Crisis Scenarios

Question 1

Most common intraoperative medications that cause anaphylaxis:

Answer 1

succinylcholine & rocuronium

Question 2

Perioperative s/s of anaphylaxis:

Answer 2

CV: hypotension & tachycardia
Respiratory: bronchospasm & pulmonary edema
Skin: flushing & hives

Question 3

Treatment for protocol:

Answer 3

1. discontinue triggering agent
2. Assess patient/ put them in trendelburg
3. Ventilate with 100% oxygen
4. Fluid administration- crystalloid or colloid
5. Medications give- epinephrine, antihistamines, corticosteroids, nebulized albuterol

Question 4

Describe the administration of epinephrine for anaphylaxis:

Answer 4

Grade II: 10-20 mcg SC/IM
Grade III: 100-200 mcg SC/IM/IV q1-2 mins
Grade IV: 1 mg IV repeat as needed

Question 5

Post anaphylaxis, it is necessary to:

Answer 5

observe for 24 hours for signs of reoccurrence, notify patient/family member of reaction, refer to allergist, serum tryptase <120 min

Question 6

Describe how much fluid you would give in the setting of anaphylaxis:

Answer 6

Normal saline/LR: 10-30 mL/kg or Colloid: 10 mL/kg

Question 7

What do you give for airway edema in the setting of anaphylaxis?

Answer 7

hydrocortisone 250 mg IV

Question 8

Describe the dosage of antihistamine for anaphylaxis.

Answer 8

diphenhydramine or hydroxyzine 0.5-1.0 mg/kg IV

Question 9

Risk factors for bronchospasm include:

Answer 9

asthmatics, reactive airway disease, & advanced age

Question 10

Manifestation of bronchospasm includes:

Answer 10

increased work of breathing, V/Q mismatch, increased PVR and RV overload

Question 11

Causes of bronchospasm:

Answer 11

Manipulation of the airway- induction, emergence & repositioning
Anaphylaxis
Medications: desflurane, histamine releasers, acetylcholinesterase inhibitors, beta 2 adrenergic antagonist, hemabate
cold air
aspiration

Question 12

Signs and symptoms of bronchospasm include

Answer 12

Changes in expiration- diffuse wheezing to no sounds
shark fin capnograph (no capnograph if severe)
elevated peak inspiratory pressures
difficult manual ventilation
may see hypotension (anaphylaxis, air trapping)

Question 13

Preventing bronchospasm includes

Answer 13

Preoperative airway assessment that identifies risk factors for reactive airways, allergies, and aspiration
intervention with albuterol & corticosteroids (3-5 days prior)

Question 14

Steps to treating bronchospasm:

Answer 14

1. high flow 100% O2
2. manual ventilation and ensure time for exhalation
3. Call for help
4. Assess for and remove irritating stimulus
5. increase volatile anesthetics or administer ketamine
6. give albuterol 2.5-5.0 mg in 5 mL NS nebulizer or 200-300 mcg via MDI

Question 15

Second line treatments for bronchospasm if patient has refractory bronchospasm:

Answer 15

10-20 mcg IV/SC epinephrine (0.1-0.5 mg if due to anaphylaxis)
0.25 mg SC terbutaline
intubate if patient is not already intubated

Question 16

Laryngospasm is due to the

Answer 16

hyperresponsive glottic closure reflux as a result of superior laryngeal nerve stimulation

Question 17

Causes of laryngospasm include:

Answer 17

airway manipulation, noxious stimuli within the pharynx, inadequate anesthetic depth causing laryngeal stimulation

Question 18

Patients with higher risk for laryngospasm include:

Answer 18

reactive airway disease, infection, inflammation or exposure to irritants, airway abnormality & GERD, & certain surgical procedures

Question 19

Ways to reduce the risk for laryngospasm:

Answer 19

deepen anesthesia, avoid desflurane, postpone surgery, optimize patient, albuterol treatment

Question 20

Signs and symptoms of laryngospasm:

Answer 20

hypoxia- observed desat., no gas exchange occurring
see-saw breathing
negative pressure pulmonary edema
CV effects

Question 21

Treatment protocol for laryngospasm:

Answer 21

1. Call for help
2. remove stimulus
3. administer 100% fiO2
4. create open and clear airway
5. perform jaw thrust
6. Apply positive pressure ventilation (10-30 cmH2O)
7. Enhance depth of anesthesia- give propofol
8. Administer succinylcholine
9. mask ventilate & monitor patient

Question 22

Causes of negative pressure pulmonary edema include:

Answer 22

Adults: laryngospasm, upper airway tumor, postoperative vocal cord paralysis, obesity
Children: epiglottitis, croup, laryngeotracheobronchitis

Question 23

S/S of negative pressure pulmonary edema include:

Answer 23

cough, pink frothy sputum, decreased lung compliance (difficulty bagging, high airway pressures), tachypnea, reduction in O2 saturation, tachycardia, pulmonary infiltrates

Question 24

Steps to treating negative pressure pulmonary edema:

Answer 24

1. elevate the head of the bed
2. Maintain patient airway- provide supplemental O2, initiate PPV
3. Administer steroids & diuretics
4. limit fluid intake
5. aerosolized bronchodilator
6. obtain/ monitor ABGs
7. Maintain lower tidal volumes & plateau airway pressures

Question 25

The fire triad includes:

Answer 25

oxidizer (O2, Nitrous oxide), ignition (ESUs, lasers, fiber-optic lights), fuel (towels, gauze, sponges, drapes, alcohol based preparation solutions)

Question 26

For a non-airway fire:

Answer 26

stop the flow of all airway gases, remove drapes and any burning material, extinguish burning solutions with saline 1. maintain ventilation 2. assess for inhalation injury if the patient is not intubated

Question 27

For airway fire:

Answer 27

remove ETT, stop the flow of all airway gases, remove sponges and any flammable material from the airway, pour saline into the airway Next: 1. re-establish ventilation 2. avoid oxidizer rich environment 3. examine to see if tracheal tube fragments are left behind 4. consider bronchoscopy