Emergency Anaesthesia Flashcards
Emergency→ Immediate operation usually within __________ of surgical consultation usually lifesaving, __________ simultaneously with surgical treatment.
Urgent→ Operation as soon as possible after __________ usually within __________ of surgical consultation.
one hour ; resuscitation
resuscitation ; 24 hours
Emergency Theatre Provision:
A 24-hour emergency operating theatre is provided
Emergency cases will be operated on at __________.
Urgent cases will be operated on between the hours of ______-______ hours.
Emergency operations will take precedence over __________ cases
anytime
0830 - 2200
all other
Preoperative challenges
Challenges of emergency anaesthesia
Full stomach-emptying of gastric contents normally is delayed due to ____________________________
This may be caused by trauma, pain, fear and opioids The _______________________________________ is used in the assessment residual gastric volume after trauma.
The gastric volume >____mls/kg and a pH < than ______ correlate with more severe complications of aspiration
reduced gastric motility
time of ingestion of food to the time of trauma
20mls/kg ;2.5
Possible causes of a full stomach
Emergency surgeries which may include ______,________,________,________
Anaesthesia causes will include _______ administration, __________ medications, __________ intubations which alters the _______ and reduce the _______________ tone
Others will include autonomic neuropathy Stress and pain
Encephalopathy
Obesity
Pregnancy
Abdominal malignancy causing raised intra abdominal pressure
TBI,Caesarian section, bowel obstruction, hiatal hernia
opioid; anticholinergic; nasogastric
gag reflex; lower esophageal
Preoperative challenges
Full stomach:
It predisposes the patients to _________ & probable _________ of gastric contents resulting in a poor outcome
This may occur due to the limited time available for patient preparation
The reduction in the time for patient assessment & evaluation increases the risk associated with anaesthesia for emergency procedures
regurgitation; aspiration
Pre-operative challenges
Hypovolaemia→ __________ or __________ from __________ or __________ which results in __________ and __________, which may then lead to __________.
Coexisting medical disorders→ uncontrolled HTN, DM, asthma, CCF,
__________ – and concomitant use of __________ medications
haemorrahge ; fluid loss
diarrhea ; vomiting
dehydration ; loss of electrolytes ; arrhythmias.
Pain; opioids
Source of emergency Patients
Hemorrhagic
General surgery
Labour ward-ruptured uterus
Feto-maternal distress
Source of emergency Patients
Femur/tibia
ectopic pregnancy
aneurysm
SOURCE of emergency patients
Intensive Care
________ (____________________)
STBI(severe traumatic brain injury)
Burst abdomen
sudden acute deteriorating
Anaesthetic Management
_____________ Assessment
_____________ Investigations
_____________
_____________
_____________
_____________ / _____________
Preoperative
Laboratory
Monitoring
Induction
Maintenance
Recovery / Shifting to ICU
Preoperative assessment
Conventional Assessments of fitness for anesthesia and surgery (can or cannot?) be followed
_______ assessment and intervention to stabilise the patient
Cannot
Rapid
Preoperative assessment
Primary survey
_________,_______,_______,_________
If not ________,_______, and __________ immediately you may not have a live patient on the operating table
Circulation
Airway
Breathing
Disability (Neurology)
assessed, diagnosed and treated
Shock index =???
And the (lower or higher?) the value the poorer the prognosis
Heart rate <0.7
—————-
Systolic pressure
Airway Assessment
Assessment of _________ and _________
Difficult Laryngoscopy with risk of failed intubation
Beware of
_________ and __________
patency and anatomy
C-Spine Injury
Full Stomach
Airway Treat
Simple airway maneuvers- ________,___________
Simple airway adjuncts- ______,________ airways
________________ – Gum elastic bougie,McCoy laryngoscope blade,Videolaryngoscope,intubating LMA
A difficult airway may require a surgical access through a _____________.
Jaw Thrust, chin lift
oral, nasal
Endotracheal Intubation
cricothyroidotomy
Breathing with ventilatory support
Respiratory rate – Bradypnoea, tachypnoea
Respiratory rates <___ or >____ are seen in life threatening conditions
Oxygen saturation – very useful if signs of _________ are present
<5 or >35
hypoxia
Anticipated problems needing intervention
List 5
Treatment – ___________ insertion , ———— of the wound, ____________ and ___________
Tension pneumothorax
Massive Hemothorax
Open Pneumothorax
Flail Chest
Cardiac Tamponade
Intercostal drain; Sealing; Intubation & ventilation
Important 5 places to access after primary survey
In posttraumatic patients
_________ injuries
_______ bones
____________ for pneumohaemthorax
____________
_________ and __________
External; Long
Chest – x ray
Abdomen
Pelvis and Retro peritoneum
Shock in a multiply injured patient is “__________ shock” unless proven otherwise
hemorrhagic
Management of shock
___________ – ______ intervention / interventional __________
_________ bore canulae – (peripheral or central?) – send for ________ and _______ - lab
2 litres of _____________________ ???
Exsanguinating hemorrhage O -ve blood
Stop Bleeding; Surgical; Radiology
2 large; peripheral; grouping and cross matching
warm crystalloids
Neurological
Quick GCS scored over 15
Prevent secondary Neurological damage
May result from
_________,_________,___________
Hypoxia Hypotension Hypercapnia
_________ _______tension probably is not to be advocated for head injured patients
Permissive Hypo
TRAUMA
Glascow Coma Scale (GCS)
•Head injury mild (_______),
moderate (_______), severe (_____)
13-15
9-12
3-8
Radiology
______
_________
________
_________- ______ view CT
X rays –
Chest
Pelvis
C Spine – lateral
Do Not Shift ___________________ patient to Radiology Room
Hemodynamically unstable
CT (reduces or lengthens?) time to diagnosis
Reduces
Shifting of Patients from Resuscitation Suite
“ Only down the corridor”
Airway
Ventilation
_______ and ______
__________
Check – __________,_________,____________
Only half way through corridor– Beware of _________ injuries
Fluids and drugs
Monitoring
Battery of ventilators, Oxygen cylinders,
Syringe pumps
undiagnosed
Positioning
Beware – ______,_______,________
All are inserted as they are important – so keep them accessible
Take care of __________ limbs
Every shifting in a _________ patient can cause further ______ in blood pressure
lines- tubes- bags
fractured; hypovolemic
fall
Monitoring
Basic Monitors
•______,_______,________,_________
•_____________________
Don’t waste time in getting an arterial line-
can be placed after surgeons have started hemorrhage control
CVP – PCWP ??
Pulse Oximetry, ECG, Temperature, NIBP
Invasive Arterial blood pressure-
Choice of anaesthesia
guided by the ________ of the injury and ________
surgical technique
the preferences of the ________
________ or ________ anaesthesia
However, due to urgency, ________ is always preferable to ________
nature ; location
anaesthetist
General ; regional anaesthesia
GA ; RA
Preparation for anaesthesia
____________ drugs,
____________ drugs , vasopressors
_______,________
IV access (large bore cannula ____/___G) Anaesthetic ____________
Tiltable _________
Informed _________
_______________
Anaesthetic drugs
Resuscitative drugs
atropine, adrenaline
16/18G
machine check
trolley ; assistant
Acid prophylaxis
RSI
Gold standard for prevention of _______________________
It is a method for achieving rapid _______________ whilst minimising the risk of __________ and __________ of ___________
It is important in patients who has not ________
aspiration of gastric content
control of the airway
regurgitation ; aspiration ; gastric contents.
fasted
RSI
The goal is to ________ without having to use __________________ ventilation
_______ table
Full _________ with _______ ready
_________ assistant
IV access
intubate ; bag-valve-mask
Tilting ; monitoring ; suction
Trained assistant
Rapid sequence induction steps
_______________________ FOR ____ MINUTES
Calculated sleep dose of induction agent ______,______,________,________
__________ or __________ maneuvers applied on the cricoid cartilage which forms a _______ ring and could directly __________ the __________
Suxamethonium ____ mg/kg
__________ and __________ is carried out immediately the patient is relaxed
Check __________ before releasing ________ pressure. Secure the tube.
PRE-OXYGENATION ; 3 MINUTES
STP, propofol ,etomidate, ketamine
Cricoid pressure ; Sellicks maneuvers
signet ring ; compress ; eosophagus
1; Laryngoscopy and intubation
position ; cricoid pressure
Choice of Induction agent
For Adequately resuscitated
Receive standard anesthetic care : ______,______,_________
STP,Propofol,Etomidate
Choice of Induction agent
Fro Inadequately resuscitated, unstable but conscious
A ________________ dose of induction agent
Choice : ______,_________
reduced titrated
Ketamine Etomidate
Choice of Induction agent
In extremis eg if patient is unconscious and apneic
Induction agents ___________________
Can use ____________________
should not be used – inappropriate
muscle relaxants
Controlled or Spontaneous ?
No Place for spontaneous ventilation in a hemodynamically unstable - critically ill patient and
Severe shock – where there is
↓______________________
increased need for __________________
And perhaps associated _________________
blood supply to diaphragm
minute ventilation
Respiratory failure
Maintenance of Anesthesia
Till hemodynamic stability is attained – Incremental dose of _______ and (low or high?) concentration of ________ agents
As the circulatory state improves dose of narcotics, volatile agents or propofol can be _____eased
narcotics; low; volatile agents
Increased
Relaxants
__________,___________– least effect on heart (not available)
____________ (??allergy)
If elective ventilation is planned – ___________ is best due to _______ and __________ effect in shocked patient
Rocuronium, vecuronium
Atracurium
Pancuronium
vagolytic; sympathomimetic
Volatile Anesthetic of choice
________ – _________ – __________
Isoflurane – sevoflurane – desflurane
Volatile Anesthetic of choice
Isoflurane
Impressive safety profile
_____tension – due to ______________ and not _______________
Hypo
vasodilatation
myocardial depression
Fluid therapy - Early Phase
Till ________________
Fluids to maintain systolic pressure of >____ mm Hg
To reduce _____ formation and ______________ and to prevent ____________ vasoactive support for most shock refractory to fluid therapy
_____________ infusion remain the mainstay of
control of hemorrhage; 80
clot; dislodgement of clots
hypoperfusion
Catecholamine
Fluid Therapy- late Phase
To maximise the __________ to correct the _________________
Fluid (crystalloids or colloids) to increase ____________
RBCs to improve ___________
Plasma and platelets to correct __________
_____________ to be continued in the _____ –until _______________
perfusion ; oxygen debt
volume ; oxygen carriage
coagulation; Resuscitation
ICU ; lactate clearance
Fluid Therapy
Adequacy of fluid therapy is accessed by monitoring the
__________,______,______,_______
_____________ Variation
_____________ Variation
Blood Pressure, Heart rate, urine output CVP
Systolic Pressure ; Pulse Pressure
In patients with intestinal obstruction the passage of __________ is very important
nasogastric tube
Anaesthesia for intestinal obstruction
•_____________________________ (concern)
balanced salt solutions ( _________,_________ )
Kcl →K correction,
• • •
darrows solution Bicarbonate GAR
NG Tube
fluid & electrolyte balance
Lactated Ringers, 0.9% saline
Anaesthesia for Penetrating eye injury
______________ RSI (↑ intraocular press)→ _________ and _______
Alternative : __________, _________
Suxamethonium
vitreous loss & blindness
rocuronium
Delay surgery
Anaesthesia for antepartum haemorrhage
Placenta praevia or accreta
GA orRA
Adequate ____________
availability of _________________
______ for caesarean
↓blood loss & need for blood transfusion
IV access
cross-matched blood
RA
Blood loss
Physiologically, haemodynamic compensatory mechanisms maintain vital organ perfusion till about ______% TBV loss, beyond which there is risk of critical ______________ .
Inadequate resuscitation at this stage leads to __________
30
hypoperfusion
Avoid Hypothermia
Core body temperature <_____°C
Causes
Coagulopathy
Acidosis
Decreased cardiac output
Arrhythmias
35
To Extubate or Not
_______________ till the physiological parameters return
____________________– worse outcomes
———————- is strongly recommended
Elective ventilation
Premature extubation
Awake extubation
Transfer to the ICU
Usually transferred by bringing the ICU _______ – reduces the number of transfers
________ from ICU brought along with the trolley/cot
_______________ with ______ Circuit
Take care of _________ tubing and ___________
Handing over to the _________ - vital
trolley; Monitors
Oxygen cylinder; Bains
invasive; Urobags
intensivist
