1. Joint Special Operations Medical Training Center Manage a Patient Under General Parenteral Anesthesia 081-833-4549 INSTRUCTOR SFC HILL

2. Joint Special Operations Medical Training Center OBJECTIVE As a Special Forces Medic given a patient under general parenteral anesthesia, continually monitor the patients vital signs, apply corrective treatment to any life threatening changes in the patients vital signs, and maintain the patient at stage three of general anesthesia in accordance with JSOMTC student manual of anesthesia.

3. Joint Special Operations Medical Training Center REASON As a Special Forces Medic performing general parenteral anesthesia, you will be responsible for maintaining the patient at stage three of general anesthesia and maintaining the life of the patient through surgery and recovery from anesthesia.

4. Joint Special Operations Medical Training Center PROCEDURES Review the principles of monitoring and maintenance Review the components, clinical signs, and depth of anesthesia Apply the principles of monitoring and maintenance (Circle of Awareness)

5. Joint Special Operations Medical Training Center Review the Principles of Monitoring and Maintenance

6. Joint Special Operations Medical Training Center Monitoring Tasks Level of Anesthesia A B C

7. Joint Special Operations Medical Training Center Monitoring Level of Anesthesia Unresponsive to pain stimuli Eyes fixed and pupils constricted Muscles relaxed

8. Joint Special Operations Medical Training Center Monitoring Airway Must maintain positive control over the patients airway (to include the tongue) Monitor the airway at all time while the patient is under general anesthesia.

9. Joint Special Operations Medical Training Center Monitoring Airway Oxygenation pre-oxygenate for Intubation 100% O2 - 6 L/min resuscitation 100% O2 - 15+ L/min Ventilation

10. Joint Special Operations Medical Training Center Monitoring Breathing The lungs and breathing must be continuously monitored. Rate and depth of respirations Dry versus wet lungs?

11. Joint Special Operations Medical Training Center Monitoring Breathing I Inspection A Auscultation P Palpation P Percussion

12. Joint Special Operations Medical Training Center Monitoring Circulation Heart rate, character, and rhythm = 68 strong and regular Tissue perfusion Body temperature Renal Function Output = >25 to 50cc/hr

13. Joint Special Operations Medical Training Center Components of General Anesthesia ¶Muscle Relaxation ·Unconsciousness ¸Analgesia

14. Joint Special Operations Medical Training Center Components of General Anesthesia Muscle Relaxation  Amount of skeletal muscle relaxation requirements depend on the type of operation.

15. Joint Special Operations Medical Training Center Components of General Anesthesia Analgesia/ Areflexia  Pain reflexes are subdued.

16. Joint Special Operations Medical Training Center Components of General Anesthesia  Unconsciousness/Hypnosis  The patient is oblivious to all sensation but pain reflexes can occur.

17. Joint Special Operations Medical Training Center Depth of Anesthesia Stages and Planes of Ether Anesthesia ¶Stage I Amnesia ·Stage II Excitement ¸Stage III Surgical Anesthesia  Plane 1 Plane 2 The Surgical Plane  Plane 3  Plane 4  Stage IV Impending Death

18. Joint Special Operations Medical Training Center Stages and Planes of Ether Anesthesia STAGE I Amnesia From the onset of drowsiness to the loss of the eyelash reflex.

19. Joint Special Operations Medical Training Center Stages and Planes of Ether Anesthesia STAGE II Excitatory Stage Agitation, delirium, irregular respiration and breath holding. Pupils dilate, eyes diverge.

20. Joint Special Operations Medical Training Center Stages and Planes of Ether Anesthesia STAGE III Surgical Anesthesia  Plane 1 From the return of regular respirations to the cessation of REM.

21. Joint Special Operations Medical Training Center Stages and Planes of Ether Anesthesia STAGE III Plane 2 The Surgical Plane From the cessation of REM to the onset of paresis of the intercostal muscles.

22. Joint Special Operations Medical Training Center Stages and Planes of Ether Anesthesia STAGE III  Plane 3 From the onset to the complete paralysis of the intercostal muscles.

23. Joint Special Operations Medical Training Center Stages and Planes of Ether Anesthesia STAGE III  Plane 4 From the paralysis of the intercostal muscles to the paralysis of the diaphragm - at the end of this plane the patient will be apneic.

24. Joint Special Operations Medical Training Center Stages and Planes of Ether Anesthesia STAGE IV Impending Death >From the onset of apnea to circulatory failure.

25. Joint Special Operations Medical Training Center The Circle of Awareness is the anesthetist monitoring management tool.

26. Joint Special Operations Medical Training Center The circle helps the anesthetist to monitor and manage: Vital signs Stage of general anesthesia Airway, respiratory and cardiac systems Input and output of all fluids and drugs Time Recording Communications

27. Joint Special Operations Medical Training Center The circle of awareness should begin a few moments after the patient is placed on anesthesia maintenance.

28. Joint Special Operations Medical Training Center PATIENT Patient should be unresponsive to painful stimuli Eye’s should be: Fixed, pupils constricted (dilated = caprine specific) and non-reactive to light Mandible and tongue: Relaxed Limbs: Relaxed, non-withdrawal to pain If being assisted by personnel within the OR, request a temperature and blood pressure be taken at this time

29. Joint Special Operations Medical Training Center AIRWAY Inspect Oxygen Tubing: From the wall to the patient Inspect Endotracheal Tube: Secured, bulb inflated, bite block present, and suction PRN Inspect Patients Respiratory Effort: Note rate and rhythm, one deep ventilation

30. Joint Special Operations Medical Training Center BREATHING Inspect Trachea: Look for Tracheal deviation or jugular vein distention (JVD) Inspect Chest: Rise and fall Auscultate Chest: Clear breath sounds, note rate and rhythm (again)

31. Joint Special Operations Medical Training Center CIRCULATION Auscultate Heart: Note rate and rhythm Inspect All IV’s : Read labels and check fluid levels, check drip rate, inspect tubing to catheter, inspect IV site for infiltration

32. Joint Special Operations Medical Training Center RECORD Record on the SF 517: Time, drug input, suction, oxygenation, ventilation, level of consciousness, vitals signs, fluid input/output, all complications throughout surgery in other remarks

33. Joint Special Operations Medical Training Center REPORT Communicate: Communication the patients status and vitals to surgical team. Insure you receive a response from the surgeon At this point, make improvements, adjustments and corrections to any deficiencies that you discovered during the circle

34. Joint Special Operations Medical Training Center SUMMARY OF PROCEDURES Review the principles of monitoring and maintenance Review the components, clinical signs, and depth of anesthesia Apply the principles of monitoring and maintenance (Circle of Awareness)

35. Joint Special Operations Medical Training Center RESTATED OBJECTIVE As a Special Forces Medic given a patient under general parenteral anesthesia, continually monitor the patients vital signs, apply corrective treatment to any life threatening changes in the patients vital signs, and maintain the patient at stage three of general anesthesia in accordance with JSOMTC student manual of anesthesia.