Chapter 16 Emergency Situations Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.

Objective 1 Define terminology related to emergency situations. Anaphylaxis An unusual or exaggerated allergic reaction of an organism to foreign protein or other substances Asystole Cardiac standstill or arrest; absence of heartbeat

Objective 1. Terms Bolus Bradycardia Bronchospasm Capnography A concentrated amount of medication administered rapidly intravenously Bradycardia Slow heart beat, less than 60 bpm Bronchospasm Involuntary contraction of the smooth muscle of the bronchi, causing impaired breathing Capnography Measurement of inspired and expired carbon dioxide concentrations

Objective 1. Terms Cyanosis Desaturation Diaphoresis A bluish discoloration of the skin and mucous membranes due to inadequate oxygen in the blood Desaturation Reduction of oxygen saturation in the blood Diaphoresis Perspiration, especially profuse perspiration

Objective 1. Terms Hemoglobinuria Hypermetabolic Pyrexia Presence of free hemoglobin in the urine Hypermetabolic Increased metabolism Pyrexia A fever, or febrile condition

Objective 1. Terms Tachycardia Tachypnea Abnormally rapid heart rate, greater than 100 beats per minute Tachypnea Very rapid respirations, greater than 30 per minute

Objective 2 Identify emergency situations associated with anesthesia. List by header in text: Respiratory emergencies Transfusion reaction, etc

Objective 3 Identify medications used in emergency situations Make drug cards Emergency situation Medications used for each

Objective 3 Anaphylaxis Dopamine Dobutamine Ephedrine or phenylephrine (Intropin) Dobutamine (Dobutrex) Ephedrine or phenylephrine (Neo-synephrine)

Objective 3 Mild allergic reaction Diphenhydramine (Benadryl, Allergan 50)

Objective 3 Bronchospasm Albuterol Terbutaline (Proventil, Ventolin) (Breathaire, Bicanyl)

Objective 3 Transfusion reaction For hypotension: Dopamine Dobutamine (Intropin) Dobutamine (Dobutrex) Ephedrine or phenylephrine (Neo-synephrine)

Objective 3 Transfusion reaction (continued) Mannitol (Osmitrol)

Objective 3 Note: respiratory obstruction Problem: bronchoconstriction Due to bronchospasm or asthma Problem: bronchoconstriction Medications: Beta agonists Proventil (Albuterol)

Objective 3 Respiratory obstruction Positive pressure ventilation Due to laryngospasm A different problem Positive pressure ventilation If unsuccessful then: Reintubate until spasm subsides Relax muscles for intubation with: Succinylcholine (Anectine)

Objective 3 Cardiac arrest Epinephrine Vasopressin Lidocaine Procainamide Amiodarone Magnesium sulfate Sodium bicarbonate

Objective 3 Malignant hyperthermia Dantrolene Sodium bicarbonate Dantrium Sodium bicarbonate Mannitol or furosemide Insulin

Objective 4 State the purpose of drugs used in emergency situations. Make drug cards Agent on one side Purpose on the other side

Objective 4 Example: Dantrolene sodium (Dantrium) Malignant hyperthermia

Objective 4 Example: Dopamine (Intropin) Lidocaine (Xylocaine) Anaphylaxis Lidocaine (Xylocaine) PVCs, ventricular tachycardia, ventricular arrhythmias Not as a local anesthetic

Objective 4 Example: Sodium bicarbonate Epinephrine Metabolic acidosis Cardiac stimulant Arrest due to anaphylaxis Note: vasoconstriction is NOT emergency use

Objective 5 Identify the category of specified emergency medications. Make drug cards Agent on one side Category of agent on other side

Objective 6 Discuss the role of the surgical technologist during a cardiac emergency in surgery.

Objective 6 Varies by scenario Justify your answers by filling in detail: When it occurs Who is present What they are doing

Objective 6 Cover ST duties in all 3 basic roles: First scrub Second scrub Circulator Other team members and their basic duties

Objective 6 Example: 7:30 am: Patient is brought in room and moves to bed, and cardiac arrest occurs.

Objective 6 Who is doing what? Anesthesia provider? Surgeon? Circulator? First scrub? Second scrub?

Objective 6 What should the ST be doing during the arrest when performing in the following roles? Circulator? First scrub? Second scrub?

Objective 6 Cardiac defibrillator

Objective 7 List clinical signs of malignant hyperthermia.

Malignant hyperthermia Background on MH: RARE, inherited muscle condition When triggered by some drugs: Causes hypermetabolic state (huge Ca+ release) Sudden; life-threatening

Malignant hyperthermia Trigger agents: Succinylcholine All inhalation agents except nitrous oxide Some antipsychotics

Malignant hyperthermia Must have defect AND exposure to trigger 50% of offspring have it Defect in sarcoplasmic reticulum Stores and releases Ca+

Malignant hyperthermia Ca+ released in massive amounts Causes very sustained contraction Cell metabolism continues at even  rate

Malignant hyperthermia Depletes O2,  CO2 which causes acidosis Muscle cells break down fast from contraction and release myoglobin into blood; clog kidneys

Objective 7 List clinical signs of MH Increase in end-tidal CO2 Tachycardia Tachypnea Masseter muscle rigidity (MMR) Unstable blood pressure Arrhythmias Cyanosis Diaphoresis Pyrexia

Objective 7  in end-tidal CO2 Tachycardia Expired levels of CO2 Many reasons, assess Tachycardia Rapid heart rate

Objective 7 Tachypnea Rapid breathing Even over ventilator setting Effort to blow off CO2 Classic for MH

Objective 7 Masseter muscle rigidity Noted at intubation Classic for MH but could be normal for patient

Objective 7 Unstable blood pressure Arrhythmias Many reasons, assess Absence of normal rhythm

Objective 7 Cyanosis Diaphoresis Abnormal condition; “blue” Check ventilator Diaphoresis Sweating Due to heat build up

Objective 7 Pyrexia Patient can die in 15 minutes High fever Late sign Temperatures can rise to 109° Patient can die in 15 minutes

Objective 8 Outline basic course of treatment for malignant hyperthermia.

Objective 8 Use pneumonic if helpful How Do Surg Techs Do It? H D S T D

Objective 8 Hyperventilate with O2 Dantrolene Why? Blow off CO2 Skeletal muscle relaxant

Objective 8 Sodium bicarbonate Temperature management Counteract metabolic acidosis Due to  CO2 = acidosis Temperature management Ice packs at pulse points on patient Attempt to cool patient rapidly

Objective 8 Diuretics Mannitol is mixed in with Dantrium Keeps kidneys from getting clogged with myoglobin

Objective 8 Insulin Treat hyperkalemia

Objective 9 Discuss the role of the surgical technologist in a malignant hyperthermia crisis.

Objective 9 First, if you aren’t paying attention to what is going on with the patient, you are not much help early in the crisis.

Objective 9 Be aware of anesthesia signs Rapid response increases survival rate When declared, drop what you are doing!

Objective 9 Anesthesia/Operation is stopped STAT First scrub role; stay sterile if procedure going Help close PRN Hand iced NaCl irrigation

Objective 9 Second scrub role Break scrub Get or send people for ice May help reconstitute Dantrium If no other personnel available e.g., on call

Objective 9 Circulating role Treat like code blue Get MH cart Call for help Change anesthesia machine when provider is ready

Objective 9 Circulating role Set up iced lavage Reconstitute Dantrium Bladder, rectum, abdomen Reconstitute Dantrium

Objective 9 Remember, all of these things are happening simultaneously. Knowing the procedure makes you more valuable in the crisis.

Objective 9 Keep in mind If the patient is identified as MH susceptible, there will be no crisis, as trigger agents are NOT administered to patient.

In summary Many emergency situations arise in surgery. Many of these situations require the administration of medications for treatment.

In summary The more you know, the more effective you are in assisting the anesthesia provider in an emergency.