Emergency Situations Management

Question 1

Acetaminophen overdose

Answer 1

1) Acetaminophen toxicity is due to centrilobular hepatic necrosis caused by N acetyl P benzoquinoneimine (napkey), which reacts with and destroys hepatocytes. Normally, this metabolite constitutes only 5% of acetaminophen metabolic products and is inactivated by conjugation with endogenous glutathione. In overdose, the supply of glutathione becomes depleted and NAPQI is not detoxified.
2) All patients who are possibly or probably at risk of hepatotoxicity and anyone for whom the time of ingestion is not known are treated with N acetylcysteine, which repletes glutathione, combines directly with N acetyl P benzoquinoneimine, and enhances sulfate conjugation of acetaminophen. Administration of N acetylcysteine is virtually 100% effective in preventing hepatotoxicity when administered within 8 hours of drug ingestion.

Question 2

Airway Fire

Answer 2

1) Stop lasering
2) Disconnect ETT or jet catheter from patient.
3) Remove tracheal tube
4) Stop the flow of all airway gases.
5) Remove sponges and any other flammable material from airway.
6) Flood area with normal saline.
7) Use a CO2 fire extinguisher if fire persists.
8) Re-establish ventilation.
9) Ventilate with air, lower oxygen levels, if clinically appropriate.
10) Re-examine airway to see if fragments may be left behind in airway, possibly using bronchoscopy.
11) Humidified gas
12) Steroids
13) Antibiotics, ICU, and possible tracheostomy

Question 3

Non-Airway OR Fire

Answer 3

1) Stop the flow of all airway gases.
2) Remove all drapes, flammable, and burning materials from the patient.
3) Extinguish all burning materials in, on, and around the patient, by saline, water, or smothering.
If the fire persists:
4) Use a carbon dioxide fire extinguisher in, on, or around the patient.
5) Activate the fire alarm.
6) Evacuate the patient, if feasible, following institutional protocols.
7) Close the door to the room to contain the fire and do not reopen it or attempt to reenter the room.
8) Turn off the medical gas supply to the room.
After the fire is put out:
9) Assess the patient’s status and devise a plan for ongoing care of the patient.
10) Assess for smoke inhalation injury if the patient was not intubated.

Question 4

Differential Diagnosis of Amniotic Fluid Embolus:

Answer 4

Answer: Amniotic fluid embolus diagnosis is one of exclusion.
Obstetric complications such as:
1)	Post partum auto transfusion
2)	Eclampsia
3)	Placental abruption
Non obstetrical complications such as:
4)	Pulmonary embolus
5)	Septic shock
6)	Anaphylaxis
7)	Transfusion reaction
8)	Peripartum cardiomyopathy.
9)	Myocardial infarction
Anesthetic complications such as:
10)	Local anesthetic toxicity
11)	Total spinal anesthesia

Question 5

Management of Amniotic Fluid Embolus:

Answer 5

1) Presents as respiratory failure with dyspnea, hypoxemia, hypotension and circulatory collapse.
2) 100% oxygen, intubate if necessary.
3) ACLS if necessary.
4) Large bore IVs, arterial line, central line.
5) Treat hypotension with crystalloids, blood and pressors.
6) Reduce afterload. Diuresis if needed.
7) Nitric oxide, inhaled prostacyclin if elevated pulmonary pressures from left heart failure.
8) Bloodwork: CBC, electrolytes, INR, PTT
9) Correct consumptive coagulopathy of DIC with blood products.

Question 6

Anaphylaxis Initial Therapy:

Answer 6

1) Differential diagnosis: Asthma, light anesthesia, carcinoid, hereditary angioedema.
2) Remove trigger
3) 100 % FIO2, call for help.
4) Discontinue all anesthetic agents.
5) Start intravascular volume expansion of 2 to 4 liters of crystalloid or colloid with hypotension. For pediatrics, fluid resuscitation of 20 milliliters per kilogram of fluids.
6) Epinephrine 5 to 10 micrograms IV bolus PRN for hypotension, or 0.1 to 1 milligram IV with cardiovascular collapse.

Question 7

Anaphylaxis Secondary treatment:

Answer 7

1) Antihistamines such as diphenhydramine 0.5 to 1 milligram per kilogram or cetirizine/ Benadryl 1 milligram per kilogram.
2) Norepinephrine or epinephrine infusion of 0.05 to 0.1 micrograms per kilogram per minute IV.
3) Bronchodilators: Salbutamol through ETT, then ketamine or magnesisum 1 to 2 milligrams if persistent.
4) Hydrocortisone 0.25 to 1 gram. Methylprednisolone 1 to 2 grams may be the drug of choice if the reaction is suspected to be mediated by complement.
5) Sodium bicarbonate of 0.5 to 1 milliequivalent per kilogram with persistent hypotension or acidosis.
6) Vasopressin for refractory shock.
7) Ranitidine 0.5 milligrams per kilogram, famotidine 20 milligrams IV, or cimetidine 300 mg IV/IM
8) Bloodwork – ABGs, tryptase between 30 minutes to 2 hours.

Question 8

Angioedema:

Answer 8

1) Episodic subcutaneous and submucosal edema formation, often involving the face, extremities, and gastrointestinal tract.
2) One type of angioedema is caused by release of mast cell mediators and is associated with urticaria, bronchospasm, flushing, and even hypotension.
3) Treatment includes that of anaphylactic guidelines, including early administration of epinephrine (0.5 milliliters increments of 1 in 1000 IM or 0.5 milliliter boluses of 1 in 10 000 IV) is essential, or nebulized epinephrine of 2 milligrams in 3 milliliters normal saline repeated PRN.
4) The other results from bradykinin release and does not cause allergic symptoms. The most common hereditary form of angioedema results from an autosomal dominant deficiency or dysfunction of C1 esterase inhibitor. An acquired form of this deficiency may also occur through autoimmune mechanisms.
5) For the second type, the preferred treatment for an acute episode is C1 inhibitor concentrate (25 units per kilogram) or fresh frozen plasma (2 to 4 units) to replace th1e deficient enzyme.
6) Should upper airway obstruction develop during acute attacks, tracheal intubation until the edema subsides may be lifesaving.
7) When laryngoscopy is undertaken, it is important to have difficult airway equipement, personnel and equipment available to perform tracheostomy if needed, but tracheostomy itself may be extremely difficult or impossible in the face of massive airway edema.
8) Position patient in comfortably upright. Avoid medications which will decrease respiratory drive and effort. Topicalize with lidocaine spray.
9) Choose the largest ETT possible, but be prepared to use smaller sizes.

Question 9

Aspirin Overdose:

Answer 9

1) Administration of activated charcoal.
2) Empirical administration of dextrose will help prevent low cerebrospinal fluid glucose concentrations.
3) Administration of sodium bicarbonate to increase arterial blood pH to 7.45 to 7.55 alkalinizes the urine, which dramatically increases renal clearance of salicylate.
4) Endotracheal intubation and mechanical ventilation, if undertaken, must be done very cautiously, because an abrupt decrease in salicylate-induced hyperventilation and hyperpnea may lead to life-threatening acidosis.
5) Hemodialysis is indicated for potentially lethal concentrations of salicylic acid (more than 100 milligrams per deciLiter) and for refractory acidosis, coma, seizures, volume overload, or renal failure.

Question 10

Bronchospasm:

Answer 10

1) Presents as hypoxia, high airway pressures, wheeze, decrease bag movement.
2) Risk factors of allergy, asthma, recent URTI, light anesthesia.
3) Differential diagnosis of circuit/ ETT obstruction, mainstem intubation, laryngospasm, pulmonary edema, pneumothorax, foreign object, anaphylaxis.
4) Increase FiO2 to 100 %
5) Deepen volatile agent.
6) Salbutamol
7) Hydrocortisone 4 milligrams per kilogram IV. 1 month to a year = 25 milligrams. 1 to 6 years = 50 milligrams. 6 to 12 years = 100 milligrams. 12 to 18 years = 100 to 500 milligrams.
8) Ketamine 2 milligrams per kilogram IV
9) Magnesium sulphate of 40 milligrams per kilogram IV to max of 2 grams.
10) If unresponsive to above, give epinephrine 10 micrograms per kilogram IM or infusion of 0.02 – 0.1 microgram per kilogram per minute.

Question 11

Carcinoid crisis:

Answer 11

1) Initial prophylactic steps to avoid release, such as anxiolytics for stress, octreotide one hundred and fifty to two hundred and fifty micrograms subQ every 6 to 8 hours.
2) Administer octreotide, a long acting somatostatin analogue.
3) Vasopressin as alternative if octreotide does not work
4) H 1, such as cetirizine or diphenhydramine and H2 blockers such as ranitidine, to block the effects of histamine.
5) Symptomatic therapy such as bronchodilators for wheezing.
6) H2 blockers, diphenhydramine and steroids to inhibit the action of bradykinin.
7) Cyproheptadine if any serotonin component.

Question 12

Carbon monoxide poisoning:

Answer 12

1) Measurement requires a CO-oximeter, which, by spectrophotometry, can detect and quantify all normal and abnormal hemoglobins.
2) Supplemental oxygen, and aggressive supportive care: airway management, blood pressure support, and cardiovascular stabilization.
3) Oxygen therapy shortens the elimination half-time of CO by competing at the binding sites on hemoglobin and improves tissue oxygenation.

Question 13

Croup:

Answer 13

1) Single dose dexamethasone 0.15 to 0.6 milligrams per kilogram PO or IM.
2) Or, nebulized budesonide 2 milligrams in 4 milliliters of water.
3) Severe croup should be treated with nebulized epinephrine 0.5 milliliters of 2.25% racemic epinephrine in 4.5 milliliters of normal saline. Or 0.5 milliliters of L epinephrine 1 to 1000 concentration diluted in 5 milliliters normal saline.
4) Observe patient for at least 2 to 4 hours after the last nebulized epinephrine treatment for possible return of obstructive symptoms.
5) If intubation is needed, children should be intubated with a smaller endotracheal tube that that predicted for their age.

Question 14

Delirium tremens:

Answer 14

1) Delirium tremens occurs 2 to 4 days after the cessation of alcohol ingestion and manifests as hallucinations, combativeness, hyperthermia, tachycardia, hypertension or hypotension, and grand mal seizures.
2) Administer diazepam (5 to 10 milligrams IV every 5 minutes) or another benzodiazepine until the patient becomes sedated but remains awake.
3) Administration of β-blockers such as propranolol and esmolol is useful to suppress manifestations of sympathetic hyperactivity. The goal of β-blocker therapy is to decrease the heart rate to less than 100 beats per minute.
4) Correct fluid, electrolyte (such as magnesium, potassium), and metabolic (thiamine) derangements.
5) Lidocaine is usually effective if dysrhythmias occur despite correction of electrolyte abnormalities.
6) Protect the airway with a cuffed endotracheal tube if necessary in some patients.

Question 15

Diabetes Insipidus (central):

Answer 15

1) Suspect if urine output is more than 100 mL/ h.
2) Order urine osmolarity (positive if less than 300 milliosmoles per liter) and serum osmolarity (positive if more than 150 milliequivalents per liter).
3) Differential diagnosis of DI includes: brain tumor, head trauma, neurosurgery, subarachnoid hemorrhage.
4) Estimate total body water deficit = 0.6 x body weight (in kilograms) x difference between patient sodium and normal sodium, which is divided by normal sodium of 140.
5) Replace water deficit over 24 to 48 hours, or 1 to 2 milliequivalents per liter per hour.
6) Hourly fluid maintenance plus two thirds of the previous hourly urine output.
7) Half normal saline and 5 percent dextrose in water are commonly used as replacement fluids due to hypo osmolar and low sodium fluid loss.
8) IV aqueous ADH of 100 to 200 milliunits per hours, with isotonic crystalloid solution.
9) If the hourly fluid requirement exceeds three hundred and fifty to four hundred milliliters, desmopressin is usually administered.
10) DDAVP subcutaneous 1 to 4 micrograms or 5 to 20 micrograms every 12 to 24 hours.
11) Measure sodium and plasma osmolality hourly until sodium is ____

Question 16

Diabetic ketoacidosis:

Answer 16

1) Normal saline intravenous fluid of 200 – 300 milliliters per hour.
2) IV loading dose of 0.1 milligrams per kilogram of regular insulin.
3) Low dose insulin infusion of 0.1 units per kilogram per hour.
4) Measure ABGs for bicarbonate, electrolytes for potassium, and glucose hourly.
5) Replace potassium, magnesium and phosphate as needed.
6) Goal is to normalize anion gap.
7) Give D5W in normal saline when glucose is around 14.
8) Stop insulin infusion when bicarbonate is 18.
9) Then place patient on sliding scale insulin with glucose check every 4 hours.
10) Stop dextrose infusion when patient is able to eat.

Question 17

HONK:

Answer 17

1) More fluid depletion than DKA. Need 1 to 1.5 liters per hour of hypotonic saline if osmolarity is over 320, before switching over to isotonic.
2) Glucose usually higher than DKA
3) Total potassium deficit, but increased extracellularly

Question 18

Epiglottitis:

Answer 18

1) avoid child distress
2) Rapid transit to OR.
3) Difficult airway cart, have surgeon in the room who is adept at rigid bronchoscopy and tracheostomy in the room.
4) Induce in preferred position.
5) Inhalational induction with spontaneous ventilation. Sevo and 100% oxygen, gentle CAP to overcome obstruction.
6) IV cannulation, intubation under deep INH GA.
7) if MH susceptible - IV propofol after some Nitrous oxide inhalation
8) Fluid resuscitation, blood culture and antibiotics.
9) No muscle relaxants until intubated.
10) Potential post op ventilation for 24 - 48 hours in ICU

Question 19

Foreign body:

Answer 19

1) Risk of airway obstruction, pneumothorax, infection if chronic.
2) NPO guidelines if stable. If hypoxic, distressed, partial obstruction will be full stomach.
3) Pre induction IV insertion.
4) Maintain spontaneous ventilation, avoid premedications.
5) Halothane, if available, is the gold standard. It is more potent and lasts longer.
6) Consider atropine 20 micrograms per kilogram for airway instrumentation with possible vagal response.
7) Lidocaine spray to avoid coughing and breath holding.
8) Discuss with surgeon whether they plan to use flexible Bronch, which they can do through ETT or LMA, or a rigid bronch, which oxygenation is through ventilation or jet vent.
9) Maintenance with inhalational agents and boluses of propofol.
10) Intubate after removal of foreign body with 0.5 size smaller ETT.
11) Give Dexamethasone, ranitidine, maxeran if full stomach. Also suction with NG if full stomach.
12) Send to ICU if significant swelling and edema, otherwise, extubate when patient is wide awake.

Question 20

Gas Embolism:

Answer 20

1) Administer 100% oxygen which may reduce bubble size by increasing the gradient for nitrogen to move out.
2) Stop surgery, stop nitrous oxide, compress bleeding points and flood wound to prevent further air or gas entry.
3) Promptly place patient in Trendelenburg (head down) position and rotate toward the left lateral decubitus position, or place operation site below the level of the heart. This maneuver helps trap air in the apex of the ventricle, prevents its ejection into the pulmonary arterial system, and maintains right ventricular output.
4) Maintain systemic arterial pressure with fluid resuscitation and vasopressors/beta-adrenergic agents if necessary.
5) Aspirate the CVP line if present. Do not delay resuscitation to put in a line if not already present.
6) Consider transfer to a hyperbaric chamber. Potential benefits of this therapy include compression of existing air bubbles and establishment of a high diffusion gradient to speed dissolution of existing bubbles.
7) Circulatory collapse should be addressed with CPR and consideration of more invasive procedures as described above.

Question 21

Traumatic brain injury:

Answer 21

Answer: Initial management includes the following 9 steps:

1) Establish ABC’s
2) Ventilate to maintain PACO2 between thirty to thirty five
3) Provide O2 to maintain PAO2 over seventy, or Oxygen saturations over ninety four percent.
4) Maintain normothermia.
5) Maintain head of bed elevated.
6) Ensure good head and neck alignment for appropriate cerebral venous drainage.
7) Use sedation such as barbiturates or propofol to decrease CMR and avoid strain.
8) Use paralysis.
9) A bolus of intravenous lidocaine, 1milligram per kilogram, may minimize increases in ICP associated with noxious airway stimulation (i.e., endotracheal suctioning)

Further management includes the following 7 steps:

1) Insert intraventricular catheter.
2) Maintain cerebral perfusion pressure over sixty.
3) Consider repeat of CT scan if ICP over twenty.
4) Mannitol of 0.25 to 1 gram per kilogram.
5) Hypertonic 3 % saline at 3 milliliters per kilogram.
6) Maintain serum osmolarity less than three hundred and twenty milli osmoles per liter and keep patient euvolemic.
7) Maintain serum sodium over one hundred and fifty.

If ICP continues to worsen, consider the following three steps:

1) decompressive craniectomy.
2) High dose barbiturate therapy.
3) Hyperventilation of PACO2 to less than thirty, and monitoring cerebral blood flow.

Question 22

Implanted Cardioverter Defibrillators:

Answer 22

1) Intraoperative dysrhythmias:
If the patient has a dysrhythmia, rule out and treat the usual intraoperative causes to prevent a recurrence.
If the dysrhythmia continues and a magnet has been used to create the no-response mode, remove the magnet from the ICD and allow the ICD to charge and deliver a response.
If the ICD has been programmed to the no-response mode, then either quickly reprogram the ICD to deliver a response or proceed directly to external defibrillation.
If external defibrillation or cardioversion is required, apply the defibrillator paddles in an anterior-posterior position, if possible, and deliver the shock at a level sufficient to terminate the dysrhythmia.
External pacing might be required if the pacemaker/ICD is damaged with the shock.
2) Monitor the patient’s ECG and be prepared to deliver an external defibrillation when transporting the patient to and from the operating room.
3) Interrogate and reprogram the ICD when the patient has entered the postoperative care unit.

Question 23

Interventional Radiology Hemorrhage:

Answer 23

Haemorrhage is often accompanied by an abrupt rise in mean arterial pressure.
Lower systemic arterial pressure.
Reverse heparin with 1 mg protamine for each 100 units of heparin given
PACO2 should be maintained between 35 and 40 millimeters mercury and mannitol of 0.25 to 0.5 grams per kilogram may be given to reduce cerebral oedema.
Emergency craniotomy and clipping of aneurysm may be required if coiling fails.
Patients may develop acute hydrocephalus secondary to new SAH necessitating transfer to theatre, for ventricular drainage.

Question 24

Interventional Radiology Occlusive Complication:

Answer 24

In the event of occlusion, the arterial pressure should be raised to increase collateral blood flow and maintain normocarbia.
Angiographically visible thrombus may be treated by mechanical lysis using a guide wire or local infusion of saline.
Thrombolytic agents are commonly used to treat intraprocedural thrombosis, but results have been mixed.
The use of local intra-arterial tissue plasminogen activator has shown to achieve recanalization rate of 44%. Antiplatelet agents, such as abciximab, a GP2B or 3A inhibitor (IV and intra-arterial), have also shown promising results.

Question 25

IV alternatives for induction:

Answer 25

1) PO midazolam of 0.5 milligrams per kilogram in children, 15 – 20 milligrams in adults, ametop and IV, parental presence and administration.
2) Nitrous oxide for IV insertion.
3) Sevoflurane induction for IV insertion.
4) IM ketamine of 5 – 10 milligrams per kilogram for induction dose, or sedation dose of 2 milligrams per kilogram.
5) Intraosseus route.

Question 26

Laryngospasm:

Answer 26

Risk factors include secondhand smoke, atopy, young age, airway surgery, URTI, and light anesthesia.
1) CPAP
2) 100% fiO2
3) Jaw thrust
4) Assess airway movement of chest
5) Suction airway
6) Give volatile or propofol 2 milligram per kilogram
7) Succinylcholine of 3 – 4 milligrams per kilogram IM
8) Atropine 20 micrograms per kilogram IM
Manually ventilate

Question 27

Local Anesthetic Toxicity Seizure Differential:

Answer 27

1) Intracranial pathology
2) Hypoglycemia
3) Hyponatremia
4) Hypocalcemia
5) Hypomagnesemia
6) Eclampsia
7) Epilepsy

Question 28

Local Anesthetic Toxicity Management:

Answer 28

1) Get help, give 100% oxygen, monitors, IV.
2) Midazolam 2 milligrams IV
3) Propofol if cardiac stability is intact.
4) Epinephrine of less than 1 microgram per kilogram.
5) Intralipid 20% 1.5 milliliter per kilogram bolus LBW over one minute, followed by infusion rate of 0.25 milliliters per kilogram per minute. Maximum of 10 milliliters per kilogram in first 30 minutes. Infusion rate can be doubled to 0.5 milliliters per kilogram per minute if blood pressure remains low.
6) Continue infusion for at least 10 minutes after attaining circulatory stability.
7) Prolonged monitoring of more than 12 hours is recommended after any signs of systemic local anesthetic toxicity, since cardiovascular depression due to local anesthetics can persist or recur after treatment.

Question 29

Malignant hyperthermia prophylaxis:

Answer 29

1) If available, use a dedicated vapor free machine for MH susceptible patients. The machine must be regularly maintained and safety checked.
2) If available, sue an ICU ventilator that has never been exposed to volatile anesthetic agents.
3) Change disposable, plastic circuit, breathing bag, CO2 absorber
4) Remove volatile cartridges and tape X across the entrance.
5) Flow 10 liters per minutes of oxygen through circuit for 20 minutes. Some newer machines may need up to 60 minutes.
6) Adding commercially available charcoal filters to the circuit will remove trace levels of volatile anesthetic agents within 10 minutes of application, without the above preparation. However, the filters should be replaced every hour.

Question 30

Malignant hyperthermia reaction

Answer 30

1) Notify the OR team and ask for help outside the room.
2) Hyperventilate with 100% oxygen at flows of 10 liters per minute or more.
3) Halt the procedure as soon as possible. If emergent, continue with non triggering anesthetic technique.
4) Don’t waste time changing the circle system and CO2 absorbant.
5) Ask helpers to dissolve the 20 milligrams in each vial with at least 60 milliliters of sterile preservative free water. Each 20 milligram bottle also has 3 grams of mannitol for isotonicity. The PH of the solution is 9.
6) Give Dantrolene 2.5 milligrams per kilogram, or 1 milligram per pound, rapidly through a large bore IV, if possible.
7) Repeat until signs of MH are versed. Sometimes more than 10 milligrams per kilogram is necessary.
8) Draw electrolytes, blood gases and CK.
9) Place foley catheter and give diuresis to titrate urine output to more than 1 milligram per kilogram per hour, along with bicarbonate to prevent myoglobinuria induced renal failure.
10) Give 1 to 2 milliequivalents per kilogram of bicarbonate for metabolic acidosis if blood gas values are not yet available.
11) Cool the patient with core temperature of more than thirty nine degrees Celsius. Lavage open body cavities, stomach, bladder, or rectum. Apply ice to surface. Infuse cold saline intravenously. Stop cooling if temperature is less than thirty eight degrees.
12) Treat hyperkalemia with the following:
(a) bicarbonate of 1 to 2 milli equivalents per kilogram IV.
(b) For pediatric patients, 0.1 units of insulin per kilogram with 1 milliliters per kilogram of D fifty. For adults, 10 units of regular insulin IV with 50 milliliters of D fifty. Check glucose levels hourly.
(c) Calcium chloride of 10 milligrams per kilogram or calcium gluconate of 10 to 50 milligrams per kilogram for life threatening hyperkalemia.
(d) Hyperventilation.

Question 31

Masseter Muscle Spasm:

Answer 31

1) Jaw muscle rigidity in association with limb muscle flaccidity after the administration of succinylcholine.
2) Trismus is generally defined as masseter spasm that still permits enough mouth opening for intubation and masseter muscle rigidity is defined as masseter spasm that completely prevents mouth opening. In more than 80% of patients with trismus but no rigidity of other muscles, it is a variant found in normal patients.
3) Look for rigidity in other muscles. Masseter spasm in children is associated with a 50% chance of MH susceptibility and a 30% chance of an actual MH episode.
4) If trismus occurs, and is also an isolated finding, elective surgery may continue. Proper monitoring should include end-expired CO2, examination for pigmenturia, and arterial or venous blood sampling for CK, acid-base status, and electrolyte levels, particularly potassium.
5) The child should receive ample intravenous hydration to maintain a urine output of at least 2 to 3 mL/kg/hr because myoglobinuria may occur.
6) Significant serum CK elevations can be seen in isolated masseter spasm; thus, the patient must be monitored postoperatively for resolution.
7) If the jaw is moderately tight and distinctly a problem, there are two choices: halt the procedure or continue with nontriggering agents. Any suggestion of MH should prompt MH therapy, including administration of dantrolene.

Question 32

Methyl alcohol ingestion:

Answer 32

1) Methanol is a weak toxin, but it has very toxic metabolites. It is metabolized by alcohol dehydrogenase to formaldehyde and formic acid, which results in an anion gap metabolic acidosis.
2) Blurred vision, optic disk hyperemia, and blindness are hallmarks of methanol intoxication.
3) Severe abdominal pain that mimics a surgical emergency may also occur.
4) Treatment of methyl alcohol poisoning includes providing supportive care and ensuring a secure airway.
5) Intravenous administration of ethyl alcohol, which is preferentially metabolized by the enzyme alcohol dehydrogenase, will decrease the metabolism of methanol.
6) Alternatively, the activity of alcohol dehydrogenase may be competitively inhibited by administration of fomepizole.

Question 33

Myxedema Coma:

Answer 33

1) Tracheal intubation and controlled ventilation as needed.
2) Levothyroxine 200 to 300 micrograms IV over 5 to 10 minutes, then 100 micrograms IV every 24 hours.
3) Hydrocortisone 100 milligrams IV, then 25 milligrams IV every 6 hours.
4) Fluid and electrolyte therapy as indicated. Usually patients are hyponatremic and hypoglycemic.
5) Cover to conserve body heat, no warming blankets.

Question 34

Neuroleptic Malignant Syndrome:

Answer 34

1) Immediate cessation of antipsychotic drug therapy.
2) Cooling patient with cooling blanket or ice.
3) Oxygen supplementation, intubate and ventilate if necessary.
4) IV fluids to support urine output.
5) Electrolytes for hyperkalemia, ABG’s for metabolic acidosis, lactate and CK.
6) Bromocriptine 5 milligrams PO every 6 hours or dantrolene 6 milligrams per kilogram daily as a continuous infusion may decrease skeletal muscle rigidity.
7) Mortality rates reach 20 percent in untreated patients, from cardiac dysrhythmias, congestive heart failure, hypoventilation or renal failure.

Question 35

Neuromonitoring Abnormality:

Answer 35

1) Ensure that oxygen delivery and spinal cord perfusion are adequate.
2) Hypovolemia and anemia should be corrected.
3) Arterial oxygen tension should be optimized, and arterial PCO2 should be normalized if the patient is being hyperventilated. It has been reported that normalizing arterial pressure if deliberate hypotension is being used or raising arterial pressure above normal may improve spinal cord perfusion and restore SSEPs to normal.
4) The surgeon should seek a surgical cause such as too much distraction or surgical trespass with instrumentation and correct the problem as quickly as possible.
5) If the abnormality persists despite corrective action, a wake-up test should be performed to determine if the instrumentation should be adjusted or removed.

Question 36

Obstetrical ACLS:

Answer 36

1) Start CPR higher up in sternum.
2) Manually displace gravid uterus to the left to avoid aortocaval compression.
3) Give calcium if suspect magnesium toxicity.
4) C-section for CPR over 5 minutes.

Question 37

Question: You are in an emergency situation where there are sudden high airway pressures during one lung ventilation. How would you proceed?

Answer 37

This is an urgent situation. I would inform the surgeon immediately of this change, and simultaneously diagnose and treat.

My top differential includes light anesthetics, bronchospasm, occlusion of the endotracheal tube or circuit, endobronchial intubation. I would also keep the serious differentials of aspiration, anaphylaxis, pneumothorax, pulmonary embolism, pulmonary edema, and pneumoperitonium in mind.

I would ensure that the FIO 2 is at 100 percent. I would quickly check that delivered tidal volume is appropriately at 7 to 8 milliliters per kilogram, and for vital signs of heart rate, blood pressure for adequate cardiac output. I would also ensure adequate end tidal CO2 on monitor.

I would ensure there is no visible kink to the outer circuit of the machine, and to the endotracheal tube. I would use fiber optic bronchoscopy to view placement of the double lumen tube, that it is not esophageal or endobronchial, and rule out cuff herniation, suction mucous, blood obstruction, and foreign body object such as teeth. If on one lung, I would ensure the clamp is applied to the appropriate limb of the Y connector. I would then auscultate the lungs for crackles, wheezes and absent breath sounds. I would listen for muffled heart sounds, and look for elevated JVP.

I would manually ventilate the patient to further assess compliance and to rule out ventilator malfunction or obstruction, and to exclude dynamic hyperinflation with a rush of air escaping. I would treat bronchospasm, if present, with ventolin. I would change to PCV to decrease high peak airway pressures.

If this problem persists, I would discuss two lung ventilation with the surgeon, and obtain an urgent chest x ray.

Question 38

Emergency: Porphyria Crisis

Answer 38

1) Remove any known triggering factors.
2) Adequate hydration and carbohydrate loading IV or PO.
3) Sedation such as phenothiazine
4) Opioids for pain.
5) Antiemetics for nausea and vomiting
6) Beta blockers for tachycardia and hypertension. Avoid nifedipine which could worsen crisis.
7) Propofol or benzodiazepine for seizures. Avoid anticonvulsants which could worsen crisis.
8) Treat electrolyte disturbances aggressively.
9) Heme administration if above fails.
10) Somatostatin or plasmapheresis to decrease ALA synthetase formation.

Question 39

Question: Describe the management steps for treatment of pulmonary artery rupture.

Answer 39

1) Ensure adequate oxygenation and ventilation, which may require endobronchial intubation with either a single- or double-lumen endotracheal tube to selectively ventilate and protect the unaffected lung.
2) Positive end-expiratory pressure applied to the affected lung may help control hemorrhage.
3) Any anticoagulation should be reversed unless the patient must remain on cardiopulmonary bypass and bronchoscopy is performed to localize and control the site of bleeding.
4) A bronchial blocker may be guided into the involved bronchus to tamponade the bleeding and prevent contamination of the uninvolved lung.
5) Some experts recommend removing the catheter, but others suggest leaving the PAC in place to monitor pulmonary artery pressures and guide antihypertensive therapy targeted at lowering this pressure and reducing bleeding. Others have suggested that the PAC balloon may be carefully reinflated and the catheter floated into the involved pulmonary artery to occlude the bleeding arterial segment as a temporizing measure. Although these techniques may be effective, many patients will require definitive surgical therapy.

Question 40

Seizures:

Answer 40

1) Place patient in semiprone position to decrease risk of aspiration if not intubated.
2) Oral airway or if prolonged, endotracheal intubation.
3) IV access.
4) Stat labs including glucose, sodium, calcium, magnesium, potassium.
5) Thiamine 100 milligrams
6) Dextrose
7) Midazolam 2 milligrams repeat if needed.
8) Phenytoin 20 milligrams per kilogram at 50 milligrams per minute.
9) General anesthesia with propofol or volatiles.

If patient has no IV access:

1) IM midazolam of 0.1 to 0.3 milligrams per kilogram q 15 minutes for children, or 5 – 10 milligrams adult.
2) Rectal diazepam of 0.2 to 0.5 milligrams per kilogram in pediatrics or 10 to 20 milligrams PR adult.
3) Buccal midazolam of 10 milligrams.
4) IM phenytoin of 20 milligrams per kilogram, gluteal region.

Question 41

List 10 differentials for stridor:

Answer 41

1) laryngospasm
2) post extubation croup
3) residual crurarization
4) Edema
5) vocal cord trauma
6) Foreign body
7) Anaphylaxis
8) negative presssure edema
9) hypocalcemia (after thyroidectomy) - muscle spasm
10) tracheomalacia after tracheal mass removal surgery

Question 42

Serotonin syndrome:

Answer 42

To fill in

Question 43

Stridor:

Answer 43

To fill in

Question 44

List the emergency management steps for stridor.

Answer 44

1) Inspiratory – AT or ABOVE larynx – croup, laryngomalacia.
2) Expiratory – LOWer trachea/bronchi – asthma, bronchiolitis.
3) Biphasic – MID tracheal – vascular ring, foreign body.
4) Sit patient upright and administered humidified oxygen.
5) Nebulized racemic epinephrine (0–20 kg: 0.25 mL in 2 mL NS, 20–40 kg: 0.50 mL in 2 mL NS, more than 40 kg: 0.75 mL in 2 mL NS). Effect lasts 2 – 3 hours. An equal volume of 1% L-epinephrine (1 to 100) is approximately equivalent in biologic activity to 2.25% racemic epinephrine. Alternatively, 5 mL of 1:1,000 L-epinephrine is equivalent to 0.5 mL of 1:100.
6) Can give dexamethasone up to 0.6 milligrams per kilogram (max 20 mg total). Give dexamethasone q 6 h for 24 hours. It has a slower onset of action of 4 to 6 hours to achieve the maximum effect.
7) Heliox.
8) Observe patient for up to 4 hours after the last nebulized epinephrine treatment in case rebound obstructive symptoms occur. Racemic epinephrine peak effect is 30 minutes to 2 hours. Cardiac monitors are recommended for 2 hours after racemic epinephrine administration. Resolution of symptoms usually occurs within 24 hours.

Question 45

What is the management for thyroid storm?

Answer 45

1) General Supportive measures such as:
a) Oxygen
b) Cooling blanket and ice
c) Intravenous hydration
d) Acetaminophen
e) Glucose and electrolyte replacement
f) Glucocorticoids: dexamethasone (two to four milligrams I V q 8 h) or hydrocortisone (fifty to one hundred milligrams I V q 8 h)
2) Reduce of synthesis thyroid hormones and peripheral conversion of T 4 to T 3
a) Antithyroid medications such as propylthiouracil 200-400 milligrams orally q 6 hours) or methimazole (20-25 milligrams orally q 6 h)
b) Iodine: sodium iodide 250 milligrams P O or I V q 6 h
3) Decrease metabolic effects of thyroid hormones
a) Beta adrenergic receptor blocking agent such as propranolol 10 to 40 milligrams P O or esmolol infusion
4) Other therapeutic maneuvers include plasma exchange or Dantrolene

Question 46

Post Tonsillectomy bleed:

Answer 46

1) Patient will have aspiration risk, hypovolemia and difficult laryngoscopy due to bleed.
2) Resuscitate with crystalloids, obtain CBC, ABGs, coags, type and cross blood to send to OR.
3) Double suctions ready. Anesthetic induction RSI with smaller sized ETT. NG tube to decompress stomach.
4) Stepdown bed, do not extubate until patient is awake.
5) If throat pack left in for bleed, take child to ICU due to risk of obstruction of airway.

Question 47

Post Operative Visual Loss Differential Diagnosis:

Answer 47

1) acute angle glaucoma
2) hemorrhagic retinopathy
3) retinal ischemia
4) retinal artery occlusion
5) anterior and posterior ischemic optic neuropathy
6) cortical blindness
7) conversion disorder
8) glycine toxicity

Question 48

Post operative eye pain Differential Diagnosis:

Answer 48

1) corneal abrasion most common.
2) Exposure keratitis (eyes open during surgery)
3) chemical keratitis (proviodine only for eye surgery to avoid alcohol irritation)
4) acute angle glaucoma
5) retinal ischemia.

Question 49

Assess and Manage a patient with postoperative eye pain:

Answer 49

1) Full visual exam.
2) Get history of onset of eye pain.
3) Previous history of ocular issues.
4) Get anesthetic history and notes.
5) Examine eye – redness, swelling.
6) Call ophtho after documentation.

Question 50

TCA overdose:

Answer 50

1) Tracheal intubation and mechanical ventilation if depressed ventilation or coma.
2) Serum alkalinization in order to increase protein binding less free drug and thereby less toxicity.
3) Intravenous administration of sodium bicarbonate or hyperventilation to a pH between 7.45 and 7.55 should be performed to a clinical end point such as narrowing of the QRS complex or cessation of dysrhythmias.
4) If polymorphic ventricular tachycardia (torsade de pointes) is present, magnesium should be administered.
5) Patients who remain hypotensive after volume expansion and alkalinization may benefit from vasopressor or inotropic support.
6) Diazepam is useful for seizure control.
Note: Hemodialysis and hemoperfusion are ineffective in removing cyclic antidepressants because of the high lipid solubility and high degree of protein binding of these drugs.

Question 51

TURP syndrome

Answer 51

1) Ensure oxygenation and circulatory support
2) Notify surgeon and terminate procedure as soon as possible
3) Consider insertion of invasive monitors if cardiovascular instability occurs
4) Send blood to laboratory for evaluation of electrolytes, creatinine, glucose, and arterial blood gases.
5) Obtain 12 lead electrocardiogram
6) Treat mild symptoms, with serum sodium of more than 120 milli equivalents per liter with fluid restriction and loop diuretic such as furosemide.
7) Treat severe symptoms, if serum sodium of less than 120 milli equivalents per liter with 3% sodium chloride I V at a rate of less than 100 milliliters per hour.
8) Discontinue 3% sodium chloride when serum sodium is more than 120 milli equivalents per liter.