EMERGENCYMANUAL

COGNITIVEAIDSFORMBADULTPERIOPERATIVECRITICALEVENTS

ACLSAsystole/PEA………………………….…………………………..….....1Bradycardia – Unstable………….…………………………..….…..2Tachycardia– Unstable………….…………………………………..3PulselessVF/VT…………………….……………………………………4CRITICALEVENTS:NON-ACLSAnaphylaxis…………………………………………………....…………5Bronchospasm……………………………………………...….……….6Difficultairway– Unanticipated…………………..…….……..7Fire…………………………………………………………….….….…..….8Hemorrhage………………………………..………………...….….….9Hypotension………………………………………………...…….…..10Hypoxia……………………………………………………..….…….….11LocalAnestheticToxicity……………………..………….….…..12MalignantHyperthermia………………………………..….……13MyocardialIschemia……………………………………..….…….14OxygenFailure…………………………………………………...…..15Pneumothorax…………………………………………………….…..16PowerFailure…………………………………………………….…….17Seizure…………………………………………………………………….18Stroke……………………………………………………………………..19Tachycardia– StableSVT………………………………….……..20TotalSpinalAnesthesia………………………………….………..21TransfusionReaction…………………………………….………...22VenousAirEmbolus………………………………………………...23

Adaptedfrom:2015AHAGuidelinesforCPRandECC,Gawande etal.ORCrisisChecklistsNEJM2013;368:246-53,&StanfordAnesthesiaCognitiveAidGroup’sEmergencyManual2014,V2.0. EditedbyMonicaHarbell,MD5/2016

1:CardiacArrest:Asystole/PEA Condition:Non-shockable pulselesscardiacarrest.

Objective:Restorepulse,hemodynamicstability

• Callforhelp.CodeCart.Informteam.• CPR (100-120chestcompressions/min+

10breaths/min,5-6cmdeep).*–Ensurefullchestrecoilwithminimalinterruptions.Rotatecompressorsq2min.

• Turnoffanesthetic.• IncreaseFiO2to100%,highflow.• Epinephrine(1mgIVq3-5min)• Checkpulse&rhythm(afterevery2min

ofCPR;limitcheckto10secs):– Ifnopulseandshockable (VF/VT):GOTO:CardiacArrest– VF/VTChecklist– IfnopulseandNOTshockable(asystole/PEA):• ResumeCPR.• Readoutpotentialcauses(H&Ts).**• ConsidercommonperioperativeDDx: hemorrhage,anestheticoverdose,sepsisorothershockstates,auto-PEEP,anaphylaxis,medicationerror,highspinal,pneumothorax,localanesthetictoxicity,vagalstimulus,pulmonaryembolus.• Restartchecklist.

– Ifpulse:• Beginpost-resuscitationcare.• Readoutpotentialcauses(H&Ts)

• CheckABG

DuringCPR:• Circulation (confirmadequateIV/IOaccess).

• IfETCO2<10,improveCPRquality• Airway(bagmaskokifventilationadequate)• Breathing (100%FiO2)• Assignrolesfor:Chestcompressions,

defibrillation,airway,vascularaccess,documentation,codecart,timekeeping.Ordersshouldbeexplicitlyacknowledgedandrepeated.

DrugDosesandTreatments:Epinephrine:1mgIV,repeatevery3-5min

HyperkalemiaTreatment:• Calciumgluconate (10mg/kg)orcalcium

chloride(10mg/kg)IV• SodiumBicarbonate1-2mEq/kg,slowIVpush• Insulin10UnitsregularIVwith1-2ampsD50W

ToxinTreatments:Opioidoverdose:Naloxone0.04-0.4mgIV,canrepeatdosingifresponseinadequate.LocalAnestheticoverdose:Intralipid 1.5mL/kgIVbolus,repeat1-2xforpersistentasystole.Startinfusion0.25-0.5mL/kg/minfor30-60minforrefractoryhypotension.Magnesiumoverdose:Calciumchloride1gIVorcalciumgluconate 10%soln 30mLIVBeta-blockeroverdose:Glucagon2-4mgIVpushCalciumchannelblockeroverdose:Calciumchloride1gIV

*Inpatientwithoutanadvancedairway:CycleofCPR=30compressionsatrateof100-120/min,followedby2breaths.Give5cyclesofCPRwhere“CPRx2min”isnoted.Ifabletoassess,keepETCO2 >10anddiastolicBP>20.

**Seebackfordifferentialdiagnosis(H&Ts)à

PotentialCauses(H&Ts):• Hypovolemia• Hypoxia• Hydrogenion(acidosis)• Hypo-/hyperkalemia• Hypo-/hyperthermia• Hypoglycemia• Hypocalcemia

• TensionPneumothorax• Tamponade (Cardiac)• Toxins(narcotic,local

anesthetic,betablocker,channelblocker,infusions)

• Thrombosis(Pulmonary,coronary)

1

• Hypovolemia:GiverapidIVfluidbolus.CheckHgb/HCT.Givebloodforanemiaormassivehemorrhage.Considerrelativehypovolemia:Auto-PEEP– disconnectcircuit;Highspinal;orshockstates(e.g.anaphylaxis).

• Hypoxemia:IncreaseFiO2to100%,highflow.Confirmconnections.Checkforb/l breathsounds.SuctionETTandreconfirmplacement.ConsiderCXR.GOTO:Hypoxemiaevent.

• Hypothermia:Activewarmingbyforcedairblanket,warmIVfluid,raiseroomtemp.ConsiderCPB.

• Hyperthermia:ConsiderMalignantHyperthermia.CallforMHcart.TreatwithDantrolene immediately(2.5mg/kg).GOTO:MalignantHyperthermiaevent.MHHotline(800-644-9737).

• ObtainABG torule-out:– Hyperkalemia:GiveCaCl2 1gIV,

D501ampIV(25gDextrose)+RegularInsulin10unitsIV.Monitorglucose.SodiumBicarbonate1AmpIV(50mEq).

– Hypokalemia: controlledinfusionofpotassium&magnesium.

– Hypoglycemia:IfABGdelay,checkfingerstick.GiveD501AmpIV(25gDextrose).Monitorglucose.

– H+acidosis:Ifprofound,considerNaHCO3 1AmpIV(50mEq).Considerincreasingventilationrate(butcandecreaseCPReffectiveness).

– Hypocalcemia:GiveCaCl2 1gIV

• TensionPneumothorax: Unilateralbreathsounds,possiblydistendedneckveinsanddeviatedtrachea(latesigns).Performemergentneedledecompression(2ndintercostalspaceatmid-clavicularline)followedbychesttubeplacement.CallforCXRbutdonotdelaytreatment.

• Thrombosis– Coronary:ConsiderTTE/TEEtoevaluatewallmotionabnormalities.Consideremergentcoronaryrevascularization.GOTO:MyocardialIschemiaevent.

• Thrombosis– Pulmonary: ConsiderTTE/TEEtoevaluaterightventricle.Considerfibrinolytic agentsorpulmonarythrombectomy.

• Toxins(e.g.infusions): Considermedicationerror.Confirmnoinfusionsrunningandvolatileanestheticoff.Considerlocalanesthetictoxicityevent.

• Tamponade – Cardiac:ConsiderTTE/TEEtoruleout.Treatwithpericardiocentesis.

PossibleCausesofCardiacArrest:H&Ts

2:Bradycardia -Unstable

Condition:Hemodynamicinstability,persistentbradycardiawithpulses.Objective:Restorehemodynamicstability,adequateperfusion.

• Callforhelp.Informteam.CallforCodeCart.Gettranscutaneouspacer.

• Checkforpulse.IfNOpulse**,GOTO:Asystole/PEAevent.

• Stopsurgicalstimulation(iflaparoscopy,desufflate).

• GiveAtropine(0.5-1mgIV;mayrepeatto3mgtotal).

• Ifmyocardialinfarctionsuspected(i.e.ECGchanges),treataccordingly- (oxygen,nitrates,considerterminatingprocedure).

• Assessfordruginducedcauses(e.g.beta-blockers,calciumchannelblockers,digoxin).

• Ifpersistentbradycardia,callforpacerandconsiderrepeatdoseofatropine,or:• Epinephrine(2-10mcg/min)or

Dopamine(2-20mcg/kg/min)• Forpacing:

1. Placeelectrodesonchestfromtrancutaneous pacer.

2. Placepacingpadsonchestperpackageinstructions.

3. Turnmonitor/defibrillatorON,settoPACERmode.

4. SetPACERRATE(ppm)to80/min.(Canbeadjustedupordownbasedonclinicalresponseoncepacingisestablished).

5. Increasemilliamperes (mA)ofPACEROUTPUTuntilelectricalcapture(pacerspikesalignedwithQRScomplex;thresholdnormally65-100mA).SetfinalmAto10mAabovethislevel.

6. Confirmpulsepresentwithcapture.**• Ifpacingineffective,– Considerexpertconsultation.

**IfPEAdevelops,GOTO:CardiacArrest– Asystole/PEAchecklist

DuringResuscitation:• Circulation (confirmadequateIVorIO

access)• ConsiderIVfluidswideopen.• Consider12-LeadECG.

• Airway(assessandsecure)• Breathing (100%FiO2)

OverdoseTreatments:Beta-blockeroverdose:

• Glucagon(2-4mgIVpush).

Calciumchannelblockeroverdose:• Calciumchloride(1gIV).

SecondaryTreatments:• Placearterialline.• CheckABG,hemoglobin,electrolytes.• Ruleoutischemia:CheckEKG,troponins.

2

Condition:Hemodynamicinstability(SBP<80,BP“low”forpatient,rapidBPdecreaseoracuteischemia),tachycardiawithpulses.Objective:Restorehemodynamicstability,adequateperfusion.

3:Tachycardia-Unstable• Callforhelp.Informteam.Get

Codecart.• CheckforPulse.IfNOpulse,GO

TO:Asystole/PEAevent.Ifstable,GOTO:Tachycardia– StableSVTevent.

• IncreaseFiO2 to100%,highflow.• Decrease/turnoffanesthetic.• Confirmadequateventilationand

oxygenation.Considersecuringairway.

• Ifunstable,IMMEDIATESYNCHRONIZEDCARDIOVERSION– biphasicdoses.

• Considersedationifpatientawake.

• Ifunsuccessfulcardioversion:Re-SYNCandincreaseJoulesincrementallyforSynchronizedCardioversion.

• Whilepreparingtocardiovert (doNOTdelay),ifnarrowcomplexandregular,considerAdenosine6mgrapidIVpushwithflushviaaccessclosesttoheart.Maygive2nd doseof12mgIV.

SVT Rhythm BiphasicDose

Narrowcomplex, &Regular

50-100JSynchronized

Narrowcomplex &Irregular

120-200 JSynchronized

Widecomplex &Regular

100 JSynchronized

Widecomplex&Irregular

UnsynchronizedDefibrillation:200J

DuringResuscitation:• Circulation(confirmadequateIVorIOaccess)

• ConsiderIVfluidswideopen.• Consider12-leadECG.

• Airway (assessandsecure)• Breathing (100%FiO2,highflow)

Atrial Fibrillation 120Jà SYNC*à 150JàSYNC*à 200J

Mono-morphic VT 100Jà SYNC*à 150JàSYNC*à 200J

OtherSVT,Atrialflutter

50Jà SYNC*à 100JàSYNC*à 150Jà SYNC*à200J

PolymorphicVTandunstable

TreatasVF,GOTO:CardiacArrest– VF/VTEvent

SynchronizedCardioversion Instructions:• Turnmonitor/defibrillatorON.Setto

DEFIBmode.• Placeelectrodesonchestperpackage

instructions.• PressSYNCbuttontoengage

synchronizationmode.• Lookformark/spikeonR-waveindicating

SYNCmode.• AdjustSIZEbuttonifnecessaryuntil

SYNCmarkersseenwitheachR-wave.• Cardiovert atappropriateenergylevel,

beginatlowerlevelandprogressasneeded:“Energyselect”buttonsà“Charge”buttonà “Shock”button[Pressandhold].

3

DuringCPR:• Circulation (confirmadequateIV/IO

access).• IfETCO2<10,improveCPRquality

• Airway(bagmaskokifventilationadequate)

• Breathing (100%FiO2,highflow)• Assignrolesfor:Chestcompressions,

defibrillation,airway,vascularaccess,documentation,codecart,timekeeping.

Ordersshouldbeexplicitlyacknowledgedandrepeated.

4:CardiacArrest:PulselessVF/VTTopPriority=EarlyDefibrillation• Callforhelp.Informteam.Code

Cart.• Getdefibrillator.• CPR (100-120chest

compressions/min,5-6cmdeep+10breaths/min).*– Ensurefullchestrecoilwithminimal

interruptions.

• Shockathighestsetting(200JoulesBiphasic).

• Epinephrine 1mgIVq3-5min.• CPR x2min.

• Checkpulseandrhythm(confirmshockable;limitcheckto10sec).**

• Shock at200J Biphasic• Epinephrine1mgIVq3-5min• CPR x2min.

• Checkpulseandrhythm(confirmshockable;limitcheckto10secs).**

• Shock athighestsetting.• Amiodarone 300mgIVx1.♯

• CPR x2min.

• Checkpulseandrhythm(confirmshockable;limitcheckto10sec).**

Condition:Shockable pulselesscardiacarrest.Objective:Restorepulse,hemodynamicstability

*Inpatientwithoutanadvancedairway:CycleofCPR=30compressionsatrateof100/min,followedby2breaths.Give5cyclesofCPRwhere“CPRx2min”isnoted.Ifable,keepETCO2>10,Diastolic>20**IfAsystole/PEAdevelopsatanypoint,GOTOCardiacArrest:Asystole/PEAchecklist.**Ifpulseatanypoint,beginpost-resuscitationcare.

Defibrillator:1. TurndefibrillatorON,settoDEFIBmode.2. Placeelectrodesonchestperpacking

instructions.3. Delivershock(“Charge”buttonà “Shock”

button)

DrugDosesandadditionalconsiderations:Epinephrine:1mgIV,repeatevery3-5minAmiodarone:300mgIV/IOonce,thenconsideradditional150mgIV/IOonce♯Lidocaine canbegiveninsteadofamiodarone forVF/pulselessVTunresponsivetoCPR,defibrillationorvasopressortherapy(1.5mg/kg).Magnesium:considergivingforTorsades dePointes(loadingdose1-2gIV/IO)ForMagnesiumToxicity:Calciumchloride10%soln 10mLIV/IOorcalciumgluconate10%soln 30mLIV/IO

4

5:AnaphylaxisCondition:Suspectedanaphylaxis(consistenthx,rash/hives,hypotension,bronchospasm/wheezing,angioedema,increasedPIP,difficultybreathing,hypoxemia).Objective:Restorehemodynamicstability,abortreaction.

• Callforhelp.Informteam.Codecart.• Discontinue/removepotentialcausative

agents.• FiO2 increasedto100%?• Decreaseanestheticifhypotensive.• GiveEpinephrineIVinescalatingdoses

every2min.– Start10-100mcgIV– Increasedoseevery2minuntilclinical

improvementnoted.– Considerearlyepinephrineinfusion.

• Considerearlyintubationtosecureairwaypriortoangioedema ofairway.

• IVfluidsopenedand/orfluidbolus givenathighrate?

• Ifnoresponse:beginIVepinephrineinfusion(rate1-4mcg/min).

• IVaccessadequate?• Considerinvasivemonitors(arterialline).

Haveweconsidered:• Terminationofproceduretofocuson

resuscitation?• Vasopressin?(2-4UnitsIV;forpatientswith

continuedhypotension)• Albuterol?(ifbronchospasmisaprominent

feature)• H1 blocker- Diphenhydramine?(25-50mg

IV)• H2 blockers?(ranitidine50mgIM/IV,

cimetidine300mgIM/IV)?• Glucagon?(1-5mgIVover5min,inpatients

takingbetablockers)• Corticosteroids?(e.g Hydrocortisone100-

200mgIVormethylprednisolone125mgIV)todecreasebiphasicresponse.

Commoncausativeagents:Neuromuscularblockingagents,latexproducts(gloves,Foleycatheter),chlorahexidine,antibiotics,colloids,bloodproducts,contrast,protamine.

DrugDoses:• Epinephrinedoses:• Startwith10-100mcgIVdependingon

severity• Increaseincrementallyevery2min

untilimprovement• 300mcg(0.3mLof1:1,000

concentration)IMifnoIVaccessIfcardiacarrest:

Give1mgepinephrineIV,beginACLSandGOTO:CardiacArrest– Asystole/PEAChecklistorCardiacArrest– VF/VTChecklist.

Considerandruleoutothercauses:• PE• MI• AnestheticOD• PTX• Hemorrhage• Aspiration

POSTEvent(considerwhenpatientstable):• Checkserumtryptase level(usefultoguide

futuremanagement;peaks<60minpost-event)

• Checkserumhistamine (peaks<30minpost-event)

• Ifeventwasmoderate/severe,considerkeepingpatientintubatedandsedated.

• Canrecurwithbiphasicresponse:Considermonitoringfor24hourspost-recovery.

• Referpatientforpost-allergytesting.

5

6:Bronchospasm(IntubatedPatient)

Condition:DecreasedSpO2,increasedpeakpressures,wheezing,increasedETCO2 withupsloping ETCO2 waveform,decreasedTVifpressurecontrol.Objective:Restorenormaloxygensaturationandpeakpressures.

• Callforhelp.Informteam.Codecart?

• IncreaseFiO2 to100%,highflows.• Ifhypotensive,considerdisconnectingpatientfromcircuittoallowforcompleteexhalationasmaybeduetoairtrapping.

• ChangeI:Etimetoallowforadequateexhalation.

• Deepenanesthetic(Sevoflurane isnon-irritating).

• Ruleoutmainstem intubationorkinkedETT.SuctionETT.

• GiveinhaledBeta-2agonist(Albuterol)+/- anticholinergic(Ipratroprium)

• Ifsevere,considerEpinephrine (startwith10mcgIVandescalate,monitorfortachycardiaandHTN).

• ConsiderKetamine (0.2-1mg/kgIV)• ConsiderMagnesiumsulfate(1-2gIV)• ConsiderHydrocortisone (100mgIV)• ConsidernebulizedracemicEpinephrine.

• Ruleoutanaphylaxis(hypotension/tachycardia/rash).GOTO:Anaphylaxischecklist.

• ConsiderABG.

6

7:DifficultAirway-Unanticipated

Condition:Failedairway(3unsuccessfulattemptsoroxygensaturation<85%)Objective:Establishadequateoxygenation/ventilation.

Callforhelp.GetDifficultAirwaycart.

Bag-maskventilate.

Bag-maskventilationadequate?*

Yes,consider:NoLaryngealMaskAirway(LMA)orotherSupraglottic (SG)device

• OperationusingLMA (+cricoid).**• Returntospontaneousventilation.• Wakepatientup.• Differentlaryngoscopeblades.***• BURPmaneuver(BackwardsUpwardsRightwardPressure)• VideoAssistedlaryngoscope.• LMA-Aintree catheterasconduit.• Fiberoptic intubation.• Trachealintroducer(bougie).

LMA/SGventilationadequate?

No

Yes,consider:

• Cricothyrotomy (bottomdrawerofAnes machine).• Transtracheal jetventilation.• CallENTConsult 443-0825forsurgicalairway.GetTracheostomyKit.• Considerrigidbronchoscope.

*Tryoralairways,sniffposition,ramp,two-handedventilation.Avoidnasalairwaysinpregnancy.**OnlyiftruecrashC-section.***LimittotalDLattemptsto3innon-pregnantpatients,limitto2inpregnantpatients.SmallerETTrecommended(6.0)inpregnancy.Donotattemptnasalintubationinpregnantpatients.

IfbagmaskventilationandLMAbecome

inadequate • Wakepatientup(forawakeintubation,doingprocedureunderregional/local,orcancellingcase).• Otheroptions(i.e.surgeryusingLMA,face-mask**)• Surgicalairwayifunabletoabortcase.

Ifalternativesfail,consider:

MBENTSurgeryConsult: 443-0825

7

8:Fire Condition:SignsoffireinOR,inairway,oronpatient(smoke,odor,flash)Objective:Protectpatient,containfire.

• Stopflowofmedicalgases(oxygen/nitrousoxide).• Remove drapesandflammablematerialsfrompatient.• Extinguishfire:• If electricalequipmentburning(laser,

Bovie,anesthesiamachine,etc),useonlyCO2 fireextinguisher(safeinwounds).

• Ifnon-electrical,extinguishwithsalineandsoakedgauze.

**Donotusealcoholbasedsolutions.**

• Disconnectbreathingcircuit.• Stopflowofmedicalgases(oxygen/nitrousoxide).• Removeendotrachealtube(mustbalanceagainstairwayloss).• Removeflammablematerialfromairway.• Poursalineintopatient’sairwayorendotrachealtube,ifkeptinplace.

AirwayFire Non-airwayFire

Activatefirealarm/Getfire-extinguisher/Removesourceofheat.

IfFireNotExtinguishedOnFirstAttempt

• Re-establishventilation.Considerpromptreintubation priortoswelling.• Avoidoxidizer-richenvironment,supplementalO2 (ifpossible).• Considerbronchoscopy toassessforinhalationalinjuryandremoveresidualdebris.• ExamineETtubetoseeiffragmentsmaybeleftbehind.• Discusscontinuationofcasewithsurgeon.

• Evacuate patient(perInstitutionalprotocol).• CloseORdoor.• TurnOFFexternalgassupplytooperatingroom.• Alertfiredepartment(Call911).

IfFirePersists

IfFireExtinguished

• Usefireextinguisher(CO2)toextinguishfire(safeinwounds).

Callforhelp.Informteam.

SeebackforFirePreventionTipsà

8

FirePrevention

Ifhighrisk procedure,includingthoselistedbelow:• Discussfireprevention&managementwithteamduringtime-out.• AvoidFiO2 >0.3andavoidN2O.

Forlaser surgeryofvocalcordorlarynx:• UselaserresistantETT.• MakesureETTcuffissufficientlydeepbelowvocalcords.• FillproximalETTcuffwithmethyleneblue- tintedsaline.• EnsurelaserisinSTANDBYwhennotinactiveuse.• SurgeonprotectsETTcuffwithWETgauze• SurgeonconfirmsFiO2 <0.3&nonitrouspriortolaseruse.

Fornon-lasersurgeryinoropharynx:• RegularPVCETTmaybeused.• ConsiderpackingwetgauzearoundETTtominimizeoxygenleakage.• Considercontinuoussuctioningofoperatingfieldinsideoropharynx.

AirwayFirePrevention

Non-airwayFirePrevention

• TeamcommunicationatTime-Outifhighriskprocedure.• HighestriskinMACheadandneckprocedure.

– Usenasalcannulainsteadoffacemask(ifpossible).– ConfiguredrapestoavoidO2 build-up,consideractivescavengingifrequired.– UseminimumO2 concentrationforadequateSpO2.

• IfhighO2 concentrationrequired,useLMAorETT.• AllowcompletedryingofEtOH skinprepsolutions.• Considercoatingpatient’sheadhairandfacialhairwithwater-solublesurgical

lubricatingjelly.

Remember:FuelSource+Oxidizer+Spark=FIRE

9:Hemorrhage• Callforhelp.Informteam.Codecart?• OpenIVfluids.GetadequateIVaccess(atleast

two18GPIVs)• ConsiderTrendelenburgorelevatepatient’slegs.• CheckHemacue.SendSTATlabs(T&C,CBC,

PT/PTT/INR,Fibrinogen,Lactate,ABG,Potassium,Calcium)

• CallBloodBank476-1404:– ActivateMassiveTransfusionProtocol(viaANESAttending phonecalltobloodbank)

– Order bloodproducts• RBC/FFP (1:1ratio)• ConsiderPlatelets (ifindicated,1:5ratiowithPRBCs)• ConsiderCryoprecipitate

• CallforadditionalNursingandAnesthesiahelp.CallfordedicatedAnesthesiaTech.

• Re-evaluateAnestheticplan.• UseRapidinfuser(orpressurebags).• Maintainnormothermia.FluidwarmerforIVand

bloodproducts.Forcedairwarmer.• Maintainnormocalcemia.• Placearteriallineasindicated.Followpatient’s

ABG(acid/basestatus)asindicatorofadequateresuscitation.

Haveweconsidered:• Additionalsurgicaltechniquesand/orpersonnel?– Hemostaticagents?Antifibrinolytics(Tranexamic acid10mg/kgIV,then1mg/kg/hr)?

– InterventionalRadiology?(Fellowpager443-9417)

– VascularSurgery?– Cell-saver(ifnoncontaminated,nonmalignantcase)?

• Damagecontrolsurgery(pack,close,resuscitate)?• ICU postop?

Condition:AcutemassivebleedingObjective:Stopbleeding,maintainhemodynamicstability,avoidcoagulopathy

HyperkalemiaTreatment:• Calciumgluconate (10mg/kg)or

calciumchloride(10mg/kg)IV• SodiumBicarbonate1-2mEq/kg,slow

IVpush• Insulin10UnitsregularIVwith1-2

ampsD50W

**Ifactivebleeding,transfusebasedonclinicalsituation.

Donot waitforlabresults.**

OtherConsiderations:• StayincontactwithBloodBank

periodicallyifMassiveTransfusionProtocolactivatedtoensurecontinueddeliveryofbloodproducts.Identifyonepersontospeaktoonepersoninbloodbankforallproductrequeststoavoidduplicates.

• Considercellsalvage.CallCellSaver (916)851-5800forsetup.

EstimatedBloodLoss=EBVX(HCTstart –HCTmeasured)/HCTstart

EstimatedBloodVol (EBV)=65-70mL/kg(4.5Lfor70kg)

RapidResponse/ResourceNurse:415-502-0562;443-FAST(3278)

MBAdult ICUAttending:502-1232MBAdult ICUNP:502-1231

9

10:Hypotension Condition:UnexplaineddropinBP.Objective:Restorehemodynamicstability.

• Callforhelp.Informteam.Codecart?• CheckEquipment/monitorscheckedformalfunction(arterialline,BPcuff).• CheckPulses. Ifnopulse,startCPR,GOTO:appropriateACLSevents.• GiveIVfluidbolusopened?EnsureIVisworking.• IncreaseFiO2 to100%,highflow.• Surgicalfieldinspectedforbleeding?Ifbleeding,GOTO:Hemorrhage Checklist• Haveweconsidered:

– Decreasinganesthesia?– Patientposition?ConsiderTrendelenberg orelevationofpatient’sleg.– Givephenylephrineorephedrinetotemporize.Ifsevererefractoryhypotension,

considerepinephrine 10-100mcgand/orvasopressin1-4units.– AdditionalIVaccess?Arterialline?– Sendlabs:ABG,Hgb,electrolytes,calcium, lactate,type&cross

• Haveweconsideredthefollowingcauses:

• Retraction• Vagalstimulation• Mechanical/surgicalmanipulation• Vascularcompression• IVCcompression(prone,obese,pregnantorsurgical)

• Otherevidenceofbleeding:• Amountofbloodinsuction

canister• Numberofbloodysponges• Bloodonthefloor

• Drugsusedonthefield(i.e.intravascularinjectionoflocaldrugs)

Airway:• UnexplainedHypoxia(GOTO:HypoxiaChecklist)• IncreasedPEEP,Auto-PEEP(disconnectcircuit)Breathing:• Hypoventilation• Pneumothorax• PulmonaryEdema• PersistenthyperventilationCirculation:• Hemorrhage• Myocardialischemia• PulmonaryEmbolism• AirEmbolism(GOTO:AirEmbolismChecklist)• Otheremboli(fat,septic,CO2,amnioticfluid)• Anaphylaxis• Severesepsis,adrenalinsufficiency• Tamponade• Bradycardia (GOTO:Bradycardia – UnstableChecklist)• Tachycardia(GOTO:Tachycardia– UnstableChecklist)• MalignantHyperthermia(GOTO:MalignantHyperthermiaChecklist)

• BoneCementing(Methylmethacrylateeffect)Drugs/allergy:• Recentdrugsgiven/doseerror/allergy• Anestheticoverdose

Surgical

Nursing

Anesthesia

10

11:Hypoxia Condition:Unexplainedoxygendesaturation.Objective:Restoreoxygenation.

• Callforhelp.Informteam.• CheckPulseoximeter placement.• IncreaseFiO2 to100%,highflow.• Handventilate toassesscompliance.Ruleoutleaks,machinefactors.• Oxygensource checked?Checkothermonitors,vitals,PIP,ETCO2.Checkforpulse.• CheckCircuitfordisconnection,kinks,holes.• End-tidalCO2 confirmed?• ListenforBreathsounds(bilateral? clear?).CheckETTposition.• SoftsuctionviaETT(toclearsecretionsandcheckobstructions).• CheckABG.ConsiderCXR.

Circulation:• Embolism

– PulmonaryEmbolus– AirEmbolism?(GOTO:AirEmbolismChecklist)– OtherEmboli(e.g.fat,septic,CO2,AFE)

• HeartDisease?– CongestiveHeartFailure– CoronaryArteryDisease– MyocardialIschemia– CardiacTamponade– Congenital/anatomicDefect

• EKG,TEE,Bypassconsidered?• Severesepsis• Ifhypoxiaassociatedwithhypotension(GOTO:HypotensionChecklist)

Drugs/allergy:• Recentdrugsgiven

– Drugerror/allergy/anaphylaxis

SuspectedAirway/BreathingIssue?

NoConsidercauses:

YesDependingonlikelydiagnosis,consider:

Considercauses:Airway:• Rightmainstem intubation• Bronchospasm• Ventilatorsettings,leadingtoAuto-PEEPBreathing:• Aspiration• Atelectasis• Obesity/positioning• Pneumothorax– CXR.Considerneedledecompression,chesttube.

• Hypoventilation• PulmonaryEdema• LowFiO2

• V/Qmismatchorshunt,diffusionproblem

• Largerecruitmentbreaths.AddPEEP (cautionifhypotensive)

• Bronchodilators (albuterolMDIornebulizer)• Neuromuscularblockade(ifindicated)• IncreaseFRC:headup(unlesslowBP),desufflate• Fiberoptic toruleoutmainstem intubationorETTobstruction.

• RemovingcircuitandusingAmbu-bag• RemoveETTandMaskVentilation/Re-Intubation• Considerterminatingsurgeryforrefractoryhypoxemia.

Seebackfordifferentialdiagnosisà

11

Hypoxia

• LowFiO2:IfgasanalyzerstateslowFiO2 whileon100%O2 likelyhaveO2 failureorpipelinecrossoverofgases.Disconnectfromanesthesiamachine,useAmbu bagorJacksonReescircuitattachedtoEcylinderofO2.

• Hypoventilation:Checkforsigns oflowminuteventilation:– LowTVorRR– HighorlowETCO2– Poorchestrise– Decreasedbreathsounds– PatientbuckingventilatorRuleout orfixequipmentandpatientcauses:– Circuitleak– ObstructedorkinkedETT– HighPIP– Residualneuromuscularblockade– Patientbreathingasynchronouslywithventilator.Postoperativerespiratoryfailurecommoncauses:– Residualneuromuscularblockade,opioid,anesthetic,laryngospasm(sudden),bronchospasm,

pulmonaryedema,highspinal,pain.• V/QMismatchorShunt:A-aGradientCommonCauses

– Mainstem intubation– Atelectasis– Aspiration– Bronchospasm(+?Anaphylaxis)– Mucusplug– Pleuraleffusion

ConsiderRAREbutCritical:• Pneumothorax• Hypotension – anycauseofpoorperfusion• Embolus – Air,blood,fat,AFE

• Diffusion abnormality:usuallychroniclungdisease• Methemoglobinemia (O2 sat~85%),COHgb (O2 Satoftennormal):Ifsuspect,checkco-

oximetry.• IncreasedmetabolicO2 demand:MH,thyrotoxicosis,sepsis,hyperthermia,neuroleptic

malignantsyndrome.• Artifacts:Poorwaveform(probemalposition,coldextremity,lightinterference,cautery),

dyes(methyleneblue,indigocarmine,bluenailpolish).ConfirmbyABG.

PhysiologicalDifferentialDiagnosis:

12:LocalAnestheticToxicity

Condition:Tinnitus,metallictaste,circumoral numbness,alteredmentalstatus,seizure,hypotension,bradycardia,ventriculararrhythmias,CVcollapseObjective:Restorehemodynamicstability

• Callforhelp.Informteam.Codecart.• CallforIntralipid (inBlockcart). AlertpossibleCardiopulmonaryBypass.

• Ifpulseless,startCPR.• Stoplocalanestheticinjection/infusion.

• Ifpatientunstable,giveepinephrine<1mcg/kg.Avoidvasopressin.

• Establishairway– ensureadequateventilationandoxygenation.Considerendotrachealintubation.

• Treatseizurewithbenzodiazepines(avoidpropofol ifhemodynamicinstability)

• Ifsignspersistorpatientunstable,rapidlygive1.5mL/kgbolusof20%Intralipid IV(70kgadultgets100mLover1min),thenstartinfusionat0.25mL/kg/min.Mayrepeatloadingdose(max3dosesor10mL/kgoverfirst30min).Mayincreaseinfusionrateto0.5mL/kg/minifpersistenthypotension.

• Monitorforhemodynamicinstability.Treathypotension.GOTO:appropriateACLSeventdependingonarrhythmiawithASRAmodifications*.

• Ifrefractorytotreatment,considercardiopulmonarybypass.

• Mayrequireprolongedresuscitation.• Monitorpatientpost-eventinICU.

DrugstoAVOID duringLocalAnestheticToxicity:

• Propofol• Vasopressin• Calciumchannelblocker• Betablocker• Localanesthetic

*ASRAModificationstoACLSwhentreatingLocalAnestheticToxicity:

• ReduceEpinephrinedosesto<1mcg/kgIV.• AVOID:Vasopressin,calciumchannel

blockers,betablockers,andlocalanesthetics.

Intralipid Dosing:• Bolus1.5mL/kg(leanbodymass)IVover1

min(~100mLin70kgpatient)• Continuousinfusion0.25mL/kg/min

(~18mL/min)• Repeatbolusonceortwiceforpersistent

cardiovascularcollapse• Doubleinfusionrateto0.5mL/kg/minifBP

remainslow• Continueinfusionforatleast10minutes

afterattainingcirculatorystability• Recommendedupperlimit:10mL/kgover

first30min

12

13:MalignantHyperthermia

Condition:Unexpected,unexplainedincreaseinend-tidalCO2;prolongedmassetermusclespasmaftersuccinylcholine;unexpected,unexplainedtachycardia,tachypnea,mixedacidosisObjective:Restorenormalhemodynamicparameters,metabolicfunction,temperature.

• Callforhelp.Informteam.• GetMalignantHyperthermia(MH)cart.

LocatedinAnesthesiaworkroomA2666.• Stopvolatileanestheticsandsuccinylcholine,

transitiontonon-triggeringanesthetic.– Don’tdelaytreatmenttochangecircuitor

CO2 absorber.– RequestchilledIVsaline.

• IncreaseFiO2 100%,highflow10L/min.• Increaseminuteventilation: 10L/minormore

(2-4xpatient’sminuteventilation)• GiveDantrolene 2.5mg/kgIVbolus!• CallMHhotline:1-800-644-9737• Haltprocedure.Ifemergent,continuewith

non-triggeringanesthetic.• GiveBicarbonate formetabolicacidosis.

– MaintainpH>7.2.• Coolpatientiftemp>38.5°C

– Lavageopenbodycavities.– NGlavagewithcoldwater.– Applyiceexternally.– Coldsalineinfusedintravenously.**Stopcoolingiftemp<38°C.**

• Hyperkalemia treatedifsuspected?• Dysrhythmias treatedifpresent?

– Standardantiarrhythmics areok;don’tuseCalciumChannelBlockers.

• SendLabs: ABG,VBG,electrolytes,serumCK,serum/urinemyoglobin,PT/PTT,lacticacid.

• PlaceFoleycatheter.Monitorurineoutput.Goal2mL/kg/h.

• ArrangeICUbed.Mechanicalventilationusuallyrequired.

• ContinueDantrolene 1mg/kgq4-6hrs for24-36hours.Observecloselyfor24hours.

DrugDosesandTreatments:Dantrolene:• Dilute250mgin5mLsterilewater.• 2.5mg/kgIVq5minuntilsymptomssubside.• Mayrequireupto30mg/kg.SodiumBicarbonate:• 1-2mEq/kgforsuspectedmetabolicacidosis

(maygiveevenifbloodgasvaluesnotavailable).

HyperkalemiaTreatment:• Hyperventilation• Calciumchloride(10mg/kg)orCalcium

gluconate (30mg/kg)IV• Sodiumbicarbonate1-2mEq/kg,slowIV

push.• RegularInsulin10UnitsIVwith1ampD50

(25gDextrose)– monitorglucose.

SignsofMH:EARLY:• IncreasedETCO2• Tachycardia• Tachypnea• MixedAcidosis• Masseterspasm/trismus• Suddencardiacarrestinyoungpersondueto

hyperkalemiaMay beLATER:• Hyperthermia• Musclerigidity• Myoglobinuria• Arrhythmia• CardiacArrest

DifferentialDiagnosis:• Lightanesthesia• Hypoventilation• InsufflationofCO2• Over-heating(external)• Hypoxemia• Thyroidstorm• Pheochromocytoma• NeurolepticMalignantSyndrome(NMS)• SerotoninSyndrome 13

14:MyocardialIschemia

Condition:Chestpain,shortnessofbreath,depressionorelevationofSTsegment,arrhythmias(conductionabnormalities,unexplainedtachycardia,bradycardia orhypotension).Objective:Increasemyocardialoxygensupply,decreasemyocardialoxygenconsumption.Restorehemodynamicstability.

• Callforhelp.Informteam.Codecart.CallHospitalistandMBAdultICUteam.

• IncreaseFiO2 to100%,highflows.• Verifyischemiawithexpandedmonitorview,12-leadEKG.

• Treathypotensionorhypertension.• Beta-blockertoslowheartrate.Holdforbradycardia orhypotension.

• Aspirin325mgchewedPOor600mgPRorNG/OG.

• IfAcuteCoronarySyndrome,callCardiologyconsultandHospitalist,whowillactivateSTEMIpager.– ConsiderCath Lab– CallforSTATURGENTCriticalCare

TransportfromAmericanMedicalResponse*.

• Treatpainwithopioids(fentanylormorphine).

• Considernitroglycerin0.4mgsublingualand/orinfusion (startat0.2mcg/kg/min,titratetoreliefofchestpainandhemodynamicstability;holduntilhypotensiontreated).

• CheckABG,CBC,Troponin.Considerarteriallineifhypotensive.

• Ifanemic,treatwithpackedRBCs.• ConsiderTTEformonitoringvolumestatusandregionalwallmotionabnormalities.

• Bepreparedforarrhythmias andhaveCodeCartatbedside.

CardiologyConsult: Checkwww.Amion.com (login:ucsf)forMB

CardiologyConsult.

MBHospitalist: 415-502-1235;443-0093RapidResponse/ResourceNurse:415-502-0562;443-FAST(3278)

MBAdult ICUAttending:502-1232MBAdult ICUNP:502-1231

AmericanMedicalResponseambulanceservice:1-800-955-8825TransferCenter:353-1937or353-9166

ForCath LabActivationcall:M-Lbacklineoperator:353-4008M-LCardiologyserviceresidentpager(fortransfersto10ICU):443-QRST

LinktoMBPolicyforAdultACS/STEMI:https://ucsfpolicies.ucsf.edu/Patient%20Transfers%20%20Intercampus/Forms/AllItems.aspx

Goal:STEMItoPCI(symptom-to-balloon)timeof90minutes.

Stentingandantiplatelettherapyarenotcontraindicationsduringpregnancy.

IfSTElevationMI,callCardiologyConsultandHospitalistSTAT.

PatientmayneedtobetransferredtoSFGHfornearestCath lab. CallResourceNurse.

*CriticalCareTransportfromAMRona“STATURGENT”basis.IfAMRcannotguaranteearrivalofaCriticalCareTransportambulancewithin30minutes,thenAMRwillofferappropriatecontingencytransportoptionssuchasALS,orBLS-leveltransport 14

15:OxygenFailureCondition:HearO2 failurealarmorwhileon100%O2,see“LowFiO2”valueongasanalyzerObjective:ProvideO2 topatient.

• Callforhelp.Informteam.Codecart?• DisconnectpatientfrommachineandventilatewithAmbu bagonRoomAir.

• Alternative:ObtainfullEcylinderofO2witharegulator.VentilatewithAmbu bagorJacksonReescircuitattachedtonewO2tank.

• Donot connectpatienttoauxiliaryflowmeteronmachine– comesfromSAMEcentralsource!

• OpenO2 tankonbackofanesthesiamachine(checknotempty)anddisconnectpipelineoxygentoforceflowfromtankintocircuit.

• Connectgassamplingadaptortoallowmonitoringofrespiratorygases.Isthepatientreceiving100%oxygen?

• Maintainanesthesia(ifnecessary)withIVdrugs.

• ReduceO2 flowratestominimumneededtoconserveoxygen.

• Obtainextrabackupsourcesofoxygen.• Whenpatientmorestable,contactBioengineerstoalertthemtotheproblemandenlisthelpwithmachinediagnosiswhileyoufocusonpatient.

• InformORleadership,ICU,hospitalofpotentiallarge-scaleO2 problem.

• DiscusswithsurgeonsimplicationofO2failureforthispatient’smanagementandORschedule.

MBAdultORfrontdesk:476-1015MBBiomed:476-1491ClinicalEngineeringPager:443-2640

6am-9:30pm:514-9797,514-3570

15

16:Pneumothorax(PTX)

Condition:IncreasedPeakinspiratorypressures,tachycardia,hypotension,hypoxemia,decreasedorasymmetricbreathsounds,trachealdeviation,increasedJVD/CVPObjective:DecompresstensionPTX;restorehemodynamicstability

• Callforhelp.Informteam.Codecart?• DonotwaitforX-Raytotreatifpatientishemodynamicallyunstable!

• Increaseto100%O2,highflow• Ruleoutmainstem intubation.• ConsiderstatCXRorTTEorUltrasoundtoassess

• Place14or16Gneedlemid-clavicularline2nd intercostalspaceonaffectedside.Shouldhearawhooshofairifundertension.

• Immediatelyfollowupneedledecompressionwiththoracostomy(chesttube).

X-RayatMB: 502-0210Ifafter3pm,X-rayLeadtech:502-0396;443-

5405

SignsofPTXonUltrasound:• Absenceoflungslidingonnon-dependent

partoflung• “Barcode”signonM-mode(seeimage

below)• Lung-pointsignincreasessensitivityof

ultrasounddiagnosisofPTX.

Images from StoneMB.JEmerg TraumaShock.2008Jan-Jun;1(1):19–20.

Seashoresign=lungsliding(normal)

Barcodesign=Nolungsliding;

?PTX

Lung-pointsign

16

17:PowerFailure Condition:Lossofpower.Objective:Ensureadequateoxygenationandventilation.

• Getadditionallightsources:flashlights(topdrawerofanesthesiamachine),laryngoscopes,cellphones.

• Opendoorsandshades toletinambientlight.

• Confirmventilatorisworkingandifnot,ventilatepatientwithAmbu bagandswitchtototalIVanesthesia(TIVA).

• Ifmonitorsfail,checkpulseandmanualbloodpressure.

• RequestTransportMonitorordefibrillatormonitor.

• ConfirmadequatebackupO2 supply(e.g.fullEcylinderO2 tanks).Powerfailuremayaffectoxygensupplyoralarms.

• Checkextentofpowerfailure.CallORfrontdesk476-1015.CallClinicalEngineering514-9797.– IstheproblemoneOR,allORs,orhospital-

wide?– IfonlyinyourOR,checkifcircuitbreaker

hasbeentripped.

MBAdultORfrontdesk:476-1015MBBiomed:476-1491ClinicalEngineeringPager:443-2640

6am-9:30pm:514-9797,514-3570

17

18:SeizureCondition:suddenshaking,tonic-clonic movements,tonguebiting,bowelorbladderincontinenceObjective:stopseizureactivity,preventhypoxia,preventrecurrenceofseizures

• Callforhelp.Informteam.Codecart?• AssessC-A-B(Circulation,Airway,Breathing)andvitals.

• ActivateCodeBlue.• CallRapidResponseRN502-0562andMBHospitalist502-1235.

• Lateralpositiontominimizeaspirationrisk.

• Ifeclampsia,giveMagnesium*(IVorIM)&TreatHTN(SBP>160orDBP>110).

• SupplementalO2 /ObtainIVaccess.• Ifseizurepersists,givebenzodiazepine(midazolam2mgIVorativan 1mgIV)

• Ifconcernforlocalanesthetictoxicity,doNOTboluspropofol.GOTO:LocalAnestheticToxicityChecklist.

• ConsultNeurology443-COMA.• Checkglucose:

– TreathypoglycemiawithD50.– Treathyperglycemiawithinsulinif

bloodglucose>200.

• Forpersistentseizures,consider:– Fosphenytoin 15-20mg/kgIV(no

fasterthan150mg/minbolus,then100-150mg/mininfusion).

– Propofol (2-3mg/kgIVbolus,followedbyupto75mcg/kg/mininfusion).

– Phenobarbital(15mg/kgIV).

• Checkelectrolytes(Sodium).• Ifthepatientispregnant,discussdeliveryurgencywithOB.

• ConsiderICUforfurthermonitoring.

MagnesiumDosing:*• Ifpatientisreceivingprophylactic

MagnesiumSulfate,give2gmIVbolusover3-5min.Otherwise,give4gm-6gmIVloadingdoseover15-20minutes.

• IfthepatientdoesnothaveanIV,giveMagnesiumSulfate5gmIM(buttock).

RapidResponse/ResourceNurse:502-0562,443-FAST(3278)MBHospitalist:502-1235,443-0093Neurology Consult:443-COMA(2662)MBAdult ICUNP:502-1231

LinktoOBEclampsia policy:http://manuals.ucsfmedicalcenter.org/NursingDept/UnitPolicyProcedure/15Long/PTCare/PreeclampsiaHELLPandHypertensiveDisorders.pdf

SeizureDifferential:• Epilepsy• Eclampsia• LocalAnestheticSystemicToxicity• Stroke/Transientischemicattack• Posteriorreversibleencephalopathy

syndrome(PRES)• Subarachnoidhemorrhage• ConvulsivesyncopeSeebackofthispageforlargerdifferentialà

NeuromuscularBlockingAgentsdonotstopseizureactivityinthebrain,butmayhelpfacilitateintubation.

18

• Epilepsy• Eclampsia• LocalAnestheticToxicity• Stroke/Transientischemicattack• Posteriorreversibleencephalopathysyndrome(PRES)

• Subarachnoidhemorrhage• Convulsivesyncope• Encephalitis• Pseudoseizure• Hypoglycemia

• Delirium,dementia• DeliriumTremens• Migraine• Sleepdisorder,parasomnia (nightterrors,sleepwalking)

• Essentialtremor• RestlessLegSyndrome• Anticholinergictoxicity• Paroxysmalmovementdisorder(acutedystonicreaction,non-epilepticmyoclonus,propofol oretomidate inducedmyoclonus)

SeizureDifferential:

19:StrokeCondition:suddennumbness,weakness,dizziness,confusion,severeheadacheortroublewithspeakingvision,coordinationObjective:timelyevaluationandtreatmentofacutestroke,possibleemergenttransfertoMoffittforthrombolysis+/- embolectomy

• Callforhelp.CodeBlue.BatchPage.• GetCodeCart• CallRapidResponseRN502-0562andMBHospitalist502-1235

• RapidresponseRNwillcontactMBICUteam

• Ifconcernforacutestroke,HospitalistwillcallNeurologyConsult443-COMA.

• HospitalistwillorderSTATNCHCT.• SupplementalO2

• ContinuousEKGmonitoringforischemiaoratrialfibrillation

• MonitorBPandonlytreatafterdiscussionwithNeurology

• Checkglucose.– TreathypoglycemiawithD50.– Treathyperglycemiawithinsulinif

bloodglucose>200.

• Treatfeverwithacetaminophen• IfGCS<8,considerintubation*

IfthepatientisNOTPREGNANT:• Ifstrokeislikelyandthrombolysisindicated,

transferimmediatelytoMoffitt-LongNeuroICU:

– RapidResponseRNwillarrangetransportthroughTransferCenterviaACLS/CCTunit.

– IfACLS/CCTunitisnotavailablewithin30minutes,thenBLSunit canbeutilized,butaACLS-trainedRNorprovidermustaccompanypatienttoMoffitt-Long.

• IfstrokeislikelyandthrombolysisisNOTindicated,HospitalistwillconsultMBAdultICUteamforadmissiontoMBAdultICU.

Thewindowforpossiblethrombolysisiswithin3hoursofsymptomonset(4.5hoursinsomespecialcases).

ImportantNumbers:RapidResponse/ResourceNurse:502-0562,443-FAST(3278)MBHospitalist:502-1235,443-0093Neurology Consult:443-COMA(2662)

MBAdult ICUAttending:502-1232MBAdult ICUNP:502-1231

CentralPatientPlacementRN:353-1937TransferCenter:353-1937or353-9166Birth CenterTriage:476-7788

MBEDChargeNurse:476-9609MBPediatric ED:502-0635

LinktoMBAdult StrokePolicy:https://ucsfpolicies.ucsf.edu/Patient%20Transfers%20%20Intercampus/Forms/AllItems.aspx

• IfthepatientisPREGNANT:– HospitalistwillconsultMBAdultICUteamforadmissiontoMBAdultICU.

– Neuro IRisavailableatMBforembolectomy.

*ForGCSscore,seebackofpageà

19

Eye Opening(E) VerbalResponse(V) MotorResponse(M)

4= Spontaneous 5=Normalconversation

6=Normal

3= Tovoice 4=Disorientedconversation

5=Localizes topain

2=Topain 3=words, butnotcoherent

4=Withdrawstopain

1=None 2=Nowords;onlysounds

3=Decorticateposture

1=None 2=Decerebrate

1=None

GlasgowComaScore(GCS)=E+V+M

Condition:Hemodynamicstability(SBP>80),tachycardiawithpulses.Objective:Restorehemodynamicstability,adequateperfusion.

20:Tachycardia–StableSVT• Callforhelp.Informteam.GetCodecart.• CheckforPulse.IfNOpulse,GOTO:PEA

event.• IfUnstable(atanypoint),GOTO:SVT-

Unstableevent.PrepareforSynchronizedCardioversion

• IncreaseFiO2 to100%,highflow.• Confirmadequateventilation,oxygenation.• Consider12leadEKG,printrhythmstrip,

thentreatperrhythm(seebelow).• IfstillSTABLESVT,considerArterialline,

sendABG&electrolytes.

SinusTachycardiaisNOTSVT:• SinusTachycardiamaybecompensatory;

searchforandtreatunderlyingcauses.• MorelikelySVTthansinusifanyof

following:• Rate>150• Irregular• Suddenonset

STABLE SVTRhythm Treatment

Narrowcomplex&Regular

1. Toconvert:Adenosine 6mg IVpushwithflush.Maygive2nd dose:12mgIV2. IfNOTconverted,mayRateControl.

ChooseBetaBlockeror CalciumChannelBlocker:BetaBlocker:• Esmolol:Start0.5mg/kgIVover1min.Mayrepeatafter1min.Maystartinfusion

50mcg/kg/min.• Metoprolol:Start1-2.5mgIV.Mayrepeatordoubleafter2.5min.CalciumChannelBlocker:• Diltiazem:5-10mgIVover2min.Mayrepeatafter5min.

3.Amiodarone:150mgIVSLOWLY over10min.Mayrepeatx1.Startinfusion1mg/minfor1st6hours

Narrowcomplex& Irregular

1.ChooseBetaBlockeror CalciumChannelBlocker:BetaBlocker:• Esmolol:Start0.5mg/kgIVover1min.Mayrepeatafter1min.Maystartinfusion

50mcg/kg/min.• Metoprolol:Start1-2.5mgIV.Mayrepeatordoubleafter2.5min.CalciumChannelBlocker:• Diltiazem:5-10mgIVover2min.Mayrepeatafter5min.

2.Amiodarone:150mgIVSLOWLY over10min.Mayrepeatx1.Startinfusion1mg/minfor1st6hours.

Widecomplex &Regular

Amiodarone: 150mgIVSLOWLY over10min.Mayrepeatx1.Startinfusion1mg/minfor1st 6hours.MayconsiderProcainamideorSotalol.

Widecomplex&Irregular

(likelyPolymorphicVT)

PreparetoDefibrillate andGOTO:VT/VFevent

SignsofUNSTABLE:• SBP<80• BP“low”forpatient• RapidBPdecrease• Acuteischemia

20

21:TotalSpinalAnesthesia

Condition:Unexpectedrapidriseinsensoryblockade,numbness/weaknessinupperextremities,dyspnea,bradycardia,hypotension,nausea/vomiting,lossofconsciousness,apnea,cardiacarrest.Objective:Restorehemodynamicstability.Ensureadequateoxygenation/ventilation.

• Callforhelp.Informteam.Codecart.• IfCardiacArrest,startCPR,immediateepinephrine,GOTO:PEAevent.

• Supportventilation andintubateifnecessary.

• Ifsignificantbradycardia,treatwithimmediateepinephrine (start10-100mcg,increaseasneeded,GOTOappropriateACLSevent).

• Ifmildbradycardia,consideratropine(0.5-1mg),butprogressquicklytoepinephrineifneeded.

• GiveIVfluidbolus.• Abortcaseifpossible.• Ifpregnant,callOB&PediatricsandBatchpage,prepareforpossibleemergentC-section.LeftUterineDisplacement.Monitorfetalheartrate.

21

22:TransfusionReactions

Condition:Hemolyticreaction(tachycardia,tachypnea,hypotension,oozing– DIC?,darkurine),Febrilereaction(fever),Anaphylacticreaction(tachycardia,wheezing,urticaria/hives,hypotension).Objective:Restorehemodynamicstability.

• Callforhelp.Informteam.Codecart?

• Stoptransfusion.• SupportBPwithIVfluidsandvasoactivemedicationsifneeded.

• IfAnaphylacticreaction,GOTO:Anaphylaxischecklist.

• Ifmildreaction,considerantihistamineandantipyretic.

• Forhemolyticreaction,placefoley.MaintainurineoutputwithIVfluids,diuretics,renaldosedopamine.

• MonitorforandtreatDICifhemolyticreaction.

• MonitorforTRALI(lunginjury)andtreataccordingly,mayrequirepostoperativeventilation.

• NotifyBloodBank(476-1404)ofreaction.Theywillneedfurthersamples.Ifneedconsultadvice,pageBloodBankFellow.

SignsofTransfusionReactions:• Hemolytic:

• Tachycardia• Tachypnea• Hypotension• Oozing– DIC?• Darkurine

• Febrile:fever• Anaphylactic:

• Tachycardia• Wheezing• Urticaria/hives• Hypotension

22

23:VenousAirEmbolism

Condition:Decreasedend-tidalCO2 andSpO2,decreasedBP,dyspnea,respiratorydistress,coughing,riseinCVP.Objective:Restorenormaloxygensaturationandhemodynamicstabilityandstopsourceofairentry.

• Callforhelp.Informteam.CallforCodeCart?

• IncreaseFiO2 increasedto100%.• TurnoffNitrousOxideanesthetic.• Decreaseanestheticlevelifhypotension.

• Stopsourceofairentrystopped.– Surgicalsite loweredbelowlevelof

heart,ifpossible?– Woundfilledwithirrigation?– Entrypoint searchedfor(including

openvenouslines)?– Intermittentjugularvenous

compressionconsideredifheadorcranialcase?

• GiveFluidbolustoincreaseCVP.• ConsiderTransesophagealechocardiography(ifavailable;toassessairandRVfunction).

• Giveepinephrine (start10-100mcg)tomaintainCO.

• StartCPR ifBPcatastrophicallylow.

Haveweconsidered:• Leftsidedownoncesourcecontrolled?

• Aspirationofairfromcentralline?• Vasopressors (e.g.dobutamine,norepinephrine)?

• Chestcompressions(100/min;toforceairthroughlock,evenifnotincardiacarrest)?

• Terminationofsurgicalprocedureifable?

Ifcardiacarrest:Give1mgepinephrineIV,beginACLSandGOTO: CardiacArrest– Asystole/PEAChecklistorCardiacArrest– VF/VTChecklist.

ConsiderhyperbaricO2therapy(requirestransfertoSt.FrancisMedicalCenter).

23

IMPORTANT MISSION BAYPHONE NUMBERS

Voalte Phones

AdultE1Attending 502-0447PediE1Attending 502-0442E1PainResident 502-0450OBANESResident 502-0452AdultE2Attending 502-0449

ORprefix 298xxAdultORFrontDesk 476-1015PediORFrontDesk 476-1018AnesthesiaWorkroom 476-0294

RapidResponse/ResourceNurse 502-0562,443-FAST(3278)MBHospitalist 502-1235,443-0093AdultICUAttending 502-1232AdultICUNP 502-1231

BloodBank 476-1404Lab 476-0192IR(pager443-9417) 476-0266MaterialServices 514-3570Pharmacy 514-2100Xray 502-0210BiomedicalEngineering 476-1491ClinicalEngineeringPager 443-2640NeedlestickHotline 353-STIC(7842)