Emergent Situations Flashcards
How to treat Bronchospasm?
How to recognize:
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).
HyperKalemia Tx:
how to recognize:
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)
DKA management
How to recognize:
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
Ischemic Event
How to recognize:
Tx:
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.
Venous Air Emboli
How to recognize:
Tx:
What cases are most common:
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).
Pulmonary Hypertension Crises
How to recognize:
Tx:
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
Massive Hemorrhage
Tx:
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
Thyroid Storm
Recognition:
Management:
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.
Anaphylaxis
Recognition:
Tx:
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.
Aortic Stenosis Management
plan:
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.
How to Manage Difficult Airway
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.
Quick Airway Assessment
steps:
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).
LAST tx:
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
Laryngospasm
Tx:
Recognition:
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.
Pre-Eclampasia
Recognition:
Tx:
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
Eclampsia: Pre-E w/ Seizure
Goal:
Tx:
*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)
HELLP (related to pre-eclampsi)
Recognition:
Tx:
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)
PPH
Recogintion:
TX:
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.
Urgent or Emergent C-Section & Emergent GA
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
Hypotension w/ spinal
prevention:
Signs:
Tx:
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.
High Spinal
Signs:
Tx:
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
Airway Obstruction
Signs:
Tx:
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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
Aspiration
Signs:
Tx:
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.
- 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.
Hypoxia
Signs:
Tx:
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.
- 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.
- 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.