ABCs of Anaesthesia Boot Camp Flashcards
(77 cards)
1
Q
What are the components of the general anaesthetic assessment?
A
- Past Anaes Hx - issues previously? PONV? FHx of issues?
- PMHx/Systems
- Global function (METS)
- ET
- CVS (IHD, CCF, Valves, Rhythm, PVD, HTN)
- Resp (COPD, Asthma, OSA, URTI, Pneumonia, smoking)
- Other (Liver, Kidney, CNS, DM, Haem, Rheum, infection) - Meds/allergies
- Fasting/Aspiration risk
- last solids, liquids
- GORD or delayed gastric emptying - Exam
Height, weight, BMI, vitals, Cardio and resp
Airway assessment (+dental) - Ix
2
Q
Additional considerations for obstetric assessment?
A
- Prev Obs Hx
- Pre eclampsia, HTN, DM etc - Gravidity / Parity
Weeks
Method of delivery and issues for each delivery - Ix
GH is valid with Ab
Obstetric US findings
plt for spinal
3
Q
how to break down perioperative risk/benefit profile?
A
Perioperative risk
- ACS NSQIP risk calculator
Surgical risk
- chance of improvement
- chance of no improvement
- chance of harm
Risk of doing nothing
4
Q
approach to anaesthetic consent
A
Common: pain, nausea/vomiting and a sore throat
There is a small chance of dental damage but this is unlikely
The risk of serious life threatening events is very unlikely
overall having this anaesthetic is probably safer than driving a car on the
road every year…
Would you like me to go through these risks or anything in more detail?’
In particularly high-risk patients you may want to mention that
• ‘Serious events include life-threatening complications with your heart and
lungs, brain, drug reactions, allergies and awareness’
5
Q
What are the general legal requirements for obtaining consent?
A
- Consent must be given freely without coercion
- Withdrawal of consent must be a realistic option
- Consent may only be given by a person capable of doing so
- Consent must be informed – benefits, risks and alternatives
6
Q
What are the possible surgical issues youd like to discuss with the surgeon?
A
- Position
- Duration
- Expected blood loss
- Antibiotics
- DVT prophylaxis
- Special requests (cell saver, avoiding muscle relaxant, tourniquet, NIM ETT, Airway preference, avoiding GA for local etc)
7
Q
How can lungs be damaged during mechanical ventilation?
A
- Volutrauma (alveolar overdistention - causes APO/atelec)
- Barotrauma (high transpulm pressure- causes PTx/pneumomediastinum)
- atelectrauma (repeated open + closing of alveoli usually low volumes cause this)
- biotrauma (damage to lung and extrapulmonary organs caused by inflammatory response to mechanical ventilation)
- shear strain
- Oxygen toxicity (oxidative injury)
8
Q
What is a normal FRC?
A
30mL/kg so around ~2L for a 70kg person
9
Q
How many mL/min of O2 does an average person use?
A
3.5mL/kg/min so about 250mL/min for 70kg person
10
Q
How many mins of apnoea do you have before running out of O2 if preoxygenated well
A
2L FRC, 80% O2 = 1600mL
3.5mL/kg O2 usage so 250mL/min
so 6 mins in ideal circumstances
11
Q
FiO2 setting during maintenance of anaesthesia?
A
30-80%, usually 50%
avoid v low FiO2 incase of airway loss
avoid v high fiO2 to avoid masking progressive lung injury / O2 toxicity
12
Q
what is the oesophageal sphincter pressure? why is this important?
A
15cmH2O (pressures above this with LMA could cause gastric insufflation)
13
Q
What ventilator mode should be used for leaky circuits?
A
PCV
- VCV gives an uncertain volume to the lung (will say it was delivered, doesnt account for leak)
- Pressure is the limiting variable, therefore target a pressure. The pressure the vent measures as delivered is a true reading
- downside is high pressure can insufflate the stomach
14
Q
What are the components of a basic anaesthetic plan?
A
- GA v Regional?
- Which components of the triad?
- ETT v LMA
- Monitors (art, CVC, Swan)
- Pain - meds, blocks, PCA/APS
- Post op HDU/ICU?
15
Q
When might a case require paralysis?
A
Surgical
- Critically still - neuro
- Access - laparotomy, laparoscopy
Anaesthetic
- RSI/Intubation
Patient
- Significant lung disease
- obesity
16
Q
When to use ETT v LMA
A
ETT - (PAVS)
- Paralyzed
- Airway protection
- need precise control of Vent (lung diseas, long case, neuro, unwell pt)
- Shared airway
LMA
- uncomplicated, fasted, well pt with no airway issues
17
Q
AS reciepe?
A
GA, Art line, Gentle induction (GAG)
Spinal may give you less control over BP which is important for AS
18
Q
Plan for 70M Laparotomy for bowel Ca, PHx severe restrictive resp disease, chronic back pain on 100mg oxycontin daily
A
- GA
- hypnosis, analgesia and Paralysis (surgical and severe lung disease)
- ETT
- Standard + Artline (gases for lung disease, elderly for bowel op)
- fent+/-morph, ketamine, regional block, APS, consider lignocaine/Mg
- ?HDU for pain
19
Q
What do you have to consider when family members have ‘nearly died’ under anaesthesia?
A
- MH
- Sux Apnoea
- Anaphylaxis
- Congenital cardiac issues/arrhythmias
20
Q
Framework to decide to proceed or postpone a case with a cardiac risk pt
A
EARLMC- Every Anaesthetist Really Loves Morning Coffee
Emergency - proceed (optimize, monitor) Active Cardiac condition - refer Risk - use RCRI risk calculator Low risk (0-1 risk factor) - proceed >4 METS - proceed will testing Change management - Yes(test) No (proceed)
can extrapolate this to more than just cardiac
21
Q
What are active cardiac conditions as per the ACC/AHA guidelines which you would refer for
A
MADVA
- MI <60days
- Angina (unstable or severe)
- Decompensated HF (NYHA IV, Worsening, new)
- Valvular disease (severe, so AV area <1cm2 or mean pressure 40mmhg, or symptomatic MS)
- Arrhythmias (Slow: high grade AV block, Symptomatic brady, Fast: new VT, symptomatic ventricular arrhythmias, SVT with uncontrolled rate >100)
22
Q
What is a MET?
A
- Metabolic equivalent
- ratio of WORK metabolic rate to REST metabolic rate
- 1 = 3.5mLO2/kg/min (250mL/min) in a 70kg Male sitting quietly
- scale is define by DASI - duke activity status index
- risk is increased if unable to meet a 4 MET demand in most daily activities
- correlates well with periop survival
23
Q
Proceed or postpone?
68M w NSTEMI 2/52 prior, ongoing unstable angina, high speed MVA w FF in abdomen and surgeon wants theatre urgently
A
Emergency - yes, proceed
Optimize with artline, avoid tachy, potentially transfuse etc
24
Q
Proceed or postpone?
78F #NOF, multicomorbid with unknown exercise tolerance, in pain with fluid overload
A
Emergency - yes (urgent), proceed
Have some time to refer and optimized (can postpone a bit)
Optimize: block, analgesia, diuresis, etc
25
Proceed or postpone?
70M w PR bleeding secondary to new Rectal Ca, Phx HTN, T2DM, Hchol, unknown ET
Emergency - yes, proceed
| optimize as possible
26
Proceed or postpone?
60F Lap chole, in rAF, nil Sx
emergency - no
Active cardiac - yes, refer (postpone)
if biliary sepsis (cause for AF) - proceed, attempt to control rate
27
Proceed or postpone?
60F for Lap incisional hernia repair, PHx RA and hear a systolic murmur
Emergency - no
| Active - potentially, refer (postpone, get TTE)
28
Proceed or postpone?
78F with recent TTE showing mod AS for cataract surgery, unable to walk up stairs due to arthritis
Emergency - no
Active - No (severe would be)
Risk - LOW - proceed
29
Proceed or postpone?
50M for inguinal hernia repair w trifasicular block and multiple fainting episodes
Emergency - no
| Active - Yes, refer and postpone
30
Proceed or postpone?
60M lap chole, unkown ET secondary to back injury, nil PHx
Emergency - no
Active - no
Risk - Low
Proceed
Could argue unsure of METS and that testing might change mgmt? then - postpone for testing
Boss call
31
Proceed or postpone?
60M for THR, AF at rate 70, Hchol, HTN, obese, stays in bed most days, walks to lounge to watch TV
```
Emerg - no
Active - no
Risk - moderate
Low risk - no, 4 RF
METS >4 - assess if good proceed, if not or unknown assess if testing is relevant
```
32
Proceed or postpone? what else do you want to know?
80F for THR, NYHA II, IHD, T2DM, AF, COPD, OSA (all stable and optimized), walks daily, iADLS
```
emergency - no
active - no
Risk - mod
Low risk - no, many
METs >4 - determine, if yes then proceed
```
33
What are the parts of an induction checklist?
4 Ms:
- Machine
- Meds (SPAAA drugs - Sux, propofol, aramine, atropine, adrenaline)
- Monitoring (Sats, ETCO2, BP, ECG)
- MABELS (airway equipment)
mask, airways (OPA, NPA, LMA), bougie and stylet, ETT, laryngoscope, suction
34
Choose hypnotic/analgesia/relaxant for 50yo for lap chole with renal impairment
hypnotic: propofol w sevo maintenance
analgesia: fentanyl (moph metabolites may accumulate)
relaxant: Atracurium/cisatracurium, if you need sux check K, could use roc/vec - have prolonged action and have reversal agent
35
Choose hypnotic/analgesia/relaxant for 60yo for umb hernia repair with PONV and difficult BMV
hypnotic: propofol induction and maintenance
analgesia: fentanyl (+muyltiumodal + Local to spare opioids)
relaxant: FAST to spare bad BMV - sux or roc at 1mg/kg
36
Choose hypnotic/analgesia/relaxant for 70yo for lap nephrectomy with cardiac, renal and liver impairment, asthma)
hypnotic: prop/ket/midaz induction
analgesia: remi (long case), or just fent
relaxant: could go cisat but long onset or roc with a reversal agent. avoid atrac due to histamine release in this pt with asthma
37
Choose hypnotic/analgesia/relaxant for 30yo for GA caesarean section with preeclampsia
hypnotic: prop
analgesia: alfentanil ( fast - avoid bp spike with PE and doesnt last too long - good for baby,
relaxant: FAST (ASP risk) sux or roc 1mg/kg
38
How to decide when to extubate?
- ABCs stable (reasonable oxygenation and PEEP, good TV, good analgesia)
- obeying
39
Extubation sequence
- insert bite block
- increase FiO2
- suction
- head up
- check equipment
- Reversal of triad (Volatile off, flow up to 15L/min, change to SIMV/PSV and bagging circuit, reversal of muscle relaxation with neostigmine 2.5mg/glycopyrrolate 0.4mg , check return of muscle function and conscious state
- when pt inhales remove ETT
- facemask
40
predictors of difficult LMA insertion and ventilation
```
RODS
Restricted mouth opening
Obstruction
Distorted airway
Stiff lungs or c-spine
```
Hx
Insertion
- small mouth (need 2cm)
LMA Placement
- abnormal airway anatomy
- absence of teeth
- laryngeal obstruction
Ventilation
- raised BMI >30
- non compliant lungs (res/obs lung disease)
41
What are the 3 Axis
- oral axis
- pharyngeal axis
- tracheal axis
42
Predictors of difficult BMV
BONES - Beard, obese, No teeth, Elderly, Sleep apnoea/snoring
Hx
Seal
- Beard
- no teeth
- elderly
Oropharyngeal obs
- OSA
- Obesity
- Mallampati III-IV
- severely limited jaw protrusion
- Neck radiation/burns
Ventilation
- Obesity
- non compliant lungs (res/obs lung disease)
43
predictors of difficult laryngoscopy
LEMON - Look externally, Eval (3-3-2), Mallampati, Obstruction, Neck extension
Hx
Introducing laryngoscope
- mouth opening <3cm
- long upper incisors
Overcrowded mouth
- high arched narrow palate
difficult view of the larynx
- mallampati III or IV
- poor jaw protrusion
- neck circumference >44cm
- TMD <6cm
- limited neck extension <20deg
Laryngeal oedema/path
- stridor/difficulty swallowing
- hoarse voice
44
Describe the mallampati score, TMD and mandibular protrusion
modified mallampati :
Class I: Soft palate, uvula, pillars visible.
Class II: Soft palate, major part of uvula
Class III: Soft palate, base of uvula visible.
Class IV: Only hard palate visible.
TMD - distance from mental protrusion to thyroid cartildge >6.5 good, 6-6.5 equivicle, <6 bad
Mandibular protrusion- A mandible protrudes beyond incisors, B in line, C cannot
45
What are the cormack lehane grades
```
I - full view of cords
IIa - most
IIb - just tip
III - no cords
IV - cant see epiglottis
```
46
5 second airway exam
- Hx
- Inspect (age, beard, BMI, malformation, trauma)
- Mouth open (mallampati, tongue, prominent teeth, inter incisor distance)
- mouth closed ( jaw protrusion, TMD, neck extension)
3-3-2 - 3 Mouth opening, 3 thryromental, 2 thyrohyoid
47
options for a very difficult airway?
- AFOI or awake look
- regional/local
- awake trache
- inhalational
48
what can you do if you predict a difficult BMV
Equipment/staff
- guedel, NPA, range of masks
- 2 hand with support
modify pt characteristics
- position
- shave
- leave dentures in
tailor anaesthetic
- meticulous preox
- use rapid muscle relaxant
- use ETT/LMA immediately without persisting with BMV
49
what can you do if you predict a difficult LMA
Equipment/staff
- different LMAs (fastrtach narrower, proseal higher seal pressure)
- have ETT ready
modify pt characteristics
- position
- leave dentures in
tailor anaesthetic
- meticulous preox
- use ETT immediately without persisting with LMA
50
what can you do if you predict a difficult intubation?
Equipment/staff
- video
- bougie
- different size tubes and blade
modify pt characteristics
- position
- dentures out
tailor anaesthetic
- meticulous preox
- apnoeic oxygenation or optiflow thrive humidified high flow O2
- sux/high dose roc to help get best conditions rapidly
51
What can you do if you are trying to pass ETT but struggling
Plan A (APPBBB)
- assistance
- position
- paralysis
- BURP
- Bougie
- Blade (different or video)
Plan B
- LMA/iLMA
- fiberoptic
- other technique
52
What can you do if you are trying to BMV but struggling
- jaw thrust
- guedel / NPA
- two hands
- assistant
53
What can you do if you are trying to pass LMA but struggling or cant ventilate with LMA
Pass
- jaw thrust
- rotation
- smaller/different LMA
- more force (careful)
Ventilate
- micro adjust
- more propofol
- paralyze
54
when do you identify CICO?
- >3 attempts
and
- failed oxygenation with 2 techniques
OR
- SaO2 persistently <90%
55
Basic framework for problem solving in anaesthesia
1 - safety
2 - temporization
3 - diagnosis
4 - treatment
56
24M appx BP 70 post induction - problem solving framework
Safety (CHeSS)
- Check reading/transducer/monitor
- call for Help
- Scan pt/surgery/monitor
- Stop surgery
Temporisation
- fluid bolus
- vasopressors
- turn down volatile
Diagnosis
- likely: medication effect, hypovolaemia
- serious: anaphylaxis, bleeding (lap port injury), sepsis
- other
Treatment
- check for signs of serious DDx - rash, wheeze, blood
57
40M lap chole - tachy on incision HR 160. Problem-solving framework
Safety (CHeSS)
- Check reading/transducer/monitor
- call for Help
- Scan pt/surgery/monitor (ECG+BP)
- Stop surgery
Temporisation
- stop surgery
- analgesia
- deepen anaesthesia
Diagnosis
- likely: pain, too light
- serious: arrhythmia, anaphylaxis
- other
Treatment
- check for signs of serious DDx
- non sinus tach: ALS
- sinus tach: increase analgesia and depth and check for anaphylaxis
58
25F femoral nail post MBA, asthmatic, post RSI pt desats. Problem-solving framework
Safety (CHeSS)
- Check reading/transducer/monitor
- call for Help
- Scan pt/surgery/monitor (vent)
- Stop surgery
Temporisation
- 100% FiO2
- increase flow
- Bag
Diagnosis
- likely: lack of preoxygenation/delay in intubation, bronchospasm
- serious: aspiration, esophageal intubation, pneumothorax, anaphylaxis, PE/air embolism
- other
Treatment
- check for signs of serious DDx
- with bag check compliance: tight/wheeze/kink or obstruction? loss of pressure - increase APL and reventilate, check ETT position
- check circuit from machine to ETT, if issues switch to laerdel bag, use bougie to check ETT
- Auscultate lungs: wheeze-salbutamol/adrenaline, mucous - suction/peep, unilat sounds-ptx, APO-LMNOP, Aspiration - suction, bronch
59
35F in recovery post diagnostic lap BP 90 and HR 105. Problem-solving framework
Safety (CHeSS)
- Check reading/transducer/monitor and trend
- Scan pt/monitors
- call for help if worried
Temporisation
- fluids, metaraminol
Diagnosis
- likely: post anaes vasoplegia, hypovolaemia
- serious: bleeding, anaphylaxis, sepsis, cardiac
- other
Treatment
- check for signs of serious DDx
- Hb, drains, ACS risk - TTE/ECG/Trop/Cardio
60
35M in recovery post transphenoidal hypophysectomy now with marked stridor. Problem-solving framework
Safety (CHeSS)
- Check reading/transducer/monitor and trend
- Scan pt/monitors
- call for help
Temporisation
- positioning
- oxygenate
- airway manuevers+adjuncts
Diagnosis
- likely: loss of airway tone and decreased conscious state
- serious: residual paralysis, throat pack/foreign body, anaphylaxis
- other
Treatment
- check for signs of serious DDx
- BVM/jaw thrust/MPA/OPA - if straining like laryngospasm - CPAP/prop/sux
- neuromuscular monitoring - TOF<0.9 give reversal
- inspect throat, suction, remove any foreign body
- inspect wound for haematoma/swelling
- auscultate - wheeze-salbutamol
61
40F diagnostic lap for endo with high ventilating pressures. 120kg and T1DM. Problem-solving framework
Safety (CHeSS)
- Check reading/transducer/monitor
- call for Help
- Scan pt/surgery/monitor
- Stop surgery
```
Temporisation
- 100% FiO2
- increase flow
- Bag
+/- paralysis
```
Diagnosis
- likely: weight and head down ventilation or circuit kink
- serious: bronchospasm, endobronchial intubation,
- other
Treatment
- check for signs of serious DDx
- with bag check compliance: tight/wheeze/kink or obstruction? loss of pressure - increase APL and reventilate, check ETT position
- check circuit from machine to ETT, if issues switch to laerdel bag, use bougie to check ETT
- Auscultate lungs: wheeze-salbutamol/adrenaline, mucous - suction/peep, unilat sounds-ptx, APO-LMNOP, Aspiration - suction, bronch
62
80M post GA for cataract op, diabetic. failed block converted to GA. now unresponsive 30min after the end of the case. Problem-solving framework
DELAYED EMERGENCE
Safety (CHeSS)
- Check reading/transducer/monitor
- call for Help
- Scan pt/monitor
Temporisation
- O2, assited ventilation maneuvers +/- adjuncts + support BP/HR (ABCs)
Diagnosis
- likely: age/length of case/opioids/BSLs
- serious: stroke, local anaesthetic spread
- other
Treatment
- Assess ABCs
- Check chart - hypontics, muscle relaxants, opioids, other. antidote - naloxone, flumazenil, sugammadex as appropriate
- ABG/VBG - Na, PCO2, BSL
- consider rare: LA spread, Stroke
63
Causes of hypoxaemia and management
1. LOW FiO2
- O2 not connected, diffusion hypoxaemia
Tx- incease O2
2. HYPOVENTILATION
- Low minute ventilation, all failure to breathe causes (CNS/muscle/chest wall), all stridor causes
Tx- ensure adequate MV, check ETCO2
3. VQ MISMATCH (MOST COMMON)
- bronchospasm, aspiration, atelectasis, APO, NPPO, consolidation, PE, PTx, anaphylaxis
Tx - bronchodilators, increase volatile, recruitment, suction, LMNOP, needle decomp/ICC
4. SHUNT
- cannot be overcome by 100% FiO2
- ARDS, pneumonia, atelectasis
5. DIFFUSION ABNORMALITY
- ILD, COPD
64
Causes of high ventilating pressures and management
1. MACHINE
- Flow valves
Tx - inspect, use laerdel bag
2. CIRCUIT
- kink in tubing
Tx - inspect, use laerdel
3. HEAT AND MOISTURE EXCHANGE (HME)
- obstruction from secretions
Tx - exhange
4. ETT
- kink, secretions, biting, cuff herniation, endobronchial intubation
Tx - inspect, pass bougie/suction
5. PATIENT
- inadequate paralysis, bronchospasm, sputum plug, PTx, pneumoperitoneum, APO
Tx - cause specific
65
Causes of tachycardia and management
1. PHYSIOLOGICAL
- Resp: O2/CO2/pH, all lung path (PTx, asp, bronchospasm)
Tx - optimize O2, ventilation
- CVS: causes of shock
Tx - check surgical field, volume, check Hb
- CNS - stroke
Tx - CT
- Metabolic/Endo: temp, thyroid, phaeo, BSLs, MH
Tx - specific to cause
- PAIN somatic (wound), visceral (full bladder), anxiety
Tx - analgesia, IDC for long case (ensure not blocked)
2. PHARMACOLOGICAL
- Depth of anaesthesia, drug error, reaction, withdrawal, illicit use
Tx - volatile, propofol, cease drug, supportive
3. SURGICAL
- bleeding, tourniquet, brainstem manipulation, pneumoperitoneum
Tx - treat blood loss, tolerate if all else ruled out
BB therapy - esmolol 0.25-0.5mg/kg bolus followed with metoprolol 1mg bolus q15min
66
Causes of bradycardia and management
1. PHARMACALOGICAL
- Metaraminol, BB, CCB, Amiodarone, Digoxin, Anticholinesterase, redose sux
Tx - cease drug
2. VAGAL
- Traction on viscera/pleura/peritoneum, barorecptor (CEA, raised ICP, metaraminol), OC reflex, Bezold-Jarisch reflex, laryngeal
Tx - cease stimulus
```
3. Physiological
CVS
- AMI/arrhythmia
Tx - glyco/atropine/ephedrine/adrenaline
Neuro
- raised ICP
Metab
- hypothermia, hyperkalaemia, hypothyroid
```
Pacing if needed
67
Causes of failure to breathe and management
1. CNS - delayed emergence
- all failure to emerg causes (phys/pharm/neuro/other)
Tx- as per delayed emergence
2. MUSCLE FUNCTION - essentially causes of hypoventilation
- CNS (UMN/LMN), NMJ, lung, chest wall, pain
Tx - assisted ventilation
68
Causes of hypertension and management
1. PHYSIOLOGICAL
- Resp: O2/CO2/pH
Tx - optimize O2, ventilation
- CNS - raise ICP, autonomic dysreflexia
Tx - CT
- Metabolic/Endo: temp, thyroid, phaeo, BSLs, MH,
Tx - specific to cause
2. PHARMACOLOGICAL
- Depth of anaesthesia, drug error, reaction, withdrawal, illicit use
Tx - volatile, propofol, cease drug, supportive
3. PAIN
- somatic (wound), visceral (full bladder), anxiety
Tx - analgesia, IDC for long case (ensure not blocked)
4. SURGICAL
- bleeding, tourniquet, pneumoperitoneum
Specific meds: can increase anaesthesia, hydralazine 5mg, phentolamine 0.5mg, BB, GTN/SNP
69
Causes of hypotension and management
1. PRELOAD
- hypovolaemia, venodilation, increased ITP
Tx- Check surgical field/drain/suction/PPV/Hb, give volume
2. RATE + Rhythm
- too fast or slow
Tx - ECG, ALS
3. CONTRACTILITY
- AMI, O2/CO2/pH, electrolytes
Tx - ECG, VBG, TTE, CO monitor
5. AFTERLOAD
- increased (AS/HOCM), decreased (Sepsis/anaphylaxis/pharm)
Tx - vasopressors, specific treatment
6. OBSTRUCTIVE
- Tampondae, Tension, PE
Tx - decrease anaesthetic agents, specific treatments
70
Causes of hypercapnoea and management
1. MAKING TOO MUCH
- MH, Thyrotoxicosis, sepsis, exogenous (Pneumoperitoneum)
Tx - specific
2. EXHALING TOO LITTLE
- hypoventilation, deadspace
Tx - increase MV, decrease pneumoperitoneum/go open, fluid resus
3. REBREATHING
- exhausted soda lime, low flow
Tx - replace soda lime, increase flow
71
Causes of stridor and management
1. INTRALUMINAL
- Foreign body, blood/mucus/vomit
Tx - suction, laryngoscope + mcgills
2. LUMINAL
- laryngospasm, Oedma/anaphylaxis, decreased airway tone, tracheomalacia, invasive ca
Tx - anaphylaxis tx, airway manuevers, ETT
3. EXTRINSIC
- RPA, PTA, Haematoma, Trauma
Tx - specific
72
Causes of delayed emergence/decreased GCS and management
1. PHYSIOLOGICAL
- O2/CO2/pH, Temp, BP, Na, BSL
Tx - monitors, vbg, Tx cause
2. PHARMACOLOGICAL
- NMBD, opioids, BZDs, volatiles, prop, neuroleptics, antipsychotics, CNS spread of LA
Tx - check etVOL/drugs given, neuromuscular monitoring, sugammedex/naloxone/flumazenil
3. NEURO
- stroke, seizure, psychosomatic
Tx - CT
4. OTHER
- Thyroid
Tx - TFTs
73
CRM - 35F for lap appx. small hospital with no ICU/CCU. induce and then 1min later BP 60 and pt is difficult to ventilated with pressures of 40cmH2O only delivering 100mL of tidal volume.
Safety (CHeSS)
- Check readings/transducer/monitor, finger on pulse
- call for Help
- Scan pt/surgery/monitor
- Stop surgery
concern for anaphylaxis
Temporizing: Combine hypotension and hypoxia/highpressure - fluids, metaraminol, 100% O2, increase flow, bag
Call for anaphylaxis box
immediate priorities
- cease trigger
- Oxygenation (ETT, obstructive ventilation strat, high flow 100% O2, salbutamol)
- volume resus (2L STAT, reassess as 2L extravasates in first 10 mins)
- adrenaline (50mcg iv bolus, infusion at 10-20mcg/min - 3mg in 50mL syringe, titrate)
- monitoring and lines (2x large PIVC, art line, CVC later)
Call ARV to locate ICU bed
74
CRM - 50F for lap hysterectomy, on inserting veress needle sudden drop in ETCO2 and BP
Safety (CHeSS)
- Check readings/transducer/monitor, finger on pulse
- call for Help
- Scan pt/surgery/monitor
- Stop surgery
concern for puncture of a major vessel and air embolism
Temporizing: fluids, metaraminol
immediate priorities
1. repairing the vessel - vasc surgeons
2. air embolus - 100% O2, +/- CPR, support foreward flow
3. fluid resus (IV, fluis, MTP, art line)
75
CRM - 60M for laminectomy in prone position. vent alarms showing loss of pressure, ETT looks dislodged, pt was grade III ariway previously
Safety (CHeSS)
- Check readings/transducer/monitor
- call for Help
- Scan pt/surgery/monitor
- Stop surgery
concern for loss of airway
temporizing: 100% O2, high flow, bag, have surgeon gain immediate hemodynamic control
immediate priorities:
- turn pt supine
- regain airway (assistant, paralysis, airway equip, video layngoscope)
76
CRM- 35F G1P0 37/40 on maternity ward with abdo pain - BP 70, HR 140 PHx large fibroid excision, after 1L fluid on ward HB returns at 60 with presumed uterine rupture
Safety (CHeSS)
- Check readings/transducer/monitor
- call for Help
- Scan pt/surgery/monitor
- Stop surgery
concern for uterine rupture
Temporizing: fluids, metaraminol
immediate priorities
1. lines - 2x PIVC
2. resus - fluids, MTP
3. control the bleeding - O&G, theatre
4. baby - notify paeds
77
CRM- 40M for lap nephrectomy PHx HTN and T1DM on induction w prop/fent/atrac unable to BMV, grade 4 view with video, after optimization O2 is 90% after 3 attempts
Safety (CHeSS)
- Check readings/probe/monitor
- call for Help
- Scan pt/surgery/monitor
concern for CICO
immediate priorities
- ask to prep for surgical airway (scalpel, bougie, size 6 tube)
- follow DAS guidelines to obtain airway with LMA
