Emergency drills

Question 1

First part of key basic plan?

Steps (4)

Answer 1

Adequate oxygen delivery

1. Pause surgery if possible.
2. Check fresh gas flow for circuit in use AND check measured FiO2 (?increase flow rate/FiO2)
3. Visual inspection of entire breathing system including valves and connections.
4. Rapidly confirm reservoir bag moving OR ventilator bellows moving.

Question 2

Key basic plan - Airway

Steps (4)​

Answer 2

1. Check position of airway device and listen for noise (including larynx and stomach).
2. Check capnogram shape compatible with patent airway.
3. Confirm airway device is patent (consider passing suction catheter).
4. Consider whether you need to isolate equipment (Ventilate lungs using self-inflating bag connected DIRECTLY to tracheal tube connector)

Question 3

Key basic plan - Breathing

Steps (2)

Answer 3

1. Check chest symmetry, rate, breath sounds, SpO2, measured VTexp, EtCO2.
2. Feel the airway pressure using reservoir bag and APL valve <3 breaths.

Question 4

Key basic plan - Circulation

Step

Answer 4

1. Check rate, rhythm, perfusion, re-check BP.

Question 5

Key basic plan - Depth

Step

Answer 5

1. Ensure appropriate depth of anaesthesia, analgesia and neuromuscular blockade.

Question 6

Key basic plan - Final steps

2 steps

Answer 6

1. Consider surgical problem.
2. Call for help if problem not resolving quickly.

Question 7

Cardiac Arrest - Immediate actions

Steps (5)

Answer 7

1. Declare “cardiac arrest” to the theatre team AND note time.
2. Delegate one person (minimum) to chest compressions 100 min-1 , depth 5 cm.
3. Call for help: nearby theatres / emergency bell / senior on-call / dial emergency number.
4. Call for cardiac arrest trolley.
5. As soon as possible, delegate task of evaluating potential causes

Question 8

Cardiac arrest - Adequate oxygen delivery

4 steps

Answer 8

1. Increase fresh gas flow, give 100% oxygen AND check measured Fi O2.
2. Turn off anaesthetic (inhalational or intravenous).
3. Check breathing system valves working and system connections intact.
4. Rapidly confirm ventilator bellows moving or provide manual ventilation.

Question 9

Cardiac arrest - Airway

3 steps

Answer 9

1. Check position of airway device and listen for noise (including larynx and stomach).
2. Confirm airway device is patent (consider passing suction catheter).
3. If expired CO2 is absent, presume oesophageal intubation until absolutely excluded.

Question 10

Cardiac arrest - Breathing

Two steps

Answer 10

Check chest symmetry, rate, breath sounds, SpO2, measured expired volume, ETCO2. • Evaluate the airway pressure using reservoir bag and APL valve.

Question 11

Cardiac arrest - Circulation

Answer 11

1. • Check rate and adequacy of chest compressions (visual and ETCO2).
2. Encourage rotation of personnel performing compressions.
3. If i.v. access fails or impossible use intraosseous (IO) route.
4. Check ECG rhythm for no more than 5 seconds.
5. Follow Resuscitation Council (UK) and ERC Guidelines.

Question 12

4 Hs, 4 Ts?

Answer 12

4 H’s, 4 T’s

Hypoxia, Hypovolaemia, Hypo/hyperkalaemia, Hypothermia

Tamponade, Thrombosis, Toxins, Tension pneumothorax

Question 13

Specific intraoperative causes of cardiac arrest (7)

Answer 13

1. Vagal tone
2. Drug error
3. Local anaesthetic toxicity
4. Acidosis
5. Anaphylaxis
6. Embolism (gas/fat/amniotic)
7. Massive blood loss

Question 14

Drug doses for peri-operative cardiac arrest

• Adrenaline
• Atropine
• Amiodarone
• Magnesium
• Calcium chloride

Answer 14

Adrenaline 10 µg .kg-1 (adult 1000 µg – may be given in increments).

Atropine 10 µg.kg-1 (adult 0.5-1 mg) if vagal tone likely cause.

Amiodarone 5 mg.kg-1 (adult 300 mg) after 3rd shock.

Magnesium 50 mg.kg-1 (adult 2 g) for polymorphic VT/hypomagnesaemia.

Calcium chloride 10% 0.2 ml.kg-1 (adult 10 ml) for magnesium overdose, hypocalcaemia or hyperkalaemia.

Question 15

Defibrillation in perioperative cardiac arrest - how many joules?

Answer 15

Continue compressions while charging: Biphasic 4 J.kg-1 (adult 150-200 J)

Question 16

Hypoxia - Adequate oxygen delivery (5)

Answer 16

1. Pause surgery if possible.
2. Increase fresh gas flow AND give 100% oxygen AND check measured Fi O2.
3. Visual inspection of entire breathing system including valves and connections.
4. Rapidly confirm reservoir bag moving OR ventilator bellows moving.
5. If SpO2 low, is it accurate? Consider whether poor perfusion could be the problem.

Question 17

Hypoxia - Airway (5)

Answer 17

1. Check position of airway device and listen for noise (including over larynx and stomach).
2. Check capnogram shape compatible with patent airway.
3. Confirm airway device is patent (consider passing suction catheter).
4. Isolate patient from anaesthetic machine and breathing system.
5. Once machine/breathing system problem excluded, consider whether airway device should be replaced or its type changed.

Question 18

Hypoxia - Breathing

Answer 18

1. Check chest symmetry, rate, breath sounds, SpO2, measured VTexp, ETCO2.
2. Feel the airway pressure using reservoir bag and APL valve <3 breaths.
3. Consider potential causes and actions.
4. Consider muscle relaxation to optimise ventilation

Question 19

Potential intraoperative causes of hypoxia (9)

Answer 19

1. Laryngospasm and stridor
2. Bronchospasm
3. Anaphylaxis
4. Circulatory embolism
5. Cardiac ischaemia (or infarction)
6. Cardiac tamponade
7. Sepsis
8. Malignant hyperthermia crisis
9. Aspiration, pulmonary oedema, congenital heart disease

Question 20

Hypoxia - Circulation (2)

Answer 20

Check heart rate, rhythm, perfusion, recheck blood pressure.

If circulation unstable, consider if this is secondary to hypoxia.

Question 21

Increased airway pressure - Adequate oxygen delivery (6)

Answer 21

1. Pause surgery if possible.
2. Consider surgery related cause.
3. Increase fresh gas flow AND give 100% oxygen AND check measured Fi O2.
4. Visual inspection of entire breathing system including valves and connections.
5. Rapidly confirm reservoir bag moving OR ventilator bellows moving.
6. Confirm increased airway pressure by switching to hand ventilation (<3 breaths)

Question 22

Increased airway pressure - Airway(5)

Answer 22

1. Check position of airway device and listen for noise (including larynx and stomach).
2. Check capnogram shape compatible with patent airway.
3. Confirm airway device is patent (consider passing suction catheter).
4. Isolate patient from anaesthetic machine and breathing system (Box C).
5. If machine/breathing system problem excluded, consider whether airway device should be replaced or its type changed.

Question 23

Increased airway pressure - Breathing (3)

Answer 23

1. Check chest symmetry, rate, breath sounds, SpO2, measured VTexp, ETCO2.
2. Feel the airway pressure using reservoir bag and APL valve.
3. Consider potential causes and actions

Question 24

Potential causes of increased airway pressure (7)

Answer 24

1. Inadequate neuromuscular blockade.
2. If laparoscopic surgery, consider releasing pneumoperitoneum and levelling patient position.
3. Laryngospasm and stridor
4. Bronchospasm
5. Anaphylaxis
6. Circulatory embolus
7. Aspiration, pulmonary oedema; bronchial intubation; foreign body; pneumothorax.

Consider potential actions: tracheal/bronchial suction; bronchodilator; PEEP; diuretic; bronchoscopy