Emergent Situations

Question 1

How to treat Bronchospasm?
How to recognize:

Answer 1

Check the Circuit for Disconnection:**
- Inspect all components of the breathing circuit for loose connections, kinks, or dislodged tubing. Start at the patient’s airway (ETT placement and cuff) and systematically follow the circuit back to the ventilator.
- Characteristic shark-fin waveform on the capnography monitor may indicate airway obstruction or bronchospasm. Auscultate wheezing

** 100% fiO@ and increase the flows to 10-15L.. ( 1L of 100% fiO2 is not = to 100% O2)
Administer Bronchodilators:
Albuterol (Beta-2 Agonist):
Administer 8-10 puffs via a metered-dose inhaler (MDI) through the ETT. Connect the MDI to the circuit and deliver the puffs while ventilating.
**REASSESS AND RE-ADMINISTER IF NEEDED Q3 MIN
Beta-2 agonists act by relaxing bronchial smooth muscle, relieving bronchospasm.
Epinephrine 10-50 mcg IV or 10mcg/kg subcutaneously
-also Terbutaline if severe (adult): 5-10mcg/kg IV q15 (max 250mcg).

Adjust Ventilation Settings: OR MANUALLY VENT IS BETTER- prevent air trapping
Decrease Respiratory Rate (RR): To prevent air trapping and allow for adequate expiration.

Increase the Expiratory Time (I:E Ratio): Ensure a longer expiratory phase to minimize dynamic hyperinflation.

Deepen Anesthesia:
Volatile Agents:
Sevoflurane is the preferred volatile anesthetic for asthma patients due to its bronchodilatory properties and minimal airway irritation.

Additional Medications:
Administer Propofol or Ketamine:
Propofol: Sedative-hypnotic that can reduce bronchial tone indirectly. 0.5–1 mg/kg IV.
Ketamine: 0.5-1 mg/kg IV for bronchodilation via NMDA receptor antagonism.

Anti-inflammatory Agents:
Dexamethasone (4-8 mg IV): Reduces inflammation and stabilizes the airway, although effects may take several hours.- give pre-op to asthma patients
Hydrocortisone (100 mg IV): Another option for reducing airway inflammation. – same give pre-op to asthma patents.

Other Supportive Measures:
Manual ventilation if auto-PEEP (positive end-expiratory pressure) is suspected to avoid barotrauma.
Magnesium @ 2gm IV over 20 min (works w/ asthma as well -prob just add it if patient has asthma).

Question 2

HyperKalemia Tx:
how to recognize:

Answer 2

Calcium: 0.5-1g CaCl (give first)
Bicarbonate: 25-50mEq
Insulin Regular: 5- 10 units
Glucose (D50): 25- 50gm
Kayexalate: 15-50g PO (probably won’t be able)
Albuterol: 10 puff or neb
Furosemide: 40-80mg IV

Tall peaked T- waves, hypotension (decreased CO)

Question 3

DKA management
How to recognize:

Answer 3

Bolus 10 units
Start IV insulin drip @ Initial Rate: 0.1 units/kg/hr (6.8 units/hr for 68 kg).

keep running IV until anion gap closed < 12 if BS < 200 and anion gap is still above 12 then start D5w & 1/2 NS and keep the insulin infusion running. Switch to subq insulin when anion gap has closed.

Make sure patient is not borderline hypokalemic before starting insulin (rare but important). If so , replace K+ first.

regonition: Kussmal’s Breathing, acidotic, BS > 400

Question 4

Ischemic Event
How to recognize:
Tx:

Answer 4

Recognition:
o Monitor ECG for signs of myocardial ischemia:
 ST depression and/or T-wave inversion
 Hypotension and tachycardia (or inappropriate bradycardia in some cases).
GET A 12 LEAD!!!

Management:
o Restore Coronary Perfusion Pressure (CPP):
 Begin with Phenylephrine drip:
 Start at 10 mcg/min and titrate up to 200 mcg/min to increase BP and improve coronary perfusion.
o Control Heart Rate:
 Administer Esmolol for HR control:
 Give a 10 mg IV bolus.
 Start Esmolol drip at 50 mcg/kg/min, titrate to a maximum of 250 mcg/kg/min as needed to achieve optimal HR (typically < 80 bpm).
o Improve Coronary Flow:
 Initiate Nitroglycerin drip to dilate coronary arteries:
 Start at 0.2 mcg/kg/min and titrate every 3 minutes by increments of 0.1.. so rang is 0.2-1.5 mcg/kg/min, or 10-200mcg/min can give a bolus of 10-50 mcg while starting drip. (note nitroprusside is the same dosing but has slightly longer effect).
Additional Supportive Measures:
o Increase FiO₂ to 100% and increase flows to 10L to optimize oxygen delivery.
o Ensure adequate volume status:
 Administer balanced salt solution or colloids as needed for preload optimization.
o Consider reducing volatile anesthetic depth if hypotension persists.
Monitor:
o Continuously monitor ECG for resolution of ischemic changes.
o Assess BP, HR, and rhythm frequently after adjustments to therapy.

Question 5

Venous Air Emboli
How to recognize:
Tx:
What cases are most common:

Answer 5

most common: Neruo where lesion is above heart.

Venous Air Embolism (VAE):
o Signs: Sudden hypotension, decreased EtCO₂, or mill-wheel murmur on precordial Doppler .
o Management:
 Notify surgeon to flood the surgical field.
 Place patient in left lateral decubitus and Trendelenburg position.
 Aspirate air through central venous catheter if in place.
 100% O2
 Start Inotrope support and fluid bolus. (patient may have distended jugular veins, sign of Right heart not pumping).
 Administer epinephrine (100- 300 mcg IV) for cardiovascular collapse. or Epi drip @ 0.02-0.3mcg/kg/min or
Use Dobutamine 2-20 mcg/kg/min as it has less decrease on SVR than Milrinone).

Question 6

Pulmonary Hypertension Crises
How to recognize:
Tx:

Answer 6

Recognition: Hemodynamic Indicators:

Increased Pulmonary Artery Pressure (PAP): Elevated readings from a pulmonary artery catheter. (normal is 25/10)

Systemic Hypotension: Due to RV failure reducing cardiac output.
Increased Central Venous Pressure (CVP - 2-6): Reflecting RV overload.
Decreased Cardiac Output (CO- 4-8L/min norm) or Index (CI- 2.5-4L norm): Measured via PAC or other hemodynamic monitors.
Right Ventricular Dysfunction:

Tachycardia: Attempt to compensate for decreased cardiac output.
Jugular Venous Distension (JVD): From RV overload.

RV strain on ECG: Right axis deviation, peaked P waves, or RBBB.
Respiratory Changes:

Hypoxemia: Worsening oxygen saturation despite adequate ventilation.

Increased Peak Airway Pressures: Secondary to pulmonary vasoconstriction (HPV) and reduced lung compliance.
Clinical Signs:

Cyanosis, cool extremities, and signs of poor perfusion.
Sudden onset of dyspnea or desaturation.

TX:
Immediate Interventions
Oxygenation:
Administer 100% FiO₂ to optimize oxygen delivery and reduce hypoxic vasoconstriction.
Optimize Ventilation:
Maintain normocapnia or mild hypocapnia (PaCO₂: 35-40 mmHg) to avoid acidosis-induced vasoconstriction.
Avoid high PEEP as it can impair venous return to the RV.

Pulmonary Vasodilators
Inhaled Nitric Oxide (iNO):

Dose: Start at 20 ppm (10-40 ppm), titrate based on PAP and systemic BP response.
Rationale: Selective pulmonary vasodilation reduces RV afterload without systemic hypotension.
Intravenous Prostacyclin (Epoprostenol):

Dose: Start at 2-4 ng/kg/min, titrate up to 20-40 ng/kg/min based on response.
Rationale: Reduces PVR and has anti-platelet effects to reduce microvascular thrombosis.

Sildenafil or Tadalafil:

Consider oral or IV formulations if available for chronic PH management, though less effective in acute crises.

Inotropic Support:

Dobutamine: Start at 2-5 mcg/kg/min (infusion range is 0.5- 20 mcg/kg), titrate for improved RV contractility and cardiac output.

Milrinone: Loading dose of 25-50 mcg/kg over 10 minutes, then infusion at 0.125–0.75 mcg/kg/min. Avoid in severe hypotension due to vasodilatory effects (greater SVR & PVR reduction than dobutamine).
Epi is also an option.

Vasopressors:

Norepinephrine: Start at 0.02 mcg/kg/min, titrate to maintain systemic perfusion and RV coronary perfusion.

Avoid RV Afterload Increases:

Treat systemic hypotension carefully to maintain RV perfusion pressure while avoiding excessive increases in PVR.

Address Precipitating Factors
Hypoxia: Increase oxygenation.
Hypercapnia or Acidosis: Optimize ventilation and administer sodium bicarbonate (50mEq) if severe acidosis (pH <7.2).
Pain or Agitation: Administer analgesia (e.g., fentanyl) or anxiolytics to blunt sympathetic stimulation.

Bolus fluid cautiously, if CVP is low < 8mmHg then probably ok.. do slowly (10 min), if worsens situation then stop immediately

Question 7

Massive Hemorrhage
Tx:

Answer 7

SPECIAL EQUIPMENT / INVASIVE LINES
* Arterial Line (Radial or Femoral): Continuous blood pressure monitoring and frequent arterial blood gas analysis.
REASONING: Critical for managing hemodynamic instability and guiding resuscitation.

Large Bore Peripheral IVs (14-16G x 2): For rapid administration of fluids and blood products.
REASONING: Ensures adequate access for massive transfusion.
Rapid Infuser (e.g., Level 1 or Belmont): For rapid administration of warmed blood products and fluids.
REASONING: Critical for managing massive hemorrhage and maintaining normothermia.
TEG- monitor ACTs
Activate Massive Transfusion Protocol - Call for HELP
Fluids Administered:
Start with 1-2 L crystalloid; transition rapidly to blood products.

Massive Transfusion Protocol (MTP): Ratio-based resuscitation (1:1:1 or 2:1:1 RBC:FFP).

Blood Products: Begin with 2 units of O-negative blood, then switch to type-specific once available. Continue with a 1:1:1 ratio of PRBCs:FFP:platelets
COMPONENTS
The three components of MTP are:
1. Packed Red Blood Cells (PRBCs): Replaces lost red blood cells to restore oxygen-carrying capacity.
2. Fresh Frozen Plasma (FFP): Provides clotting factors to help correct coagulopathy.
3. Platelets: Replenishes platelet count to aid in clot formation.
* 1:1:1 Ratio (PRBCs:FFP): This means for every unit of PRBCs given, one unit of FFP and one dose of platelets are also administered. This approach aims to provide a balanced replenishment of red cells, plasma, and platelets.
* 2:1:1 Ratio (PRBCs:FFP): This means for every two units of PRBCs given, one unit of FFP and one dose of platelets are administered. This approach might be used initially to rapidly restore oxygen-carrying capacity while still addressing coagulopathy.

First Cooler:
o 2 Units of O-Negative PRBCs
o 4 Units PRBCs
o 4 Units FFP
o 1 Six-Pack Platelets
o Cryoprecipitate: As indicated by laboratory results and clinical assessment.
o Use the Belmont rapid transfuser/warmer or pressure bag. Set blood transfusion tubing up with a fluid warmer(s).
o 100% O2 & increase flows lower volatile concentration.
o Actively warm the patient. Bair Hugger where you can
Calcium Gluconate: 1-2 g IV after every 4-6 units of PRBCs.
Calcium Chloride: 1 g IV (preferred for acute hypocalcemia or cardiac instability).

Laboratory Monitoring: After the first cooler, draw blood for TEG, CBC, ABG, and CMP. Repeat as necessary to guide further blood product administration.
Active Coagulation Monitoring with TEG/ROTEM:

Incorporate thromboelastography (TEG) or ROTEM to guide targeted blood product administration:
FFP: For prolonged clotting time. ACT > 140
Platelets: For low MA (maximum amplitude) < 50 .
Cryoprecipitate: For low fibrinogen levels (<1.5 g/L). FIBTEM MCF low (ROTEM) or K time > 3 min (TEG) or @ angle < 53 (TEG)

Laboratory monitoring should include TEG, CBC, fibrinogen, ABG, ionized calcium, and lactate.
Cryoprecipitate and Fibrinogen Replacement:

Indication: Use cryoprecipitate if fibrinogen is <1.5-2 g/L.
Dose:

Cryoprecipitate: 1 bag per 10 kg body weight (usually 10-15 bags).

Fibrinogen Concentrate: 3-4 g IV for rapid correction.

If Coagulopathy is suspected give 1g TXA over 10 min
Vasopressor support

Question 8

Thyroid Storm
Recognition:
Management:

Answer 8

Thyroid Storm:
Signs: Fever, tachycardia, hypertension, arrhythmias.
Management:
 Esmolol drip for HR and BP control. 50-300mcg/kg/min or 10-40mg boluses (drip better)
 Propylthiouracil (PTU) 200-400 mg NG to inhibit thyroid hormone release.
 Hydrocortisone 100 mg IV to block peripheral conversion of T4 to T3.
Hemodynamic Instability:
o Treat hypotension with Phenylephrine boluses (50-100 mcg IV- rare).
o Avoid ephedrine or other agents that can exacerbate tachycardia.

Question 9

Anaphylaxis
Recognition:
Tx:

Answer 9

IF not INTUBATED THEN RSI FIRST

100% fiO2 & increase flows
Balanced salt solution or colloid - often rapid infusion of 1 - 4 lL !!! required.
Epinephrine (initial dose 10 - 100 mcg IV): reassess and redose if needed q3 min
o Beta adrenergic effect inhibits degranulation of mast cells and causes bronchodilation.
o Alpha effect causes vasoconstriction.
Diphenhydramine (initial dose 50 - 100 mg IV): Blunts histamine effects. and ranitidine (zantac) 50mg
Albuterol Inhaler (initial dose 10 puffs per ETT): For bronchospasm.
Phenylephrine (initial dose 25-100 mcg IV): Raises BP through alpha-adrenergic effect.
Corticosteroids - Methylprednisolone (40-60mg): 4x more potent than hydrocortisone.
o Enhances beta effects of Epinephrine.
o Inhibits production of leukotrienes.
o Reduces complement system activation.
Methylene Blue for refractory hypotension: 10-50mg IV

Laboratory Tests: Obtain serum tryptase levels (ideally within 1–2 hours of the reaction) to help confirm anaphylaxis.

Question 10

Aortic Stenosis Management
plan:

Answer 10

Maintain Preload, Afterload, and Sinus Rhythm:
Preload: Ensure adequate volume to maintain ventricular filling.
Afterload: Avoid hypotension as the heart relies on systemic vascular resistance (SVR) for forward flow.
Sinus Rhythm: Preserving atrial contraction is critical for diastolic filling in a non-compliant left ventricle. (Have pads on, quickly cardiovert any A-fib!!!)

Induction Plan
Medications to Administer:

Etomidate 0.2-0.3 mg/kg IV: Preserves SVR with minimal myocardial depression.
Fentanyl 2-5 mcg/kg IV: Blunts sympathetic response to intubation.
Rocuronium 0.6-1.2 mg/kg IV: For muscle relaxation.
Rapid Response to Hypotension:

Administer Phenylephrine 100 mcg IV bolus to quickly restore afterload if hypotension occurs.

Maintaneance Phase: (keep MAP > 70)
Anesthetic Agents:

Sevoflurane 0.5-0.7 MAC: Maintain lower MAC to reduce myocardial depression and maintain SVR.
Supplement with Remifentanil infusion (0.05-0.2 mcg/kg/min) to achieve adequate analgesia and further reduce MAC requirements.
Avoid Nitrous Oxide: Prevents hemodynamic compromise.
Ventilation Settings:

Avoid hyperventilation; maintain normocapnia (EtCO₂ 35-40 mmHg) to avoid decreasing preload.
Fluid Management:

Use crystalloids judiciously to maintain preload without causing volume overload.
Avoid rapid boluses; use a controlled infusion if needed, guided by CVP or PAC monitoring.
Vasopressor Support:

Start a Phenylephrine infusion (0.05-0.1 mcg/kg/min) 40-80mcg/min is most common dose and titrate to maintain MAP > 70 mmHg.

Emergence Phase
Extubation Criteria:

Ensure hemodynamic stability (MAP > 70 mmHg).
Confirm adequate spontaneous ventilation and airway reflexes.
Neuromuscular Reversal:

Use Sugammadex to avoid bradycardia associated with neostigmine.
Postoperative PONV Prophylaxis:

Ondansetron 4 mg IV at the end of surgery

Special Considerations for Aortic Stenosis
Hypotension Management:

Use Phenylephrine (50-100 mcg IV) or titrate infusion to maintain afterload.
Avoid ephedrine, as tachycardia worsens diastolic filling.
Tachycardia Management:

Esmolol 0.5 mg/kg (10-40mg) IV bolus or infusion for HR > 90 bpm.
Avoid Fluid Overload:

Monitor urine output and CVP to guide fluid resuscitation.
Intraoperative Dysrhythmias:

**Treat atrial fibrillation aggressively with cardioversion (100 -200 joules) and amiodarone 150mg.

Question 11

How to Manage Difficult Airway

Answer 11

Vortex Principle:

Get Help First, try adjuncts w/ the 3 techniques

Three Airway Techniques:
Face mask ventilation.
Supraglottic airway (e.g., LMA).
Endotracheal intubation.

no more than 3 attempts per technique - Oxygenation is key, if you cannot oxygenate at the end of the vortex and are unable to reverse the patient to wake up THEN…make sure you have an extra set of hands, place a foam roll under the shoulders to expose the neck, adjust lighting and start an emergency cricothyrotomy.

Airway Optimization Strategies - FOR EVERY PHASE CONSIDER OXYGENATION, ADJUNCTS, SWITCHING PROVIDERS, AND MUSLCE RELAXANTS for optimal position.

Face Mask Ventilation
Seal: Ensure a tight seal by adjusting head position, mask grip, or using a two-person technique (two handed). (JAW THRUST).. Try a new mask size.
Airway Adjuncts: Insert an oropharyngeal (OPA) or nasopharyngeal (NPA) airway to reduce obstruction.

Pressure: Increase positive pressure ventilation (PPV) cautiously, using PEEP or CPAP if needed.

Supraglottic Airway (SGA)
Placement: Ensure correct placement of the SGA.
Size: Switch to a larger size if ventilation is inadequate. if 3 go 4. Also you can switch to a different type of LMA.

Position: Adjust head/neck alignment or reposition the device.

Endotracheal Intubation- more Paralysis ??
Positioning: Optimize the sniffing position for better glottic visualization. (Try different blade, different size).
Video Laryngoscopy: Use if direct laryngoscopy fails or is predicted to fail. (Fiberoptic if available as well)

Bougie: Insert to facilitate tube passage.

External Manipulation: Apply BURP (Backward, Upward, Rightward Pressure) on the larynx.

REVERSE PARALYTICS w/ SUGGAMADEX 16mg/kg - WAKE THE PATIENT UP- ( I think you only do this if you can mask vent the patient? - otherwise too time consuming)

DON’T KEEP DOING THE SAME SHIT, GET HELP AS SOON AS YOU RECOGNIZE YOU CANNOT OXYGENATE PATIENT ACCORDING TO ORIGINAL PLAN.

Question 12

Quick Airway Assessment
steps:

Answer 12

Past History:

Look for conditions like OSA, prior difficult intubation, or airway surgery.
Facial Features (Predictors of Difficult Mask Ventilation):

Beard: Often requires RSI; difficult to achieve a seal.
Edentulous (No teeth): Increases difficulty in mask ventilation.
Jaw protrusion limitation: Predicts difficulty with both bag-mask ventilation and intubation.
Airway Exam (Predictors of Difficult Intubation):

Mallampati Score: Class 3-4 predicts difficulty.
Neck Extension: Limited extension (<35°) is predictive of difficulty.
Thyromental Distance (TMD):
Normal: >6.5 cm (~3 fingerbreadths).
Difficulty: <6 cm.
Inter-incisor Distance (Mouth Opening):
Normal: >4 cm (~3 fingerbreadths).
Difficulty: <3 cm.
Neck Circumference:
Normal: <40 cm.
Predicts difficult intubation if >43 cm (especially in obese patients).

Question 13

LAST tx:

Answer 13

Adult & Peds: LAST: 1.5 mL/kg followed by infusion 0.25 mL/kg/min up to 0.5 mL/kg/min (IDBW)

start CPR, bolus 20% intralipid @ 1.5mL/kg. Repeat bolus q3-5 min and double infusion if still unresponsive.

Continue infusion until hemodynamically stable.

Max total dose 8mL/kg

Question 14

Laryngospasm
Tx:
Recognition:

Answer 14

Recognition: Upper airway obstruction; inspiratory stridor, Typically on emergence), O2 sats drop

TX: Turn APL valve to 40-70, (positive pressure). increase flows, Tight mask seal with jaw thrust and Larson’s maneuver (two handed).

If doesn’t work then Succinylcholine 10-20 mg IV or 3-4mg/kg IM in kids without IV access.

Question 15

Pre-Eclampasia
Recognition:
Tx:

Answer 15

BP > 140/90 x2 ≥ 20 wks, proteinuria, +/- organ dysfunct. *Consider delivery
*Prevent seizure: Mg 4-6 g IV over 15-20 min + 1-2 g/hr gtt for 24 hr post delivery (do NOT d/c in OR); (10 g IM load described if no PIV)
*Tx severe HTN (SBP > 155, DBP > 105): 1st line: Labetalol IV, hydralazine IV, nifedipine PO and no IV (others okay if 1st line unavailable)
*Watch for Mg tox: ↓ DTRs, Resp/cardiac comp. Tx: CaCl 1g IV or CaGluc 1-3 g IV

Question 16

Eclampsia: Pre-E w/ Seizure
Goal:
Tx:

Answer 16

*Goal: prevent hypoxia, trauma, additional seizures.
*Tx HTN, eval for prompt delivery
*LUD/full lateral, O2, airway, +/- ETT (If intubation: control BP to avoid cerebral hemorrhage)
*IV Mg load & gtt, as above
*If persistent/recurrent seizure: IV benzo (IM/IO okay)
*If severe HTN, tx as above
*Prepare for prompt delivery (NO neuraxial until rule out HELLP)

Question 17

HELLP (related to pre-eclampsi)
Recognition:
Tx:

Answer 17

H: Hemolysis (breakdown of red blood cells).
EL: Elevated Liver enzymes (indicating liver dysfunction or damage).
LP: Low Platelet count (thrombocytopenia).

Tx: As above for seizure ppx, HTN, consider delivery (vaginal if able)
*If active bleeding, consider plt transfusion
*Prepare for delivery, likely GA if C-Section (Control BP to avoid cerebral
hemorrhage)

Question 18

PPH
Recogintion:
TX:

Answer 18

recognition: EBL: Vaginal: > 500 mL, C-section: > 1000 mL
4 T’s: Tone/atony, Thrombin/coags, Tissue/retained placenta, Trauma/artery lac

Oxytocin/ Pitocin (Syntocinon): -Can be given: IM/IV/IU routes (WHO rec: 10 U IM/IV) -Do NOT bolus IV rapidly
-Consider Rule of 3’s:
- Dose: 3 U load IV over 30 sec
- Consider repeat 3 U doses q 3 min for total 3 doses - Infusion at 3 U/hr for up to 9 hr postop
- COMMUNICATE w/ OB TEAM re: TONE q 3 min
-SE: hypotension, N/V, coronary spasm

Methylergon ovine/ Methergine: Dose: 0.2 mg IM; q 5-10 min max 2 doses, then q 2-4 hr - Avoid IV, but if IV, 0.2 mg/10 mL NS, give 2 mL q 1 min - Relatively contraindicated if GHTN, HTN, Pre-E
- SE: HTN, seizures, HA, N/V, chest tightness

Hemabate/ Carboprost: Dose: 0.25 mg only IM or IU q 15-90 min, Max 2 mg/24 hr - Contraindicated in asthma
- SE: N/V, flushing, bronchospasm, diarrhea

Misoprostol/ Cytotec: - Dose: 600-1000 mcg buccal/PR (10 min onset) - SE: temp ↑ to ~ 38.1, N/V, diarrhea

Tranexamic Acid/TXA: Consider for all PPH
- Dose: 1 g IV over 10 min, repeat x 1 after 30 min prn

Fibrinogen concentrate/ RiaSTAP: Consider for PPH w/ confirmed/suspected low fib state: (DIC, AFE,
abruption, major hemorrhage) - 2 g fibrinogen = 2 vials RiaSTAP = 2-4 U FFP = 10-20 cryo U - To ↑ fibrinogen 100 mg/dL, give 2-4 g fibrinogen conc

Other Considerations: Keep pt. warm
- Don’t forget CaCl
- Consider IR for uterine artery embolization
- Call for help
- Consider MTP, cell salvage
- Consider POC testing/ROTEM
- Syntometrine = oxytocin + ergometrine
- Prepare for hysterectomy if bleeding still uncontrolled (↑IV access, consider airway)- switch to general if only doing epidural.

Question 19

Urgent or Emergent C-Section & Emergent GA

Answer 19

For all: Pre-induction checklist
* Call for help, take AMPLE Hx, IV access, NaCit, pulse ox, LUD.
* Neuraxial preferred if time - plan determined by degree of urgency,
communication w/OB team, resources, & pt. condition
* If CS for fetal distress, ↑ O2 to baby: SPOILT-Stop oxytocin, Position-LUD, O2, IV fluid, Low
BP (give pressor), Tocolytics (terbutaline 250 mcg subQ, +/-NTG SL spray 400 mcg x2)

For Emergent GA:
*ENSURE OBs PREPPED AND DRAPED BEFORE INDUCTION
*Pre-oxygenate 4 breaths. RSI w/ cricoid:
*Meds: Sux 1.5 mg/kg w/ either: propofol 2-3 mg/kg or etomidate 0.2 mg/kg or
ketamine 1-2 mg/kg or thiopental 4-5 mg/kg
*Once ETT placement verified, INSTRUCT SURGEONS TO “CUT”
*Until cord clamp: High gas flow & 2 MAC. Try to avoid benzo/narcs *After cord clamp: 0.5 MAC + 70% N2O or TIVA .Benzo/narcs OK *When able: Timeout, Abx, OG, +/-NMB, +/- post-op TAP block or PCA

Question 20

Hypotension w/ spinal
prevention:
Signs:
Tx:

Answer 20

prevention: Bolus 500-1000ml IVF at time of placement & consider preemptive phenylephrine gtt.

Signs: * AMS: confusion, agitation, somnolence, unconsciousness * Nausea, vomiting
* Inability for BP cuff to read
* Increased HR

Tx: * IV ephedrine 5-10mg or IV phenylephrine 50-100mg * Will likely need phenylephrine infusion
* Pt positioning (left lateral + reverse trendelenburg)
Avoid steep Trendelenburg (>15°), especially in patients with a dense block.

Question 21

High Spinal
Signs:
Tx:

Answer 21

Signs: * Numbness, paresthesia, or weakness of UE’s
* Rapid unexpected rise of sensory block
* SOB, apnea, bradycardia, hypotension, or nausea/vomiting * Loss of consciousness (LOC = total spinal), Cardiac arrest

Tx: * Call for help & code cart, inform team
If not code the reverse trendelenburg.
* If cardiac arrest: start CPR, refer to ACLS protocol
* Support ventilation. Intubate if necessary
* If significant brady or hypotension: 10mcg boluses epi,
↑prn, consider ACLS/pacing pads
* If mild brady can try atropine, low threshold for epi
* Give IV fluid bolus
* IF PARTURIENT: LUD, alert OB, prepare for possible C/S,
monitor fetal HR. If arrest, see ACLS in parturient

Question 22

Airway Obstruction
Signs:
Tx:

Answer 22

Signs of Airway Obstruction:

Complete Obstruction: Absence of breath sounds, inability to ventilate, no chest movement.

Partial Obstruction: Stridor, snoring, gurgling sounds, decreased oxygen saturation, increased respiratory effort.

Initial Management Steps
Call for Help: Immediately summon additional assistance.

Ensure Optimal Positioning:

Head-Tilt/Chin-Lift or Jaw-Thrust Maneuver: To open the airway, especially if the obstruction is due to soft tissue collapse.
Administer 100% Oxygen: Use a tight-fitting mask to enhance oxygenation, increase flows.

3. Clear the Airway
   Suction: Remove any visible secretions, blood, or foreign bodies from the oropharynx.

Magill Forceps: If a foreign body is visible and accessible, carefully remove it using Magill forceps.

4. Airway Adjuncts
   Oropharyngeal Airway (OPA): Useful if the patient is unconscious and the tongue is causing obstruction.

Nasopharyngeal Airway (NPA): Can be used in semi-conscious patients or when OPA is contraindicated.

5. Advanced Airway Management
   Supraglottic Airway Device (e.g., Laryngeal Mask Airway - LMA): If basic maneuvers fail, insert an LMA to secure the airway. Fiberoptic to see what is going on.

Endotracheal Intubation: Perform laryngoscopy and intubation if trained and if the obstruction persists.

Cricothyrotomy or Tracheostomy: If unable to secure the airway through the above methods and the situation is life-threatening, perform an emergency surgical airway.

6. Confirm Airway Patency
   Capnography: Ensure the presence of end-tidal CO₂ to confirm effective ventilation.

Auscultation: Listen for bilateral breath sounds to confirm lung ventilation.

7. Monitor and Support
   Continuous Monitoring: Keep track of oxygen saturation, heart rate, and blood pressure.

Ventilatory Support: Provide mechanical ventilation if necessary once the airway is secured.

8. Identify and Treat Underlying Causes
   Anatomical Obstruction: Such as tumors or swelling; may require surgical intervention.

Laryngospasm: Manage with positive pressure ventilation and consider administering a muscle relaxant if it persists.

Foreign Body Aspiration: May require bronchoscopy for removal.

9. Post-Event Evaluation
   Documentation: Record the event, interventions performed, and patient response.

Review and Debrief: Analyze the incident to improve future responses and update protocols if necessary.

Question 23

Aspiration
Signs:
Tx:

Answer 23

Signs of Aspiration:

During Anesthesia: Coughing, choking, desaturation, bronchospasm, or unexpected changes in ventilatory parameters.

Post-Anesthesia: Respiratory distress, hypoxia, tachypnea, or new infiltrates on chest imaging.

2. Immediate Management
   Stop the Procedure: Pause the surgical procedure if possible to focus on airway management.

Positioning:

Place the patient in a head-down (Trendelenburg) 10degree and turn head to reduce the risk of aspirated material reaching the upper lobes and to facilitate drainage.

Suctioning:

Oral and Tracheal Suctioning: Immediately suction the oropharynx and, if intubated, the trachea to remove aspirated material.

Consider Bronchoscopy to suction and remove contents. (Do not lavage).

Airway Management:
Remove LMA and suction/ head turn

If patient starts wheezing then give some albuterol (Proventil) puffs if possible.

Intubation: If not already intubated, consider rapid sequence induction and intubation to protect the airway, especially if the patient is at risk for further aspiration.
Avoid Positive Pressure Ventilation:

Until the airway is secured, avoid positive pressure ventilation to prevent forcing aspirated material deeper into the bronchial tree.
3. Supportive Care
Oxygenation:

Administer 100% oxygen and monitor oxygen saturation continuously.
Ventilatory Support:

Provide mechanical ventilation with appropriate settings to maintain adequate oxygenation and ventilation.
Hemodynamic Support:

Monitor blood pressure and heart rate; administer intravenous fluids or vasopressors as needed to maintain hemodynamic stability.
4. Post-Aspiration Management
Chest Imaging:

Obtain a chest X-ray to assess for infiltrates, atelectasis, or other complications.
Laboratory Studies:

Monitor arterial blood gases (ABGs) to evaluate oxygenation and acid-base status.
Antibiotic Therapy:

Prophylactic antibiotics are generally not recommended. Initiate antibiotics only if there is clinical or radiographic evidence of infection, such as aspiration pneumonia.
Steroid Therapy:

Routine use of corticosteroids is not recommended due to a lack of evidence supporting their efficacy in aspiration-induced lung injury.
Bronchoscopy:

Consider bronchoscopy to remove large particulate matter if present, especially if there is evidence of airway obstruction.
5. Monitoring and Follow-Up
Intensive Care Monitoring:

Admit the patient to an intensive care unit (ICU) for close monitoring if significant aspiration has occurred.
Serial Examinations:

Perform frequent assessments of respiratory status, including auscultation and monitoring of respiratory rate and effort.
Repeat Imaging:

Obtain follow-up chest imaging as needed to monitor the resolution or progression of pulmonary infiltrates.
6. Prevention Strategies
Preoperative Assessment:

Identify patients at high risk for aspiration, such as those with a full stomach, gastrointestinal disorders, obesity, pregnancy, or undergoing emergency surgery.
Fasting Guidelines:

Ensure adherence to appropriate preoperative fasting guidelines to minimize gastric volume.
Pharmacologic Prophylaxis:

Consider administering non-particulate antacids, H₂ receptor antagonists, or prokinetic agents preoperatively in high-risk patients to reduce gastric acidity and volume.
Rapid Sequence Induction (RSI):

Employ RSI with cricoid pressure in patients at high risk for aspiration to minimize the time the airway is unprotected.
Extubation Considerations:

Ensure patients are fully awake and have intact protective airway reflexes before extubation to reduce the risk of aspiration during emergence from anesthesia.

Question 24

Hypoxia
Signs:
Tx:

Answer 24

Immediate Recognition
Monitoring: Continuous pulse oximetry is essential for early detection of hypoxia. A drop in oxygen saturation (SpO₂) below 94% should prompt immediate evaluation.

2. Immediate Management Steps
   Administer 100% Oxygen: Increase the fraction of inspired oxygen (FiO₂) to 1.0 to maximize oxygen delivery.

Assess Equipment:

Check Oxygen Supply: Ensure the oxygen source is functioning and connected properly.
Inspect Breathing Circuit: Look for disconnections, leaks, or obstructions in the anesthesia circuit.
Verify Ventilator Settings: Confirm appropriate settings and proper functioning of the ventilator.
Evaluate the Patient (ABCDE Approach):

Airway:
Patency: Ensure the airway is clear of obstructions.
Positioning: Adjust the patient’s head and neck to maintain an open airway.
Breathing:
Ventilation: Assess chest rise, breath sounds, and end-tidal CO₂ to confirm adequate ventilation.
Lung Auscultation: Listen for bilateral breath sounds to detect issues like pneumothorax or bronchospasm.
Circulation:
Hemodynamics: Monitor blood pressure and heart rate; hypotension can exacerbate hypoxia.
Disability: Assess the patient’s level of consciousness, as hypoxia can lead to altered mental status.
Exposure: Look for signs of cyanosis or other indications of poor oxygenation.
3. Identify and Address Underlying Causes
Airway Obstruction:

Interventions: Suction secretions, reposition the airway, or consider advanced airway management if necessary.
Hypoventilation:

Interventions: Adjust ventilator settings to increase tidal volume or respiratory rate.
V/Q Mismatch:

Interventions: Apply positive end-expiratory pressure (PEEP) to improve alveolar recruitment.
Equipment Failure:

Interventions: Switch to manual ventilation using a self-inflating bag if equipment malfunction is suspected.
4. Advanced Interventions
Arterial Blood Gas (ABG) Analysis: Obtain ABG to assess oxygenation, ventilation, and acid-base status.

Imaging: If the cause of hypoxia is unclear, consider a chest X-ray to identify issues like pneumothorax, atelectasis, or pulmonary edema.

Bronchoscopy: In cases of suspected airway obstruction not resolved by initial measures, bronchoscopy may be necessary for diagnosis and management.

5. Prevention Strategies
   Preoperative Assessment: Identify patients at risk for hypoxia, such as those with underlying pulmonary disease or obesity.

Intraoperative Monitoring: Maintain vigilant monitoring of oxygenation and ventilation parameters throughout the procedure.

Equipment Checks: Perform thorough checks of anesthesia equipment before use to ensure functionality.

Question 25

HyperCarbia
Signs:
Tx:

Answer 25

Immediate Recognition
Monitoring:
End-Tidal CO₂ (EtCO₂): Continuous capnography is vital; normal EtCO₂ ranges from 35 to 45 mmHg. An increase suggests rising PaCO₂.

Arterial Blood Gas (ABG): Provides direct measurement of PaCO₂ and pH, confirming hypercarbia and associated acidosis.

2. Immediate Management Steps
   Increase Minute Ventilation:

Adjust Ventilator Settings: Increase tidal volume and/or respiratory rate to enhance CO₂ elimination.
Manual Ventilation: If using a manual mode, ensure adequate ventilation to prevent CO₂ buildup.
Assess Equipment:

Breathing Circuit: Check for disconnections, leaks, or obstructions that may impair ventilation.
CO₂ Absorber: Ensure the absorber isn’t exhausted, as this can lead to rebreathing of CO₂.

Fresh Gas Flow: Verify appropriate flow rates to prevent rebreathing, especially in low-flow anesthesia systems.

3. Identify and Address Underlying Causes
   Increased CO₂ Production:
   Causes: Fever, sepsis, hyperthyroidism, malignant hyperthermia, or systemic absorption during laparoscopic procedures using CO₂ insufflation.
   Interventions: Treat underlying conditions (e.g., cooling measures for fever, specific protocols for malignant hyperthermia).

Hypoventilation:
Causes: Depressed respiratory drive due to anesthetic agents, neuromuscular blockade, or patient positioning.
Interventions: Adjust anesthetic depth, reverse neuromuscular blockade if appropriate, and optimize patient positioning to facilitate ventilation.

Rebreathing:
Causes: Faulty breathing circuits, inadequate fresh gas flow, or exhausted CO₂ absorbent.
Interventions: Replace CO₂ absorbent, increase fresh gas flow, and inspect the breathing circuit for defects.

Increased Dead Space Ventilation:
Causes: Conditions like chronic obstructive pulmonary disease (COPD) or pulmonary embolism.
Interventions: Optimize ventilatory settings and consider strategies to reduce dead space.

4. Advanced Interventions
   Arterial Blood Gas Analysis: Obtain ABG to assess the severity of hypercarbia and guide further management.

Hemodynamic Support: Monitor and support cardiovascular function, as hypercarbia can lead to sympathetic stimulation and increased cardiac workload.

Consider Differential Diagnoses: Evaluate for rare causes such as thyroid storm or malignant hyperthermia, which are characterized by hypermetabolic states leading to increased CO₂ production.

5. Prevention Strategies
   Preoperative Assessment: Identify patients at risk for hypercarbia, such as those with underlying pulmonary diseases or conditions leading to increased CO₂ production.

Intraoperative Monitoring: Maintain vigilant monitoring of ventilatory parameters, including capnography and, when indicated, arterial blood gases.

Equipment Checks: Perform thorough preoperative checks of anesthesia machines and breathing circuits to ensure all components are functioning correctly.

Question 26

Tension PNX

Answer 26

1. Immediate Recognition
   Clinical Signs:

Respiratory: Sudden increase in PEAK PRESSURES, decreased or absent breath sounds on the affected side, hypoxia, and cyanosis.

Cardiovascular: Hypotension, tachycardia, jugular venous distension, and tracheal deviation away from the affected side (though tracheal deviation is often difficult to detect intraoperatively).

Monitoring Changes:

Unexpected hypoxemia and increased airway pressures during positive pressure ventilation may indicate tension pneumothorax.

2. Immediate Management Steps
   Call for Assistance: Alert the surgical and anesthesia team immediately.

Administer 100% Oxygen: Increase FiO₂ to 1.0 to maximize oxygenation.

Reduce Positive Pressure Ventilation: If possible, reduce tidal volumes to minimize further air trapping.

Needle Decompression:

Procedure: Insert a large-bore needle (e.g., 14-gauge) into the second intercostal space at the midclavicular line on the affected side.

Purpose: This allows immediate decompression of the pleural space, converting a tension pneumothorax into a simple pneumothorax.

Definitive Management with Chest Tube:

Insertion: Place a chest tube (thoracostomy) in the fifth intercostal space at the midaxillary line to provide continuous evacuation of air and prevent re-accumulation.

3. Supportive Care
   Hemodynamic Support: Administer intravenous fluids and vasopressors as needed to maintain blood pressure and organ perfusion.

Analgesia and Sedation: Provide adequate analgesia and sedation to reduce patient distress and oxygen consumption.

4. Monitoring and Follow-Up
   Continuous Monitoring: Closely monitor vital signs, oxygen saturation, and airway pressures.

Chest Imaging: Obtain a chest X-ray or ultrasound to confirm chest tube placement and lung re-expansion.

Assess for Complications: Monitor for potential complications such as re-expansion pulmonary edema or infection.

5. Prevention Strategies
   Preoperative Assessment: Identify patients at risk for pneumothorax, such as those with underlying lung disease or those undergoing procedures involving the thoracic cavity.

Cautious Use of Positive Pressure Ventilation: Avoid excessive airway pressures during mechanical ventilation to reduce the risk of barotrauma.

Equipment Checks: Ensure all anesthesia equipment is functioning properly to prevent iatrogenic causes of pneumothorax.

Question 27

PE
Signs:
Tx:

Answer 27

1. Immediate Recognition
   Clinical Signs:

Respiratory: Sudden onset of hypoxia, increased peak airway pressures, unexplained desaturation, and difficulty in ventilation.

Cardiovascular: Hypotension, tachycardia, arrhythmias, and signs of right ventricular strain (e.g., jugular venous distension).

Monitoring Changes:

End-Tidal CO₂ (EtCO₂): A sudden decrease in EtCO₂ may indicate reduced pulmonary perfusion.
Arterial Blood Gas (ABG): Hypoxemia and respiratory alkalosis may be present.

2. Immediate Management Steps
   Call for Assistance: Activate the emergency response team immediately.

Administer 100% Oxygen: Increase FiO₂ to 1.0 to optimize oxygenation and flow to 10L.

Support Hemodynamics:

Fluids: Administer intravenous fluids cautiously to maintain preload without causing fluid overload.
Vasopressors: Use agents like norepinephrine to support blood pressure if hypotension persists.
Consider Inotropic Support: If signs of right ventricular failure are present, inotropes such as dobutamine or epinephrine may be beneficial.

3. Diagnostic Evaluation
   Transesophageal Echocardiography (TEE): Can be performed intraoperatively to assess right ventricular function and detect emboli.

Pulmonary Artery Catheterization: May reveal increased pulmonary artery pressures indicative of PE.

4. Definitive Treatment
   Non-Massive or Submassive PE:

First-Line: Heparin (unfractionated or low-molecular-weight):
Heparin stabilizes the clot and prevents further thrombus formation but does not dissolve the existing clot.

Initial Bolus: 80 units/kg IV (maximum 5,000–10,000 units).
Continuous Infusion: 18 units/kg/hour IV, adjusted based on activated partial thromboplastin time (aPTT) or anti-Xa levels.

Massive PE with Hemodynamic Instability:

First-Line: Thrombolytics (e.g., alteplase):
Used when there is acute right heart strain, severe hypoxemia, or cardiac arrest.

Anticoagulation: Initiate intravenous heparin therapy as soon as PE is suspected, provided there are no contraindications.

Thrombolytic Therapy: Consider in cases of massive PE with hemodynamic instability, weighing the risks of bleeding.

Alteplase (tPA - Tissue Plasminogen Activator)
Standard Dose: 100 mg IV over 2 hours:
Administer 10 mg as an initial bolus over 1–2 minutes.
Follow with an infusion of 90 mg over the remaining 2 hours.
Alternative Dose for Cardiac Arrest:
50 mg IV bolus if PE is causing cardiac arrest during CPR.
Repeat a second 50 mg bolus in 15 minutes if no response.
Pediatric Dose: 0.5–1 mg/kg (up to a max of 50 mg

Reteplase (rPA)
Dose: Two IV boluses of 10 units, 30 minutes apart.

Surgical Embolectomy: In cases where thrombolysis is contraindicated or ineffective, surgical removal of the embolus may be necessary.

5. Postoperative Care
   Intensive Monitoring: Admit the patient to an intensive care unit for close hemodynamic and respiratory monitoring.

Continued Anticoagulation: Maintain anticoagulation therapy as per guidelines to prevent recurrence.

Investigate Underlying Causes: Assess for deep vein thrombosis and consider hypercoagulable states.

6. Prevention Strategies
   Preoperative Assessment: Identify patients at high risk for thromboembolism, such as those with a history of DVT, malignancy, or prolonged immobility.

Thromboprophylaxis: Implement mechanical (e.g., compression stockings) and pharmacological (e.g., low-molecular-weight heparin) prophylaxis as appropriate.

Early Mobilization: Encourage postoperative ambulation to reduce venous stasis.

Question 28

Negative Pressure Pulmonary Edema
Signs:
Tx:

Answer 28

Recognition
Clinical Signs:

Respiratory Distress: Tachypnea, dyspnea, and use of accessory muscles.

Hypoxemia: Decreased oxygen saturation levels.

Pink Frothy Sputum: Indicative of pulmonary edema.
Auscultation: Presence of rales or crackles.
Timing: Symptoms typically develop rapidly after relief of the airway obstruction.

Management
Immediate Actions:

Relieve Airway Obstruction: Ensure patency by removing the cause of obstruction. (break spasm)

Supplemental Oxygen: Administer 100% oxygen to correct hypoxemia.
Ventilatory Support:

Non-Invasive Ventilation: Apply Continuous Positive Airway Pressure (CPAP) or Bi-level Positive Airway Pressure (BiPAP) to improve oxygenation and reduce the work of breathing.
Intubation and Mechanical Ventilation: Indicated for severe cases; utilize Positive End-Expiratory Pressure (PEEP) to prevent alveolar collapse.
Hemodynamic Support:

Fluid Management: Maintain euvolemia; avoid excessive fluid administration.
Inotropic Support: Consider if there is evidence of cardiac dysfunction.
Pharmacologic Interventions:

Diuretics: Use is controversial; may be considered if there’s evidence of fluid overload, but caution is advised to prevent hypovolemia.
LITFL
Bronchodilators: Administer if bronchospasm is present.
Monitoring:

Continuous Pulse Oximetry: To monitor oxygen saturation.
Arterial Blood Gases (ABGs): To assess gas exchange and acid-base status.
Chest Radiography: To evaluate the extent of pulmonary edema.
Disposition:

Intensive Care Unit (ICU): Admit for close monitoring and supportive care.
Prevention
Airway Management:

Gentle Suctioning: To minimize mucosal irritation.
Adequate Anesthetic Depth: To prevent coughing or bucking during emergence.
Extubation Criteria: Ensure the patient is fully awake and has regained protective airway reflexes before extubation.
Risk Assessment:

Identify High-Risk Patients: Such as those with a history of airway obstruction or reactive airway disease.
Prophylactic Measures: Consider using steroids or bronchodilators in patients with known reactive airway disease.

Question 29

BradyCardia

Answer 29

Atropine Administration:

Dose: 0.5–1 mg IV, repeat every 3–5 minutes as needed (maximum dose: 3 mg).

Glycopyrrolate:
Alternative to atropine: 0.2–0.4 mg IV for vagally-mediated bradycardia.

Advanced Interventions

Epinephrine or Dopamine:

If atropine is ineffective:
Epinephrine: Start infusion at 2–10 mcg/min, titrate to effect.
Dopamine: Start infusion at 2–10 mcg/kg/min.
Transcutaneous Pacing:

If pharmacologic interventions fail, apply transcutaneous pacing pads and initiate pacing.

Consider Reversible Causes:

Hypoxia: Ensure adequate oxygenation and ventilation.
Hyperkalemia: Treat with calcium gluconate, insulin with glucose, and sodium bicarbonate.
Acidosis: Correct with bicarbonate therapy as needed.

Question 30

TACHY
Atrial (SVT - narrow):
Ventrical (Wide complex):
Atrial Fib w/ RVR

Answer 30

Narrow Complex Tachycardia (e.g., Supraventricular Tachycardia - SVT):

Vagal Maneuvers: Attempt carotid sinus massage or Valsalva maneuver.
Adenosine: 6 mg IV rapid push, followed by a 12 mg dose if the first dose is ineffective.

Wide Complex Tachycardia (e.g., Ventricular Tachycardia):

Amiodarone: 150 mg IV over 10 minutes, repeat as necessary, followed by an infusion (1 mg/min for 6 hours, then 0.5 mg/min). (use a filter on the line for bubbles)

Defibrillation: If unstable, perform synchronized cardioversion (100-200j).

Sinus Tachycardia:

Treat the underlying cause (e.g., hypovolemia, pain, or anxiety).

Atrial Fibrillation with Rapid Ventricular Response (RVR):

Beta-Blockers: Esmolol 0.5 mg/kg bolus, followed by infusion at 50–300 mcg/kg/min.

Calcium Channel Blockers: Diltiazem 15–20 mg IV over 2 minutes, repeat after 15 minutes if needed.

Question 31

Hypovolemia
signs:
Tx:

Answer 31

Recognition

Clinical Signs:

Hypotension and tachycardia.
Cool, clammy skin with delayed capillary refill.
Decreased urine output (<0.5 mL/kg/hr).
Altered mental status (e.g., confusion or agitation).
Flat jugular veins (in low intravascular volume).
Monitoring Changes:

Drop in systolic blood pressure.
Increased heart rate.
Low central venous pressure (CVP) or mean arterial pressure (MAP).

Question 32

HTN
Signs:
Tx:

Answer 32

Recognition

Clinical Signs:

Systolic blood pressure (SBP) >160 mmHg or diastolic blood pressure (DBP) >110 mmHg.
Associated symptoms: headache, dizziness, chest pain, or blurred vision (if severe).
Risk factors include pain, light anesthesia, or preexisting hypertension.
Monitoring Changes:

Sudden increase in blood pressure.
Signs of end-organ dysfunction (e.g., EKG changes, decreased urine output).

Identify and Address Underlying Causes:

Pain: Administer analgesics (e.g., fentanyl 25–50 mcg IV).
Light Anesthesia: Deepen anesthesia with propofol or inhalational agents.
Hypoxia or Hypercarbia: Administer 100% oxygen and adjust ventilation to address these factors.

Short-Acting Antihypertensives:

Beta-Blockers:
Esmolol: 0.5 mg/kg IV bolus, followed by an infusion of 50–300 mcg/kg/min.
Calcium Channel Blockers:
Nicardipine (cardene): drip: 1-15mg/hr

Titration: Increase by 2.5 mg/hour every 5-15 minutes to achieve the desired blood pressure

Direct Vasodilators:
Hydralazine: 5–10 mg IV bolus every 15–30 minutes as required.

Alpha-Blockers:
Labetalol: 5–10 mg IV bolus, repeat every 10 minutes (maximum dose: 300 mg).
Nitroglycerin (if myocardial ischemia is present):

Bolus: 10-50mcg
Adult: Infusion: 10-200 mcg/min IV or 0.1-1mcg/kg/min
(Note these doses are the same for nitroglycerin)

Question 33

Hypothermia
signs:
Tx:

Answer 33

Clinical Signs:

Core temperature <36°C (96.8°F).
Shivering (if the patient is awake postoperatively).
Bradycardia and hypotension.
Prolonged coagulation times or excessive bleeding.
Altered mental status (in severe cases).
Monitoring:

Use an accurate core temperature measurement device (e.g., esophageal, rectal, or bladder probes).

Prevent Further Heat Loss:

Increase the ambient temperature of the operating room (≥24°C/75°F).
Minimize patient exposure by covering exposed skin with blankets or surgical drapes.
Use a warming mattress or forced-air warming device (e.g., Bair Hugger).
Rewarming:

Passive Rewarming:
Apply warm blankets if the hypothermia is mild (35–36°C).
Active External Rewarming:
Use forced-air warming devices for moderate hypothermia (32–34°C).
Apply warm packs to the axillae, groin, and neck.
Active Core Rewarming:
Administer warmed IV fluids (37–40°C) using fluid-warming devices.
Consider warmed, humidified oxygen or heated insufflation gases during ventilation.
Use peritoneal or thoracic lavage with warm saline in severe cases.
Correct Electrolytes and Coagulation Abnormalities:

Administer calcium if ionized calcium is low.
Provide blood products to correct coagulopathy.

Continuous Monitoring:
Monitor temperature, heart rate, blood pressure, and oxygen saturation.
Laboratory Tests:
Check coagulation profile, electrolytes, and blood gases.

Question 34

Hyperthermia
Sign:
Tx:

Answer 34

Clinical Signs:

Core body temperature >38°C.
Tachycardia, flushed skin, or sweating (if awake).
Possible altered mental status or agitation.
Common Causes in Anesthesia:

Infection: Sepsis or surgical site infection.
Drug Reactions: Serotonin syndrome or neuroleptic malignant syndrome (NMS).
Environmental: Excessive warming or prolonged exposure to high ambient temperatures.
Thyroid Storm: If the patient has a history of hyperthyroidism.

Identify and Address Underlying Causes:

Infection/Sepsis:
Start broad-spectrum antibiotics if sepsis is suspected.
Provide aggressive fluid resuscitation.
Drug Reaction:
Discontinue suspected drugs (e.g., serotonin agonists, antipsychotics).
Consider antidotes such as cyproheptadine for serotonin syndrome or dantrolene for NMS.
Thyroid Storm:
Administer beta-blockers (e.g., propranolol) and antithyroid drugs (e.g., propylthiouracil).
Cooling Measures:

Passive Cooling:
Remove excessive warming devices or blankets.
Active Cooling:
Apply ice packs to axillae and groin.
Use a cooling blanket or fan.
Administer cooled IV fluids (4°C saline or Ringer’s lactate).
Consider gastric, bladder, or peritoneal lavage with cold saline for severe hyperthermia.
3. Monitoring and Support

Continuous Monitoring:
Track core temperature, heart rate, blood pressure, and oxygen saturation.
Laboratory Tests:
Check blood gases, electrolytes, renal function, and markers of infection (e.g., WBC count, procalcitonin, or C-reactive protein).
4. Prevention

Preoperative Measures:
Screen for risk factors like infections, recent fevers, or thyroid disorders.
Intraoperative Monitoring:
Avoid unnecessary warming in patients with normal body temperature.
Continuously monitor temperature to detect early signs of hyperthermia.

Question 35

Stroke During Anesthesia
Signs:
Tx:

Answer 35

Clinical Signs (difficult to detect under anesthesia):

Sudden hemodynamic instability.
Unexplained decrease in oxygen saturation or abrupt changes in end-tidal CO₂.
Delayed emergence or altered mental status postoperatively.
Asymmetric pupil size or response if intraoperative monitoring permits.
Neuromonitoring:

For high-risk cases (e.g., carotid surgery, cardiac bypass), intraoperative neuromonitoring such as EEG or cerebral oximetry may detect ischemia early.

Supportive Measures:

Maintain adequate oxygenation (administer 100% oxygen).
Optimize hemodynamics:
Keep systolic blood pressure >140 mmHg (if ischemic stroke is suspected).

Avoid excessive hypotension or hypertension.
Ensure blood glucose is within a normal range, as both hypo- and hyperglycemia worsen outcomes.
Rule Out Other Causes:

Hypoxia, hypercarbia, or systemic hypotension may mimic stroke symptoms.
3. Postoperative Management

Neurological Assessment:

Perform a detailed neurological exam as soon as the patient awakens.
Order imaging studies (CT or MRI) to confirm the diagnosis.
Thrombolytic Therapy (if Ischemic):

Administer tissue plasminogen activator (tPA) within 4.5 hours of symptom onset if no contraindications exist.
Neurosurgical Consultation (if Hemorrhagic):

Consider immediate intervention for intracranial hemorrhage.
4. Prevention

Preoperative Optimization:

Identify patients with a high risk of stroke (e.g., history of atrial fibrillation, carotid artery stenosis, or prior stroke).
Ensure anticoagulation is appropriately managed in patients with atrial fibrillation.
Intraoperative Strategies:

Maintain stable blood pressure and avoid excessive fluctuations.
Avoid prolonged periods of hypoxia, hypercarbia, or hypotension.
5. Monitoring

Continuous Monitoring:

Track hemodynamics, oxygen saturation, and cerebral oximetry (if available) in high-risk cases.
Laboratory Tests:

Check arterial blood gases, glucose levels, and coagulation parameters.

Question 36

Hypokalemia
signs:
Tx:

Answer 36

Clinical Signs:

Cardiovascular:
Palpitations, arrhythmias (e.g., premature ventricular contractions, atrial fibrillation).
ECG changes: Flattened T waves, U waves, ST depression, prolonged QT interval.
Neuromuscular:
Weakness, fatigue, or cramps.
In severe cases, paralysis or respiratory muscle weakness.
Other:
Ileus or decreased gastrointestinal motility.
Monitoring Changes:

Unexplained arrhythmias on ECG.
Decreased potassium on laboratory testing.

Stop Contributing Factors:

Discontinue drugs that exacerbate hypokalemia (e.g., loop or thiazide diuretics, insulin without dextrose).
Administer Potassium:

IV Potassium Replacement:
Mild to Moderate Hypokalemia (2.5–3.5 mmol/L):
Infuse potassium chloride (KCl) 10–20 mmol/hr IV.
Severe Hypokalemia (<2.5 mmol/L or symptomatic):
Use higher rates (20–40 mmol/hr) with continuous ECG monitoring.
Maximum rate: 20 mmol/hr via peripheral IV or 40 mmol/hr via central line.

Question 37

Seizure
Signs:
Tx:

Answer 37

Clinical Signs:

Tonic-Clonic Movements: Rhythmic jerking or rigidity.
Autonomic Changes: Hypertension, tachycardia, or excessive salivation.
Ventilation Issues: Apnea or difficulty ventilating the patient.
ECG Monitoring: Can sometimes reveal bradycardia or arrhythmias due to autonomic involvement.
Differentiation:

Rule out myoclonus (e.g., from propofol or etomidate) or shivering, which may mimic seizures.

Stop Seizure-Inducing Stimuli:

Discontinue potential triggers (e.g., local anesthetic in toxic doses or seizure-inducing drugs like ketamine).
Ensure Airway Patency:

Protect the airway and prevent aspiration by positioning the patient laterally if not intubated.
Administer 100% oxygen to correct hypoxia.
Terminate the Seizure:

First-Line Agents:
Benzodiazepines:
Midazolam: 2–5 mg IV.
Lorazepam: 4 mg IV over 2 minutes.

Second-Line Agents:
Propofol: 1–2 mg/kg IV to terminate prolonged or refractory seizures.
Thiopental: 3–5 mg/kg IV if benzodiazepines are ineffective.
Address Underlying Causes:

Hypoglycemia: Administer dextrose 25–50 mL of 50% solution IV.
Electrolyte Imbalances:
Hypocalcemia: Calcium gluconate 1–2 g IV.
Hypomagnesemia: Magnesium sulfate 2 g IV.
Hyponatremia: Correct with hypertonic saline (if severe).
Local Anesthetic Systemic Toxicity (LAST): Treat with lipid emulsion therapy as discussed earlier.

Question 38

Right MainStem Intubation
Signs:
Tx:

Answer 38

Signs: In this case the problem is endobronchial intubation. Notice that the airway pressure is high with positive pressure ventilation since only one lung is ventilated. The arterial oxygen saturation declines due to shunted blood through the unventilated lung.To make the diagnosis, listen to the breath sounds, check the insertion depth of the tube, and/or perform fiberoptic bronchoscopy through the tube to locate the carina in relation to the tip of the tube.

Tx: Pull the tube back a couple cm.. normal is around 22cm at the teeth. Check breath sounds.. reconfirm fiber-optics that you can see the carina.

The differential diagnosis for intubated but hard to ventilate includes obstruction of the endotracheal tube due to kinking, plugging, or positioning; and problems with the breathing circuit such as obstruction or malfunctioning valve. You must rule out these problems before assuming that the problem is bronchospasm.

Question 39

Fire in OR
airway:
not airway:

Answer 39

airway: extubate, use 21% O2. Pour sterile saline down airway.

Not Airway: do not extubate

Surgical Field Fire:

Remove burning drapes and extinguish flames with sterile saline.
Airway Fire:

Disconnect the breathing circuit and immediately remove the endotracheal tube (ETT).
Extinguish the ETT fire and remove any visible debris from the airway.
Reintubate with a smaller ETT after confirming airway patency.
Administer 100% oxygen and humidified air to treat thermal injury.

Assess Patient Injuries:

Inspect for burns or airway damage.
Treat thermal burns with sterile dressings and cool irrigation.
Support Airway and Breathing:

Perform bronchoscopy to evaluate airway injury if an airway fire occurred.
Consider corticosteroids and humidified oxygen for airway injury.
Maintain Hemodynamic Stability:

Monitor for hypotension or shock from injuries or smoke inhalation.

Question 40

Neurogenic Shock (spinal surgery)
Signs:
Tx:

Answer 40

Why Does Spinal Cord Injury Cause Hypotension?

Loss of Sympathetic Tone (Neurogenic Shock):

Damage to the spinal cord, particularly at or above the T6 level, disrupts the sympathetic nervous system.
Loss of sympathetic outflow leads to:
Vasodilation: Widespread peripheral vasodilation reduces systemic vascular resistance (SVR).
Bradycardia: Unopposed vagal tone can slow the heart rate, further reducing cardiac output.
Reduced Preload:

Vasodilation causes venous pooling in the extremities, decreasing venous return and preload.
Anesthetic Contributions:

Spinal anesthesia or general anesthetics may exacerbate hypotension by causing additional vasodilation or myocardial depression.
Blood Loss:

Surgical blood loss can contribute to hypovolemia, compounding hypotension.
Clinical Presentation

Hypotension (mean arterial pressure <65–70 mmHg).
Bradycardia, particularly with high spinal cord injuries.
Signs of poor perfusion: Cool extremities, low urine output, or altered mental status (if awake).
Management of Hypotension

1. Address the Underlying Cause

Identify and treat neurogenic shock or hypovolemia.
Minimize further spinal cord damage with careful hemodynamic control.
2. Optimize Hemodynamics

Fluids:

Administer isotonic crystalloids (e.g., normal saline or Ringer’s lactate) to restore intravascular volume.
Use blood products if hypotension is due to surgical bleeding.
Vasopressors:

Phenylephrine: Preferred for its alpha-adrenergic effects, increasing SVR without significant beta activity.
Dose: 50–100 mcg IV bolus or 0.1–0.5 mcg/kg/min infusion.
Norepinephrine: Used for refractory hypotension or combined vasodilation and bradycardia.
Dose: 0.05–0.2 mcg/kg/min infusion, titrated to effect.
Dopamine: Consider if bradycardia is prominent and unresponsive to atropine.
3. Treat Bradycardia

Atropine:
Dose: 0.5–1 mg IV, repeated every 3–5 minutes (maximum dose: 3 mg).
Epinephrine:
In cases of severe bradycardia with hypotension, epinephrine infusion may provide both beta (chronotropic) and alpha (vasoconstrictive) effects.
4. Optimize Oxygen Delivery

Supplemental Oxygen:
Administer 100% oxygen to maintain oxygenation and tissue perfusion.
Hemoglobin Levels:
Consider transfusion to maintain adequate oxygen-carrying capacity.
5. Positioning

Reverse Trendelenburg:
Elevate the head slightly to reduce venous pooling.
Avoid Excessive Trendelenburg:
This can worsen cerebral perfusion pressure if intracranial pressure is elevated.
Role of the CRNA

Monitoring:

Continuous blood pressure monitoring (preferably arterial line).
Monitor heart rate, oxygen saturation, end-tidal CO₂, and urine output.
Communication:

Keep the surgical team informed of hemodynamic changes.
Coordinate with the surgeon to minimize blood loss.
Interventions:

Administer fluids and titrate vasopressors promptly.
Treat bradycardia with atropine or epinephrine as needed.
Adjust anesthetic depth to avoid excessive vasodilation.
Prevention:

Preload the patient with fluids before spinal anesthesia.
Proactively use vasopressors in patients at risk for neurogenic shock.

give 1L of fluids and check CBC.. determine if need blood products.

consider retroperitoneal bleeds as well. If so, Have the patient with 2 large bore IVs and hooked up to belmont and fluid warmer with MTP activated before starting the lapartomy in the supine position.

The retroperotenial bleed can cause a bit of Tamponade that can maintain your hemodynamics. The second the surgeon cuts you could quickly lose BP.

Make sure you are trending Hb in back surgeries. Just bc the surgeons don’t see blood in their field and there isn’t any on the floor you will need for them to consider other bleeds if your trends are suggesting such. Don’t be afraid to speak up.

Question 41

Hypovolemic Pediatric Patient
Signs:
Tx:

Answer 41

Signs: even if the MAP seems ok the HR could be high.. for example a 1kg newborn HR should be in the 140s but if the HR is in the 180s and the MAP looks ok, (around 30s) consider the patient history and why they are there.

Tx: Try boluses of 20mL/kg and assess the HR if lowered but not within normal range, give another bolus.

Make sure to rehydrate adequately before induction as induction can cause even further hypotension.