Employ measures below before continuing with further work-up
Elevated HOB
Hyperventilate PCO2 26-30mmHg
IV mannitol (1-1.5 g/kg)
If not an emergency (increased ICP is suspected and no immediately treatable cause)
Use ICP monitoring
Goal ICP < 20mmHg
Proceed with general strategies to lower ICP as proximate cause is being investigated
General strategies to lower ICP:
Aim for euvolemia
Serum osmolality 295 to 305 mOsm/L
Avoid free water
Use 0.9% NaCl
Elevate Head of bed
Treat fevers with acetominophen
Consider neuromuscular blockade
Sedate with propofol
Consider cooling
Consider seizure prophylaxis
Specific therapies to lower ICP:
Hypertonic Saline (250mL of 7.5%)
Mannitol (1g/kg bolus, then 0.25-0.5mg/kg q6-8hrs)
Consider glucocorticoids if brain tumor or CNS infection
Hyperventilate to PaCO2 26-30 (lasts <24hrs)
Barbiturates (pentobard load 5-20 mg/kg bolus then 1-4 mg/kg/hr)
Need EEG monitoring to avoid burst suppression
Ventriculostomy if hydrocephalus is present
Remove CSF at 1-2 mL/minute for 2-3 mins at a time, aim for ICP <20mmHg
Decompressive craniectomy
Laryngospasm
Background
Considerations
Management
Prevention
Laryngospasm
Background
Involuntary closure of the vocal cords leading to airway obstruction with folding over of epiglottis
Delayed treatment can lead to:
↓O2, ↓HR, negative pressure pulmonary edema, aspiration & cardiac arrest
Considerations
Can occur anytime (induction, emergence, maintenance) while in a light plane of anesthesia
Needs to be recognized and treated rapidly
Risk factors:
Airway manipulation
Vocal cord irritation (blood or mucus etc.)
Young age (i.e. infants)
URTI
OSA
Altered airway anatomy
Procedures on the airway (e.g. tonsillectomy)
Signs & symptoms:
inspiratory stridor
Retrosternal/substernal retractions
Rocking movement with inspiration
Management
100% O2 with facemask + CPAP + optimize airway position +/- OPA
Consider Larson’s maneuver (bilateral firm digital pressure on the styloid process behind the posterior ramus of the mandible)
Deepen anesthesia (i.e. propofol or volatile agent)
Definitive treatment:
Succinycholine 0.25-0.5 mg/kg IV
Atropine 0.02mg/kg IV ready for bradycardia
BMV until muscle relaxant wears off
Prevention
Delay surgery if recent URTI
Suction!
Manipulate airway only during deep plane of anesthesia
Avoid ETT (use LMA instead) for > 1 y/o’s
If intubating using NDMR
Lidocaine IV prior to extubation
Local Anesthetic Toxicity (LAST)
Signs & Symptoms
Management
Local Anesthetic Toxicity (LAST)
Signs & Symptoms
Tinnitus, metalic taste, circumoral numbess
Altered mental status
Seizures
Hypotension
Bradycardia
Ventricular arrhythmias
Cardiovascular collapse
Management
Stop local anesthetic injection &/or infusion
Call for help
Initial focus:
Airway management: ensure adequate ventilation & oxygenation; 100% FiO2, consider ETT, prevent hypoxia & acidosis (aggravate LAST)
Seizure suppression: benzodiazepines preferred, avoid/minimize propofol if hemodynamically unstable; if seizures persist, small doses of succinylcholine to minimize acidosis & hypoxia
Alert nearest facility having cardiopulmonary bypass capability
Management of cardiac arrhythmias:
If pulseless, start CPR
ACLS will require adjustment of medications & perhaps prolonged effort
Epinephrine doses <1 mcg/kg (small boluses of 10-100 mcg IV)
Avoid vasopressin, calcium channel blockers, beta blockers, & local anesthetics
If ventricular arrhythmias occur, amiodarone is preferred; avoid lidocaine & procainamide
If refractory to treatment, consider cardiopulmonary bypass
Lipid emulsion (20%) therapy:
Rapidly administer at the first signs of LAST 1.5ml/kg bolus (70kg = 105ml) over 1 minute, then start infusion at 0.25mL/kg/min
Repeat bolus once or twice for persistent cardiovascular collapse
May ↑ infusion rate (max 0.5mL/kg/min) if BP remains low
Continue infusion for at least 10 minutes after attaining circulatory stability
Recommended upper limit 10mL/kg over the first 30 minutes
Propofol is not a substitute for lipid emulsion
Failure to respond to lipid emulsion & vasopressor therapy should prompt institution of cardiopulmonary bypass (ECMO)
Seizure
Differential Diagnosis
Management
Seizure
Differential Diagnosis
Epilepsy or other primary seizure disorder
Drugs:
Withdrawal syndromes (e.g. alcohol)
Drug overdoses
Illicit drugs (cocaine)
Local anesthetic toxicity
Infection:
Meningitis
Encephalitis
Sepsis
Metabolic:
Hypoglycemia
Hypoxemia/hypercarbia
Hyponatremia/hypocalcemia/hypomagnesemia
Toxins (uremic, hepatic encephalopathy)
Dialysis disequilibrium syndrome
Porphyria
Structural:
Ischemic or hemorrhagic stroke
Intracranial tumor
Cerebral edema
Pregnancy:
Eclamptic seizure
Amniotic fluid embolism
Management
Inform surgical team & call for help
Supplemental oxygen, monitors, establish IV access
If needed, hand ventilate with 100% O2 - DO NOT hyperventilate (↓ seizure threshold)
Focused cardiorespiratory & neurological exams
Rapid glucometer
Bloodwork: CBC, electrolytes, extended electrolytes, blood glucose, liver enzymes, kidney function tests, ABG
Give anticonvulsants if seizure > 2min:
Benzodiazepines = 1st line
Midazolam 0.05mg/kg or 1mg at a time, titrate to effect
Diazepam 0.1-0.4mg/kg IV, 0.04-0.2 mg/kg PR
Lorazepam 1-2 mg at a time, titrate to effect
Propofol 0.5mg/kg at a time, titrate to effect
Phenytoin 20mg/kg total loading dose at a rate of 50mg/min, watch for hypotension & arrhythmias
Barbiturates:
Phenobarbital 20 mg/kg infused at a rate of 50 mg/minute
Thiopental 25-100mg dose
Pentobarbital 10 mg/kg infused at a rate of up to 100 mg/minute
Valproic acid IV 30mg/kg over 15 min
Consult neurology for further diagnosis & management
If ↑ ICP: institute treatment (mannitol, furosemide, hypertonic saline, mild hyperventilation, elevate HOB, etc)
If eclampsia: MgSO4 4g IV bolus over 15 min, then 1-2g/hr
If no resolution & respiratory compromise:
Paralyze & intubate
Succinylcholine IM (4mg/kg) for intubation if no IV access
Perioperative MI
Signs
Management
Perioperative MI
Signs
New ST segment or T wave changes
New left bundle branch block
Arrhythmias, conduction abnormalities
Unexplained tachycardia, bradycardia, or hypotension
Development of pathological Q waves
Regional wall motion abnormalities or new/worse mitral regurgitation on TEE
Management
Assess need for airway management & initiation of cardiopulmonary resuscitation
Verify ischemia (12 lead ECG or expanded monitor view)
Optimize myocardial oxygen supply:
↑ FiO2
Treat anemia if present
Optimize BP (maintain coronary perfusion pressure) & HR (avoid tachycardia)
↓ coronary oxygen demand:
Analgesia
Nitrates (careful in hypotension)
Beta blockers (careful in hypotension & acute heart failure)
Optimize BP (avoid increased afterload) & HR (avoid tachycardia)
Discuss aborting procedure with surgical team
Discuss aspirin & anticoagulation with surgical team & cardiology team
Send labs: troponin, CBC, ABG
Initiate invasive monitoring, consider central venous access
Consider TTE/TEE for monitoring volume status & regional wall motion abnormalities
If hemodynamically unstable, consider intra-aortic balloon pump
Admit to HAU/ICU/CCU
Postoperative Visual Loss
Differential Diagnosis
Risk Factors
Management
Postoperative Visual Loss
Differential Diagnosis
Corneal abrasion
Ischemic optic neuropathy (ION)
Central/branch retinal artery occlusion (CRAO, BRAO)
Cortical blindness secondary to visual field stroke
Transient ischemic attack (TIA)
Acute glaucoma
Expansion of intraocular vitrectomy gas bubble (nitrous oxide)
TURP glycine toxicity
Risk Factors
External eye compression from improper patient positioning
Retrobulbar hemorrhage due to vascular injuries following sinus/nasal surgery
Retinal microemboli associated with open-heart surgery
Prone positioning
Lengthy spinal fusion surgery, ↓ arterial pressure, ↑ blood loss, anemia, high volume crystalloid resuscitation
Cardiothoracic, instrumented spinal fusion surgeries, head & neck, nose or sinus surgeries
Systemic vascular risk factors: hypertension, diabetes, atherosclerosis, hyperlipidemia, smoking, obesity, obstructive sleep apnea & hypercoagulability
Management
Immediate normalization of vital signs & metabolics
Urgent ophthalmology consultation +/- neurology consultation
CRAO:
Ocular massage to dislodge clot
Localized hypothermia to affected eye
Acetazolamide (500mg IV)
Inhaled CO2 (mixture of 95% oxygen & 5% carbon dioxide)
Anterior chamber paracentesis
Intraarterial fibrinolysis
ION:
Elevate head of bed
Correct volume depletion & blood loss
Restore BP to normal range
Potential benefit from acetazolamide, mannitol, furosemide
Steroids, hyperbaric oxygen controversial
Surgeon to bedside for multidisciplinary debriefing with patient & family
Call CMPA for counselling around disclosure & documentation
Tension Pneumothorax
Background
Signs
Management
Tension Pneumothorax
Background
A tension pneumothorax happens when air in the pleural space builds up enough pressure to reduce venous return, resulting in hypotension, tachycardia and severe dyspnea.
Patients receiving mechanical ventilation are more likely to progress to cardiovascular collapse
Signs
Tachycardia and Hypotension
High airway pressure and oxygen desaturation
Contralateral shift of the trachea
Management
Notify surgeon and call for help as necessary
Apply 100% oxygen and reduce anesthetic agents
Treat hypotension with fluids and pressors as required
Decompress the pneumothorax immediately
14G needle at the 2nd intercostal space in the midclavicular line
Definitive management with chest tube insertion by qualified personnel
Total Spinal
Signs
Management
Total Spinal
Signs
Numbness or weakness in upper extremities
Nausea/vomiting
Dyspnea/respiratory depression
Loss of consciousness
Bradycardia
Hypotension
Dilated pupils
Management
Supportive care:
Assess need for intubation and/or cardiopulmonary resuscitation
Maintain oxyvenation/ventilation & protect against aspiration
Support hemodynamics:
IV fluid bolus, atropine, epinephrine (10 - 100ug IV, increase as needed)
If pregnant: left uterine displacement & fetal heart rate monitoring
Consider sedation when hemodynamically stable
Change position based on baricity (careful with reverse trendelenberg & hypotension → venous pooling)
Support until spinal wears off
Transfusion Reactions
General Management
Signs and management for:
- Acute hemolytic reaction
- Febrile nonhemolytic reaction
- Anaphylaxis
- Transfusion-associated circulatory overload (TACO)
- Transfusion-related acute lung injury (TRALI)
- Urticarial reaction
Complications
Transfusion Reactions
General Management
Stop transfusion
Support blood pressure with IV fluids, vasoactive medications if needed
Notify blood bank of all possible reactions
Determine diagnosis
Acute hemolytic reaction
Signs:
Awake: chills, fever, nausea, chest & flank pain
Anesthetized: hyperthermia, tachycardia, hypotension, hemoglobinuria, diffuse oozing in surgical field
Management:
Stop transfusion & notify blood bank
Support hemodynamics
Recheck unit against blood slip & patient’s identity bracelet
Draw bloodwork to identify hemoglobin in plasma, repeat compatibility testing, obtain coagulation studies & platelet count
Insert urinary catheter & check urine for hemoglobin
Initiate osmotic diuresis with IV fluids +/- mannitol
Monitor for hyperkalemia, DIC
Febrile nonhemolytic reaction
Signs:
Fever
No evidence of hemolysis
Management:
Antipyretics
Transfusion may be continued if reaction mild
Use leukoreduced transfusions in the future
Anaphylaxis
Signs:
Rash/hives
Angioedema
Hypotension
Tachycardia
Hypoxemia
Bronchospasm/wheezing
Increased peak inspiratory pressure
Management:
Stop transfusion
Epinephrine
IV fluids
Antihistamines, corticosteroids
See “Anaphylaxis” page for further details
Transfusion-associated circulatory overload (TACO)
Signs:
Respiratory distress, hypoxia
↑ BP
Acute or worsening pulmonary edema
Positive fluid balance
Management:
Stop transfusion
Supplemental oxygen
Diuretics
Transfusion-related acute lung injury (TRALI)
Signs:
Acute hypoxia & noncardiac pulmonary edema within 6 hours of transfusion (usually plasma)
↓ BP
Management:
Supplemental oxygen, endotracheal intubation / ventilation
Similar treatment to acute respiratory distress syndrome (ARDS)
Hemodynamic support
Urticarial reaction
Signs:
Erythema, hives, itching
No fever
Management:
Antihistamines, steroids
Transfusion may be continued if reaction mild
Complications of Massive Transfusion
Dilutional coagulopathy
Hypothermia
Hyperkalemia
Complications of citrate infusion:
Hypocalcemia
Metabolic acidosis or alkalosis
Venous Air Embolism
Signs
Management (includes goals)
Venous Air Embolism
Signs
Air on TEE or change in doppler tone if monitoring
↓ ETCO2
↓ BP
↓ SpO2
↑ CVP
Bronchospasm
Dyspnea & respiratory distress or cough in awake patient
Mill wheel murmur on cardiac auscultation (late sign)
Management
Goals: prevent further entrainment of air, hemodynamic support, treat existing air
Inform surgeon
Flood surgical field with saline & apply bone wax
Supportive therapy:
100% oxygen, decrease or turn off volatile anesthetic
Stop nitrous oxide
IV fluid bolus
Vasopressors (epinephrine, norepinephrine, dobutamine)
Positioning:
Place surgical site below heart (if able)
Lower the head position & compress the jugular veins (if surgical site above the neck)
Reposition the patient into left lateral decubitus, trendelenberg, or left lateral decubitus head down position (controversial - poor evidence & often impractical to do in the OR)
Definitive therapy:
Hyperbaric oxygen therapy (especially if paradoxical air embolism)
Aspirate air from the central catheter if in situ
Chest compressions
PEEP is of no value & increases risk of paradoxical air embolism
Consider TEE to assess air & RV function
Hypoglycemia
Signs
DDx
Management
Hypoglycemia (blood glucose <3.9 mmol/L)
Signs
Sympathetic system activation: diaphoresis, tremor, tachycardia, anxiety, hunger
Neuroglycopenia: weakness, fatigue, altered mental status, coma
Differential diagnosis
Exogenous insulin
Critical illness/sepsis
Endocrine: Addison’s disease, adrenal crisis, hypopituitarism
Insulin producing tumors
Fasting hypoglygemia: inherited liver/fatty acid oxidation enzyme deficiencies, drugs (ethanol, haloperidol)
Reactive (postprandial) hypoglycemia: idiopathic or enzyme deficiencies
Management
Confirm glucose level
Treat: IV dextrose (D5W 50ml IV); glucagon 1-2mg IM if no IV access
Seizure precautions
Continue to monitor & treat until glucose levels stable
Hypotension
Differential Diagnosis
Management
Hypotension
Differential Diagnosis
↓ preload:
Bleeding
Relative
↓ afterload/distributive shock:
Anaphylaxis
Sepsis/SIRS
Neurogenic
Blood transfusion reaction
Neuraxial
Drugs: anethetic overdose/drug swap
Endocrine: Addison’s, myxedema, carcinoid
Metabolic: hypocalcemia, hypoglycemia
Obstructive shock:
Tension pneumothorax
Tamponade
Embolic events
Pulmonary hypertension
Cardiogenic shock:
Rate:
Bradycardia
Tachycardia
Arrhythmias
Contractility:
Ischemia
Drugs or toxins
RV failure/pulmonary hypertension
Acute valvular pathology
Management
Emergency situation requiring simultaneous diagnosis & management
Inform the surgeon
Call for help
↓ anesthetic & hand ventilate with 100% O2
Vasopressor bolus +/- IV fluid bolus:
Phenylephrine 100 mcg IV PRN
Norepinephrine 5 mcg IV PRN
Ephedrine 5-10 mg IV PRN
Epinephrine 1-10 mcg IV PRN
Cycle BP & scan monitors for HR, rhythm, ST changes, SaO2, EtCO2, PAP
Feel for a pulse:
If no pulse → ACLS as per protocol
Ensure crash cart in room:
If pulse present → targeted physical exam
Urticaria, flushing, angioedema
Tracheal deviation, jugular venous distention, subcutaneous crepitus, bilateral air entry
JVP (jugular venous pressure) / CVP (central venous pressure) / PCWP (pulmonary capillary wedge pressure)
↑ CVP / PCWP = obstructive or cardiogenic
↓ CVP / PCWP = hypovolemic or distributive
Peripheral perfusion (↑ in distributive, ↓ in others)
Look at surgical field (blood loss, IVC compression, pneumoperitoneum pressure)
Check IV fluids, vasopressors, blood products
Reassess differential diagnosis based on findings
