Anaesthetic Vivas - Anaesthetic Emergencies

Front 1

Hypoxia

Back 1

Management depends on the severity and rapidity of the hypoxia.

My initial mx would be to give 100% O2 and confirm the reading. I would assess the patient with an ABC approach, and check my monitors, and the surgical field. For severe hypoxia, I would call for help immediately.

I would then approach the problem systematically, by assessing O2 supply from the wall through to the patient.
- pipeline/cylinder, confirm flow/fio2
- machine
- Circuit - exclude if need be (self-inflating bag on to ETT)
- Airway. Assess patency and position - suction catheter, position, cuff herniation
- ventilation (auscultation, airway pressure, CO2)
- circulation, anaemia
- increased tissue uptake?

Front 2

High Airway Pressures

Back 2

I would switch to manual ventilation of the patient on 100% oxygen to assess compliance, and quickly scan the patient, my monitors and the surgical field.

My initial assessment would be a brief A, B, C approach, I would then assess the problem systematically from gas supply to the patient.
- Gas pressures
- Machine (measured pressures, valves)
- Circuit (exclude if necessary)
- Airway (assess position and patency)
- Breathing (auscultation, percussion)
- circulation

Depending on the findings I would initially treat by
- deepening the anaesthetic
- bronchodilators
- adrenaline

I would call for help with severe difficulty ventilating the patient.

Front 3

Hypercarbia / Hypocarbia

Back 3

Hypercarbia
- Initial approach, ABC, assess manual ventilation/compliance, scan monitors/patient/surgeon.

Systematic approach considers
- Inhaled / exogenous CO2
(CO2 insufflation, rebreathing check CO2 trace, soda lime)
- Hypoventilation
(ventilator settings, obstruction - circuit/ETT/patient)
- Increased production
(fever, TPN, MH, Thyroid storm, etc - check temp)


Hypocarbia
- Immediate Mx depends on reading
- None - consider oesophageal intubation or loss of CO, accidental extubation
- low

- Initial ax is ABC, assess monitors, patient, surgical field. Check for output.

- Systematic Ax considers:-
- Airway
(oesophageal or accidental extubation)
- Circuit
(air entrainment, sampling issue)
- ventilation
(over ventilated, errors)
- Gas exchange
(PE, Cardiac arrest, hypotension)
- Decreased Production
(Hypothermia, hypothyroidism, decreased metabolism).

Front 4

Hypotension

Back 4

Management depends on the severity of the hypotension, and also the related vitals signs.

My initial mx would be to briefly scan my monitors, the patient and the surgical field, and check the heart rate and rhythm. I would give a (fluid bolus and a ml of metaraminol) initially, before assessing in a systematic way. If severe I would notify the surgeon's and request help.

I would assess the patient with an A, B, C approach, and turn off the volatile if severe hypotension.

The possible causes are:-
- Hypovolemia
- Cardiogenic
- Obstructive (possibly a circuit/machine/ventilator problem)
- Distributive (anaphylaxis, overdose volatile)

Front 5

Hypertension

Back 5

My initial response would be to quickly scan the patient, monitors and surgical field - and treat with (propofol/fentanyl?). I would check A, B, C.

The thing I am most concerned about in this situation is..

I would then systematically assess the situation by considering
- pre-existing HT
- Sympathetic response (light anaesthesia? check ETAG, pain, hypoxia, hypercarbia, intracerebral event?)
- Sympathomimetic (exogenous, ie drug error, or endogenous, ie, phaeo)
- surgical (clamp, pneumoperitoneum, tourniquet).

Front 6

Myocardial Ischaemia

Back 6

-

Front 7

Difficult Airway

Back 7

-

Front 8

Arrythmias

Back 8

-

Front 9

Initial & Systematic Approach to Emergencies

Back 9

This is obviously an emergency situation...

I would commence treatment as I assessed the patient... and confirm the problem.
(or... I would simultaneously diagnose/assess and treat)

I would call for help

My initial mx would be to..... (ie, 100% oxygen, or give a dose of aramine) as I assessed the patient with an A,B,C approach. I would quickly scan my patient, monitors and the surgical field.

The thing I am most concerned about here is X.... however, I realise there are a number of different causes for this problem and would attempt a systematic approach to assessing the patient.

My systematic approach is....
- to work my way from machine/equipment (including gas supplies), to circuit, to patient
- check my gas supplies, confirm oxygen delivery and assess the capnography and other monitors. I would give 100% O2 and turn the vaporiser off.
- I would hand ventilate the patient to assess compliance, and if there is any doubt, I would switch over to a self-inflating bag directly attached to the ETT.
- I would check the ETT for position and patency (+/- deflate the cuff)
- I would auscultate the lungs, assess the circulation....

Front 10

The Anaesthetist's ABC

Back 10

A - Airway & Anaesthesia

Check patency of airway and turn anaesthetics agents OFF.

B - Breathing

Give 100% oxygen and verify (monitors). Maintain oxygenation at all costs. may need self-inflating bag or other O2 source.

C- Circulation

Fluids, Vasopressors, ACLS as necessary
Check suction bottles

Front 11

Failure to Emerge / Wake

Back 11

I would attend the patient immediately. My main concern here is....

I would initially assess and manage with an A, B, C approach, and then consider diagnoses. This would involve airway maneouvres to ensure no obstruction, ventilation with 100% oxygen, and ensuring the CPP was adequate.

I would then continue with D, E, F, G.
D - Neurology exam (GCS, pupils, focal neurology)
E - temp
F - anaesthetic, opioid, sedative, relaxant (SOAR)
G - glucose and other metabolic/electrolyte (check ABG)

After ensuring the patient was safe, and considering these initial diagnoses - the patient should now have a CT scan to rule out intracranial pathology. The home team should also be notified to attend.