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CA Association of OMFS Presents Respiratory Emergencies CA Association of OMFS presents Respiratory Emergencies William K. Tom, DDS MS Healdsburg, CA 1 1 OUR OVERALL GOALS IN THE TREATMENT OF EMERGENCIES Get 02 to heart and brain Get glucose to the brain 2 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 3 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 4 4 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. 5 5 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? 6 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! 7 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 8 8 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 10 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 11 11 A. Respiratory Emergencies 1. Airway Obstruction 2. Laryngospasm 3. Bronchospasm / Asthmatic Attack 4. Emesis with Aspiration 5. Respiratory Depression 12 12 4 Respiratory Emergencies 1. Airway Obstruction 13 13 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 22 22 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… 26 26 Foreign Body Obstruction - Treatment Visualize the larynx with a laryngoscope. Suction the hypopharynx. Insert the Magill Forceps and retrieve the foreign body. 27 9 Abdominal Thrusts – Heimlich Maneuver vs Chest Compressions Abdominal thrusts greater intrathoracic pressure Xiphoid process (GR.-”sword shaped”) puncture of viscus 28 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…………………….............
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