CA Association of OMFS presents Respiratory Emergencies
William K. Tom, DDS MS Healdsburg, CA
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OUR OVERALL GOALS IN THE TREATMENT OF EMERGENCIES
Get 02 to heart and brain Get glucose to the brain
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HYPOXIA
• A deficiency of oxygen in the body’s tissues
• Can result in dysrhythmias, cardiac arrest,
brain damage and death
• Therefore, the airway must be maintained
and breathing uncompromised for life to be
sustained
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1 Complications in Outpatient Anesthesia
• Jeffery Dembo-Vice Chairman –Dept. of OMFS at University of Kentucky • Dembo’s Assessment • Most complications are Airway Related • Most of these complications are Preventable
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This is first and foremost a simulation course… We’ll base much of our discussion on closed claims – yes, real cases treated by some of our colleagues.
Our discussion will concentrate on how these cases could have been managed to have possibly saved the patients, and you will have an opportunity to simulate these rescue efforts.
We will finish our discussion with a look at some preventive strategies which might have avoided the catastrophes altogether.
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And what if a serious anesthetic or medical emergency were to take place in your office?
While the EMT’s are on the way, what will your new job descriptions be?
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2 Get me the AED! Get the quick connect syringe of Epi 1:10,000 fast.
Here, I have the AED. I’ll get the I told Suzie to call pads on. 911.
SoInstantaneously make those simulationsyour surgical at yourteam stationsmust perform realistic as this a afternoonprecision – medical we know youemergency can do it! team!
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Our thanks to Lew Estabrooks for sharing these closed- claims cases with us .
Lewis Estabrooks, DMD, MS Chairman of the Board OMS National Insurance Company, RRG
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Lew Estabrooks’ Late Night Top Ten List of Errors Leading to Catastrophes 10. Trying to intubate even when the patient is breathing and can be ventilated. 9. Failure to understand that a patient can have a NSR on the EKG without a pulse (PEA). 8. Poor documentation of the resuscitation. 7. Lack of documentation of medical status. 6. Poorly trained assistants. 5. Hoping things will get better and failing to react in a timely manner. 4. Failure to follow accepted protocols for resuscitation – e.g. establishing an airway. 3. Not knowing what the EKG monitor is telling them. 2. Failure to recognize the pending demise in a timely manner resulting in a delay in calling 911. 1. Failure to recognize a higher risk patient. 9 9
3 Incidence of In-Office Anesthesia Death & Brain Damage Cases Most involve a fatal cardiac dysrhythmia, often precipitated by respiratory compromise. Cases Reported to OMSNIC 2000 ‐ 2011 91 91 cases = 1 33,191,562 procedures 364,742
Deaths after taking post-op pain meds at home ‒ 7
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A Systems Approach to the Management of Anesthetic and Medical Emergencies
Respiratory System Airway Obstruction (including laryngospasm) Bronchospasm
Emesis and Aspiration Respiratory Depression Endocrine System Hypoglycemia Immune System Allergic Reactions
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A. Respiratory Emergencies
1. Airway Obstruction 2. Laryngospasm 3. Bronchospasm / Asthmatic Attack 4. Emesis with Aspiration 5. Respiratory Depression
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4 Respiratory Emergencies
1. Airway Obstruction
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Airway Obstruction – Signs/Symptoms:
Stridor Wheezing Use of accessory muscles of respiration Decreased oxygen saturation – cyanosis Tachycardia Bradycardia Respiratory arrest Asystole 14 14
Case #1 - Presentation
History and Planned Treatment: 49 year old businessman is referred for biopsy of an ulcerated lesion on the posterior one third of the left tongue. The lesion has been present for 6 months, has increased in size and was originally thought to be due to irritation from a tipped molar tooth. There is a maximal incisal opening of 25 mm with pain and firmness to the left base of the tongue and floor of the mouth but no apparent involvement of the lateral pharyngeal space. BMI: 36 Hght: 5’8”
VS’s: BP: 146/88 Pulse: 97 O2Sat: 92% Wgt: 232 15 15
5 Case # 1 – Presentation (con’t)
History and Planned Treatment: It is suspected that the lesion is an infected malignancy. PMH: DM Type II with oral meds sup- plemented by insulin. HTN lisinopril. Patient has smoked threepacksofcigarettesper day for 21 years and has 3-4 martinis per day. He is about to leave for a week on business and the OMS is about to go on vacation for 2 weeks.
VS’s: BP: 146/88 Pulse: 97 O2Sat: 92% Wgt: 232 16 16
Case # 1 – Clinical Course Clinical Course: On the day of surgery, monitors are attached and show
BP: 154/92, O2 Sat : 93, EKG: NSR
Nasal O2 placed with a CO2 monitor attached. Infusion started, bite prop inserted and 5 mg of midazolam, 50 µg of fentanyl and 50 mg of propofol given. Mandibular block and infiltration of the tongue administered with 2% lidocaine with 1:100,000 epi. A posterior oral packing is placed and incisional biopsy performed and sutured. VS unchanged, surgical site packed, patient taken to recovery and surgical assistant cleans up. BMI: 36 Hght: 5’8”
VS’s: BP: 154/92 Pulse: 86 O2Sat: 93% Wgt: 232 17 17
Case # 1 – Clinical Course (con’t) Clinical Course: Anesthesia assistant checks on patient in 5-10 min., notes no
CO2 wave and O2 Sat of 89 with the alarm going off. Team responds by suctioning and attempting to support the airway without success. It is not possible to ventilate the patient with either an oral or nasal airway.
EKG: Sinus tachycardia, rate of 125, occasional PVC’s, O2 Sat 50 and declining rapidly. Surgeon’s attempt to intubate unsuccessful due to bleeding and limited opening. LMA placed but appropriate tubing connector not available.
VS’s: BP: 163/98 Pulse: 125 O2Sat: 50% EKG: PVCs 18 18
6 Case # 1 – Clinical Course (con’t)
Clinical Course: EMT’s arrive, remove LMA and are unable to intubate.
EMT’s place Combitube, some ventilation but O2 Sat <60 and patient bradycardic. Patient transported to ER, arrested in transit and pronounced at ER. Autopsy – apparent tumor mass at the base of tongue that could obstruct the airway and a bloody gauze in the right mainstem bronchus.
VS’s: BP: 86/42 Pulse: 52 O2Sat: 58% EKG: PVCs 19 19
Case # 1 – Diagnosis DIAGNOSIS: Airway obstruction secondary to gauze sponge and tumor mass CRITICAL ERRORS: Failure to appreciate the potential for airway obstruction from the suspected tumor and associated swelling. Failure to provide adequate post-operative monitoring for such a high risk case and not accounting for missing gauze sponge which ended up in the right mainstem bronchus. Failure to assess airway risk based on BMI and possible OSA.
Failure to appreciate significance of pre-op O2 Sat of 93 and potential for reactive airway from probable smoking-induced COPD. Putting the convenience of the patient at a higher priority than appropriate anesthetic management. Bypassing routine (recommended) protocols trying to do someone a favor. 20 20
Lew Estabrooks’ Late Night Top Ten List of Errors Leading to Catastrophes 10. Trying to intubate even when the patient is breathing and can be ventilated. 9. Failure to understand that a patient can have a NSR on the EKG without a pulse (PEA). 8. Poor documentation of the resuscitation. 7. Lack of documentation of medical status. 6. Poorly trained assistants 5. Hoping things will get better and failing to react in a timely manner. 4. Failure to follow accepted protocols for resuscitation – e.g. establishing an airway. 3. Not knowing what the EKG monitor is telling them. 2. Failure to recognize the pending demise in a timely manner resulting in a delay in calling 911. 1. Failure to recognize a higher risk patient. 21 21
7 Let’s look at a Combitube
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What is the safest way for us to protect the airway intraoperatively?
The conventional A commercially posterior oral packing available soft foam with gauze. sponge.
The foam sponge provides full A compressed 3 x 3 sponge coverage of the oropharyngeal vs the foam sponge at the 23 opening. end of the case. 23
How to utilize the soft foam sponge…
A single suture is used to One end of the sponge is tucked fold the sponge in half like in and next to the left anterior a taco. tonsillar pillar.
The pack is carried across the The sponge is maximally absorbent tongue and tucked in on the right. and leaves no oropharyngeal 24 opening. 24
8 Preparing for recovery…
Folded gauze over surgical A 3 x 3 sponge opened site – not secured extra-orally. and rolled into a “ball”.
Ball placed over the surgical The “tail” is taped to the
25site with “tail” extra-orally. cheek extra-orally. 25
Effective charting can save you…
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Foreign Body Obstruction - Treatment
Visualize the larynx with a laryngoscope. Suction the hypopharynx. Insert the Magill Forceps and retrieve the foreign body.
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9 Abdominal Thrusts – Heimlich Maneuver vs Chest Compressions
Abdominal thrusts greater intrathoracic pressure Xiphoid process (GR.-”sword shaped”) puncture of viscus
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Effective use of cognitive aids…
If an emergency is encountered during the procedure, press Alt‐Tab in sequence which will immediately take 29 you to your emergency algorithms. 29
Algorithms for the Management of Left click on the name of the emergency to go to the Medical and Anesthetic Emergencies algorithm for its treatment. Once you are on the Table of Contents algorithm page, left-click again for pathophysiology. Acute Adrenal Insulin Shock / Hypoglycemia Insufficiency……………………….. 3 …..…………………. 44 Acute Coronary Syndrome Intra-Arterial ………………………... 5 Injection………………………...... 46 • Laryngospasm…………………………………… Angina……………………………………………. ……. 48 6 Local Anesthetic • Myocardial Overdose………………………….. 50 Infarction………………………….. 8 Malignant Airway Obstruction Hyperthermia……………………...... 52 ………………..……………….. 10 Respiratory Depression – • The Overdose………………. 54 Tongue………………………………………. 11 Seizures…………………………………………… • Foreign ……. 56 Body…………………………………….. 13 Stroke • Persistent Obstruction - (CVA)….……………………………………….... Cricothyrotomy 58 (Coniotomy)…………………. 14 Syncope…………………………………………… Allergic ……. 60 Reactions…………………………………….. 15 Appendix…………………………………………… Bronchospasm / ……. 62 Asthma……………………………. 17 1. The Autonomic Nervous Cardiac Dysrhythmia System………………. 63 ……………………………….. 19 2. Dilution of Emergency • Drugs………………..…. 66 Bradycardia………………………………………. 3. Esmolol for Severe 2 20 Hti 68 30
10 Airway Obstruction • The tongue………………………… 11 • Foreign Body...……….………….. 13 • Persistent Obstruction – Cricothyrotomy (Coniotomy)..... 14
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The most frequent This can usually be cause - The tongue corrected with head AIRWAY OBSTRUCTION closes off throat tilt, chin lift FROM THE TONGUE
Tongue suture to maintain airway
Oropharyngeal Nasopharyngeal airway airway
Airway adjuncts to assist in If patient not breathing – maintaining the airway positive pressure 02 To manage a difficult airway, begin with routine airway maneuvers as illustrated here. If unsuccessful, proceed to advanced airway interventions on the next page, and call 911 PRN. 11 32
The #1 Threat to Anyone’s Airway - The Tongue
Tongue falls back
Loss of airway muscle tone Behind the tongue and just above in an anesthetized patient the epiglottis to allow flow of air leads to obstruction. behind the tongue.
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11 Nasopharyngeal Airway (can be utilized in the sedated or sleeping patient) –
A Nasopharyngeal airways: Traditional trumpet – contains latex. Non-latex trumpet Adjustable length airway – non-latex B Sizing – tip of nose to lobule C Not so large as to cause blanching of the A soft tissues of the naris.
B C 34 34
Nasopharyngeal Airway - Con’t A Passed behind the relaxed tongue, which is positioned posteriorly in the throat. B A pharyngeal catheter ‒ remove secretions from the hypopharynx. C Positive pressure ventilation A with the airway in place.
B C
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Adjustable Length Oropharyngeal Airway
A. Nasal trumpet of appropriate diameter is too short. B. Adjustable collar tube enables the airway to be passed behind the tongue. C. The collar is adjusted so that A it is in contact with the naris.
B C
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12 Oropharyngeal Airway (for the unconscious patient - not well-tolerated by an awake patient) Hard Plastic Soft plastic A.Sizes and styles of airways B.Sizing - corner of mouth to the Large Adult angle of the mandible. C.The site packed off & airway Small Adult inserted “upside down” Child D.As the airway is passed over the tongue posteriorly it is rotated A 180°.
B C D 37 37
Oropharyngeal Airway – con’t E. The airway provides a channel for air to pass behind the tongue. F. Passing an oropharyngeal catheter: Side Channels of the hard molded plastic airway or Lumen of the soft plastic oral airway. G. The airway assures passage of air posterior to the tongue during positive pressure ventilation. E
Lumen Side channel
F G
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Exciting New Avenues in Social Interaction
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13 Adjuncts for Airway Management - Tongue Suture
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Management of the Difficult Airway
Laryngeal Head tilt / Chin lift Mask Airway Endotracheal (LMA) Intubation Bag-Valve-Mask I-Gel
Supraglottic Difficulty,Airways Invasiveness
King LT-D Nasal Airway Airway Tongue Suture Esophageal - Crico- Tracheal thryroidotomy Oral Airway Combitube
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The Difficult Airway - Advanced Airway Adjuncts
LMA (Laryngeal Mask LMA ProSeal with i Gel Airway Airway) Gastric Tube Access
LTA (Laryngeal Tube Endotracheal intubation – Intubation with a Airway) no more than three Video Laryngoscope attempts. If foreign body obstruction is suspected, go to Page13. For persistent obstruction, go to cricothyrotomy Page 14. 12 42
14 2nd Generation Supraglottic Airways with gastric ports
LMA ProSeal i‐gel
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The laryngeal tube airway (LT-D)
The original LT-D
2nd generation LT-D with gastric port
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How to insert a LMA
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15 What about mouth-to-mouth ventilation?
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How to intubate aka “passing the tube”
A-The tube is introduced into the mouth-passed down the right side of the laryngoscope. B-The tube is advanced until the maxillary incisors are at 21-23 cm. Magill forceps can be used to guide the tip through the cords if necessary. C-The tube has been passed through the cords and is in the trachea above the carina.
A
B C
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Video laryngoscopes This video laryngoscope is battery operated, and has disposable blades with an appropriate curvature for passage of the tube.
Here we see the endotracheal tube passing into the larynx and through the vocal cords.
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16 Passing the endotracheal tube
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Persistent Obstruction – Cricothyrotomy (Coniotomy)
The trocar is removed and…
Point of penetration is through the cricothyroid membrane
The cannula secured to its tubing… The cannula is placed through the overlying soft tissues and the cricothyroid membrane into the Which is attached to the oxygen trachea supply
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Persistent airway obstruction -- Cricothyrotomy with the Quick Trach®
The penetration is begun with the syringe angled at approximately 90°and the trocar is passed into the trachea.
Air is aspirated from the trachea to assure that the lower airway has been entered.
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17 AIRWAY OBSTRUCTION – PERSISTANT CRICOTHYROTOMY (Melker)
3 4 Advance cannula Remove syringe, Point of penetration is through through advance guidewire, the cricothyroid membrane membrane. remove cannula.
1 2 5 6 Advance dilator Palpate, make Slide the dilator- Remove dilator and into cricothy- a midline catheter over the guidewire together,
roidotomy tube incision guidewire into airway attach to O2 Also see Appendix 8A. QuickTrach® p. 71 and 8b. Melker p.73. 14 52
But there’s a problem – A really big one… Approaches such as the Quick Trach or the Melker technique require ident- ification of the cricothyroid membrane by palpation.
Studies by Dr. Hung and investigators at a number of other centers have revealed that identification by palpation is only accurate ORLANDO HUNG, MD, FRCPC Prof. of Anesthesiology, Dalhousie 37% of the time! University, Halifax, Nova Scotia 53 53
The finger-bougie assisted cricothyrotomy
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18 Bougie‐Assisted Cricothyrotomy
1. Make a vertical 2. Continue through the subcutaneous skin incision. tissues and palpate for the membrane.
3. Make a horizontal incision 4. Insert a finger through the inci‐ through the membrane. sion and enlarge the aperture. 55
5. The bougie Passage of the is withdrawn bougie and the endotracheal tube
3. A 6 mm endotracheal tube 4. Using the bougie as a is passed over the guide, the endotracheal bougie. tube is advanced into the trachea
2. The bougie is 1. The aperture has been passed through enlarged with a finger to the aperture into accommodate passage the trachea of the bougie.
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Respiratory Emergencies
2. Laryngospasm
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19 Laryngospasm - Diagnosis
Early crowing, but no sound for complete spasms Suprasternal retraction
’d respiratory effort and ’d exchange
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Laryngospasm – But what does it look like when it’s happening?
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Pathophysiology - Laryngospasm
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20 0 0 Laryngospasm – 2 2 Treatment
Tongue forward, 02, suction oral suction oral cavity, pack site pharynx
Push, listen for If still present – SUX, support “huff” – if not, respiration, mask monitor
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Non-Pharmacologic Interventions ‒ Laryngospasm
”Laryngospasm Notch” by Philip Larson Jr, MD. First provide forceful mandibular protrusion and then Application of Digital Pressure at the Laryngeal Notch.
The “NOTCH” is located behind the lobule of the pinna of each ear. Bound anteriorly of the ascending ramus (adjacent to the condyle). Posteriorly by the mastoid process of the temporal bone Cephalad by the base of the skull 62 62
The depolarizing muscle relaxant Succinylcholine (Anectine®) Dose: Partial 10-20 mg; Complete. 20-40 mg IV. Onset 30-60 sec.; Duration 2-3 min. 2nd dose 40 mg IV w/ atropine. Disadvantages: Hyperkalemia. Bradydysrhythmias (esp. children). Trigger for malignant hyperthermia ‒ dantrolene may be required.
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21 The non-depolarizing muscle relaxant rocuronium: Dose:
0.6 – 1.2 mg/kg
Onset 1-2 min.; Duration 20-60 min. Disadvantage:
None of those noted for Sux
However, prolonged ventilatory support
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Fortunately, there’s an exciting new development – Sugammadex
Rocuronium
Sugammadex
Sugammadex encapsulates rocuronium
65 & deactivates it within 3 min. 65
Head position – proper Laryngospasm– airway maintenance. Well placed posterior oral prevention packing. Minimizing secretions (consider anticholinergic). Effective suctioning .
Careful titration of medication. Monitor level of anesthesia.
Consider agent – fewer laryngospasms with propofol.
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22 Case # 2 - Presentation History and Planned Treatment: A 16 y/o female was referred to have her third molars removed. Her past medical history stated that she had seasonal allergies to HIPA A pollens and a cold/exercise induced asthma. She currently was playing school basket ball and used her albuterol inhaler “several times a month.” The last time was 2 days ago. BMI: 22 Hght: 5’8”
VS’s: BP: 116/72 Pulse: 86 O2Sat: 99% Wgt: 142# 67 67
Case # 2 – Clinical Course Clinical Course: On the morning of surgery she was NPO. Her mother functioned as her driver and signed the consents.
Monitors were applied and on room air her SaO2 was 97. The BP was 118/68. Respiration rate was 14. The EKG showed a NSR with a rate of 74. The chest was clear on auscultation and no wheezing was noted.
N2O/O2 50% was begun and an IV started with a 21 gauge needle and D5W. Valium 10 mg was titrated slowly followed by 50 µg of fentanyl and 100 mg of Brevital. A mouth prop was inserted and a throat screen placed. 4 carpules of 2% Lidocaine 1/100,000 epinephrine were given in blocks and infiltrations. Part way through the surgical removal of the first tooth, the doctor noted that the blood looked dark and noticed that the
SaO2 was 70. The chest was straining.
VS’s: BP: 118/68 Pulse: 74 O2Sat: 97% Wgt: 142 68 68
Case # 2 – Clinical Course (con’t) Clinical Course: The oral cavity was suctioned and the throat screen
removed. Positive pressure O2 was not successful and the SaO2 dropped to 60. The EKG showed a sinus tachycardia of 140 and there was a palpable pulse. 911 was called. The doctor assumed this was an asthmatic attack and gave 3 (three) mg of epinephrine IV. The HR went to 240 and then to 40. The BP was 180/90.
The SaO2 was 30. The EMTs arrived and intubated the patient. The IV was lost as they placed the patient on the stretcher. The patient was transported to the ER and expired.
VS’s: BP: 180/90 Pulse: 240 O2Sat: 40% Wgt: 142# 69 69
23 …the doctor noted that the blood looked dark and noticed that the SaO2 was 70…
Why did the doctor not realize that there was a problem until the blood looks dark and the
SaO2 drops to 70%? Was ventilation even being monitored in this case? It would certainly appear that it was not. Could early detection of the problem with appropriate monitoring have made it possible to manage this case successfully, and saved this young woman’s life?
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Wouldn’t this have picked up the problem with ventilation first?
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Bluetooth/Piezo Pretracheal Auscultation Device
A Piezo microphone (C) The Bluetooth earpiece provides high fidelity lightweight and pick up. comfortable 72 72
24 Case # 2 – Diagnosis DIAGNOSIS: Bronchospasm associated with asthma. Possible airway obstruction with unmonitored ventilation. CONCERNS: Why was she not using an inhaled corticosteroid? Why don’t we know when she last had an ER visit for management of her asthma? Could a peak flow meter reading at the time of the consultation and preoperatively been of benefit? Should preoperative use of her inhaler have been considered? Since the incidence of wheezing associated with propofol is far less than that with methohexital, should propofol not have been considered for the primary anesthetic agent? 73 73
Case # 2 – Critical Errors DIAGNOSIS: Bronchospasm associated with asthma. Possible airway obstruction with unmonitored ventilation. CRITICAL ERRORS: Incomplete preoperative assessment to assess severity of asthma. Failure to monitor ventilation adequately and rely
on SpO2. 911 should have been called sooner. Inappropriate IV technique with a straight needle and D5W. Inappropriate dose of epinephrine administered. 74 74
Epinephrine for severe allergic reactions and bronchospasm 0.3 – 0.5 mg IM
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25 Each vial is labeled with its use and how it is administered
Drug and Size of syringe concentration
Emergency
Route of Dose administration 76 76
To assure that the inappropriate medication is not administered, the staff member should show the medication to the surgeon before it is administered.
And…
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Case # 2 – Parameters of Care
Clinical Guidelines for patients with asthma: Consider consultation with physician. Determine severity based on history (frequency of inhaler use, respiratory- related hospitalizations and examination (wheezing). Consider prophylactic use of inhaler. Use stress reduction techniques. Consider pulmonary function testing.
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26 Respiratory Emergencies
3. Bronchospasm / Asthmatic Attack
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Impaired Airflow in Asthma
Non-asthmatic Asthmatic
Through the bronchoscope 80 80
Asthma – Pathophysiology
Redisposing conditions: Increase secretions. Increase viscosity of secretions. Inflammation – constriction Response to a stimulant – bronchospasm.
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27 Bronchospasm - Causes
Genetic – inherited tendency. Environmental. Immune system – inflamed airways react to trigger substances. Inflammation of the sinuses – often associated with nasal polyps. GERD. Reactions to medications (ASA, NSAIDS, penicillin).
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Bronchospasm - Diagnosis
Labored, rapid breathing, difficulty with expiration
Skin and mucous ’d 02, ’d C02 membranes - cyanosis Wheezing– especially expiratory ’d resistance to ventilation
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Bronchospasm - Treatment Beta 2 agonists Albuterol Epinephrine
Constricted BronchioleDilates Bronchiole
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28 The most efficient method in the awake patient – the spacing chamber…
When the inhaler is activated, the Now the patient inhales deeply. mist fills the spacing chamber. And the mist “cloud” is inhaled into the tracheobronchial tree.
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Use of the Inhaler Adapter for the Anesthetized Patient A.Connected to an Ambu-Bag.
Inhaler B.Inserted “in-line” with the tube Adapter from the N20/02 machine. C.To deliver the spray the mask is applied “upside down” and the nose closed off, mouth prop in
β2 place, tongue suture. agonist The metered dose is followed by A D. positive pressure ventilation.
Anesthesia C D Tube Adapter
Nose clip
Mask Tongue pulled B “upside forward with down” tongue suture 86 86
Bronchospasm
TREATMENT – SEVERE: Epinephrine 1:1000 0.3 - 0.5mg IM or 1:10,000 IV SLOWLY!!! Repeat q 20 min. Maximum – 1mg Especially if patient unable to use nebulizer Intubation
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29 Asthma – Patients at Risk!
Frequent attacks ER – Hospital Medications –
More than one canister a month of β2 agonist indicates poor control. Most patients should not require
daily β2 agonist. Need for frequent steroids Recent intubation
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Prevention ‒ The Peak Flow Meter
A Patient inhales as deeply as possible.
B Exhalation with maximal force into the peak flow meter.
C Repeat 3x and compare maximal A flow with table norms.
B C
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36 yr old female with impacted #32 An OMS shares a satellite office with other specialists and treats patients there twice a month. He and two assistants transport their monitors, equipment, crash cart and meds. A periodontist screened and worked up the patient for ext #32 with IV sedation and obtained consent. PMH: Last exam 2.5 yrs ago, childhood asthma but currently taking no medications. She has a high level of stress and is very apprehensive.
BMI: 33 Hght: 5’4” VS’s: BP: 135/85 Pulse: 102 O Sat: 99% Wgt: 185# 90 2 90
30 36 yr old female with impacted #32
The patient was escorted by her husband and two unruly twin daughters who are acting up. The husband indicated he needed to be at work at 1:00 pm and the OMS and staff felt pressured. Monitors were attached and an angiocath placed in the dorsum of the left hand. IV meds included: Versed 5mg, Fentanyl 50ug, propofol 50mg A bite prop and posterior oral gauze pack were placed and one carpule of lidocaine 2% with epi 1:100,000 administered.
VS’s: BP: 124/86 Pulse: 105 O2Sat: 99% EKG: S. Tach 91 91
36 yr old female with impacted #32
A mucoperiosteal flap was elevated and bone relief begun with a dental drill with internal irrigation and a saliva ejector for suction. The suction was inadequate. A surgical suction tip was located and connected to the suction tubing, but the suction system could still not adequately remove the blood and irrigation from the field.
The patient began coughing and the SpO2 dropped to 80%.
An Ambu bag with O2 was assembled, but the plastic connector was cracked and leaking. The SpO2 dropped to 60% and continued bleeding threatened the airway. The OMS decided to intubate the patient and called for an ET tube, but it was in the assistant’s car.
VS’s: BP: 142/94 Pulse: 136 O Sat: 80% EKG: S. Tach VS’s: BP: 162/98 Pulse: 145 O2Sat: 60% EKG: PVCs 92 92
36 yr old female with impacted #32
Anectine 40mg IV given, but the intubation attempt had to be aborted because the laryngoscope bulb was burned out. An LMA was placed with connection to another
O2 tank and ambu bag; 911 activated. BP 150/92, HR 122. Inspiratory/expiratory wheezes were noted, despite epi 1mg.
EMT arrival; SpO2 88%, patient unconscious. O2 tank empty.
VS’s: BP: 150/92 93 BP: 162/98 Pulse: 145122 O2Sat: 60%88% EKG: PVCsS Tach 93
31 36 yr old female with impacted #32
Pt transported to hospital and died 3 days later. Postmortem chest x-ray revealed evidence of pulmonary aspiration. Autopsy showed massive MI as cause of death. Gauze found in intestines. Dental Board investigation revealed that the surgeon’s ACLS and staff’s BLS cards were expired and that the office was past due for its office anesthesia evaluation.
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36 yr old female with impacted #32
Legality of medication transportation by office staff. Lack of continuity drugs/equipment in second office. Failure to document equipment review/maintenance. Expired BLS, ACLS, State, AAOMS GA evaluations. Different docs performing workup and procedure.
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36 yr old female with impacted #32
Using dental equipment (drill) for surgical procedure. Using dental suction during surgical procedure. Appropriate epi dose? Reversal meds? All emergency meds outdated, so efficacy questioned.
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32 Pulmonary Aspiration
• Preoperative normal X‐ ray • Pulmonary aspiration • Note definition of ribs and • Note loss of definition of lacey radiodensity pattern ribs and increased radio‐ in lungs. density in lungs.
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Respiratory Emergencies
4. Emesis & Aspiration
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Emesis and Aspiration - Pathophysiology
EMESIS STOMACH Acidic stomach contents ACID digest the walls of the alveoli 99 99
33 Emesis and Aspiration - Diagnosis
Skin and mucous membranes – pale, then cyanotic
Pre-tracheal steth gurgling / Dyspnea abdomen heaving Rales
Tachycardia Wheezing
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VOMITUS
Tip patient back into the Trendelenburg position
Rotate to the right. MANAGEMENT OF EMESIS TO PREVENT
VOMITUS ASPIRATION
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Bronchi
Right Mainstem Wider Straighter
Left Mainstem Narrower More acute angle
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34 Management of Emesis to Prevent Aspiration – Rolling the Patient
ROTATE RIGHT ROTATE LEFT
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Emesis and Aspiration - Treatment
TRENDELENBURG ‒ head to right, finger sweeps for accessible solids
ROTATE TO THE INTUBATE AND SUCTION: RIGHT ‒ Suction, No levage -< 10mL NS 02, Auscultate, to facilitate suction check 02 sat. 10 4 104
Emesis and Aspiration – Prevention
Pre-operative screening – Identify at risk patients Woman Non-smokers Acid related GI disease e.g. GERD Immediate pre-op questioning regarding NPO status – three tiers
For high risk groups consider H2 antagonist e.g. Ranitidine
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35 When you do your simulations, film them …
If you really want to get it down cold, do film it. It’s amazing what you’ll learnAttempt when you watch to suspend yourself going disbelief!! through the simulations. 106 106
Respiratory Emergencies
5. Drug Overdose (Respiratory Depression)
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The Control Mechanisms of Respiration
Blood pCO2
Blood pH
Blood pO2
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36 RESPIRATORY DEPRESSION – SECONDARY TO ANESTHETIC AGENTS
ANESTHETIC AGENT Blood pC02
In respiratory rate and depth
Sensors insensitive
to Blood pC02
109 10 9 109
Narcotic-Analgesic Overdose SYMPTOMS: ’d respiratory rate
’d O2 Sat. Cyanosis MANAGEMENT: Supine position
Airway, 100% O2, vs’s Narcan (Naloxone) 0.4-2mg IV, IM, SQ 0.01 mg/kg for children Repeat at 2-3 minute intervals Not to exceed 10mg. OBSERVE for re-sedation and
respiratory depression 110 110
Sedative/Hypnotic Overdose SYMPTOMS: Decreased respiratory rate, pale appearance followed by cyanosis Unresponsiveness TREATMENT: Supine position
Maintain airway – 02, VS’s Reverse Benzodiazepine Flumazenil (Romazicon) 0.2mg IV initially. Then 0.1mg/min. up to 1 mg. OBSERVE FOR RE-SEDATION!
1 1 1 111
37 Prevention of Respiratory Depression Use the lowest dose necessary of “longer- acting” depressants such as Versed and fentanyl. Rely instead on very short-acting drugs such as propofol and low dose ketamine and remifentanil which are redistributed and metabolized rapidly. Decrease the dose for elderly patients. Obese patients who are more likely to have airway problems – base dose on lean body mass.
11 For all patients titrate dose to response!! 2 112
ASSESS RESPIRATION
BREATHING LABORED OR NO BREATHING
VERY SLOWLY NOT OBSTRUCTED OBSTRUCTED
FOREIGN BODY DRUG INDUCED RESPIRATORY DEPRESSION NARCOTIC OR BENZODIAZEPINE LARYNGOSPASM
BRONCHOSPASM
11 3 113
DIABETES MELLITUS
114
38 Types of Diabetes
The pancreas does not produce Although insulin is produced, adequate insulin, and insulin the tissues are insensitive to from an external source must the insulin, and glucose does be administered daily. not pass into the tissues. 115
DIABETES
116
Interpretation of Glucometer Readings
Levels of hypoglycemia: Mild (<60-65 mg/dL) – cold, clammy, trembling. Moderate (< 50mg/dL) – anxiety, irritability, weakness. Severe (< 30mg/dL) – seizures, loss of consciousness.
117 117
39 HYPOGLYCEMIA – SIGNS/SYMPTOMS (MILD TO MODERATE 50-60 mg.dL) Dizziness Confusion / Headache Hunger
Slurred Tachycardia speech
Sweating Lethargy
118
HYPOGLYCEMIA: EARLY TREATMENT Always treat as hypoglycemic until otherwise proven! Conscious patient - supine position Monitor BP/Pulse Check blood glucose levels Treat blood glucose < 50 mg/dL (even with no symptoms) High sugar content substitute: Orange juice Soft drink Candy / Cake frosting 119
When the patient INSULIN SHOCK – takes his normal insulin dose, but has PATHOPHYSIOLOGY no oral intake (e.g. fasting)
When glucose drops below the critical level for brain function, the patient looses consciousness.
120
40 Remember Our Overall Goals in the Treatment of Emergencies
Get 02 to the heart and brain Get glucose to the brain And
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INSULIN SHOCK - DIAGNOSIS Anxiety and mental Loss of clouding Consciousness and seizures
Hypersalivation Tachycardia
Coolness of the skin, diaphoresis (sweating) ADRENALIN RUSH
122
INSULIN SHOCK – Glucose is given IV or PO TREATMENT to re-store the low level of sugar in the blood
Or, glucagon can be administered IM, which will stimulate breakdown of glycogen in the liver and provide sugar through this route
123
41 HYPOGLYCEMIA: PREVENTION Careful medical history
Determine the severity of disease
Hospitalization
Frequency of hypoglycemic events
Patient control of diabetes / conscientious
insulin management – hemoglobin A1c
Watch time of the day for surgery – early AM
Glucometer checks preop., intraop. and postop
124
Monitoring Your Patient’s Diabetic
Management – Hemoglobin A1c
Glucose attaches to some of the hemoglobin in the RBC’s to form glycated hemoglobin
(hemoglobin A1C or HbA1c).
HbA1c is the % of total hemoglobin which is glycated and can be used to monitor how high the patient’s blood sugar has been. The reference range in healthy persons) is about 4%–6%. 125 125
Correlation of Average Blood
Glucose with the A1c Value
Higher levels of HbA1c are found in people with persistently elevated blood sugar. The American Diabetes Association recommends
that the HbA1c be below 7.0% for most patients.
A “good” HbA1c level of 4-6 in a patient with diabetes may mean that there is a history riddled with recent hypoglycemia.
126 126
42 ALLERGIC / DRUG REACTION
2. Anaphylactic Shock
127
Immune System –Allergy
• Definition: • A reaction of the immune system to substances which have sensitized the system (allergens). • The immunologic response of the body to a substance recognized to be toxic. • Previous exposure to a foreign antigenic substance which caused antibody formation (IgE)
128
ALLERGY TO DRUGS - PATHOPHYSIOLOGY
129
43 ALLERGY TO DRUGS - PATHOPHYSIOLOGY
Life-threatening components of anaphylaxis are bronchoconstriction, laryngeal edema and cardiovascular collapse
130
ALLERGIC REACTIONS – TYPES • Contact dermatitis • Allergic rhinitis • Urticaria • Angioedema • Bronchospasm and edema (asthma) • Anaphylactic shock
131
ALLERGY TO DRUGS -DIAGNOSIS
Skin: Rash, Watery Eyes Hives, Itching
Sneezing Shortness of breath , wheezing Coughing Hypotension
Nausea
132
44 THE TIMING OF ALLERGIC REACTION • DELAYED ALLERGIC REACTION (1 hour or more after exposure) – usually mild reactions • IMMEDIATE (usually within 1 hour of time of exposure) – in most cases these are severe reactions • ANAPHYLAXIS (usually within 5-10 minutes of time of exposure) – most severe of reactions, life threatening
133
ALLERGIC REACTIONS TO DRUGS SKIN REACTIONS MOST COMMON: • Rash • Urticaria (itching) • Erythema (redness) • Angioedema (swelling of the lips)
134
SEVERE ALLERGIC REACTIONS - TREATMENT
Bronchoconstriction β2 Bronchodilation EPINEPHRINE
• - Vasoconstriction • β Effects
• β 1 ’s HR, ’d BP Vasoconstriction of • β 2 Bronchodilation β1 ’s HR, ’d BP edematous (swollen) membranes of throat - 135
45 Potential life-threatening manifestation– laryngeal edema
The normal larynx Laryngeal edema during through a broncoscope anaphylaxis
136 136
Treatment of Allergic Reactions – Additional Medications
• Diphenhydramine (Benadryl®) for: • Rash • Itching • ’d nasal secretions • Watery eyes • Dexamethazone (Decadron®): • To stabilize membranes which will reduce swelling • To combat the other symptoms of inflammation 137
Allergic Reactions - Immediate Onset SEVERE: • Discontinue medications • Epinephrine 0.3ml of 1:1000 IM Or..Epinephrine 3ml of 1:10,000 IV • Repeat every 5 minutes if signs progress • Benadryl 50 mg IM or IV (TID x 2days) • Bronchodilator – for wheezing • Monitor VS, observe • Hydrocortisone 100mg IM/IV • Transfer to hospital
138
46 Anaphylaxis - Diagnosis
Loss of consciousness
Stridor - laryngeal Cyanosis – oral edema mucosa and nailbeds Wheezing, ’d breath sounds - bronchospasm Nausea, vomiting incontinence BP and HR - cardiovascular collapse
139
We need Epi ASAP!
However, it has been found that the needle on the pediatric EpiPen may not be of sufficient length in an obese child, and the EpiPen consequently ineffective.
140
141
47 LOCAL ANESTHETIC TOXICITY Signs and symptoms: • Nervous System – Seizures • Respiratory System – Depression followed seizure • Cardiovascular system (CVS) • Hypotension • Dysrhythmias • Asystole
142
LOCAL ANESTHETICS - OVERDOSE
● Early signs – Patient may become anxious, talkative and disoriented ● At higher doses the patient may develop seizures which can lead to respiratory depression and require support of the airway.
143
LOCAL ANESTHETIC TOXICITY ●SIGNS AND SYMPTOMS – (CNS) ● Increasing severity ● Tinnitus (ringing in ears) ● Slurred speech ● Late ● Seizures ● Coma • May lead to a seizure - an aberrant electrical discharge which stimulates bizarre contractions such as: • Tonic contractions Clonic contractions
144 144
48 LOCAL ANESTHETIC TOXICITY
PREVENTION:
• Aspirate before
injection • Use only what is
necessary
• Know safe doses!
145
146
MAXIMUM SAFE DOSE OF LIDOCAINE Maximum safe dose of lidocaine = 4.5 – 6.5 ≈ 5 mg/kg 70 kg (avg. male) x 5 mg/kg = 350 mg 1 cartridge = 1.8 cc’s of 2% sol. = 36 mg/cartridge 350 mg (total safe dose) ÷ 36 mg/cart. ≈ 10 cart. 70 kg x 2.2 lb./kg = 154 lb. body weight ÷ 10 cart. ≈ 1 cart. /15 lb.
165 lbs. ÷ 15 lbs. per cartridge = 11 cart. 45 lbs. ÷ 15 lbs. per cartridge = 3 cart. 147
49 LOCAL ANESTHETIC TOXICITY TREATMENT: • Stop administration of local anesthetic • 100% oxygen • Supine position • Monitor vital signs • Establish IV • Treat symptomatically – IV Valium 5-10 mg IV over 1-2 minutes
148
50