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Final FRCA > Critical Incidents > Flashcards

Critical Incidents Flashcards

1
Q

Accidental decannulation of tracheostomy

A

I would follow the National Tracheostomy Safety Project Guidelines
* ABC
* Increase FiO2 and FGF
* Get help
* Airway opening manoeuvres to upper airway
* Look, listen and feel at trache for 10 seconds
* If the patient is breathing - apply 100% oxygen to upper airway and to tracheostomy
* If the patient is not breathing and no signs of life —> call 2222 and start CPR
* If the patient is not breathing but there is signs of life —>
* Assess stoma patency, remove speaking valve, cap and inner tube, try to suction
* Consider attempting recannulation or intubation through stoma (smaller tube/size 6 ETT)
* Consider oral intubation (risk of difficult intubation)
* Consider oxygenation via iGel/LMA over stoma site

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2
Q

Adult status epilepticus

Convulsive seizures that continue for 5 minutes or more

A
  • A - ensure airway patent, consider NP airway, apply oxygen
  • B - assess breathing
  • C - assess circulation
  • Establish IV/IO access
  • Follow individualised emergency management plan if available
  • D - 1st line treatment - buccal midazolam 0.5mg/kg (10mg) or rectal diazepam 10mg if no IV access
    – Lorazepam 0.1ml/kg (max 4mg) IV
    – consider cause of seizure - check BM, consider Mg if pregnant, infection, withdrawal
  • 2nd dose of benzodiazepine after 5-10 minutes
  • If no response to 2x benzos –> 2nd line IV treatment
    – levetiracetam 60mg/kg
    – phenytoin 20mg/kg
    – sodium valproate 40mg/kg
  • Consider alternative 2nd line agent
  • Consider 3rd line options - phenobarbital/GA
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3
Q

Airway fire (Laser)

A

Fire triad:
1. Ignition source - electrocautery, lasers, static electrocity, heated probes, drills and burrs, fibreoptic light sources and cables, defib pads, argon beam coagulators
2. Oxidiser - O2 or N2O via closed or semi-closed breathing circuits, open-breathing circuits with inappropriately configured surgical drapes that trap oxygen
3. Fuel source - ETT, surgical drapes

  • Early recognition
  • Alert surgeon and theatre team
  • Discontinue laser surgery/discontinue diathermy
  • Stop ventilation - disconnect breathing circuit
  • Disconnect oxygen source
  • Remove burnt ETT/flammable material from airway
  • Flood site with sterile water/saline to extinguish fire
  • May need to use CO2 extinguisher if fire remains active (activate fire alarm etc if relevant)
  • Re-instate ventilation via ambu-bag/re-intubate and ventilate with room air
  • Perform bronchoscopy to assess damage and identify residual materials
  • Consider further management e.g. trache, steroids, BAL, antibiotics, ITU, humidified O2
  • Incident report
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4
Q

Anaphylaxis

A
  • Call for help
  • A - ensure patent airway (listen for hoarse voice, stridor)
    – apply high flow oxygen - titrate to SpO2 94-98%
  • B - assess breathing (look for increased WOB, wheeze, fatigue, cyanosis and SpO2 <94%), consider ABG
  • C - assess circulation (look for hypotension, signs of shock, confusion and reduced consciousness)
    – obtain IV access, give fluid bolus 10ml/kg (500-1000ml), lie flat/raise legs
  • give IM adrenaline (anterolateral aspect - middle third of the thigh)
    – 500mcg 0.5ml of 1:1,000 IM child >12 years and adults
    – 100-150mcg child <6 months
    – 150mcg child 6 months to 6 years
    – 300mcg child 6-12yrs
  • Remove trigger if possible
  • Apply monitoring - pulse oximetry, ECG, BP
  • Repeat IM adrenaline after 5 minutes
  • If no improvement in breathing or circulation problems despite two doses of IM adrenaline
    – confirm additional help has been called
    – follow refractory anaphylaxis algorithm
    – 0.5-1ml/kg/hr adrenaline infusion, titrated to clinical response
    – repeat IM adrenaline every 5 minutes until adrenaline infusion started
    – take blood sample for mast cell tryptase, repeat at 1-2hrs and >24hrs

Additional ABC Interventions
* Airway
– nebulised adrenaline 5ml of 1:1000
– consider early intubation
* Breathing
– BMV
– consider intubation
– nebulised salbutamol and ipratropium
– consider IV salbutamol or aminophylline
– inhalational anaesthesia
* Circulation
– further fluid boluses
– arterial BP monitoring
– consider CVC
– consider addition of second vasopressor if needed (glucagon if beta blocked)
– consider extracorporeal life support

Consider steroids and antihistamines for refractory reactions after initial resuscitation

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5
Q

APH

A

Definition
* Spotting - staining, streaking or blood spotting noted on underwear or sanitary protection
* Minor haemorrhage - blood loss less than 50ml that has settled
* Major haemorrhage - blood loss 50-1000ml, with no signs of clinical shock
* Massive haemorrhage - blood loss greater than 1000ml and/or signs of clinical shock
* Recurrent - episodes of APH on more than one occasion

Causes
* Abruption
* Placenta praevia
* Vasa previa
* Trauma

Management
* Assess and support ABCs
* IV access (x2)
* Take bloods, VBG + ROTEM
* Declare MOH if relevant

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6
Q

Awareness under anaesthesia

1:8000 with NMBA

A

Becoming consious when the intention was for the patient to be unconscious

  • Failure to deliver sufficient anaesthetic agent to the body
    – interruptions in supply of agent
    – drug errors
    – low-dosing regimens
  • Individual patient resistance to an otherwise sufficient dose of anaesthetic agent
    – physiological
    – pharmacological
    – genetic?

Management
* NAP 5 AAGA Bundle
* Meet F2F with patient (and witness)
* Listen to story in detail, elicit sensations experienced (accept as genuine)
* Express regret at occurance of AAGA
* Consult with local psychology support
* Analysis - seek cause using NAP 5 bundle, check details of patients story with documentation/staff, seek independent opinion of analysis
* Support patient - detect impact early, active follow up, formal referral for psychological support if impact persists

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7
Q

Blocked/displaced tracheostomy

A
  • Follow algorithm
  • Safety, stimulate, shout for help
  • Open airway, apply high flow O2 to trache and face
  • Suction to assess trache patency, consider changing inner tube if present
  • If patent –> continue ABC assessment and stabilisation
  • If not patent –> attempt tube change
  • Attempt oral airway manouevres and oxygenation (cover stoma)
  • Attempt oxygenation via stoma (paediatric face mask or SGA)
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8
Q

Bone Cement Implantation Syndrome

A

BCIS is characterised by hypoxia, hypotension or both and/or unexpected loss of consciousness occurring around the time of cementation, prosthesis insertion, reduction or joint or, occasionally, limb tourniquet deflation in a patient undergoing cemented bone surgery.

Grade 1 - moderate hypoxia or hypotension
Grade 2 - severe hypoxia or hypotension or unexpected loss of consciousness
Grade 3 - cardiovascular collapse requiring CPR

Cause (theories)
* Increased intramedullary pressure at cementation leading to embolisation
* Embolic showers
* Mediator release from emboli –> increased PVR
* Histamine release and hypersensitivity
* Complement activation

Risk factors
* old age
* poor pre-existing physical reserve
* impaired cardiopulmonary function
* pre-existing pulmonary hypertension
* osteoporosis
* bony metastases
* pathological or intertrochanteric fractures
* PFO/ASD
* previously un-instrumented femoral canal
* long stem arthroplasty

Management
* Assess and support ABCs
* Increase FiO2 and FGF
* Aggressive fluid resuscitation
* Alpha agonists
* Invasive monitoring

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9
Q

Bradyarrhythmia

A
  • Increase FiO2 and FGF
  • Call for help and alert theatre team
  • Identify and treat reversible causes
    – stop any stimulus, check pulse, rhythm and BP
    – if adverse features –> atropine 20mcg/kg (0.5-1mg adult - max 3mg)
  • ABCD
  • Follow ALS bradyarrhythmia algorithm
  • Consider transcutaneous pacing (electrical and mechanical capture, set pacer output 10mA above capture) +/- transvenous pacing +/- PPM
  • Consider other drugs
    – glycopyrrolate 5mcg/kg (200-400mcg)
    – ephedrine 100mcg/kg (3-12mg)
    – isoprenaline 0.5mcg/kg/min (5mcg/min)
    – adrenaline 1mcg/kg (10-100mchg)

Causes
* consider drug error
* consider known drug causes - remifentanil, digoxin, LA toxicity, beta blocker, calcium channel blocker
* surgical stimulation with inadequate depth
* oculocardiac reflex?
* pneumoperitoneum
* raised ICP
* electrolyte abnormalities
* hypothermia
* MI

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10
Q

Bronchospasm

A
  • ABC
  • Call for help
  • Increase FiO2 and increase FGF
  • Cease any stimulation (airway or surgical)
  • A - exclude malpositioned or obstructed tracheal tube/SGA, consider suction if evidence of airway soiling
  • B - inspect, percuss, palpate and auscultate
  • Deepen anaesthesia
  • Drugs that may help:
    – Salbutamol +/- ipratropium nebulisers
    – IV salbutamol
    – Consider IV or nebulised adrenaline
    – Steroids - 4mg/kg hydrocortisone (200mg adult)
    – Magnesium - 50mg/kg (2g adult dose)
    – Aminophylline 5mg/kg bolus then infusion
    – Volatile agent
    – Ketamine - 20mg, infusion of 1-3mg/kg/hr
  • Ventilation strategies
    – increased expiratory time
    – PCV
    – permissive hypercapnia
    – avoid “breath stacking” - decompress chest if required
  • Consider alternate diagnoses
  • Perform CXR when possible
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11
Q

Cardiac Arrest

A

D - check for danger
R - shake and shout for response
CALL for help

A - open airway
B - check for breathing (10s)
C - check for circulation
CONFIRM cardiac arrest, COMMENCE CPR, CONNECT defib, CONFIRM rhythm

CPR 30:2/asynchronous
Shockable - defib, 1mg adrenaline + 300mg amiodarone after 3rd shock, 1mg adrenaline + 150mg amiodarone after 5th shock
Non shockable - adrenaline 1mg then every 3-5 minutes
4Hs and 4Ts

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12
Q

Cardiac arrest following cardiac surgery

A
  • DR ABC
  • Get help
  • Confirm cardiac arrest
  • Assess rhythm
    – if VF/VT –> give 3x 150J DC shocks
    – asystole/bradycardia –> external/internal pacing
    – PEA –> stop any pacing and commence chest compressions
  • Commence BLS (withold chest compressions up to 1 minute if shocking/pacing)
  • Avoid adrenaline
  • Amiodarone 300mg + 150mg in refractory cases (can give 1mg/kg lidocaine as alternative)
  • DC shock every 2 minutes if shockable rhythm
  • Prepare for resternotomy within 5 minutes of arrest –> internal cardiac massage or defibrillation (20J)

Causes
* Hypovolaemia
* Arrhythmias
* Tamponade

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13
Q

CICO

A

Plan A - intubate
Plan B - LMA (consider fibreoptic intubation through LMA)
Plan C - oxygenate - FM/LMA/2 person + adjuncts
Plan D - CICO - surgical cricothyroidotomy

  • Call for help
  • Declare CICO, call for airway rescue trolley and cardiac arrest trolley
  • Continue 100% oxygen via upper airway
  • Ensure neuromuscular blockade
  • Position patient with neck extended
  • Equipment - scalpel no. 10 blade, bougie, cuffed 6.0 ETT
  • Laryngeal handshake
  • FONA - stab, twist, bougie, tube technique
    – identify cricothyroid membrane
    – transverse incision through skin and membrane
    – rotate scalpel 90 degrees with sharp edge facing caudally
    – slide angled tip of bougie past the scalpel into the trachea
    – railroad lubricated tube over bougie
  • If impalpable anatomy - scalpel, finger, bougie technique
    – make an 8-10cm vertical incision head to tow orientation
    – blunt dissect to identify trachea
    – stabilise trachea and proceed as above
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14
Q

CPR in Pregnancy

A

D - check for danger
R - shake and shout for response
CALL for help
left lateral displacement of uterus if visible pregnancy/>20 weeks gestation
A - open airway
B - check for breathing (10s)
C - check for circulation
CONFIRM cardiac arrest, COMMENCE CPR, CONNECT defib, CONFIRM rhythm

  • CPR 30:2/asynchronous
  • Early intubation with cricoid pressure
  • Shockable - defib, 1mg adrenaline + 300mg amiodarone after 3rd shock, 1mg adrenaline + 150mg amiodarone after 5th shock
  • Non shockable - adrenaline 1mg then every 3-5 minutes
  • 4Hs and 4Ts
  • Decision to deliver by 4 minutes
    Uterus evacuated by 5 minutes (at site of arrest)
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15
Q

Decreased end tidal CO2 level

A
  • Adequate oxygen delivery - check FiO2, connections, bag/bellows moving, increase FiO2 and FGF
    ** if sudden fall: disconnection/cardiac arrest**
    – check equipment, hand ventilate
  • Clear airway - airway position, airway noise, adjuncts, LMA/ETT clear, check capnograph trace shape
  • Check breathing - rate, symmetry, SpO2, expiratory tidal volume, EtCO2, airway pressure
  • Check circulation - rate, rhythm, perfusion, BP
    – exlude/manage decreased cardiac output
  • Check depth - anaesthesia, analgesia
  • Adjust ventilation

Causes
* increased elimination of CO2 - hyperventilation, apnoea, total airway obstruction, extubation
* decreased perfusion (decreased CO) - hypotension, hypovolaemia, PE
* decreased CO2 production - hypothermia
* equipment issues - circuit disconnection, leaks in sampling tube, ventilator malfunction

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16
Q

Dental damage

A
  • Minor injuries to lips and/or tongue are common 1in 20 GAs
  • Serious damage to the tongue is rare
  • Overall risk of damage to teeth requiring subsequent removal or repair occurs in around 1 in 4,500 GAs
  • Risk increased in poor dentition, crowns, bridges, veneers or implants (especially on front teeth) and those with reduced mouth opening or neck movement, prominent upper teeth or small lower jaw, RA/AS

Management
* Avulsion (tooth out of socket) –> if patient not immunocompromised, push tooth into socket and hold for several minutes (do not touch root surfaces)
* Avulsion –> store tooth in saline or milk
* Damage –> locate loose fragments
* Documentation
* Inform supervising consultant (if relevant)
* Explain to the patient and offer apology
* Follow local guidelines for dental involvement

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17
Q

Difficult IPPV

A
  • ABC
  • Increase FiO2, increase FGF
  • Visual inspection of entire breathing system including valves and connections
  • Check ETT +/- pass suction catheter
  • Check capnogram trace
  • Hand ventilate
  • Check chest symmetry, rate, breath sounds, SpO2, exp TV, ETCO2, assess airway pressure
  • Auscultate
  • Check HR, rhythm, perfusion, BP, consider possibility of gas trapping
  • Ensure adequate depth or anaesthesia and analgesia
  • Get help, check ABG, ECG, CXR
  • Manage specific cause e.g. laryngospasm, bronchospasm, anaphylaxis etc
    – suction
    – bronchodilator
    – PEEP
    – diuretic
    – bronchoscopy
    – release pneumoperitoneum and levelling patient position

Causes
* Equipment fault
* Obstruction
* Increased airway resistance
* Decreased respiratory compliance

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18
Q

Difficult mask ventilation

A
  • Optimise position
  • Airway manouevres
    consider depth of anaesthesia, consider relaxant
  • Airway adjuncts
  • CPAP
  • Call for help and difficult airway trolley
  • 2 person technique/change operator
  • Consider waking
  • Attempt SAD x2 or ETT x2
  • If O2 sats <90% –> CICO

Risk Factors
* male
* mask seal - beard, edentulous
* mallampati 3 or 4
* mandibular protrusion
* age >55
* snoring/sleep apnoea
* kilograms - BMI >26

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19
Q

DKA

A

DKA is a potentially life-threatening complication of diabetes.

Diagnostic criteria
* capillary BM >11
* capillary ketones >3 or urinary ketones ++
* venous pH <7.3 or bicarb <15

Immediate Management
* Assess and support ABCs
* IV access
* IV fluid resuscitation
* FRII 0.1 units/kg/hr
* Check lab glucose, VBG, U+Es, FBC, cultures, ECG, CXR, MSU
* Hourly BM and capillary glucose
* Monitor VBG
* Monitor + replace K+
* Consider and treat precipitating causes
* Avoid I+V (due to compensatory respiratory alkalosis)
* Follow local protocols

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20
Q

Extravasation injury

Accidental injection or leakage of fluid into the subcutaneous tissues

A

Risk factors
* Patient factors - elderly, neonates, infants, scalp veins, multiple IV therapies, obesity, oedematous tissue, concurrent disease causing decreased peripheral sensation or circulation
* Adminstration methods - automated syringe drivers, pressure bags, insufficient depth of CVC lumens
* Drug and formulation factors
– vesicants - cause inflammation, pain and blistering leading to tissue death and necrosis
– exfoliants - inflammation and shedding of skin but less likely to result in loss of tissue viability
– irritants - inflammation and irritation but rarely lead to tissue breakdown
– cytotoxic drugs - damage tissues
– hyperosmolar substances e.g. CaCl, glucose, MgSo4, TPN, mannitol
– highly acid/alkali solutions
– vasoconstrictors - local ischaemia and tissue death
– drugs prepared in formulations containing alcohol or polyethylene glycol –> tissue necrosis
– high volume –> mechanical compression
– stronger concentration formulation

Pathophysiology
* Vasoconstriction and ischaemic necrosis
* Direct toxicity
* Osmotic damage
* Extrinsic mechanical compression
* Superimposed infection

Specific drugs
* Amiodarone - tissue necrosis
* Atracurium, ketamine, thiopental - ischaemia, necrosis
* Phenytoin - cellulitis, ischaemia, necrosis
* Rocuronium - local irritation
* Atropine, fentanyl, midazolam, morphine, sux - none reported
* Propofol - usually none

Management
* stop the injection/disconect the infusion
* aspirate as much drug as possible from the cannula
* leave cannula in place until advice sought regarding further treatment - then remove
* if visible, mark the area of extravasation or take photographs
* elevate the limb
* consider specific treatments if appropriate
– saline ashout
– liposuction
– steroids
– hyaluronidase
– phentolamine
– regional sympathetic block
* consider referral to plastic surgery
* ensure documentation is complete

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21
Q

Circulatory embolus

Thrombus, fat, amniotic fluid, air/gas

A

Signs: hypotension, tachycardia, hypoxaemia, decreased ETCO2
Symptoms: dyspnoea, anxiety, tachypnoea, sudden loss of CO

  • Call for help and alert theatre team
  • Call for cardiac arrest trolley
  • Stop all potential triggers. Stop surgery
  • A - maintain the airway, and if necessary, secure it with tracheal tube
  • B - Give 100% oxygen and ensure adequate ventilation
  • C - if indicated, start CPR
  • Give IV crystalloid +/- inotropes
  • Consider ABG, TOE, CT

Thromboembolism
* consider thrombolysis
* consider embolectomy/IR

Fat embolism
petechial rash, desaturation, confusion/irritability
* supportive measures

Amniotic Fluid Embolism
* supportive measures
* monitor the fetus, if undelivered
* treat coagulopathy - FFP/fibrinogen/platelets
* consider plasmaphoresis

Air/Gas Embolism
“mill wheel” murmur may be present
* discontinue source of air/gas if applicable and discontinue N2O
* tell surgeon to flood wound with saline and cover with wet packs
* lower surgical field to below level of heart if possible (trendelenburg)
* jugular venous compression to reduce air entrapment
* place patient in left lateral position if possible (relieve air lock in RA)
* if CVC in situ, attempt to aspirate air with tip in RA
* volume loading and Valsalva may help - increase venous pressure

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22
Q

High/complete spinal

A

Symptoms (progression may be slow or fast)
* hypotension and bradycardia
* difficulty breathing
* paralysis of arms
* impaired consciousness
* apnoea and unconsciousness

  • ABC, increase FiO2 and FGF
  • Call for help and inform theatre team
  • Stop epidural, consider head up position
  • Consider I+V if A/B/D compromised
  • Treat circulatory compromise - fluids, elevate legs, releave aorto-caval compression, treat bradycardia or hypotension
  • Maintain sedation and ventilate until block worn off
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23
Q

Hypertension under anaesthesia

A
  • Immediately recheck BP, increase anaesthesia AND reduce stimulus
  • Check adequate oxygen delivery, consider increasing FGF/FiO2
  • ABC assessment
  • Breathing - exclude hypoxia and hypercarbia
  • Check depth and delivery of anaesthesia
  • Exclude drug response
  • Eliminate measurement artefact
  • Consider (and treat) underlying problem
  • Temporising drug:
    – alfentanil
    – propofol
    – labetalol/esmolol
    – hydralazine/GTN
  • Call for help if not resolving

Causes
* inadequate analgesia/anaesthesia
* inadequate neuromuscular blockade
* drug error/interaction
* ommission of usual antihypertensives
* distended bladder
* vasopressor administered by surgeon
* surgical tourniquet
* excess fluid (over-administration/overload/TURP syndrome)
* medical causes: renal failure, raised ICP, seizure, thyrotoxicosis/phaeochromocytoma

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24
Q

Hypotension under anaesthesia

A
  • Check adequate oxygen delivery
  • Confirm airway position and patency
  • Exclude high intrathoracic pressure as a cause, assess breathing
  • Check circulation
  • Consider anticholinergic if HR <60 - glycopyrrolate 5mcg/kg or atropine 5mcg/kg
  • Consider vasopressor - ephedrine 200mcg/kg, phenylephrine 5mcg/kg, metaraminol 5mcg/kg, adrenaline 1mcg/kg
  • Consider fluid bolus
  • Consider positioning head down
  • If HR >100 (sinus) –> treat as hypovolaemia
  • If HR >100 (non-sinus) –> follow tachycardia management
  • Ensure correct depth of anaesthesia and analgesia (consider risk of awareness)
  • Exclude potential surgical causes (e.g. cement reaction, vagal response tosurgical stimulus) , consider other causes and call for help if not resolving quickly

Causes
* unnecessarily deep anaestheia
* autonomic effects of neuraxial block –> vasodilatation
* hypovolaemia - fluid/blood loss
* obstructive shock e.g. PTX/high intrathoracic pressure, tamponade, embolus
* cardiac ischaemia/cardiogenic shock
* anaphylaxis
* LA toxicity
* sepsis
* cardiac valvular problem
* impaired venous return e.g vena caval compression, pneumoperitoneum
* endocrine cause e.g. steroid dependency

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25
Q

Hypoxia in OLV

A

Immediately after initiation of OLV, there is a fall in arterial oxygenation and saturation which gradually picks up as HPV increases.
HPV is characteristically biphasic, with an early response begining within the first few seconds to reach a maximum in about 15 minutes, followed by a second phase that begins about 30-40 minutes later to peak at 2hrs.

Ideally, aim for oxygen saturations of >90% during OLV, no accepted figure for the safest lower limit.

Management
* Increase FiO2 to 1.0 (except in patients who have received bleomycin)
* Recheck position of DLT/BB
* Ensure that haemodynamics are acceptable and cardiac output optimal - treat with fluid, vasopressors, or inotropes as appropriate
* Perform recruitment manoeuvre to the ventilated lung (can cause transient hypotension and worsening of hypoxaemia if more blood diverted to the non-ventilated lung)
* Adjust PEEP to the ventilated lung (caution in COPD)
* Insufflation of oxygen to the non-ventilated lung
* Application of 1-5cmH2O of CPAP to the non-ventilated lung
* Intermittent re-inflation of the non-ventilated lung
* Mechanical restriction of blood flow to the non-ventilated lung by clamping of the pulmonary arteries by the surgeons (only in surgery for which the PA is due to be clamped anyway)
* Resumption or intermittent two lung ventilation

26
Q

Intra-arterial injection

A

Risk factors - morbidly obese, darkly pigmented skin, hypotensive patients, patients receiving multiple infusions through lines with numerous ports, ACF/groin, vascular anomalies

Identification - discomfort and pain on injection, failure of drug to have expected effect, pallor/parasthesia/hyperaemia/cyanosis of affected limb –> profound oedema and gangrene

Pathophysiology - arterial spasm, direct tissue destruction, chemical arteritis, drug precipitation and crystal formation –> tissue ischaemia and thrombosis

Specific drugs
* amiodarone, atracurium, rocuronium –> ischaemia
* ketamine –> necrosis
* phenytoin, thiopental –> ischaemia, necrosis, tissue death
* propofol –> hyperaemia, distal ‘blanching’
* atropine, fentanyl, midazolam, morphine, sux –> none reported

  • ABC
  • Get help
  • Stop injecting
  • Elevation of limb
  • Leave cannula in situ - administer saline, lidocaine (contentious) + papaverine
  • Obtain alternate IV access
  • Analgesia including regional/sympathetic block
  • Involve vascular surgeon + plastics
  • Careful documentation
27
Q

LA Systemic Toxicity

A
  • Numbness of tongue/perioral tingloing –> lightheadedness –> visual and auditory disturbances –> muscular twitching
  • Sudden alteration in mental status, severe agitation or loss of consiousness, with or without convulsions
  • Cardiovascular collapse - sinus bradycardia, conduction blocks, asystole, ventricular tachyarrhythmias

Management
* ABC
* Increase FiO2 and FGF
* Stop injecting the LA
* Call for help and inform team
* Call for cardiac arrest team and lipid rescue pack
* Secure airway if needed
* Ensure adequate lung ventilation, hyperventilation may help reduce acidosis
* Confirm or establish IV access
* Lipid emulsion regime (20% intralipid)
– 1.5ml/kg over 1 min then 15ml/kg/hr infusion
– can repeat bolus at 5-10 minutes if cardiovascular stability not restored or adequate circulation deteriorates
– double rate to 30ml/kg/hr as above
– do not exceed maximum cumulative dose 12ml/kg
* Manage seizures (benzo/thio/prop) and arrhythmias
* Monitor in critcal care area
* Report to MHRA
* Exclude pancreatitis - regular clinical review, daily amylase or lipase

28
Q

Laryngospasm

A
  • Call for help and alert team
  • Perform firm jaw thrust and stop any other stimulation
  • Remove airway devices and anything else that may be stimulating or obstructing the airway - direct visualisation and suction
  • Give CPAP with 100% oxygen via FM +/- OP/NPA
  • Deepen anaesthesia
  • Consider tracheal intubation
  • Drugs:
    – propofol 0.25-0.5mg/kg
    – rocuronium 0.25-0.5mg/kg
    – atracurium 0.25-0.5mg/kg
    – suxamethonium (4mg/kg IM into tongue + atropine)
29
Q

Malignant Hyperpyrexia

A
  • Call for help and inform theatre team
  • Aim to abandon or finish surgery asap
  • Call for MH treatment pack and cardiac arrest trolley
  • Maintain anaesthesia with TIVA, NMBA with non-depolarising drug
  • Eliminate trigger drug - activated charcoal filters on both limbs of breathing circuit
  • Give dantrolene - 2.5mg/kg IV bolus, repeat 1mg/kg every 5 minutes until ETCO2 <6 and temp <38.5
  • Begin active cooling - apply ice, use cold IV fluids, consider cold peritoneal lavage, other cooling methods
  • Additional monitoring - invasive BP, CVC, core and peripheral temp, UO
  • Check ABG, U+Es, glucose, FBC, coagulation, urinary pH, CK
  • Seek and treat complications
    – metabolic acidosis - hyperventilate, sodium bicarb
    – hyperkalaemia - sodium bicarb, glucose/insulin, calcium
    – myoglobinuria - forced alkaline duiresis
    – DIC - FFB, fibrinogen, platelets
    – tachyarrhythmias - amiodarone, beta blockers
    – compartment syndrome - surgical decompression
  • Avoid calcium channel blockers!
  • Continue ventilation and plan admission to critical care
  • Ensure plan exists to counsel patient and family and refer to Leeds MH unit.
30
Q

Cardiac ischaemia under anaesthesia

A

Indications
* ST elevation or depression
* T wave flatening or inversion
* Arrhythmias, especially ventricular
* Other haemodynamic abnormalities (HR/BP)
* New or evolving regional wall motion abnormalities if echo
* In conscious patients - chest pain, SOB, dizziness, N+V

Management
* ABC
* Increase FiO2 and FGF
* Call for cardiac arrest trolley and 12 lead ECG
* Ensure adequate oxygenation and anaesthesia/analgesia
* Treat haemodynamic instability - correct hypovolaemia, anaemia (aim Hct >30%), vasodilatation, control arrhythmias, electrolyte abnormalities
* Apply CM5 ECG (upper R sternum, 5th ICS under left nipple, L shoulder)
* If persistent ischaemia, call for help, alert theater, stop or rapidly complete surgery
* Consider GTN sublingual, morphine
* Consider invasive BP monitoring
* If persistent ST elevation, consider need for anticoagulation, antiplatelet therapy and revascularisation
* Admit to critical care environment and consult cardiology
* Maintain head up position post operatively
* Obtain serial 12-lead ECGs and cardiac enzymes

31
Q

Needlestick injury

A
  • Call for help
  • Encourage free bleeding of the wound
  • Wash with soap and water
  • Follow local policy - occupational health/A+E
  • Documentation
  • Risk assessment (carried out by line manager/surrogate)

HIC 0.3%, Hep C 3%, Hep B 30%

32
Q

Negative pressure pulmonary oedema

A

A form of noncardiogenic pulmonary oedema that results from the generation of high negative intrathoracic pressure needed to overcome upper airway obstruction.
It may occur in otherwise health individuals who can generate high negative intrathoracic pressure and typically resolves over 12-48hrs with appropriate care.

Mechanism
* any cause of upper airway obstruction
* hydrostatic mechanism due to increased preload and increased LV afterload
* high NIP augments venous return to the R side of the heart - increased pulmonary venous pressure, pulling fluid from pulmonary capillaries into the interstitium and alveolar spaces
* mechanical stress mechanism from attempted respiration against an obstructed upper airway leading to disruption of the alveolar epithelial and pulmonary microvascular membranse, leading to increased pulmonary capillary permeability and pulmonary oedema

Features
* pink froth sputum, crackles, wheeze, increased JVP/CVP, liver engorgement
* increased airway pressures, HR, RR
* decreased SpO2
* CXR - basal shadowing, upper lobe diversion, perihilar infiltrates, effusions, Kerley B lines, fluid in fissue, cardiomegaly
* ECG - right heart strain, ischaemic change

Management
* ABCs
* Apply high FiO2 to keep SpO2 >94%
* If awake - sit upright and apply CPAP
* If intubated - IPPV + PEEP, head up positiong, aspirate fluid from endotracheal tube (may need frequent changes of HMEF)
* No evidence for diuretics - may exacerbate hypovolaemia and hypoperfusion
* Consider pre-load reduction with GTN if adequate BP

33
Q

Obstetric difficult airway

A
  • Pre-induction planning and preparation
  • Rapid sequence induction - consider facemask ventilation/apnoeic oxygenation while awaiting onset of paralysis
  • Laryngoscopy - max 2+1
    – reduce/remove cricoid
    – ELM
    – repositioning of head/neck
    – bougie/stylet
    – alternate laryngoscope
  • If successful - verify + proceed, plan extubation
  • If unsuccessful - declare failed intubation
  • Call for help
  • Maintain oxygenation - SAD (2nd gen, max 2 attempts) or FM - remove cricoid
  • If successful - follow DAS table re: wake vs proceed
  • If unsuccessful - declare CICO
  • Give 100% oxygen
  • Exclude laryngospasm
  • Ensure neuromuscular blockade
  • Optimise neck position
  • FONA (scalpel-bougie-tube)
  • If unsuccessful - maternal ALS + perimortem C-section

Pre-induction preparation
* Airway assessment
* Fasting status
* Antacid prophylaxis
* Intrauterine fetal resuscitation if appropraite

Plan with team
* WHO safety checklist/GA checklist
* Identify senior help, alert if appropriate
* Plan equipment for difficult/failed intubation
* Plan for/discuss: wake up or proceed with surgery

RSI
* Check airway equipment, suction, IV access
* Optimise position - head up/ramping + left uterine displacement
* Pre-oxygenated to ETO2 >0.9/consider nasal oxygenation
* Cricoid pressure
* Deliver appropriate induction/neuromuscular blocker doses

Proceed or wake
* Maternal condition
* Fetal condition
* Anaesthetist seniority
* Obesity
* Surgical factors and risks
* Aspiratory risk
* Alternative anaesthesia options - regional, awake airway techniques
* Airway device/ventilation in situ after failed intubation
* Airway hazards present

34
Q

Paediatric Cardiac Arrest

A

D - check for danger
R - shake and shout for response
CALL for help

A - open airway (sniffing position/neutral position)
B - check for breathing (10s)
Give 5 rescue breaths
C - check for circulation - if HR less than 60 or absent pulse
CONFIRM cardiac arrest, COMMENCE CPR, CONNECT defib, CONFIRM rhythm

  • CPR 15:2/asynchronous (infants 25/1-8yrs 20/8-12yrs 15/>12yrs 10-12)
  • Vascular access - IO preferable
  • Shockable - defib 4J/kg, 0.1ml/kg of 1:10,000 adrenaline + 5mg/kg amiodarone after 3rd shock, 1mg adrenaline + 5mg/kg amiodarone after 5th shock
  • Non shockable - adrenaline 0.1ml/kg of 1:10,000 then every 3-5 minutes
  • 4Hs and 4Ts
35
Q

Paracetamol Overdose

A

Features
* N+V (early)
* right subcostal pain
* hepatocellular necrosis (late)
* renal tubular necrosis

Management
* assess and support ABCs
* TOXBASE
* NAC
* bloods 4hrs post-ingestion
* haemodialysis if very high serum concentration (increase dose of NAC if on HD)
* monitor U+Es, LFTs, INR
* d/w liver specialist - INR >6.5, hepatic encephalopathy, hyperlactataemia (lactate >3)/hypotension despite resuscitation, ph <7.25, Cr >300

36
Q

Post dural puncture

A

Immediate
* resite vs spinal catheter
* take the needle out and reinsert in an adjacent space
* thread epidural catheter into subarachnoid space
* careful labelling of catheter, cautious top-ups by anaesthetist only (2-3ml of low dose or 1ml of 0.25+/- fentanyl 15-25mcg), regular neuro obs
* document, explain to patient and team

Early
* daily follow up
* written information leaflet

Later (management of PDPH)
* conservative
– adequate hydration
– conventional analgesics
– analgesic adjuvants?
* epidural blood patch (wait >24hrs post dural puncture)
– 1 space higher than dural tap
– stop if pain/discomfort on injection
– supine for 2hrs, no strain for 102 weeks
– can cause back pain, meningeal irritation, radicular pain, CN palsy, infection
– 1st patch 60%, 2nd up to 80%

37
Q

Post extubation stridor

A

Presence of inspiratory noise post-extubation, suggestive of narrowing of the airway (can be supraglottic, glottic or infraglottic).

Risk factors
* Intubation factors
– excessive airway manipulation
– traumatic intubation
– prolonged intubation attempt
– larger attemps
* Post-intubation factors
– intubation >36hrs
– agitation while intubated
– high cuff pressures
– recurrent intubations
* Patient factors
– female
– short neck
– trauma patients
– known airway pathology (tracheal stenosis, tracheomalacia)
– children
– small height:ID ETT ratio

Management
* Prior to extubation - attend to reversible risk factors, perform cuff leak test, consider pretreatment with IV steroids, apply high flow O2
* Post-extubation - close monitoring and observation
* High flow O2 (consider HFNO)
* Nebulised adrenaline 0.5ml/kg or 1:1000 up to 5ml
* Conisder NIV
* Re-intubation if develops airway obstruction or respiratory failure

38
Q

Post-operative Acute Cardiac Failure

A
  • Optimise environment
    – correct acid-base balance
    – correct electrolytes
  • Control HR and rhythm
    – pacing and chronotropic agents for low HR
    – aggressive treatment with drugs and DCCV for high HR
  • Optimise preload
    – inadequate - crystalloid/colloid
    – excessive - venodilators, diuresis, inotropic agents
  • Enhance contractility
    – inotropic agent directed towards either decreasing excessive SVR or augmenting inadequate SVR
  • Consider mechanical circulatory support e.g. IABP
39
Q

PPH

A

Causes
* Tone
* Tissue
* Trauma
* Thrombin

  • All Wales ObsCymru pathway
  • Stage 0 - Recognition of at risk patients, ensure suitable for EI, IV access?, planned active 3rd stage?
  • Measure blood loss in all patients
  • Stage 1 - >500ml - record obs, IV access, uterine massage, uterotonics, empty bladder, inspect urogenital tract, check placenta and membranes, bimanual compression
  • Stage 2 - >1000ml - get help, obs, 2nd IV access + fluid bolus, take bloods, consider ranitidine, give TXA, transfer to theatre
  • Stage 3 - >1500ml, activate MOH, ensure consultants aware 2+2, consider repeat TXA

General measures
* Call for help
* ABCDE
* 100% oxygen
* Activate MOH
* 2x large bore IV
* Arterial line
* Fluid rescuscitation –> early blood transfusion (warmed)
* Cell salvage?
* TXA
* Treat underlying cause
– uterotonics - synto 5 units IV, synto 10 units/hr infusion, ergometrine 500mcg IM, carboprost 250mcg IM (x4 at 15 minute intervals), misoprostil 400mcg
– B lynch suture
– Bakri balloon
– interventional radiology
– hysterectomy
– suture tears
– ensure placenta out and complete
* Near patient coagulation testing - correct with FFP/fibrinogen dependent on ROTEM

40
Q

Pre-eclampsia

A

A disorder of pregnancy characterised by persistent high blood pressure, and often a significant amount of protein in the urine or other evidence of systemic involvement.

Diagnostic factors
* > 20 weeks gestation
* Systolic BP >140 and diastolic >90
* Headache, upper abdominal pain, oedema, visual disturbances, seizures, breathlessness, oliguria, hyper-reflexia
* Reduced fetal growth or movement

Risk factors
* nulliparity
* previous pre-eclampsia or family history
* BMI >30
* maternal age >40
* multiple pregnancy
* subfertility
* autoimmune disease, renal disease, PCOS, migraine, diabetes, hypertension
* gestational hypertension

Management - dependent on disease severity and progression
* Monitoring
* Deciding on a delivery date and method
* Lowering BP (aim <135/85)
– labetalol (200mg PO, 50mg IV)
– oral nifedipine
– methyldopa
– hydralazine (10mg IV, volume expansion with 250ml first)
* Controlling seizures
– magnesium 4g IV over 5 minutes
– magnesium 1g/hr for 24hrs
– monitor deep tendon reflexes 4hrly
– 2g IV bolus for recurrent seizures
* Postnatal fluid management

General management
* Strict input/output monitoring
* Catheterise
* Fluid restrict 80ml/hr
* Avoid NSAIDs, ergometrine

41
Q

Premature ventricular complexes

A

A PVC is a premature beat arising from an ectopic focus within the ventricles. These are a normal electrophysiological phenomenon not usually requiring investigation or treatment. In patients with underlying predispositions, a PVC may trigger the onset of a re-entrant tachydysrhythmia.

ECG features:
* broad QRS complex with abnormal morphology
* premature - occurs earlier than would be expected for the next sinus impulse
* discordant ST segment and T wave changes
* usually followed by a full compensatory pause
* retrograde capture of the atria may or may not occur

Frequent if >5 per minute on routine ECG or >10-30 per hour during ambulatory monitoring

Classification
* Unifocal - arising from single ectopic focus, each PVC is identical
* Multifocal - arising from two or more extopic foci; multiple QRS morphologies
* Bigeminy - every other beat is a PVC
* Trigeminy - every third beat is a PVC
* Quadrigeminy - every fourth beat is a PVC
* Couplet - two consecutive PVCs
* NSVT - 3-30 consecutive PVCs

  • ABC
  • Increase FiO2 and FGF
  • Identify underlying cause - ?ABG
  • If haemodynamically unstable, consider antiarrhythmic agent

Causes
* Cardiac
– acute MI
– valvular disease
– tachy/bradycardia
– cardiac contusion
– cardiomyopathy
* Non-cardiac
– electrolyte disturbance - hypokalaemia, hypomagnesaemia
– medications e.g. TCAs, SSRIs, digoxin, beta agonists, sympathomimetics
– other drugs e.g. cocaine, caffeine, ETOH
– anaesthetic, surgery, infection, stress, anxiety

42
Q

Progressive decrease in MV

A
  • ABC
  • Increase FiO2 and FGF
  • Call for help
  • Check for leak, check all connections
  • Check ETT cuff
  • Check capnography shape and tubing
  • Assist ventilation if needed

Causes
* equipment failure - ETT underfilled/punctured, disconnected capnograph or expiratory limb

43
Q

Pulmonary Hypertensive Crisis

A
  • Early recognition - increased PVR/RV filling pressure with decreased CO and BP
  • Treat hypotension aggressively –> noradrenaline, vasopressin
  • Inhaled + IV pulmonary vasodilators –> inhaled NO, prostacyclin NEB, IV prostanoid
  • Optimise pre-load (CVP 8-12), contractility and afterload –> IV fluids (50-100ml boluses), loop diuretics
  • Restore sinus rhythm if relevant - chemical/DC cardioversion
  • Consider inotropes –> dobutamine, milrinone
  • Consider ECMO to support RV as a bridge to post-op recovery or transplantation
44
Q

Raised end tidal CO2 level

A
  • ABC
  • Increase FiO2 and FGF
  • Get help
  • Check minute ventilation
  • Check depth of anaesthesia
  • Check for leaks/disconnections
  • Evidence of re-breathing?
  • Consider MH/thyroid storm

Causes
* increased CO2 production - fever, bicarb, tourniquet release
* increased CO2 delivery to the lungs - increased CO/BP
* decreased CO2 excretion - hypoventilation, bronchial intubation, partial airway obstruction
* increased inspired CO2 - exhausted soda lime, inadequate FGF

45
Q

Raised ICP

A

Surgical, medical and mechanical methods of managing

  • ABC
  • Titrate FiO2 to PaO2 >13
  • Aim for normothermia, normoglycaemia
  • Mechanical ventilation - avoid high intrathoracic pressures, prevent straining
  • Maintain MAP 80-90 (achieve CPP 60-70)
  • Moderate hyperventilation (aim PaCO2 4.5) - hyperventilation only for temporary, emergency control of dangerously raised ICP prior to surgery
  • Ensure adequate sedation + analgesia + paralysis
  • Treat convulsions
  • Control pyrexia
  • Head up position with no jugular compression from ties/head position
  • Seek expert advice
  • CSF - shunt/EVD
  • Brain tissue - surgical decompression, evacuate haematoma, treat cerebral oedema with mannitol 0.5-1g/kg or hypertonic saline, corticosteroids if mass effect oedema
  • CBF - hypothermia, barbiturate therapy
46
Q

Raised inspiratory CO2 level

A
  • Check FGF adequate for circuit
    – Mapleson D (Bain) - 70ml/kg for IPPV (5l/min), 200-300ml/kg for SV (14L/min)
  • Increase FiO2 and FGF
  • Remove dead space
  • Check soda lime
  • Check paralysis
  • Increase RR
  • Get help
47
Q

Regurgitation/Aspiration

A
  • ABC
  • Increase FiO2 and FGF
  • Get help and alert team
  • Position head down and left lateral
  • Suction oropharynx
  • RSI + tracheal suctioning
  • PEEP
  • Early bronchoscopy
  • Bronchodilators if necessary
48
Q

Respiratory Arrest

A

D - check for danger
R - shake and shout for response
CALL for help

A - open airway
B - check for breathing (10s) - 5 initial rescue breaths if paediatric
C - check for circulation

If circulation present but absent or insufficient breathing
* BMV (2 person)
* 100% oxygen
* Support ventilation
– 10-12 breaths per minute aged >12yrs
– 15 breaths per minute 8-12yrs
– 20 breaths per minute 1-8yrs
– 25 breaths per minute infants
* consider and correct underlying cause

49
Q

Salicylate Overdose

A

Features
* Hyperventilation
* Tinnitus
* Deafness
* Vasodilatation
* Sweating
* Coma - very severe respiratory alkalosis + metabolic acidosis (raised anion gap)

Management
* Assess and support ABCs
* TOXBASE
* Activated charcoal if <1hr with 125mg/kg OD
* Replace IV fluid losses
* Give NaHCO3 (225ml of 8.4%) to enhance urinary salicylate excretion
* Replace K+ prior to alkalinisation
* HD if >700mg/l or 5.1mmol/L in presence of severe metabolic acidosis
* Avoid I+V unless there is evidence of respiratory failure as loss of hyperventilatory drive can lead to sudden decompensation
* Check salicylate level 2hrly

50
Q

Seizures during and after anaesthesia

A

Relatively rare to have seizures under anaesthesia but may occur in patients with poorly controlled epilepsy or in the context of high risk surgery e.g. neurosurgery.

Suggestive signs
* increased ETCO2
* tachycardia
* hypertension
* increased muscle tone
* pupillary dilatation
* increased oxygen consumption
* more classical signs if not paralysed

Management
* ABCs
* Increased FiO2 and FGF
* Get help and alert theatre team
* Deepen anaesthesia
* Correct any precipitating factors
– hypoxia
– hypoglycaemia
– hypercarbia
* Consider differential diagnosis

Postoperative Seizures
Causes
* epileptic seizure - underlying epilepsy, post-neurosurgery, eclampsia, metabolic disturbance, alcohol withdrawal
* postoperative shivering
* acute dystonic drug reaction e.g dopamine antagonists
* psychogenic non-epileptic seizure
* syncopal episode

Management
* as for any other seizure

51
Q

Sinus tachycardia

Often due to inadequate depth of anaesthesia/analgesia or hypovolaemia

A
  • Stop stimulus, check pulse, rhythm and BP
  • If narrow complex and NOT hypotensive, first increase depth of anaesthesia or analgesia
  • Confirm adequate oxygen delivery
  • Check airway position and patency
  • Check breathing
  • Check circulation, obtain 12-lead ECG if possible
  • Consider underlying problems
  • Identify and treat reversible causes e.g. fluid bolus
  • Other drugs: Mg 50mg/kg (2g), labetalol/esmolol 0.5mg/kg (25-50mg)
  • ALS tachyarrhythmia algorithm if relevant
  • Call for help: consider electrical cardioversion (synchronised 1-2J/kg) if not sinus rhythm and not resolving quickly
  • Check depth of anaesthesia and adequacy of analgesia

Potential underlying problems
* stimulation with inadequate depth of analgesia/anaesthesia
* consider drug error
* central line/wire
* hypovolaemia
* MI
* electrolyte disturbance
* LA toxicity
* sepsis
* circulatory embolus
* anaphylaxis
* PTX
* unusual conditions e.g. phaeochromocytoma, thyroid storm, MH

52
Q

Paediatric Status Epilepticus

Generalised convulsion >5 minutes

A

D - check for danger
R - shake and shout for response
CALL for help

A - open airway
B - check for breathing (10s)
C - check for circulation

  • High flow oxygen
  • Check glucose
  • Vascular access (IV/IO)
  • 1x benzo
    – lorazepam 0.1mg/kg
    – midazolam 0.5mg/kg buccal
  • 2nd benzo after 10 minutes
  • 2nd line agents (after 15-35 minutes)
    – phenytoin 20mg/kg IV over 20 minutes
    – levetiracetam 30-60mg/kg IV over 5 minutes
    – phenobarbital 20mg/kg IV over 5 minutes
  • RSI with thio 4mg/kg or prop 1-1.5mg/kg
53
Q

Tachyarrhythmias

Often due to inadequate depth of anaesthesia/analgesia

A
  • Stop stimulus, check pulse, rhythm and BP
  • If narrow complex and NOT hypotensive, first increase depth of anaesthesia or analgesia
  • Confirm adequate oxygen delivery
  • Check airway position and patency
  • Check breathing
  • Check circulation, obtain 12-lead ECG if possible
  • Consider underlying problems
  • Identify and treat reversible causes e.g. fluid bolus
  • Consider rate control - amiodarone for broad complex, adenosine for narrow complex
  • Other drugs: Mg 50mg/kg (2g), labetalol/esmolol 0.5mg/kg (25-50mg)
  • ALS tachyarrhythmia algorithm
  • Call for help: consider electrical cardioversion (synchronised 1-2J/kg) if not resolving quickly
  • Check depth of anaesthesia and adequacy of analgesia

Potential underlying problems
* stimulation with inadequate depth
* consider drug error
* central line/wire
* hypovolaemia
* primary cardiac arrhythmia
* MI
* electrolyte disturbance
* LA toxicity
* sepsis
* circulatory embolus
* anaphylaxis
* MH

54
Q

Tension Pneumothorax

A
  • ABC
  • Increase FiO2 and FGF
  • Call for help and alert theatre team
  • Needle decompression - 2nd intercostal space, mid clavicular line
    – 14-16G IV cannula attached to 5 or 10ml syringe along superior margin of 2nd or 3rd rib
    – advance needle until air is aspirated to syrine
  • Finger thoracostomy - 5th intercostal space and anterior/mid axillary line
    – clean skin
    – consider LA to skin, muscle and pleura
    – sterile gloves
    – no. 10/11 scalpel - 4cm through skin over and parallel to the superior border or the inferior rib
    – Kelly clamps blunt dissection through s/c tissue and muscle
    – closed Kelly clamps - puncture the parietal pleura - whoosh or air or swift return of blood
    – remove Kelly clamps and insert full gloved finger into the space
  • Formal chest drain
55
Q

Transfusion Reaction

A
  • Maintain airway
  • Increase FiO2 and FGF
  • Stop transfusion
  • Check patient and blood details
  • Supportive measures

Mild (urticaria or fever but WELL)
* restart transfusion at slower rate
* consider antipyrexic (paracetamol 1g IV)/antihistamine (chlorphenamine 10mg IV)
* if no improvement within 30 minutes or worsening symptoms –> treat as Moderately severe

Moderately severe
* stop transfusion
* replace giving set and flush with saline
* send the blood unit + giving set + fresh samples to lab
* monitor UO
* administer antipyretic/antihistamine
* if clinical improvement, restart transfusion slowly with new blood unit and observe
* if no clinical improvement within 5-10 minutes or worsening symptoms –> treat as life-threatening

Life-threatening
* Maintain patent airway
* Give high concentration of oxygen
* send the blood unit + giving set + fresh samples to lab
* monitor UO
* If stridor/increased RR/hypoxia/tachycardia/hypotension/GCS –> get help
– ABO compatibility (back pain, fever, hypotension, tachycardia, wrong blood) –> change giving set, give IV fluid boluses, target UO 100ml/hr (diuretic if necessary), seek expert advice
– Anaphylaxis (wheeze, rash, stridor, hypotension, tachycardia) –> IM adrenaline, follow anaphylaxis management
– Bacterial contamination (fever, hypotension, tachycardia) –> give IV fluid, take blood cultures, give IV Abx, sepsis management

56
Q

Traumatic Cardiac Arrest

A

Peri-arrest trauma patient or cardiac arrest without likely medical cause
* penetrating trauma to chest/epigastrium - consider immediate thoracotomy
* hypovolaemia
– control external bleeding
– splint pelvis/fractures
– IV/IO fluid or blood if possible
* hypoxia
– give oxygen
– basic/advanced airway management
* tension pneumothorax
– decompress chest (thoracostomy)
* tamponade - cardiac
– consider thoracotomy
* spontaneous circulation?
– prehospital - transfer to appropriate hospital/operating theatre/IR etc
– if no, continue CPR/consider termination of resuscitation

If cardiac arrest with likely medical cause
* follow ALS algorithm

57
Q

Tricyclic Overdose

A

Features
* dry mouth
* decreased GCS
* hypotension
* hypothermia
* hyperreflexia
* convulsions
* respiratory failure
* cardiac conduction defects + arrhythmias
* dilated pupils
* urinary retention
* metabolic acidosis

Management
* Assess and support ABCs
* TOXBASE
* Charcoal if <1hr
* Treat seizures with benzos
* Correction of hypotxia and acidosis usually reduces arrhythmias
* If prolonged QRS –> 100ml 8.4% sodium bicarbonate
* Maintain UO 0.5ml/kg/hr

58
Q

TURP Syndrome

A
  • ABC - address life threats, invasive monitoring
  • Fluid overload - frusemide 40mg IV
  • Seizures - benzodiazepines, consider magnesium
  • Hyponatraemia - hypertonic saline (aim no more than 10-20mmol/24hrs)
  • Treat AKI, oedema, dysrhythmias as required
  • Treat hypocalcaemia
  • Treat underlying cause - stop surgery asap, coagulate bleeding points, stop IV fluid, monitor Hb
  • Admit to HDU/ITU
59
Q

Unexpected decrease in saturations

A
  • Increase FiO2 and FGF
  • Get help and alert theatre team, pause surgery if possible
  • Adequate oxygen delivery - check measured FiO2, visual inspection of entire breathing system including valves and connections, exclude failure to deliver oxygen to airway, check sats probe
  • Airway - check position of airway device, check capnography, confirm airway device patency, isolate patient from system
  • Breathing - check chest symmetry, rate, breath sounds, SpO2, TV, ETCO2, hand ventilate, consider muscle relaxation
  • Circulation - check HR, rhythm, perfusion, recheck BP, consider poor perfusion and correct
  • Depth - ensure adequate depth of anaesthesia and analgesia

Causes
* failure of delivery of oxygen to airway - oxygen/machine/ventilator/circui failure
* failure of delivery of oxygen to alveoli - device/low MV/obstruction
* failure of delivery of oxygen to the capillaries - VQ mismatch
* failure of delivery of oxygen to the tissues - heart failure/shock/anaemia/increased demand

60
Q

Unexpected increased peak airway pressures

A
  • Increase FiO2 and FGF, check measured FiO2
  • Call for help and alert theatre team
  • Pause surgery if possible, consider surgical cause
  • Visual inspection of entire breathing system including valves and connections
  • Confirm increased airway pressure by switching to hand ventilation +/- use ambubag to isolate
  • Airway - check position of airway device and listen for noise, check capnograph shape, suction
  • Breathing - check chest symmetry, rate, breath sounds, SpO2, TV, ETCO2, treat underlying problem
  • Circulation - check heart rate, rhythm, perfusion, BP, consider gas trapping
  • Depth - ensure adequate depth of anaesthesia and analgesia
  • Check relaxation
  • Release pneumoperitoneum +/- level patient
  • Consider bronchodilators, suction, PEEP, diuretic, bronchoscopy

Causes
* equipment failure: occluded inspiratory limb/ETT
* surgical issues: patient position, pneumoperitoneum
* anaesthetic issues: inadequate paralysis, endobronchial intubation
* patient issues: bronchospasm, laryngospasm, anaphylaxis, circulatory embolus, foreign body, PTX, pulmonary oedema

61
Q

Variceal bleed/UGIB

A

Causes
* Ulcerative including drugs, infection
* Portal hypertension
* Vascular malformations
* Traumatic/surgical
* Tumour
* Iatrogenic

Mortality associated with upper GI bleed is high, so I would carry out a thorough assessment and stabilisation using an ABCDE approach.
* Declare the emergency
* A - early intubation prevents airway soiling
* B - high flow O2
* C - wide bore cannulae, arterial line, CVC, CO monitoring, massive haemorrhage protocol, POC coagulation testing and correction of coagulopathy, reversal of anticoagulation
* D - GA/sedation, check BM
* E - keep warm
* Drugs
– terlipressin
– octreotide
– PPIs (post OGD)
– beta blockers
– erythromycin (improves view)
– antibiotics - based on local guidelines
* Other management
– endoscopy - injection, haemospray, clips, thermal, ligation
– sengstaken tube
– TIPSS/surgery

62
Q

Wrong sided block

A

Prevention
* WHO sign in
* Avoid distractions - personnel present, teaching
* Prep-Stop-Block
* Surgical site marking
* Regional blocks while awake to allow verbal confirmation of correct side
* Check/re-check consent form

Implications
* increased risk of complications
* LA systemic toxicity
* increased length of stay and delayed discharge
* potential conversion to HA
* psychological impact
* logistical implications for conduct of list

Actions
* Recognition
* Explanation and apology
* Right side block if possible
* Through documentation
* Incident report

Final FRCA (11 decks)

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