(6) BRONCHOSPASM (Intubated patient) Signs: Increased peak airway pressures Bilateral wheezing Increased expiratory time Increased ETCO2 with upsloping ETCO2 tracing Decreased volumes if pressure controlled CALL FOR HELP CODE CART? Treatment: If patient hypotensive, disconnect patient circuit (to relieve air trapping) 100% O2 High Flow Increase expiratory time Deepen volatile anesthetic Suction ETT Medications: Give inhaled Albuterol +/- Ipratropium If severe Epinephrine IV start 10 ug and escalate Ketamine 0.2 – 1 mg/kg IV Hydrocortisone 100 mg IV Nebulized racemic epinephrine Consider ABG Rule Out: Mainstem intubation Anaphylaxis Go to anaphylaxis algorithm (7) DELAYED EMERGENCE Management: All anesthetics Off No residual muscle paralysis Go to Residual Paralysis algorithm Hypoxemia/Hypercarbia Bag/Mask vs. Intubation Hypothermia: Warm Blankets and fluids, Bare hugger, Warm the room ABG with electrolytes: If CO2 narcosis Intubate, Correct electrolytes Rule out medication swap or dosing error See below If all of the above negative/normal: consider STAT Head CT and consult neurology/neurosurgery (If intubated, look for pupils, asymmetric movement, gagging) If residual mental status abnormalities, monitor in ICU with serial neurologic and repeat imaging as needed If suspect medication overdose: Opioid reversal: Naloxone 40 ug IV: Repeat q2 minutes up to 5 (200 ug total) BZD reversal: Flumazenil 0.2 mg IV: Repeat q1 minutes up to 5 doses (1 mg total) Scopolamine patch reversal: Physostigmine 1 mg IV (Have Atropine ready for potential cholinergic crisis)
(10) SEVERE HYPOTENSION CALL FOR HELP CODE CART Management Ensure and regular rate and rhythm If not, go to ACLS Inspect field for blood loss or If non-bleeding cause: Pause surgery If bleeding Hemorrhage algorithm IV Fluid bolus Pressors Phenylephrine and Ephedrine If severe: Epinephrine 10-100 mcg, Vasopressin 1-4 units 100% O2 High flow Turn down/off anesthetic agent Talk to surgeon Go to Other management management: Algorithms for ACLS, Anaphylaxis, Hemorrhage, Hypoxemia, Local anesthetic toxicity, Myocardial ischemia, Pneumothorax, Total spinal anesthesia, Transfusion rxn, VAE TEE More IV access and Arterial line Steroid for adrenal insufficiency (Hydrocortisone 100mg IV) Send labs: ABG, Hgb, Electrolytes, T&C Foley catheter to monitor UOP Differential Diagnosis: MAP = CO X SVR and CO = SV X HR SV depends on preload, contractility, and afterload ↓ Preload: Hemorrhage Hemorrhage algorithm Hypovolemia Auto-PEEP: D/C circuit IVC Compression: Decrease tidal volume, Reposition patient Embolism (Air/Fat/Blood/AFE): Go to algorithm Pneumothorax Pneumothorax algorithm Pneumoperitoneum or Surgical manipulation ↓ Contractility: MI/Ischemia myocardial ischemia algorithm Low EF: Inotrope Valvular disease, HOCM Hypoxemia Medications Local anesthetic toxicity Arrythmias ↑ Afterload: Pneumoperitoneum or surgical manipulation Medications ↓ HR: Vagal stimulus: Pause surgery if needed ↓ SVR: High volatile anesthetic Neuraxial blockade Anaphylaxis Go to algorithm Medications Shock: Sepsis, Spinal Neurogenic Endocrine abnormalities Steroids
(17) TACHYCARDIA – STABLE SVT Signs: CHECK FOR PULSE If no pulse, Go to PEA algorithm If Unstable, Go to SVT – UNSTABLE and Prepare for Synchronized Cardioversion UNSTABLE = SBP<80, BP low for patient, rapid BP decrease, or acute ischemia Sinus Tachycardia is NOT SVT. May be compensatory. Search for and treat underlying cause(s) More likely SVT if any of: Rate > 150 Sudden onset Irregular rhythm CALL FOR HELP CONSIDER HAVING CODE CART AVAILABLE INFORM TEAM Treatment: 1. Increase to 100% O2, high flow 2. Confirm adequate ventilation, oxygenation 3. Consider 12-lead EKG or Print Rhythm Strip, then treat per rhythm 4. If UNSTABLE at any point: Go to Unstable SVT algorithm 5. If still STABLE Supraventricular Tachycardia: a. Consider cardiology consult b. Consider ABG with electrolytes Narrow Complex and Regular 1. To convert: Adenosine 6 mg IV push with flush. May give 2nd dose: 12 mg IV 2. If NOT converted, may Rate Control Choose beta blocker or calcium channel blocker: a. Esmolol: Start 0.5 mg/kg IV over 1 min. May repeat after 1 min and may start infusion 50 b. Metoprolol: Start 1-2.5 mg IV. May repeat or double after 2.5 min c. Diltiazem: 5-10 mg IV over 2 min. May repeat after 5 min 3. Amiodarone: 150 mg IV SLOWLY over 10 min. May repeat once. Start infusion 1mg/min for first 6 hours Narrow Complex and Irregular Choose beta blocker or calcium channel blocker: Esmolol: Start 0.5 mg/kg IV over 1 min. May repeat after 1 min and may start infusion 50 Metoprolol: Start 1-2.5 mg IV. May repeat or double after 2.5 min Diltiazem: 5-10 mg IV over 2 min. May repeat 5 min Amiodarone: 150 mg IV SLOWLY over 10 min. May repeat once. Start infusion 1 mg/min for first 6 hours Wide Complex and Regular Amiodarone: 150 mg IV SLOWLY over 10 min. May repeat once. infusion 1 mg/min for first 6 hours May also consider Procainamide or Sotalol