Anesthesia Emergencies This Material Is Not Intended to Be, and Should Not Be Considered, a Substitute for Medical Or Other Professional Advice

Anesthesia Emergencies This material is not intended to be, and should not be considered, a substitute for medical or other professional advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances. And, while this material is designed to offer accurate information with respect to the subject matter cov- ered and to be current as of the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules for medications are being revised continually, with new side effects recognized and accounted for regularly. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation. The publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material. Without limiting the foregoing, the publisher and the authors make no representations or warranties as to the accuracy or efﬁ cacy of the drug dosages mentioned in the material. The authors and the publisher do not accept, and expressly disclaim, any responsibility for any liability, loss or risk that may be claimed or incurred as a consequence of the use and/or application of any of the contents of this material.

Anesthesia Emergencies

K eith J . R uskin, MD Professor of Anesthesiology and Neurosurgery Yale University School of Medicine New Haven, Connecticut

S tanley H . R osenbaum, MD Professor of Anesthesiology, Medicine, and Surgery Yale University School of Medicine New Haven, Connecticut

1 3

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Library of Congress Cataloging-in-Publication Data Anesthesia emergencies / [edited by] Keith J. Ruskin, Stanley H. Rosenbaum. p. ; cm. Includes bibliographical references and index. ISBN 978-0-19-539671-3 1. Anesthetic emergencies—Handbooks, manuals, etc. I. Ruskin, Keith. II. Rosenbaum, Stanley H. [DNLM: 1. Anesthesia—Handbooks. 2. Emergencies—Handbooks. WO 39 A579 2011] RD82.5.A55 2011 617.9´6042—dc22 2010003454

9 8 7 6 5 4 3 2 1 Printed in the United States of America on acid-free paper Contents

Series Preface vii Preface ix Managing Emergencies: Lessons Learned from Aviation xi Contributors xv

1 Airway Emergencies Sekar S. Bhavani and D. John Doyle 1 2 Cardiovascular Emergencies Ajoy Katari and Benjamin A. Kohl 25 3 Equipment Problems James B. Eisenkraft 63 4 Ethical Considerations Robert B. Schonberger and Stanley H. Rosenbaum 77 5 Metabolic and Endocrine Emergencies Lewis J. Kaplan 85 6 Miscellaneous Problems Keith J. Ruskin 127 7 Neurosurgical and Neurologic Emergencies Ira J. Rampil 143 8 Obstetric Emergencies Robert Gaiser 165 9 Pediatric Emergencies Jessica L. Wagner 203 10 Postanesthesia Care Unit CONTENTS Sean M. Quinn and Keith A. Candiotti 239 11 Procedures Ramachandran Ramani and Ala Haddadin 267 12 Regional Anesthesia Complications Raymond S. Sinatra and Dan B. Froicu 297 13 Respiratory Emergencies Vivek K. Moitra and Tricia E. Brentjens 313 14 Surgical Emergencies Linda L. Maerz and Stephen M. Luczycki 337 15 Thoracic Emergencies Marc S. Azran and Michael Nurok 363 vi Index 389

Series Preface

Emergency physicians care for patients with any condition that may be encountered in an emergency department. This requires that they know about a vast number of emergencies, some common and many rare. Physicians who have trained in any of the subspe- cialties – cardiology, neurology, OBGYN and many others — have narrowed their fi elds of study, allowing their patients to benefi t accordingly. The Oxford University Press Emergencies series has combined the very best of these two knowledge bases, and the result is the unique product you are now holding. Each handbook is authored by an emergency physician and a sub-specialist, allowing the reader instant access to years of expertise in a rapid access patient-centered format. Together with evidence-based recommendations, you will have access to their tricks of the trade, and the combined expertise and approaches of a sub-specialist and an vii emergency physician. Patients in the emergency department often have quite different needs and require different testing from those with a similar emergency who are in-patients. These stem from different priorities; in the emergency department the focus is on quickly diagnosing an undiffer- entiated condition. An emergency occurring to an in-patient may also need to be newly diagnosed, but usually the information available is more complete, and the emphasis can be on a more focused and in-depth evaluation. The authors of each Handbook have produced a guide for you wherever the patient is encountered, whether in an out-patient clinic, urgent care, emergency department or on the wards. A special thanks should be extended to Andrea Seils, Senior Editor for Medicine at Oxford University Press for her vision in bringing this series to press. Andrea is aware of how new electronic media have impacted the learning process for physician-assistants, medical students, residents and fellows, and at the same time she if a fi rm believer in the value of the printed word. This series contains the proof that such a combination is still possible in the rapidly changing world of information technology. Over the last twenty years, the Oxford Handbooks have become an indispensable tool for those in all stages of training throughout the world. This new series will, I am sure, quickly grow to become the standard reference for those who need to help their patients when faced with an emergency. Jeremy Brown, MD Series Editor

SERIES PREFACE Associate Professor of Emergency Medicine The George Washington University Medical Center

viii

Preface

Anesthesiology is unique among medical specialties, in that most anesthetics and surgical procedures are uneventful. Critical events can, however, occur without warning, are usually sudden, and may be life-threatening. Anesthesiologists must be ready to detect and manage unpredicted emergencies at any time. The initial response to a critical event may determine its outcome. A recent study found that early recognition and effective management of complications were as important as their avoidance in improving mortality during surgery. 1 The use of checklists and established procedures, long an accepted practice in aviation, can help health care providers quickly establish a diagnosis and begin treatment. Anesthesia Emergencies can be used to prepare for emergencies that may occur in the future, and to deal with critical events as they happen. ix Anesthesia Emergencies is written to help an anesthesia provider deal with common complications or unforeseen emergencies during the perioperative period. Chapters have been organized alphabetically, and each section within a chapter is arranged alphabetically by type of problem. Critical information has been highlighted. Each chapter contains one or more references to textbook chapters or review articles that will provide additional information. Emergency readiness requires that the caregiver have the knowledge, skills, and equipment necessary to resolve the problem. This book will ideally be used to prepare for emergencies before they occur. The authors recommend that if a speciﬁ c type of problem can be anticipated (e.g., massive hemorrhage in a postpartum patient being brought to the operating room) the appropriate chapter should be reviewed beforehand. All personnel on the care team should be briefed on the critical events most likely to occur, and the actions that will be taken during an emergency. This book can be used outside of the operating room to prepare for future events by reviewing a section and thinking through the steps that would be needed for successful resolution of the problem. Ideally, Anesthesia Emergencies will be one part of an organized approach that includes simulation and training in crisis resource management. The authors recommend that when an emergency occurs, the anesthesia provider call for help as quickly as possible and

1. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009 Oct 1;361(14):1368–1375. delegate tasks as personnel arrive. There should be one person who is clearly in charge and directs the others, but that person should ask for advice and help as needed. When an anticipated critical event PREFACE occurs, the “Immediate Management,” “Differential Diagnosis,” and “Subsequent Management” sections can be used as checklists, to help the anesthesia provider remember each of the steps that must be taken. If an unforeseen emergency occurs, the same sections can be used as a “Do” list. Follow the suggested procedure, and then refer to the article in “Further Reading” for more information after the patient has been stabilized. This book would not have been possible without the help of many people. The authors would ﬁ rst like to thank their families for their constant support. We would like to thank our editors, Andrea Seils and Staci Hou, for their advice and guidance. We also thank our authors, who produced outstanding manuscripts and turned them in on time. We thank Ashley Kelley, MD; Jorge Galvez, MD; Glenn Dizon, MD; Emilio Andrade, MD; Michele Johnson, MD; and Viji Kurup, MD for their assistance with the illustrations. Lastly, we thank the residents and faculty of the Yale University School of Medicine, x Department of Anesthesiology, for their critical review of the man- uscript and their thoughtful comments.

Managing Emergencies: Lessons Learned from Aviation

Dan Gryder

A “crash” is never a good thing, whether it happens to an airline fl ight or to a patient in the operating room. When an airline fl ight crashes, the entire world knows about it, and everyone can read about it. Keith Ruskin and I have had the opportunity to fl y together; we talked a lot about the similarities between the OR and the cockpit, and in those discussions were able to draw many parallels. In the airlines, the captain used to be the “boss” of the fl ight and often xi could never be told that he was wrong. This might sometimes still be true in the operating room, where one or more members of the patient care team may appear to be unapproachable, or become hos- tile when questioned. In one tragic aviation accident, the aircraft was dangerously low on fuel. The captain insisted that they had enough, but the other two pilots, who knew the truth, were afraid to disagree with him. Because two members of the fl ight crew were afraid of being fi red, the aircraft ran out of fuel and crashed near New York, killing all aboard. In another infamous airline accident, the left engine caught fi re after takeoff. The captain mistakenly insisted that the right engine was on fi re. The fl ight attendant in the back could have told the captain where the problem was, had he or she been asked. The captain elected to shut down and secure the right engine and run the left engine at full power, adding more fuel to the fi re. Everyone died. In yet another accident, one of the green landing-gear indicator light bulbs had burned out, falsely indicating that one of the gears was unsafe for landing. All three pilots bent over the instrument panel in fl ight, trying to determine if the gear was safe for landing, but no one paid attention to what the airplane was doing. The airplane began a slow descent and eventually crashed in the Florida Everglades west of Miami. Many aboard died. The National Transportation Safety Board (NTSB) is the govern- ment agency tasked with the responsibility of determining causes of airplane crashes and implementing methods of assuring that the same types of accidents do not happen again. In the late 1970s the NTSB determined that a signifi cant number of accidents were caused by problems related to “human factors.” In other words, there was no mechanical failure. The trained fl ight crew made time-critical mistakes that in many cases could have been prevented. As a result, the airline industry has evolved and grown safer in recent years. Professional pilots are now required to undergo detailed training in the classroom and in a simulator to learn what to do when an abnormal event takes place. Cockpit resource management (CRM) has been largely cred- ited with the dramatic improvement in airline safety. MANAGING EMERGENCIES The common thread of more than 50 fatal aircraft accidents is very simple: lives were lost that could have easily been spared. It may be possible to draw parallels to similar events in the operating room that are caused by human factors. The only difference between the two professions is that nobody outside the hospital may ever know what really happens during a “crash” in the operating room. The patient can’t tell his story. The family may never know. The personnel who were there have to sleep at night knowing that a preventable chain of errors may have been responsible for that patient’s death. Like aviation, the outcome of decisions made in the operating room is fre- xii quently irrevocable. There are, however, lessons that anesthesiologists could possibly adapt from aviation and place into practice that will improve their performance during an abnormal event. The following is a summary of what we in the airline industry have learned: • The situation always turns from NORMAL to ABNORMAL at some clearly defi ned point. Learn to recognize that point and announce that point in time. • If there are any aural or visual warnings that have been activated, acknowledge what they represent, and then silence them. Studies have shown that fl ight crew performance, and their ability to think and reason, is impaired by as much as 60% by the constant noise from audible alarms. • During any ABNORMAL scenario, the captain should quickly verbally review the role of each person and assign tasks. For instance, he or she may say, “You fl y the aircraft and let the controllers know about our situation. I will run the appropriate checklists and coordinate with the company maintenance department.” The physician primarily responsible for the patient can perform the same role. • Stabilize the situation and fi nd a way to buy time. • Once stabilized, solicit as many inputs as possible given the possible time constraints. Even information from a fl ight attendant or passenger could be useful. Learn to differentiate data that arrives, as “what I saw or smelled or felt” as opposed to “what I think we should do.” Almost every accident review has revealed that someone, somewhere, had the missing piece of information that could have solved the problem. There is a passenger, a fl ight attendant, a mechanic, another pilot, or a dispatcher who saw, smelled, or felt something. That person may have the missing clue if only someone would ask. • Ask for advice. It is not necessary to comply with every suggestion that is offered, but it is best to solicit that information and at least consider each opinion. • After careful consideration, and using all available resources as

tools, the captain will ultimately select the best course of action MANAGING EMERGENCIES and implement it, monitoring the situation closely as he or she does so. • Start the sequence again from the top as necessary. There are some general strategies that will improve your ability to manage a critical event: • Announce the abnormal condition! You may be the only person that realizes what you see and the signiﬁ cance of it. It is not necessary to offer a solution at the same time. Simply state that at this point in time, something is wrong. • Encourage every member of your team to announce a problem. Charge them with the responsibility of announcing anything xiii seen as abnormal at any time. You will deal with what you see later, but it is imperative that someone announce an abnormal condition as soon as it is recognized. • Build time. Find a way to stabilize the situation while resources can be mobilized. • You are not a fool if you ask for the opinions of others. You are a fool if you do not. • At some point, a decision must be made. Consider the consequences of each choice and make the best choice after having considered all options and opinions. The Federal Aviation Administration has developed a “3P” model of decision-making, and this may be applied to the management of critical events in the operating room. The 3P model has three steps: Perceive, Process, and Perform . The ﬁ rst step is to perceive that a problem has occurred. Next, all available information is processed to determine if a change in management is necessary and, if so, what intervention is likely to solve the problem. The last step is to perform , or to make the intervention. After making the intervention, return to the perceive step to determine if the intervention had the desired result, and the entire process starts all over again. If the intervention did not have the desired result, consider the possibility that the intervention was not performed correctly, or that the intervention was not appropriate for the problem. Simple changes in the way you approach a problem and work with members of your team may prevent an adverse event from occurring xiv MANAGING EMERGENCIES SundarE,S,PawlowskiJ,BlumR,FeinsteinD,PrattS.Crewresource FurtherReading emergencies inthisbook. introduction willhelpyoubemoreeffectivewhenmanagethe and maybeevensaveyourpatient’slife.Usingtheinformationinthis FederalAviationAdministration: management andteamtraining. Washington, DC.FederalAviationAdministration,2008.17.2–17.32.

Pilot’s HandbookofAeronauticalKnowledge . Anesthesiol Clin . 2007Jun;25(2):283–300.

Contributors

Marc S. Azran, MD D. John Doyle, MD, PhD, Assistant Professor of FRCPC Anesthesiology Professor of Anesthesiology Division of Cardiothoracic Cleveland Clinic Lerner College Anesthesiology of Medicine of Case Western Department Reserve University of Anesthesiology Staff Anesthesiologist Emory University School of Department of General Medicine Anesthesiology, Cleveland Clinic Atlanta, GA Cleveland, OH Sekar S. Bhavani, MD, MS, James B. Eisenkraft, MD FRCS(I) Professor of Anesthesiology Department of Anesthesiology Resident in Anesthesiology xv Institute of Anesthesiology Mount Sinai School of Medicine Cleveland Clinic New York, NY Cleveland, OH Dan B. Froicu, MD Tricia E. Brentjens, MD Robert Gaiser, MD Associate Clinical Professor Professor of Anesthesiology Department of Anesthesiology Hospital of the University of Section of Critical Care Pennsylvania Columbia University Philadelphia, PA Medical Center New York, NY Dan Gryder, ATP Keith A. Candiotti, MD Gryder Networks, LLC Grifﬁ n, GA Vice Chairman for Clinical Research Ala Haddadin, MD Chief, Division of Perioperative Assistant Professor of Medicine Anesthesiology Associate Professor of Yale University School of Anesthesiology and Internal Medicine Medicine New Haven, CT Department of Anesthesiology, Perioperative Medicine Lewis J. Kaplan, MD and Pain Management Associate Professor of Surgery University of Miami Director, Surgical Intensive Miami, FL Care Unit Yale University School of Medicine New Haven, CT xvi CONTRIBUTORS Boston,MA Women’s Hospital Brighamand DepartmentofAnesthesiology MichaelNurok,MD,PhD NewYork,NY Physicians andSurgeons ColumbiaUniversityCollegeof DivisionofCriticalCare Anesthesiology AssistantProfessorof VivekK.Moitra,MD NewHaven,CT Medicine YaleUniversitySchoolof AssistantProfessorofSurgery LindaL.Maerz,MD NewHaven,CT Medicine YaleUniversitySchoolof Anesthesiology AssistantProfessorof StephenM.Luczycki,MD Philadelphia,PA School ofMedicine UniversityofPennsylvania and CriticalCare DepartmentofAnesthesiology Anesthesiology AssistantProfessorof BenjaminA.Kohl,MD Philadelphia,PA TempleUniversity DepartmentofAnesthesiology AssistantProfessor AjoyKatari,MD

Stanley H. Rosenbaum, MD StanleyH.Rosenbaum,MD StonyBrook,NY UniversityatStonyBrook AnesthesiaDepartment DirectorofClinicalResearch and NeurologicalSurgery ProfessorofAnesthesiology IraJ.Rampil,MD NewHaven,CT Medicine YaleUniversitySchoolof Anesthesiology AssociateProfessorof RamachandranRamani,MD Miami,FL School ofMedicine UniversityofMiamiMiller Management Perioperative MedicineandPain DepartmentofAnesthesiology, Anesthesiology AssistantProfessorofClinical SeanM.Quinn,MD NewHaven,CT Medicine YaleUniversitySchoolof and Neurosurgery ProfessorofAnesthesiology KeithJ.Ruskin,MD NewHaven,CT Medicine YaleUniversitySchoolof Medicine, andSurgery ProfessorofAnesthesiology

NewHaven,CT Medicine YaleUniversitySchoolof ProfessorofAnesthesiology RaymondS.Sinatra,MD NewHaven,CT Medicine YaleUniversitySchoolof of Anesthesiology Department ResidentinAnesthesiology MD, MA RobertB.Schonberger,

Washington,DC Center Children’sNationalMedical Pain Medicine DivisionofAnesthesiologyand PediatricAnesthesiologyFellow JessicaL.Wagner,M.D.

xvii CONTRIBUTORS This page intentionally left blank Chapter 1 Airway Emergencies Sekar S. Bhavani and D. John Doyle

Airway Fire 2 Airway Obstruction in the Spontaneously Breathing Patient 3 Aspiration 4 Bleeding Following Tonsillectomy 8 Blood in the Airway 9 Bronchial Intubation 13 Cannot Intubate/Can Ventilate 14 Cannot Intubate/Cannot Ventilate 16 Difﬁ cult Mask Ventilation 17 1 Difﬁ cult Ventilation through an Endotracheal Tube 18 Laryngospasm 19 Ludwig’s Angina 20 Rapid-Sequence Intubation (RSI) 22

2 CHAPTER 1 Airway Emergencies

• • • • • • Prevention • • SubsequentManagement of ignition(e.g.,cautery,laserbeam). based skinprepsolution,plastictrachealtube),oxygen,andasource Anyﬁ re requiresthreecomponents: afuelsource(e.g.,alcohol- Presentation airway. Ignitionofcombustiblematerials(e.g.,plastictrachealtube)inthe Deﬁ

• • • • • • • ImmediateManagement

AirwayFireAirwa

(40% orless). Avoid useofN When usinglasers ontheairway,uselowestpossible FiO electrocautery duringatracheostomy. UsethelowestFiO Ensure thatthesurgeondoesnotenter thetracheawith fi Whenever thesurgicalsiteisnear airway,a60mLsyringe operating room. Display aprotocolforfire preventionandmanagementinevery fi procedure andformulateaplanofactionthatwillbetakenif Determine whetherthereisriskofasurgicalfire beforeevery Admission toanICUisoftenrequired. determine theextentofairwayinjury. reintubated andexaminedbyfiberoptic bronchoscopyto After anairwayfire hasoccurred,thepatientshouldbe the patientwilltolerate. lled withsalinesolutionshouldbeimmediately available. re occurs. apparent. Reintubate thepatient,evenifinjuryisnotimmediately Pour salineintotheairwaytoextinguishanyfl Remove allotherflammable materialsfromtheairway. Stop flow ofallairwaygases,especiallyN Remove theendotrachealtube. Inform thesurgeonsthatafire hasoccurred. endotracheal tube. Immediatelydisconnectthebreathingcircuitfrom nition y Fire

2 Oforsurgerynear theairway.

2 O.

aming debris.

2 that

burn injury). apnea, andairway edema(e.g.,anaphylaxis,smoke inhalation,or way, traumatothe airway,tonsillarhypertrophy,obstructive sleep tumors impingingontheairway,hematomas impingingontheair- titis, diphtheriaLudwig’sangina), laryngospasm,bronchospasm, causes, includingaspiratedforeign bodies,infections(e.g.,epiglot- Airwayobstructioninthespontaneously breathingpatienthasmany Pathophysiology • • • • • • • • • • Presentation tance andresultsindifﬁ cult ventilationandimpairedoxygenation. Partialorcompleteairwayblockagethatincreasesupperresis- Deﬁ AmericanSocietyofAnesthesiologistsTaskForceonOperatingRoomFires. FurtherReading • • • SpecialConsiderations RinderCS.Firesafetyintheoperatingroom.

Breathing PatientB AirwayObstructionintheSpontaneouslyA sPA.pdf Fires. Availableat: Practice AdvisoryforthePreventionandManagementofOperatingRoom 2008;21(6):790–795. Tracheal tug Use ofaccessorymusclesrespiration Stridor Wheezing Snoring Hypoxemia (cancontributetoobtundation) Hypercarbia (cancontributetoobtundation) Dyspnea under ordinaryroomlightingandcanspreadwithinseconds. Fires causedbyalcohol-basedprepsolutionsmaybeinvisible ﬂ The onlyindicationofanairwayﬁre maybeapuffofsmokeand Alcohol-based skincleansingsolutionsareeasilyignited. Agitated patient Apnea ash oflight. irway ObstructionintheSpontaneously reathing Patient nition AccessedOctober6,2009.

http://www.asahq.org/publicationsAndServices/orFire-

Curr OpinAnaesthesiol .

3 CHAPTER 1 Airway Emergencies 4 CHAPTER 1 Airway Emergencies PatilSP,SchneiderH,SchwartzAR,SmithPL.Adultobstructivesleepapnea:

vocal cords. Inhalationofmaterialintotheairwaybelowleveltrue Deﬁ NicholauD.ThePostanesthesiaCareUnit.In:MillerRD,ed. FurtherReading • • • DIFFERENTIALDIAGNOSIS MathoeraRB,WeverPC,vanDorstenFR,BalterSG,deJagerCP.Epiglottitis

• PatientRelated • RiskFactorsforAspirationwith General Anesthesia • • • • • • ImmediateManagement

Asp Aspiration

pathophysiology anddiagnosis. 7th ed.ppPhiladelphia:ElsevierChurchillLivingstone;2010:2711–2712. in theadultpatient. Bradypnea orapneafromdrugoverdoseothercauses Bronchospasm Ordinary snoring when intubationisnotfeasible. Consider helioxasabridgetherapyinpatientswithstridor Consider endotrachealintubationforunremittingobstruction. bronchospasm issuspected. Administer aninhaledbronchodilator(e.g.,albuterol)if dexamethasone. Consider nebulizedracemicepinephrineand/orIV (e.g., LaryngealMaskAirway). airway, anoropharyngealorasupraglotticairwaydevice Attempt toopentheairwaywithajawthrust,nasopharyngeal Increase FiO • reﬂ Inability toclearpharyngealsecretions/poor orabsentgag Emergency surgicalproceduresor surgery atnight

nition Altered mentalstatus • • ex

i Medications Head injury rat

i on 2 to100%ensureadequateoxygenation.

Neth JMed

. 2008;66(9):373–377. Chest

. 2007;132(1):325–337.

Miller’s Anesthesia .

Risk FactorsforAspirationwithGeneral(continued)

• • • • • • • SurgeryandAnesthesiaRelated

• • • • • • • • • • • • Increased volumeoffoodandacidinthestomach. • Difﬁ • Poor inductiontechnique Extremes ofage Patients withahistoryofpriorupperabdominalsurgery • Increased intra-abdominalpressure • • Incompetence oftheloweresophagealsphincter. • •

Cerebral palsy Muscular dystrophies Guillain-Barre syndrome Parkinson’s disease Multiple sclerosis Bulbar palsy Poor gastricemptying/gastroparesis tube. Inability tointubate andprotecttheairwaywithacuffed Incorrectly performedSellickmaneuver Pregnancy Hiatal hernia Recent ingestionoffoodorfl Gas insufflation intothestomachduringmaskventilation ventilation Large tidalvolumeorhighairwaypressure duringmask Obesity Achalasia cardia Esophageal refl Pyloric stenosis Intestinal Obstruction • • • • • • • • •

cult intubationresultingin: Stress Pain Head injuries Renal failure Ileus Pregnancy Autonomic neuropathy Diabetes Obesity

uids

5 CHAPTER 1 Airway Emergencies 6 CHAPTER 1 Airway Emergencies

• • • • • • Factorsaffectingoutcomeafteraspirationinclude: Pathophysiology • • • • • Presentation

Risk FactorsforAspirationwithGeneral(continued)

• • • •

• Host responses • Blood intheairway Bacterial load • Particulate matter Volume ofaspiratedmaterial • pH Clinical ﬁndings of ARDSassyndromedevelops Inﬁ Elevated airwaypressure Wheezing Material foundintheoropharynx

• • Increased intra-abdominalpressure • • Patient positioning • Depth ofanesthesia • Medications anddrugs •

Aspiration ofbileisassociatedwithextensivetissueinjury. predispose thepatienttoinfection Blood intheairwaygenerallyproduces minimalinjury,butmay pneumonitis andbacterialovergrowth. Particulate matterincreasesthemortalityandincidenceof aspirated material. In general,theextentofinjuryincreaseswithacidity ltrates seenonchestX-ray reﬂ Topicalization oftheairwayleadingtosuppressiongag Intra-abdominal airinsufﬂ Lithotomy position Trendelenberg position to gaggingandvomiting Manipulation ofupperairwayunderlightanesthesia,leading Opioids External pressureontheabdomen ex

ation

• • • • • Prevention • • • • DIFFERENTIALDIAGNOSIS

• • • • • • • • • • • • • • • ImmediateManagement

prior tothesurgicalprocedure. Reduced pulmonarycompliance(ARDS) Hypoventilation, dyspnea,apnea Bronchospasm, wheezing,orcracklesfollowingintubation Laryngospasm orairwayobstructionduringintubation Use H Exercise increasedvigilanceduring intubation Practice goodinductiontechniques. or sensorium. Ensure earlycontroloftheairwayin patientswithpoorgagreﬂ Strictly followNPOguidelines. outcome afteraspiration. Antacids andprokineticdrugshavenotbeenshowntoimprove indicated. Administer bronchodilators(e.g.,nebulizedalbuterol)as at least5cmH Initiate mechanicalventilationasindicated(mayrequirePEEPof Suction thelowerairway. patient isnotcooperative) Intubate thepatient(considerrapid-sequenceinductionif Aspirate thenasopharynxandoropharynx. Maintain cricoidpressure. Position thepatientwithheaddown. Increase FiO Initiate CXRandABGsasindicated. Defer plannedornoncriticalsurgerywherefeasible. that leadtopulmonaryedema). Ensure carefulﬂuid management(sincevolumeshiftsmayoccur Do notadministerH antibiotic therapywhenthereisacleardiagnosisofpneumonia. (e.g., aspirationoffeculentmatter).Inmostcases,initiate Avoid empiricalantibioticsunlessthereisaclearriskfactor Routine prophylacticsteroidsshould Perform bronchoscopyandremoveparticulatematter. 2 blockers/protonpumpinhibitorsat least90–120minutes 2

to100%. 2 O). 2 blockersorprotonpumpinhibitors.

not

beadministered.

and extubation.

7 CHAPTER 1 Airway Emergencies 8 CHAPTER 1 Airway Emergencies SmithG,NgA.Gastricreﬂ ux andpulmonaryaspirationinanaesthesia. NgA,SmithG.Gastroesophagealreﬂux andaspirationofgastriccontentsin

anticoagulant therapy, hemophilia,etc.). hemostasis, and various coagulopathicstates(antiplatelet agents, Causesofbleedingaftertonsillectomy includeincompletesurgical Pathophysiology the fi rst fewhoursaftersurgery. lectomy isseveraldaysfollowingsurgery, bleedingmayoccurwithin Although themostcommonperiodforachildtobleedaftertonsil- Presentation Bleedingfromthesurgicalfi eld aftertonsillectomysurgery. Defi EngelhardtT,WebsterNR.Pulmonaryaspirationofgastriccontentsinanaes- FurtherReading • • • SpecialConsiderations • • • •

BleedingFollowingTonsillectomyBleed MinervaAnestesiol anesthetic practice. thesia. general anesthesiatheincidenceis1in400–900. increases to1in600–800,andforcaesareansectionsunder anesthetics. Inpatientsundergoingemergencysurgery,thisrisk The incidenceofaspirationinadultsisroughly13000 is anticipated. Use anawakeﬁberoptic intubationtechniqueifadifﬁ Use rapid-sequenceintubationwhereappropriate. contents. decrease theriskofaspirationbydecreasingvolumegastric Administration ofprokineticagentspriortosurgerymay gastric pHforover7hours. Use nonparticulatebufferedsaltslikeBicitrathatdecreasethe a 50%mortalityrate. requiring ventilationformorethan48hourspost-aspirationhave The consequencesofaspirationcanbecatastrophic:patients setting ofemergencysurgery. incidence of1in2600andan400casesthe Children areatincreasedriskforaspirationwithanoverall nition Br JAnaesth i ng Follow

. 2003;69(5):402–406. . 1999;83(3):453–460. Anesth Analg

i ng Tons

. 2001;93(2):494–513.

llectomy

cult airway

• • • Presentation of atleast1000mLbloodarate ofmorethan150mL/h. 24 hours,andexsanguinatinghemoptysis isconsideredtobetheloss Massivehemoptysisisdeﬁ Deﬁ HendersonJ:AirwayManagementintheAdult.In:MillerRD,ed.Miller’s FurtherReading the externalcarotidarteryinpatientswithseverehemorrhage. artery anditsbranches.Itissometimesnecessarytoembolizeorligate Thebloodsupplytothetonsilscomesfromexternalcarotid SpecialConsiderations • • DIFFERENTIALDIAGNOSIS

• • • • • • • ImmediateManagement

BloodintheAirway B

2010:1573–1610. Anesthesia Nontonsillar bleeding Hemoptysis Chest X-raymay show signsofaspiratedblood. Frothy orfrankbloodintheETTof intubatedpatients. Hemoptysis inpatientswhoareunintubated. Consider surgicalre-explorationofthetonsillarbed. hypovolemia. Restore intravascularvolumeifthepatienthassignsof Request anemergencyevaluationbyENTservice. recommended. aspiration. Rapid-sequenceinductionofgeneralanesthesiais or postoperativeoralintakemayresultinextensivepulmonary Assume thatthepatienthasafullstomach.Regurgitatedblood oropharynx mayobscuretheviewduringlaryngoscopy. Ensure thatadequatesuctionisavailable.Bloodinthe patient isunabletoprotecthisorherownairway. Consider reintubationinthesettingofbriskbleedingorif Evaluate thepatient’sairwayrapidly. lood intheAirwa nition . 7thed.Philadelphia:ElsevierChurchillLivingstone;

nedasmorethan600mLofblood lossin

9 CHAPTER 1 Airway Emergencies 10 CHAPTER 1 Airway Emergencies Neoplastic Traumatic Hematologic Pulmonary • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Infection Etiology

Cardiovascular

Primary lungcancer Parasitic infection Fungal infection Tuberculosis Lung abscess Necrotizing pneumonia Bronchitis Tracheal-innominate arteryfi Foreign bodyaspiration Chest injury Ruptured bronchus Aortic aneurysm Platelet dysfunction Uremia Thrombocytopenia Disseminated intravascularcoagulopathy Disorders ofcoagulation Upper airwaybleeding Tumors Arteriovenous fi Related totracheostomy Trauma duringintubation,endoscopyorendobronchialsurgery Tuberculosis Bronchiectasis Cystic fi Pulmonary hypertension Congenital heartdisease Atrioventricular fi Left ventricularfailure Mitral stenosis Pulmonary embolism Metastatic lungcancer Bronchial adenoma brosis

stula

AlveolarHemorrhageSyndromes • • • • • • • • • • • • • Iatrogenic Cryptogenic

• • • • • • • • • • ImmediateManagement

Idiopathic pulmonaryhemosiderosis Hematemesis andaspirationintotheairway Wegener’s granulomatosis Systemic lupuserythematosus Henoch Schonleinpurpura Goodpasture syndrome Bechet syndrome Antiphospholipid syndrome Pulmonary hypertension Endobronchial brachytherapy Pulmonary arterycatheterization Lung biopsy Bronchoscopy Consider ECMO as abridgetodefi vasoconstrictors. by cauterization,ablationorsubmucosal injectionof and mayofferanopportunityforimmediate treatment Rigid bronchoscopyfacilitatesidentification ofsite bleeding nonbleeding sidetoachievelongisolation. possible topushtheETTintoamainstem bronchusonthe In anemergencywhenaDLTorBB isnotavailable,it bronchial blocker(BB)toisolatethelungsifindicated. Convert toadoublelumenendotrachealtube(DLT)oruseof bronchoscopy. of bloodfromtheairway,bronchiallavage,andfi Use asinglelumenETTinordertofacilitateevacuation Control theairway—intubateifETTisnotinplace. phenylephrine orepinephrineinfusion. or phenylephrine(100mcgIV)boluses.Ifrefractory,consider Support bloodpressureasneededwithephedrine(5mgIV) Initiate aggressiveresuscitationwithIVfl the massivetransfusionprotocol. In thesettingofexsanguinatinghemoptysis,consideractivating Ensure thatadequatesuppliesofbloodproductsareavailable. Increase FiO

2 to100%.

nitive treatment.

uids.

beroptic

11 CHAPTER 1 Airway Emergencies 12 CHAPTER 1 Airway Emergencies

• • • SubsequentManagement • • • • • • • DiagnosticStudies

9(12):538–541. AdaptedwithpermissionfromLeeKG,AnaesthesiaandIntensiveCareMedicine2008; Table1.1

manipulations Dislodgementduring suture line Riskofinclusionin during resection Interruptventilation pneumonectomy Repositioningduring defl Repeatedinfl Defl secretions Suctionandclearingof Migrationduringsurgery one-lung ventilation Airwayresistancewith Selectivelobarcollapse Timetoisolation Positioning Diffi Age Treat theprimary causeofbleeding. alveolar bleeding. Recombinant activated factorVIIissometimesused with diffuse page 93.) Correct anycoagulationdefects.(See CoagulopathyinChapter5, Right heartcatheterization ECHO toR/Ocardiacorigin Bronchial arteriogram CT scanofthechestandneckasindicated Chest X-Ray Rigid/Fiberoptic bronchoscopy Coagulation profile (PT/INR/aPTTetc.) ations cult Intubation ation oflung

ation and Comparing BronchialBlockerstoDLTs

Possible Possible Needed Required Diffi Takeslonger balloon Diffi Common Lower Possible Longer Diffi Easier Applicableatallages BronchialBlocker cult cult distalto cult

Moredifﬁ Unlikely Notneeded Notrequired Easytoaccomplish Easytoaccomplish Easiertoaccomplish Uncommon Higher Notpossible Quick Relativelyeasier Difﬁ Notapplicableinchildren DoubleLumenTube

cult toposition cult

LeeKG.Anestheticequipmentforthoracicsurgery.

• • • DiagnosticStudies endobronchial ETTplacementcancause atelectasisandhypoxemia. the ETTininfantsandsmallchildren. One-lungventilationasaresultof Small changesinheadpositioncan cause endobronchialmigrationof can moveasmuch5cmwithmaximal cervicalrangeofmotion. when theneckisextendedandcaudadﬂ changes withage,height,andheadposition.Thetubemovescephalad Theaveragedistancefromthelarynxtocarinais12–14cmand Pathophysiology • • • • Presentation potential complications. bronchus) occurscommonly.Earlydetectionandcorrectionavoids Inadvertentendobronchialintubation(usuallyintorightmainstem Deﬁ Seijo LM,DanielH,StermanDH.Interventionalpulmonology. GodfreyS.Pulmonaryhemorrhage/hemoptysisinchildren. Shigemura N,etal.Multidisciplinarymanagementoflife-threateningmassive FurtherReading • • •

BronchialIntubationB 2004;37:476–484. 2008;9(12):538–541. hemoptysis: a10-yearexperience Atelactasis onCXR Unilateral breathsounds Increased airwaypressure Hypoxemia causedbyone-lungventilation threatening massiveintrapulmonaryhemorrhageandhemoptysis. Adopt amultidisciplinaryapproachtomanagementoflife- bilobectomy orasegmentalwedgeresection. not feasible.Thiscouldbeapneumonectomy,lobectomy, Surgery isindicatedwhenbronchialarteryembolization life-threatening massivehemoptysis. Bronchial arteryembolizationiseffectiveinthemanagementof Auscultation Fiberoptic bronchoscopy Chest X-ray 2001;344(10):740–749. ronchial Intubation nition

. AnnThoracSurg.

2009;87(3):849–853.

Anaesth IntensiveCare. Pediatr Pulmonol . N EnglJMed. exed and and exed

13 CHAPTER 1 Airway Emergencies 14 CHAPTER 1 Airway Emergencies

still possible. Inabilitytointubatethepatient.Adequatefacemaskventilationis Deﬁ VergheseST,etal.Auscultationofbilateralbreathsoundsdoesnotruleout OwenRL,CheneyFW.Endobronchialintubation:apreventablecomplica- FurtherReading • • • • • Prevention

• • • • • • • • ImmediateManagement

CannotIntubate/CanVentilateC

endobronchial intubationinchildren. tion. tube 5–7cmabovethecarina. Fiberoptic endoscopyshouldshowthetipofendotracheal 4th thoracicvertebralbody. Chest radiographyshowsthetipoftubeoverlying3rdor Ensure equalbilateralbreathsounds. 21 cminwomenand23men(measuredattheteeth). As ageneralrule,donotpasstheendotrachealtubemorethan beyond theglottis. ensure thattheupperendofcuffisnomorethan3–4cm Observe theendotrachealtubepassingthroughglottisand Airway) ifappropriate. Consider insertingasupraglotticairway(e.g.,LaryngealMask Ensure FiO Callforhelp. Cover Refer totheASADifﬁ cult AirwayAlgorithm,Inside Front options listedinBox1.1. If anotherattemptatintubationiswarranted, considerthe consider asurgicalairway.(i.e.,cricothyrotomy) If thepatientbecomeshypoxicand cannotbeventilated, Cannot Ventilate”(Page16) If ventilationbecomesdifﬁcult, proceedto“CannotIntubate/ deferring thesurgeryorproceedingwithawakeintubation. at intubationisnotappropriate,awakenthepatient.Consider If asupraglotticairwayisnotfeasible,andifanotherattempt annot Intubate/ nition Anesthesiology

2 is100%. . 1987;67(2);255–257.

an Ventilate

Anesth Analg

. 2004;99(1):56–58.

AmericanSocietyofAnesthesiologists TaskForceonManagementofthe HendersonJ.AirwayManagementin the Adult.In:MillerRD,ed. FurtherReading • • • SubsequentManagement

Alternativestoconsiderinthissettingincludethefollowing:

• • • • • • • • • • Makeadecisionastohowapproachthenextattempt. patients). “snifﬁ ng position,”useofpillowsortowelsto“rampup”obese Placethepatient’sheadinanoptimalposition(e.g., Box1.1 patient breathesspontaneously. other method(e.g.,retrogradeintubationtechnique)whilethe attempts andproceedwithintubationusinganFOBtechniqueor Asageneralrule,awakenthepatientafterthreeunsuccessful

Accessed: February 25,2010. http://www.asahq.org/publicationsAndServices/Difficult%20Airway.pdf way: anupdatedreport. Diffi 2010:1573–1610. Anesthesia. obtain a“difficult airway”bracelet. Write thepatienta“difficult airway”letter.Instructthepatientto her towarnfutureanesthesiaproviders. Explain thesequenceofeventstopatientandadvisehimor attention tothosetechniquesthatweresuccessful. Document theintraoperativeeventscarefully,withspecial intubating LMA (See intubating Laryngeal Mask Airway, Page 282) intubating LMA(SeeLaryngealMaskAirway,Page282) Insert anintubatingLMA(Fastrach)andthenETTviathe A largerblade(e.g.,MAC4) External laryngealmanipulation (keeping patientasleep) Use aSyracuse-Patilfacemasktofacilitatefi high ventilatorypressuresandtohelppreventaspiration Insert anLMAProSealoraCombitubetoallowapplicationof Use aTrachlight Is asleepfiberoptic intubationapracticaloption? Consider aGumElasticBougie(Eschmanstylet) Consider avideolaryngoscopesuchastheGlideScope Use ofastraightblade(e.g.,Miller) cult Airway.Practiceguidelinesformanagement ofthediffi

When anInitialAttemptatIntubationFails 7thed.Philadelphia:Elsevier Churchill Livingstone;

Anesthesiology

2003;98:1269–1277. Availableat:

beroptic intubation

cult air- cult Miller’s

15 CHAPTER 1 Airway Emergencies 16 CHAPTER 1 Airway Emergencies facemask. Inabilitytointubatethetrachea.ventilatepatientby Deﬁ inserted intothetrachea throughthecricothyroidmembrane. Figure1.1

• • • • • • • • • • ImmediateManagement

CannotIntubate/CannotVentilateCann

Cover Refer totheASADiffi cult AirwayAlgorithm,InsideFront transtracheal jetventilation(TTJV).SeeFigure1.1. Consider asurgicalairway(e.g.,cricothyrotomy)or laryngoscope (e.g.,GlideScope)orfi If oxygenationremainssatisfactory,considertheuseofavideo the emergencyO other ventilatesthepatientbyhandusingreservoirbagand in positionanddeliversajawthrustusingbothhandswhilethe Consider two-personventilation.Onepersonholdsthemask with insertionofasupraglotticairway. supraglottic etc.)Inmanysuchcasestheairwaycanberescued Insert anairwayofsomekind(oropharyngeal,nasopharyngeal, succinylcholine 0.1–2mg/kg. Treat suspectedlaryngospasmwithpropofol0.25–0.8mg/kgor Reposition thepatient’sheadandjaw. Call forthedifficult airwaycart. Ensure FiO Callforhelp.Asurgicalairwaymaybecomenecessary.

nition o

A 14gneedlewithcatheter (witha10mLsyringeﬁlled withsaline)is t Intubate/Cann

2 is100%. 2 ﬂ ush asneeded.

t Ventilate

beroptic intubation.

ScraseI,WoollardM.Needlevssurgicalcricothyroidotomy:ashortcutto HsiaoJ,Pacheco-FowlerV.Videosinclinicalmedicine.Cricothyroidotomy. KellerC,BrimacombeJ,KleinsasserA,L.Thelaryngealmaskair- severe obstruction, cyanosis, gastric air entry or dilatation, hypoxemia, severe obstruction, cyanosis,gastricairentryordilatation, hypoxemia, Absentorinadequate chestmovementorbreath sounds, signsof Presentation mask seal,excessivegasleak,or resistancetothegasfl Inabilitytoprovideadequatefacemask ventilationduetoinadequate Defi ParmetJL,Colonna-RomanoP,HorrowJC,MillerF,GonzalesJ,Rosenberg HendersonJ.AirwayManagementintheAdult.In:MillerRD,ed. FurtherReading McGrath, FOB,etc.)readilyathand. patients). Havespecialintubationequipment(e.g.,GlideScope, (“sniffi adequately preoxygenated.Positionthepatient’sheadcorrectly airway managementmaybediffi cult. Becertainthatthepatientis Ensurethatextrahelpisavailablebeforestartingananestheticwhen SpecialConsiderations • • • • SubsequentManagement

D Diffi effective ventilation. Analg. obese patientsbeforelaryngoscope-guidedtrachealintubation. way ProSealTMasatemporaryventilatorydeviceingrosslyandmorbidly Engl JMed tilation. of unanticipateddifficult trachealintubationalongwithdiffi cult maskven- H. Thelaryngealmaskairwayreliablyprovidesrescueventilationincases 2010:1573–1610. Anesthesia. ENT consultation. If asurgicalairwayhasbeenattempted,requestanemergency her toobtaina“difficult airway”bracelet. Write thepatienta“difficult airway”letterandinstructhimor her towarnfutureanesthesiaproviders. Explain thesequenceofeventstopatientandadvisehimor attention tothosetechniquesthatweresuccessful. Document theintraoperativeeventscarefully,withspecial iffi nition ng position,”useofpillowsortowelsto“rampup”obese cult MaskVentilati cult MaskVentilation 2002;94:737–740. Anesth Analg . 2008;358(22):e25. 7thed.Philadelphia:ElsevierChurchillLivingstone;

Anaesthesia .1998;87(3):661–665.

. 2006;61(10):962–974. o n

Miller’s Anesth ow. N 17 CHAPTER 1 Airway Emergencies 18 CHAPTER 1 Airway Emergencies LangeronO,MassoE,HurauxC,GuggiariM,BianchiA,CoriatP, El-OrbanyM,WoehlckHJ.Difﬁ cult maskventilation.

ence of a beard; (4) edentulous patient; and (5) history of snoring. ence ofabeard;(4)edentulouspatient;and(5)historysnoring. (reservoir bagdoesnotfi • • • Presentationmayinclude tube Highairwaypressureand/orinability toventilatewellwithatracheal Defi AmericanSocietyofAnesthesiologistsTaskForceonManagementthe FurtherReading (1) ageover55years;(2)bodymassindex(BMI)26kg/m Therearefive independentpredictorsfordiffi cult facemaskventilation: Pathophysiology absent orinadequateexhaledCO

• • • • • • • ImmediateManagement

Endotracheal Tube Di Difﬁ

Riou B.Predictionofdiffi cult maskventilation. Dec;109(6):1870–1880. www.asahq.org/publicationsAndServices/Diffi an updatedreport. Diffi 2000;92:1229–1236. Hypercarbia/elevated end-tidalCO High airwaypressure duringmanualormechanicalventilation Stiff rebreathingbagduringmanual ventilation Consider trachealintubation. mask airway(LMA). Consider insertingasupraglotticairway,suchasthelaryngeal Consider theuseofanoralairwayoranasopharyngealairway. second persondoingtheventilation. using bothhandstogetagoodfacemaskfit andwiththe Consider theuseoftwo-personventilation,withoneperson Ensure thatanappropriatelysizedfacemaskisinuse. Administer ajawthrust. Increase FiO nition ffi in situ. cult Airway.Practiceguidelinesformanagementofthediffi cult Ventilation throu cult Ventilation throughan

2 to100%. Anesthesiology 2003;98:1269–1277.Availableat: http://

ll). ll).

2 ,orlowgasﬂ 2 levels

g cult%20Airway.pdf h an

ows onspirometry Anesth Analg Anesthesiology

cult airway: 2 ;(3)pres-

. 2009

. musculature. Reﬂ Deﬁ HendersonJ.AirwayManagementintheAdult.In:MillerRD,ed. FurtherReading Willdependonthenatureofunderlyingproblem. SubsequentManagement • • • DiagnosticStudies • • • • • • • DIFFERENTIALDIAGNOSIS

• • • • • ImmediateManagement

L Laryngospasm

2010:1573–1610. Miller’sAnesthesia. FOB CXR Auscultation oflungfi Other causes(ARDS,pulmonaryedemaetc.) Endobronchial intubation Anaphylaxis Pneumothorax Bronchospasm Blood orsecretionsoccludingendotrachealtube Kinked endotrachealtube aryn urticaria, hypotension,tachycardia,etc.). Examine thepatientforsignsofanaphylaxis(erythema, (“Ambu bag”)issatisfactory. breathing circuit,checkthatventilationwithaself-infl To ruleoutaproblemwiththeanesthesiamachineandpatient presence ofbloodorsecretions. Pass asuctioncatheterdownETTtoruleoutkinkingorthe unilateral ventilation. Auscultate thelungfields toruleoutwheezes,cracklesand Administer 100%oxygen. ex closureoftheupperairwaydue tospasmoftheglottic nition g ospasm

7thed.Philadelphia,ElsevierChurchillLivingstone;

elds

ating bag 19 CHAPTER 1 Airway Emergencies 20 CHAPTER 1 Airway Emergencies

The infectionusually startswithinfectedmandibular molarsand Ludwig’sanginais amultispaceinfectionoftheﬂ Deﬁ VisvanathanT,KlugerMT,WebbRK,Westhorpe RN.Crisismanagementdur- TsuiBC,WagnerA,CaveD,etal.Theincidenceoflaryngospasmwitha FurtherReading • • SpecialConsiderations • • • • DifferentialDiagnosis blood orsecretions)irritatingthevocalcordsandnearbystructures. light planesofanesthesiaandthepresenceforeignmatter(e.g., Laryngospasmisespeciallycommoninchildrenandassociatedwith Pathophysiology • • • Presentationmayinclude

• • • ImmediateManagement

Ludwig’sAnginaLudwig

ing anaesthesia:laryngospasm. AnesthAnalg. “no touch”extubationtechniqueaftertonsillectomyandadenoidectomy. “Crowing” soundoninspiration. Difﬁ Difﬁ negative-pressure pulmonaryedema. attempting tobreatheagainsttheobstructionmaydevelop Patients whogeneratehighnegativeinspiratorypressuresin produce hypoxemiaandhypercarbia. Failure torapidlydiagnoseandtreatlaryngospasmcanquickly Airway obstructionfromedema,infection,tumor,hematoma,etc. Foreign bodyintheairway Stridor Bronchospasm Consider succinylcholine0.1mg/kgIV. anesthesia. Administer propofolorotherdrugstodeepenthelevelof Administer 100%oxygenwithpositivepressureventilation. nition cult orimpossibleventilationwithsupraglotticairway cult orimpossiblefacemaskventilation

’ s Angina 2004;98:327–329.

Qual SafHealthCare

. 2005June;14(3):e3. oor ofthemouth.

• SpecialConsiderations • • SubsequentManagement • • • • DIFFERENTIALDIAGNOSIS supine position. lead tolossoftheairway,especiallywhenpatientisplacedin Thetonguebecomeselevatedanddisplacedposteriorly,whichmay Pathophysiology • • • • • • Presentation spaces. spreads tosublingual,submental,buccal,andsubmandibular

• • • • ImmediateManagement

Dental abscess Epiglottitis Submandibular abscess Retropharyngeal abscess Leukocytosis Fever Drooling Dyspnea muscles ofrespiration Signs ofairwayobstruction,suchastheuseaccessory Edema anddistortionofairwaystructures Ludwig’s angina. Loss oftheairway istheleadingcauseofdeathinpatients with Transfer thepatienttoICU. and sensitivitytesting. Initiate antibiotictherapy,eitherempirical orbasedonculture may benecessaryinthesettingofsignifi cant airwaycompromise. 279), butelectivetracheostomypriortoincisionanddrainage Consider awakefi beroptic intubationifatallpossible(seePage must bepresent. A skilledsurgeonandemergencycricothyroidotomyequipment operating roomforairwaymanagement. If theclinicalsituationpermits,transportpatientto preferences, andotherfactors(e.g.,CTscanorMRIfi Airway managementdependsonclinicalseverity,surgical

ndings).

21 CHAPTER 1 Airway Emergencies 22 CHAPTER 1 Airway Emergencies MarpleBF.Ludwigangina:areviewofcurrentairwaymanagement. Boscolo-RizzoP,DaMostoMC.Submandibularspaceinfection:apotentially Considerawakeintubationinthese situations. • Prepareallnecessaryequipmentand drugs,andhaveabackupplan. Preparation TheRapidSequenceInduction (“The9Ps”) • • Contraindications • • • • • Indications to compresstheesophagus,reducingriskofregurgitation. agement. Pressureisappliedtothecricoidarea(Sellick’smaneuver) to quicklyrenderthepatientunconsciousandfacilitateairwayman- neuromuscular blockingagent(e.g.,succinylcholineorrocuronium) propofol oretomidate)isadministered,immediatelyfollowedbya of pulmonaryaspirationgastriccontents.Aninductionagent(e.g., Atechniqueofinducinggeneralanesthesiasoastoreducetherisk Deﬁ OvassapianA,TuncbilekM,WeitzelEK,JoshiCW.Airwaymanagementin FurtherReading • •

Rapid-SequenceIntubation(RSI) lethal infection. Otolaryngol HeadNeckSurg literature. adult patientswithdeepneckinfections:Acaseseriesandreviewofthe This mayresultinlungsoiling. laryngoscopy andintubation,flooding thehypopharynxwithpus. The abscessmayrupturespontaneouslyorafterattemptsat use ofatubeexchangecatheter,maybeappropriate. Extubation maybehazardous.Specialprecautions,suchasthe diffi GlideScope orother videolaryngoscopemaybedesirable ifa A workinglaryngoscope anddifferenttypesofblades. A Situations wherelaryngealinjurymay bepresent Patients withanticipateddiffi Women presentingforsurgeryinthelasttrimesterofpregnancy Patients withacutetraumarequiringimmediatesurgery Patients withsignifi Patients withparalyticileusoracuteabdomen Emergency surgeryinwhichapatienthasnotbeenfasting nition cult airwayisanticipated. Anesth Analg

Int JInfectDis cant reﬂ . 2005;100:585–589.

. 1999;125(5):596–599. . 2009;13(3):327–333. ux orachalasiacardia cult airway

( RSI

)

Arch

PositionandProtectthePatient the adverseeffectsofendotrachealintubation. Shouldbeusedjudiciously.Thesemedicationsaretoprevent Premedication nearly aseffective. the mask.Ifpatientiscooperative,ﬁ ve vital-capacity breathsare Administer100%oxygenfor3–5minuteswithatightsealaround Preoxygenation PatientEvaluation • • • • • • • • • • • • • • • • ing agent.Donottitratemedicationtoeffect. Rapidlyadministerananestheticfollowedbyaneuromuscularblock- ParalysisandInduction

• • Choose aneuromuscularblockingagent: • Choose aninductionagent: Lidocaine: 1.5mg/kgIV2–3minutesprior Fentanyl: 3mcg/kgIV2–3minutesprior head injuryorwhomayneedtoberapidlyawakened. Midazolam: 0.02–0.05mg/kg.Usewithcautioninpatients Review possiblecontraindicationstomedications. Ensure thatventilationbyfacemaskwillnotbediffi Evaluate theairwaytoruleoutpossiblediffi Attach appropriatemonitoringequipment Establish IVaccess. appropriate. Equipment foremergencytracheotomy/cricothyrotomywhere Device toconfirm properplacementofETT(e.g.,capnograph) Styletted ETTsofthedesiredsize. • • • Wait for45–60seconds toallowfulleffectofthemuscle relaxant. ETT positionisconfi gone tosleep.(Donotreleasethe cricoid pressureuntilcorrect Apply cricoidpressure(Sellick’smaneuver) afterthepatienthas head ifanadequateviewoftheglottic openingisnotachieved. the neckandextendingatlanto-occipital joint.Repositionthe Position theheadandneckinto sniffing position by fl Rocuronium:1–1.2mg/kg Succinylcholine:1–2mg/kg Etomidate:0.3mg/kgIV Thiopental:3–5mg/kgIV Propofol:1–2mg/KgIV Ketamine:1–2mg/KgIV

rmed.)

cult intubation.

cult.

exing

23 CHAPTER 1 Airway Emergencies 24 CHAPTER 1 Airway Emergencies Securethetube,ventilate. Post-intubationCare nographic means. EstablishthattheETTisincorrectpositionbyclinicalandcap- ProofofPlacement Visualizethetubegoingthroughvocalcords. PasstheETT LangeronO,BirenbaumA,AmourJ.Airwaymanagementintrauma. ReynoldsSF,HeffnerJ.Airwaymanagementofthecriticallyillpatient:rapid- FurtherReading •

sequence intubation. this timetopreventgaseousdistensionofthestomach. If thepatientwilltolerateapnea,donotventilateat Anestesiol . 2009May;75(5):307–311.

Chest

. 2005;127(4):1397–412.

Minerva Chapter 2 Cardiovascular Emergencies Ajoy Katari and Benjamin A. Kohl

Asystole 26 Cardiac Tamponade 27 Pathophysiology 28 Cardiac Trauma 29 Congestive Heart Failure 31 Dysrhythmias: Atrial Fibrillation 33 Dysrhythmias: Bradycardia 35 Dysrhythmias: Narrow Complex Tachycardia 37 25 Dysrhythmias: Wide Complex Tachycardia 39 Hypertension 41 Hypotension 43 Gas Embolism 45 Myocardial Ischemia 47 Postoperative Hemorrhage 49 Valvular Disease: Aortic Regurgitation 51 Valvular Disease: Aortic Stenosis 53 Valvular Disease: Mitral Regurgitation 55 Valvular Disease: Mitral Stenosis 56 Thoracic Aortic Dissection 58 Ventricular Fibrillation 60

26 CHAPTER 2 Cardiovascular Emergencies

• • • SubsequentManagement • • DiagnosticStudies • • • • DIFFERENTIALDIAGNOSIS or myocardialinfarction. other conditionssuchashypoxia,hyper-orhypokalemia,acidosis, Primaryasystolehasapoorprognosis.Itisusuallysecondaryto Pathophysiology sive intraocularpressure,cansometimesbetheinitialtrigger. insufﬂ Usuallyprecededbyotherarrhythmias.Vagalstimulation,caused Presentation Completeabsenceofelectricaland/ormechanicalcardiacactivity. Deﬁ

• • • • • • ImmediateManagement

• • • RiskFactors A Asystole

Temporary transcutaneousortransvenous cardiacpacing Sodium bicarbonateasnecessaryto correctmetabolicacidosis Treat underlyingcauses(hypoxia,acidosis, etc.) Echocardiogram Electrocardiogram Low-voltage ECG Ventricular ﬁ Severe bradycardia Monitor leaddisconnection

Atropine (1mgevery3–5minutesforthreedoses) Vasopressin (40Uwithintheﬁrst 10minutesofCPR) Epinephrine (1mgIVevery3–5minutes) Establish anairway(endotrachealintubationpreferred) Begin CPR Conﬁ s Hypoxia Hypovolemia Electrolyte imbalances (e.g.,hyperkalemia) nition y ation oftheabdominalcavityforlaparoscopicsurgeryorexces- stole rm asystoleinmorethan1ECGlead

brillation

• • • • • • Presentation pensation andmaynotresultinsymptomatic tamponade. is 25–50mL.)Gradualaccumulationofthisfluid allowstime for com- Acuteaccumulationoffluid inthepericardialspace.(Normalvolume Defi AmericanHeartAssociation.Guidelinesforcardiopulmonaryresuscitation FurtherReading • • • • tion efforts.Themostcommonlyusedparametersinclude: vival unlessinstitutedearly. Transcutaneouspacinghasnotbeenshowntofavorablyaffectsur- SpecialConsiderations and ensuingarrhythmias. Earlyidentification ofunderlyingconditionssuchashypoxia,acidosis, Prevention

Risk Factors(continued)

• • • •

CardiacTamponadeC

Circulation and emergencycardiovascularcare.Part7.2:Managementofcardiacarrest. terminated. Ensure thatthepatientisnormothermicbeforeresuscitation Advanced agewithseverecomorbiddisease Asystole asaninitialﬁ perfusing rhythm Resuscitation formorethan30minuteswithoutasustained, Pulsus paradoxus (Systolic dropof10mmHgwithinspiration) Distant heartsounds Jugular venousdistention Tachycardia Orthopnea Dypnea Severalfactorsmustbeconsideredbeforeterminatingresuscita- Other underlyingcardiacconductionabnormalities Hypersensitive carotidsinus Ocular surgery Hypothermia ardiac Tamponade nition . 2005;112:IV-58–IV-66.

nding

27 CHAPTER 2 Cardiavascular Emergencies 28 CHAPTER 2 Cardiovascular Emergencies

• • • SubsequentManagement • • • • DiagnosticStudies • • • • • • • tamponade) (Someoftheseconditionscanalsocausepericardial DIFFERENTIALDIAGNOSIS Externalpressureontheheartreducesventricularpreload. •

• • • • ImmediateManagement

Pathophysiolo Pathophysiology opened. Maintain spontaneousventilationuntil thepericardialsacis heart Equalization ofdiastolicpressuresinallfourchambers arterial pressure) Beck’s triad(small,quietheart,risingvenouspressure,falling help tomaintainheartrateandblood pressure). Administer ketamineforinduction of generalanesthesia(may Request asurgicalpericardiectomy. Accumulation ofﬂuid onechocardiography Globular heartonchestradiography alternate beats) Electrical alternansonECG(variationofR-waveaxiswith Positive endexpiratorypressure(“auto-peep”) Uremia Connective tissuedisorders Iatrogenic (e.g.,catheterinsertion) Aortic dissection Postoperative bleeding Acute myocardialinfarction Maintain normalsinusrhythm. Maintain heartratetomaintaincardiacoutput. Consider IVﬂuid administration toincreasepreload. pericardiocentesis maybenecessary. In thesettingofprofoundhypotension,emergency

g y

• • • • Presentation Penetratingorbluntinjurytothemyocardium. Deﬁ Soler-SolerJ,etal.Managementofpericardialeffusion. FurtherReading • • SpecialConsiderations • • • • Prevention • • •

• • • • RiskFactors

CardiacTraumaCa

relief oftamponade Pulmonary edemaandglobalsystolicdysfunctionmayoccurafter cardiocentesis. Pneumothorax andcardiacperforationmayoccurduring management. Early recognitionandinterventionarecriticaltosuccessful implantation orremoval Awareness ofriskcardiacinjuryduringpacemakerelectrode Early recognitionandcontrolofcardiacsurgicalbleeding Control ofuremia Maintain adequatepreload. Keep heartratehigh. intrathoracic pressure. Consider lowtidalvolumeswithhighventilationratetominimize Flail chest Chest pain Tachycardia Dyspnea 2001;86:235–240. Trauma Uremia Connective tissuedisorders Myocardial infarction nition r d i ac

au m

Heart. 29 CHAPTER 2 Cardiavascular Emergencies 30 CHAPTER 2 Cardiovascular Emergencies

timely intervention iskey. early recognition and diagnosisofunderlyingpathology followedby Althoughcardiac traumaisnottrulyapreventable phenomenon, Prevention • • • SubsequentManagement • • • • • DiagnosticStudies • • • • • • • • DIFFERENTIALDIAGNOSIS cause thoracicorganinjury. Severebluntinjuryduetohighimpactforceisusuallyrequired Pathophysiology

• • • • • ImmediateManagement • RiskFactors

Cardiac tamponade Myocardial laceration Esophageal disruption Pneumothorax Pulmonary andmyocardialcontusion Use lungisolationtechniquesasrequired tooptimizeventilation. Request asurgicalconsultationforpossiblechestexploration. Transesophageal echocardiography(TEE) Esophagoscopy Bronchoscopy CT scan Chest radiography Diaphragmatic injury Coronary laceration Dissection ofthethoracicaorta Evalute the tracheobronchial tree to rule out concomitant lung injury. Evalute thetracheobronchialtreetoruleoutconcomitantlunginjury. Supportive management. may benecessary. Emergency surgery,possiblyrequiringcardiopulmonarybypass, pericardiocentesis. Request asurgicalconsultationforchesttubeinsertionand/or Provide supplementalO Assess airway,breathing,andcirculation. Trauma

asrequiredtomaintainoxygenation.

• • • DIFFERENTIALDIAGNOSIS myopathies andareotherwisesimilar tosystolicHF. Diastolic HFriskfactorsincludehypertrophic andrestrictivecardio- connective tissuedisease,substance abuse,drugs(e.g.,doxorubicin). loidosis), peripartumcardiomyopathy, hypertension,HIVinfection, include myocarditis,ischemicheart disease,infiltrative disease(amy- ForsystolicHF,about50%ofcasesareidiopathic.Othercauses Pathophysiology • • • Presentation • • • • the ventricletofill with(diastolic)oreject(systolic)blood. Astructuralorafunctionalcardiacdisorderwithimpairedabilityof Defi SybrandyKC,etal.Diagnosingcardiaccontusion:oldwisdomandnew BastosR,etal.Penetratingthoracictrauma. FurtherReading tive period. so theECGshouldbemonitoredcontinuouslyinpostopera- degree ofcardiacinvolvementshouldbeanticipatedinbluntinjury, ary toatensionpneumothoraxduringone-lungventilation.Some Be alertforimpairedventilationofthedependentlungsecond- surgery becauseanundiagnosedpneumothoraxmaybepresent. Nitrousoxideshouldbeavoidedinpatientsundergoingtrauma SpecialConsiderations

CongestiveHeartFailureC NewYorkHeartAssociation(NYHA)classiﬁcation ofseverity: 2008;20:19–25. insights. Edema Fatigue Dyspnea Class IV:symptomsofHFatrest Class III:symptomsofHFwithlessthanordinaryexertion Class II:symptomsofHFwithordinaryexertion would limitnormalindividuals Class I:symptomsofheartfailure(HF)onlyatactivitylevelsthat Cardiomyopathy Primary pulmonary pathology Myocardial ischemia on nition g estive HeartFailure Heart.

2003;89:485–489.

Semin ThoracCardiovascSurg.

31 CHAPTER 2 Cardiavascular Emergencies 32 CHAPTER 2 Cardiovascular Emergencies failure Carefulﬂ uid managementinthe patientatriskforcongestiveheart Prevention • • • • • • SubsequentManagement • • • • DiagnosticStudies

therapy: SpecializedmanagementforHFthatisrefractorytopharmacologic

• • • • • RiskFactors • • • • • • • • • ImmediateManagement

Heart transplantation Left ventricularassistdevices Intra-aortic balloonpump Discontinue drugsimplicatedinHF Lifestyle modiﬁ Correction ofcontributingsystemicdisease Serum brainnatriureticpeptide(BNP)(Elevatedinheartfailure) Echocardiogram toevaluatecardiacfunction ECG toevaluateforischemicorhypertrophicchanges Chest X-rayshowscardiomegaly,KerleyBlines,pleuraleffusions Aldosterone antagonist(spirinolactone) angiotensin IIreceptorblockers(candesartan) If thepatientisawakeandcantakeoralmedication,consider Consider digoxin0.125–0.25mgIV then 50mcg/kg/mintoamaximumof300mcg/kg/min) Consider beta-blockers(esmolol500mcg/kgover1minute, a maximumof0.03mcg/kg/min) Consider nesiritide(2mcg/kgIVbolus,then0.01mcg/kg/minto increase every3–5minutestodesiredeffect) Consider nitroglycerine(infusionstartingat0.5mcg/kg/min, Consider anACEinhibitor(enalapril2.5mgIVevery6hours) Administer aloopdiuretic(furosemide20–40mgIV) Increase FiO Valvular heartdisease Obesity Hypertension Smoking Coronary arterydisease

2 tomaintainoxygenation. cation

• • • • • DIFFERENTIALDIAGNOSIS tation andfibrosis aretheprimarychangesobserved. hypertension, hyperthyroidism,andmyocardialischemia.Atrialdila- hearts. Itisalsoassociatedwithexcessivealcoholconsumption, Atrialfi brillation isoftenseeninpatientswithotherwisenormal Pathophysiology • • • • • • Presentation ECG. Thisisthemostcommoncardiacarrhythmia. AnirregularlyirregularheartrhythmwiththeabsenceofPwaveson Defi Hunt, SA,etal.2009focusedupdateincorporatedintotheACC/AHA2005 FurtherReading of heartfunctionbypreventingfurtherdilationtheventricles. cardiac resynchronizationtherapyviabiventricularpacing. arrhythmias associatedwithheartfailure,andmayalsobeusedfor Implantablecardiacdefi brillators areusedtodetectandtreat SpecialConsiderations

Dysrhythmias:AtrialFibrillationD Coll Cardiol. with theInternationalsoScietyforHeartandLungTransplantation. Association TaskForceonPracticeGuidelines,developedincollaboration report oftheAmericanCollegeCardiologyFoundation/AmericanHeart guidelines forthediagnosisandmanagementofheartfailureinadults:A Transient ischemicattacks Syncope Congestive heartfailure Chest pain/angina Palpitations May beasymptomatic Atrial ﬂ Junctional tachycardia Reentrant tachycardia Multifocal atrialtachycardia Sinus tachycardia Cardiacwrapshavebeenusedtopreventfurtherdeterioration ysrhythm nition utter

2009;53(15):e1–e90.

i as: Atr

al F

br i llat i on

J Am 33 CHAPTER 2 Cardiavascular Emergencies 34 CHAPTER 2 Cardiovascular Emergencies Anticoagulationwithheparinandwarfarin RiskControl(Stroke) • Prevention • • • • RhythmControl SubsequentManagement • • • • DiagnosticStudies

• • • • • • • • • RiskFactors • • • • (RateControl) • ImmediateManagement

Avoid acutebeta-blocker discontinuationperioperatively. Surgical ablation Electrophysiology andcryoablation Amiodarone inresistantcases Cardioversion (electricalorchemical) Holter monitoring Echocardiogram Electrophysiology study ECG 1 minute,then50mcg/kg/mintoamaximumof300mcg/kg/min) Administer betablockingdrugs(esmolol500mcg/kgover Digoxin 0.125–0.25mcgIV hypotension whenadministeringabolusdose. IV for6hours,then0.5mg/min18hours.) Amiodarone (150mgIVover10minutes,then1mg/min Calcium channelblockers(diltiazem) DC cardioversionifthepatientishemodynamicallyunstable Stress Coronary arterydisease Alcohol consumption Smoking Male >Female Hyperthyroidism Atrial dilatation Recent cardiothoracicsurgery(particularlyvalvularsurgery) Age (8%ofpeopleover80)

Be alertfor

NationalInstituteforHealthandClinicalExcellence.Guidelines EchahidiN.Mechanisms,prevention,andtreatmentofatrialﬁ

• • • • DIFFERENTIALDIAGNOSIS dia. Theabovepresentationsaresuggestive oforganmalperfusion. hypoxemia, acidosis,ordrugs(e.g., narcotics,beta-blockers) Maybesecondarytocardiacischemia,atrioventricularnodedisease, Pathophysiology • • • • • Presentation Aheartratelessthan60beatsperminute. Deﬁ AmericanHeartAssociation.Guidelinesforcardiopulmonaryresuscitation FurtherReading • • SpecialConsiderations • •

Dysrhythmias:Bradycardia Dysrhythm CG036niceguideline.pdf atrial fi brillation. Availableat: cardiac surgery. bradycardia andtachycardia. and emergencycardiovascularcare.Part7.3:Managementofsymptomatic Chest pain Pulmonary edema Altered mentalstatus Nausea Hypotension thrombus. transesophageal echocardiogram(TEE)showsnoevidenceof atrial fibrillation withinlessthan48hoursofonset,orifa Cardioversion shouldonlybeperformedfornew-onset Atrial fibrillation increasestheriskofstrokesevenfold. Reduce stress. magnesium). Maintain normalelectrolytes(particularlypotassiumand Hypersensitivity of carotidsinus High dosenarcotic administration Excessive vagalstimulation Excessive betaorcalciumchannelblocker therapy Asicksinusnodeorconductionabnormalities maycausebradycar- nition

J AmCollCardiol. i as:

. AccessedAugust9,2009.

radycard

Circulation.

2008;51:793–801. http://www.nice.org.uk/nicemedia/pdf/

2005;112:IV-67–IV-77). i a

brillation after brillation

35 CHAPTER 2 Cardiavascular Emergencies 36 CHAPTER 2 Cardiovascular Emergencies

• • • SubsequentManagement • • • DiagnosticStudies • • • • • •

• • • • • • • • • • • • RiskFactors • • • ImmediateManagement

Electrolyte abnormalities Cardiac tamponade Acidosis Hypoxia Elevated systemicvascularresistance Excessive intraocularpressure Permanent pacemakerplacement micrograms/kg/min) infusion Epinephrine (2–10micrograms/min)ordopamine Transvenous pacingiftranscutaneousfailstocapture Angiogram (ruleoutacutemyocardialinfarctionascause) Echocardiogram ECG narcotics) Pharmacologic (beta-blockers,calciumchannelblockers, repeat every5minutestoatotaldoseof3mg). Administer atropinewhilepreparingforpacing(0.5mgIV, tissue hypoperfusion. Initiate immediatetranscutaneouspacingifthereisevidenceof the surgeonstoreduceintra-abdominalpressure.) Remove possiblecauses.(E.g.,duringlaparoscopicsurgery,ask Psychological stress oranxiety Use ofrecreational drugs Heavy alcoholconsumption Smoking Elevated cholesterol Elevated bloodpressure Age Laparoscopic surgery Surgery nearcarotidsinus(e.g.,endarterectomy) Ocular surgery Alpha-agonists

• • DIFFERENTIALDIAGNOSIS due toareentryphenomenon. QRS complextachycardiaismost commonlysinustachycardia,or originates withinorabovetheAV node (supraventricular).Narrow via thenormalHis-Purkinjesystem. Thissuggeststhatthearrhythmia AnarrowQRScompleximpliesa rapid activationoftheventricles Pathophysiology • • • • • Presentation a narrowQRScomplex(<120msec) Heartrate>100beatsperminute(mayberegularorirregular)with Deﬁ AmericanHeartAssociation.Guidelinesforcardiopulmonaryresuscitation FurtherReading can beusedifbradycardiaisattributedtobeta-blockertherapy. the bundleofHis.Glucagon3mgIVfollowedbyaninfusionatmg/h tive inhearttransplantpatientsorforbradycardiaduetoablockbelow Atropineworksattheatrioventricularnodeandisunlikelytobeeffec- SpecialConsiderations • • • • Prevention

Tachycardia T Dysrhythmias:NarrowComplexD bradycardia andtachycardia. and emergencycardiovascularcare.Part7.3:Managementofsymptomatic Pulmonary edema Chest pain Altered mentalstatus Palpitations Hypotension Exercise cautioususeofalpha-agonistagents. Release intraocularorintra-abdominalpressure. endarterectomy. Inject thecarotidsinuswithlidocaineduring Maintain normalplasmaelectrolytelevels. Atrial tachycardia Sinus tachycardia achycard ysr nition h y t

hmias: Narrow i a

Circulation.

C 2005;112:IV-67–IV-77). omplex

37 CHAPTER 2 Cardiavascular Emergencies 38 CHAPTER 2 Cardiovascular Emergencies

• • • SubsequentManagement • • • DiagnosticStudies • • • • •

• • • • • • RiskFactors • • • • • ImmediateManagement

Atrial ﬂ Atrial ﬁ Junctional tachycardia Reentrant tachycardia(e.g.,Wolff-Parkinson-Whitesyndrome) Multifocal atrialtachycardia hemodynamically unstable. pharmacological interventionsand/orinpatientswhoare Use electricalcardioversionfortachycardiaresistantto 15 minutes). up toadoseof18–20mg/kg)oramiodarone(5mg/kgIVover Chemical cardioversion:Administerprocainamide(50mg/minIV, calcium-channel blockersorbeta-blockers. If adenosinefails,initiateratecontrolwitheitherintravenous Echocardiography Electrophysiology testing ECG cardioversion. Treat unstablearrhythmiaswithimmediateelectrical Consider DCcardioversionifhemodynamicallyunstable. (5 mgIVq5minutes). rate withdiltiazem(15mgIVover20minutes)ormetoprolol Stable, irregular,narrowcomplextachycardias:controlheart cause (fever,anemia,shock,sepsis,pain,etc.). Stable regularnarrowcomplextachycardia:treatforunderlying Administer adenosine(6mgrapidIVpush,repeat12×2). Vagolytic drugs Hyperthyroid Myocardial ischemia Hypovolemia Inadequate anesthesia Fever brillation utter

• • • Regular DIFFERENTIALDIAGNOSIS wide complextachycardiaismostoften ventriculartachycardia. tion system,butmaybeventricular orsupraventricular.Aregular, Commonly thearrhythmiaoriginates outsideofthenormalconduc- AwidenedQRScompleximpliesslowventricularactivation. PulmonaryEdemaPathophysiology • • • • Presentation irregular) withawideQRScomplex(>120msec) Heartrategreaterthan100beatsperminute(mayberegularor Deﬁ AmericanHeartAssociation.Guidelinesforcardiopulmonaryresuscitation FurtherReading • • • • SpecialConsiderations • • • • Prevention

Dysrhythmias:WideComplexTachycardiaD bradycardia andtachycardia. and emergencycardiovascularcare.Part7.3:Managementofsymptomatic Chest pain Palpitations Altered mentalstatus Hypotension Consider theriskofembolicstrokebeforecardioversion. adenosine administration. Transient chestdiscomfort,dyspnea,andflushing mayoccurwith fi Irregular narrowcomplextachycardiamaybeatrialfl tachycardia. Regular narrowcomplextachycardiaismostoftensinus Avoid vagolyticdrugs(e.g.,atropine,pancuronium). Avoid beta-blockerdiscontinuationperioperatively. Volume resuscitation. Maintain normothermia. Artifact Supraventricular tachycardia withaberrantconduction Ventricular tachycardia brillation, ormultifocalatrialtachycardia. y nition s r h y thmias: WideCom

Circulation.

2005;112:IV-67–IV-77). p lex Tach

utter, atrial cardia

39 CHAPTER 2 Cardiavascular Emergencies 40 CHAPTER 2 Cardiovascular Emergencies

• • SubsequentManagement • • • DiagnosticStudies • • • Irregular •

• • • RiskFactors

• • IrregularRhythm • RegularRhythm • ImmediateManagement

Polymorphic ventriculartachycardia syndrome) Atrial fibrillation withpreexcitation(e.g.,Wolff-Parkinson-White Atrial fibrillation withaberrancy(bundlebranchblock), paced) Paced rhythmwithatrialtachycardia(atrialsense,ventricular (20 ECG (e.g.,deltawave),procainamideisthepreferredtreatment Parkinson-White syndrome),orevidenceofpreexcitationonthe If thepatienthasahistoryofpreexcitationsyndrome(e.g.,Wolff- pharmacological intervention,orifhemodynamicallyunstable. Cardioversion forregulartachycardiaresistantto Electrophysiology testing Echocardiogram ECG a maximum dose of 17 mg/kg is administered). a maximumdoseof17mg/kgisadministered). the patientishypotensive,QRSwidens 50%beyondbaseline,or Known reentrant pathway Myocardial ischemia (oroldinfarction) Age >50 needed tototalof3mg/kg) Lidocaine (1mg/kgIV,mayrepeat0.5every5minutesas Procainamide (20mg/minIVuptoatotalof17mg/kg) needed toatotalof2.2gIVoverthefirst 24hours) Amiodarone (150mgIVgivenover10minutes,repeatedas DC cardioversionifhemodynamicallyunstable mg/min

continuous infusion until the arrhythmia is suppressed, continuous infusionuntilthearrhythmiaissuppressed,

• • DIFFERENTIALDIAGNOSIS hypertension. Anything thatincreasespreload,afterload, orcontractilitycancause Thepathophysiologyofhypertension isoftenmultifactorial. Pathophysiology • • • • • Presentation Abloodpressuregreaterthan160/100onaseriesofmeasurements. Deﬁ AmericanHeartAssociation.Guidelinesforcardiopulmonaryresuscitation FurtherReading precipitate ventricularﬁbrillation anddeath. tachycardias, especiallywhentheetiologyisunknown,astheymay AVnodalblockersarecontraindicatedinwidecomplex,irregular SpecialConsiderations • • • • • • Prevention

H Hypertension bradycardia andtachycardia. and emergencycardiovascularcare.Part7.3:Managementofsymptomatic Maintain normal electrolytes (particularly potassium and magnesium). Maintain normalelectrolytes(particularlypotassiumandmagnesium). Palpitations Headache Chest pain ﬁ converting tounstableventriculartachycardiaor of irregularwidecomplexdysrhythmiaduetopreexcitation Although amiodaroneisanalternativetreatment,beware inhibition (VVI)oratrial-paced,atrial-sensing,(AAI) Change pacemakertoventricular-paced,ventricular-sensing, Consider Implantablecardiacdeﬁ catheter ablation. Request aninterventionalcardiologyconsultationtoperforma Prescribe anti-arrhythmic(ClassIandIII)drugs. Agitation Inadequate anesthetic depth Pulmonary edema Stroke brillation withtheuseofamiodarone. y nition p ertension

Circulation.

brillator (ICD).

2005;112:IV-67–IV-77).

41 CHAPTER 2 Cardiavascular Emergencies 42 CHAPTER 2 Cardiovascular Emergencies

• • • • SubsequentManagement • • • • DiagnosticStudies • • • • • • • •

• • • • • RiskFactors • • • • • ImmediateManagement

Post electroconvulsivetherapy Eclampsia inpregnancy Transection ofthespinalcordatoraboveT5 Elevated intracranialpressure Aortic crossclamp Thyrotoxicosis Pheochromocytoma Vasopressor error(inadvertentadministrationoroverdose) Anxiolytics Clonidine Hydralazine ACEinhibitorsorangiotensinreceptorblockers Long-acting beta-blockers Intra-arterial catheterization Angiogram Echocardiogram ECG properties) preferred becauseithasbothalpha-andbeta-blocking Administer beta-blockers(labetolol5mgq2minutesis Maximum doseis10mcg/kg/min. hypertension: Startat0.3mcg/kg/minandincreaseslowly. Administer sodiumnitroprussideforacute,life-threatening 2.5 mg/hevery5–15minutes.Maximumdoseis15mg/h. Administer nicardipine:Startat5mg/hIVandincreaseby Check formedicationerror Increase depthofanesthesia Stress Weight Race Male >Female Age >60

VaronJ.Thediagnosisandtreatmentofhypertensivecrisis.

• • • nitions include: Therearenouniversallyacceptedcriteria. Commonlyaccepteddefi Defi LaslettL.Hypertension:Preoperativeassessmentandperioperativemanage- FurtherReading venous PaO and developunexplainedmetabolicacidosisand/orincreasedmixed toxicity. Considercyanidetoxicityinpatientswhobecomeconfused kg/min resultinaccumulationofcyanideandcanleadto duce widevariationsinbloodpressure.Infusionratesabove2mcg/ autoregulation curveinpatientswithchronichypertension. more than20–30%ofbaselinetocompensateforarightshiftthe Hg mustbetreatedpromptly. but systolicpressure>220mmHganddiastolic120 AnacuteriseinBPisofmoresignifi cance thantheactualnumbers, SpecialConsiderations • • Prevention

• • • • • • RiskFactors(continued)

H Hypotension

2009;121:5–13. ment. Avoid rapidterminationofantihypertensivemedications. Maintain adequatedepthofanesthesia. Decline ofSBPor MAPby20%frombaseline Mean arterialpressure lessthan60mmHg Systolic BP<80mmHg Sodiumnitroprussideisveryrapidinonsetandoffsetcanpro- Preexistingelevatedbloodpressureshouldbedecreasedbyno Sleep apnea Diabetes Renal disease Family history Smoking Alcohol ypot nition West JMed. ens

2 .Tachyphylaxismayalsooccur.

1995;162:215–219. n

Postgrad Med.

- 43 CHAPTER 2 Cardiavascular Emergencies 44 CHAPTER 2 Cardiovascular Emergencies

• • • SubsequentManagement • • • • DiagnosticStudies • • • • • • • • DIFFERENTIALDIAGNOSIS heart rate,preload,afterload,orcontractilitycancausehypotension. Thepathophysiologyisoftenmultifactorial.Anythingthatdecreases Pathophysiology • • • • • Presentation

• • • • • • ImmediateManagement

Oliguria Altered mentalstatus Nausea Shortness ofbreath Chest pain insufﬁ Administer acorticosteroid (hydrocortisone100mg IV)ifadrenal hypotension (recommended rateis0.01–0.04units/min). Consider vasopressin infusionforcatecholamine-resistant known. Establish adifferentialdiagnosisand treattheunderlyingcauseif Intra-arterial catheterization Angiogram Echocardiogram ECG Anaphylaxis Endocrine dysfunction Acute heartfailure Pnuemothorax Pericardial tamponade Spinal/epidural anesthesia Hypovolemia Deep anesthesia refractory hypotension. vasopressor (e.g.,phenylephrine)oraninotropeincasesof Depending onsuspectedetiology,considerinfusionofa Administer epinephrine. Administer phenylephrine(100mcgIVbolus). Administer ephedrine(5mgIVbolus). Check formedicationerror. Administer IVﬂ ciency issuspected.

uid.

vascular system. vascular accessto air,andapressuregradientbetween airandthe Twocomponents mustbepresentforagasembolism tooccur: Pathophysiology • • • • • Presentation of thebloodstream. Gas(air)bubblesinthevascularsystemthatdisruptcontinuity Deﬁ medications. citation andemergencycardiovascularcare.Part7.4:monitoring AmericanHeartAssociation.Guidelinesforcardiopulmonaryresus- FurtherReading narrow thetherapeuticoptionsandimprovepatientoutcome. Hypotensionhasmanyetiologies.Rapiddifferentialdiagnosiscan SpecialConsiderations • • • Prevention

• • • • • • RiskFactors

GasEmbolism

vancomycin) slowly. Administer vasodilatingmedications(e.g.,phenytoin,protamine, neuraxial blockade. Monitor thelevelofanesthesiainpatientswhohaveundergone preoperative andintraoperativeﬂuid lossandthird-spacing. Provide adequatevolumeresuscitationaccountingfor Tachycardia Tachypnea Hypotension Dyspnea Minor gasembolismisoftenasymptomatic Medications Cardiac disease Neuraxial analgesia Beta-blocker orcalciumchannelblockertherapy Age >65 Dehydration nition Emb

Circulation.

o lism

2005;112:IV-78–IV-83).

45 CHAPTER 2 Cardiavascular Emergencies 46 CHAPTER 2 Cardiovascular Emergencies

is locatedabovethe rightatrium.PEEPdoesnotappear toreducethe central venousaccess. Maintainnormovolemiawhen thesurgicalsite site ofentryandright atriumwhenattemptingtoplace orremovea Tilttheheadofbeddowntoreduce thepressuregradientbetween Prevention • SubsequentManagement • • • DiagnosticStudies • • • • • DIFFERENTIALDIAGNOSIS

• • • RiskFactors • • • • • • • ImmediateManagement

Cardiogenic shock COPD Angina Stroke Acute anemia refractory toothertreatment Consider hyperbarictherapyinthefaceofmassivegasembolism Respiratory alkalosis,decreasedpCO Precordial Dopplerultrasound Echocardiogram Provide supportivecareuntiltheepisoderesolves. Begin CPRifnecessary. possible. Place thepatientleftsidedowninTrendelenburgpositionif available. Remove airfromtherightatriumifacentralvenouscatheris required. Support thebloodpressurewithfluids andvasopressorsas saline solution. Alert thesurgeonsandrequestthatfield befl Increase FiO Disruption ofbloodvesselslocated abovethelevelofheart Craniotomy inthesittingposition Lung barotrauma

to100%ensureadequateoxytenation.

2 ,hypoxia

ooded with

• • • DIFFERENTIALDIAGNOSIS coronary perfusionpressure. nary spasms),adecreaseinoxygencarryingcapacity,ordiminished obstruction fromplaqueand/orthrombus,orphysiologiccoro- This deﬁ ciency maybeduetocoronaryobstruction(physical Aninabilitytosupplyenoughoxygenmeetmyocardialdemands. Pathophysiology • • • • Presentation Oxygensupplyinadequatetomeetmyocardialdemand. Deﬁ MirskiM,etal.Diagnosisandtreatmentofvascularairembolism. FurtherReading systemic arterialcirculation. are usuallytrappedinthelungs)becausebubblescanmigrateto which cancomplicateavenousgasembolism(inthebubbles 20–30%ofthepopulationhasanasymptomaticpatentforamenovale, SpecialConsiderations Avoid nitrousoxideinpatientsatriskforgasembolism. risk ofgasembolismandshouldbeusedonlytoimproveoxygenation.

• • • ImmediateManagement

MyocardialIschemiaM

only ﬁndings in an anesthetizedpatient. Dysrhythmias, STsegmentchanges,orhypotensionmaybethe emotional Usually associatedwithincreaseinactivity,eitherphysicalor Radiates toeitherarm,neck,jaw,backorabdomen awake patient) Chest pain,pressureortightness,oftenbehindthesternum(inan Thoracic (boneandcartilage)orpleuritic pain Myopathic pain Heartburn/dyspepsia 2007;106(1):164–77. increase astolerated untilECGchangesorsymptoms reverse) Begin anitroglycerine infusion(startat0.5mcg/kg/min and Administer paincontrol (IVmorphine)ifthepatient is awake. Increase FiO y nition ocard

i al Ischemia 2 to100%.

Anesthesiology.

47 CHAPTER 2 Cardiavascular Emergencies 48 CHAPTER 2 Cardiovascular Emergencies cs,orcoronaryartery vasoconstriction.Therole of preoperative result fromcatecholamines, inﬂ ammation, altered hemodynami- Perioperativemyocardial ischemiaismultifactorial, andmay Prevention • • • • SubsequentManagement • • • DiagnosticStudies

• • • • • • • • RiskFactors (continued) Immediate Management

• • • • •

clopidogrel toreducemortality. Long-term careshouldincludeantiplatelettherapywith surgery topreservemyocardium. Prepare foremergencycoronaryarterybypassgrafting(CABG) intra-aortic balloonpump) Initiate percutaneouscardiopulmonarysupport(pacemaker, angioplasty and/orstents) Initiate primarypercutaneouscoronaryintervention(coronary Coronary arteryangiogram. Echocardiogram ECG Age >50 Drug use(cocaine) Family history Smoking Hyperlipidemia Diabetes mellitus Hypertension Male >Female myocardial infarction) if the surgical procedure permits. myocardial infarction)ifthesurgicalprocedurepermits. Heparin orLMWH(1mg/kgevery12hoursfornonST-elevation Manage dysrhythmiasaggressively permits). Theﬁrst doseis300mgbymouth Consider clopidogrel(ifawakeandthesurgicalprocedure are nocontraindications. Administer aspirin325mgPOifthepatientisawakeandthere (1–2 mg/IVq5min) Control heartratewithesmolol(50mcg/kg/min)ormetoprolol

• • • DIFFERENTIALDIAGNOSIS sure causinggeneralizedbleeding,arealsocontributory. hemostasis resultinginsuturelinebleeds,andelevatedbloodpres- agulation therapy,resultinginchestwallbleeding.Inadequatesurgical Coagulopathyaftercardiothoracicsurgerymaybearesultofantico- Pathophysiology • • Presentation hours) Excessivepostoperativebleeding(>300mL/hinthefirst fewpost-op Defi AmericanHeartAssociation.Guidelinesforcardiopulmonaryresuscitation FurtherReading those whoproceedtoCABGduringtheinitialhospitalization. is recommendedasanearlyintervention(onadmission)evenfor has beenidentified asasignifi cant predictorofmortality. unclear foracuteMI,cardiogenicshockpriortoCABGintervention to leftmaincoronary)approximates9%. MortalityforemergencyCABGacutecoronarysyndrome(due SpecialConsiderations cation andearlyinterventioninat-riskpatients. revascularization iscontroversial.Preventionfocusesonriskstratifi

• • ImmediateManagement

PostoperativeHemorrhagePosto

acute coronarysyndromes. and emergencycardiovascularcare.Part8:Stabilizationofthepatientwith Hemodynamic instability Increased outputfromchesttubesorotherdrains Pericardial tamponade Cardiac dysfunction Hypovolemia DespiteconcernsofexcessivebleedingduringCABG,clopidogrel AlthoughoutcomesofemergencyCABGinterventionremain blood products. Maintain normovolemia withcrystalloids,colloidsolutions, and the ﬁrst fewhours. Consider reoperationifbleedingis greaterthan300mL/hover nition p erati

e Hemorrha

Circulation.

2005;112:IV-89–IV-110). g e

- 49 CHAPTER 2 Cardiavascular Emergencies 50 CHAPTER 2 Cardiovascular Emergencies

DespotisG,etal.Prediction andmanagementofbleeding in cardiacsurgery. FurtherReading instability. thetic managementinpatientswith hypovolemiaandhemodynamic sions. Considerscopalamine,midazolam andketamineforanes- and replacecalciumavoidhypothermia bywarmingallinfu- cardiac tamponade.Ifpatientrequiresmassivetransfusion,check carefully examinedforclots.Occludedchesttubescanresultin Ifchesttubeoutputdecreasessuddenly,tubesshouldbe SpecialConsiderations • • • Prevention • • SubsequentManagement • • DiagnosticStudies

meit aaeet (continued) Immediate Management • • • • RiskFactors

• • •

JThrombHaemost Coagulation studies Adjuncts likefibrin glueatspecifi c surgicalsitescanbeuseful. activated clottingtime(ACT)ismandatory. Adequate reversalofheparin(withprotamine)confi Adequate surgicalhemostasisisthebestprevention. Antifi Blood componenttherapy Temperature

Hypothermia Coagulopathies Inadequate surgicalhemostasis Elevated bloodpressure Fluid resuscitation Maintain normothermia. necessary tocorrectcoagulopathy. Administer freshfrozenplasmaandcryoprecipitateas brinolytic therapy

2009;7Suppl1:111–117.

rmed with

• • • DiagnosticStudies • • • • DIFFERENTIALDIAGNOSIS to pulmonaryedema. ing worseningdilationandhypertrophyoftheLVeventuallyleading end diastolicpressure(LVEDP).LVEDPgraduallyincreases,indicat- minimal symptoms,asitapproaches60%thereisanincreaseinLV umes. Aregurgitantfractionoflessthan40%iswelltoleratedwith Aorticinsuffi ciency leadstoincreasedLVsystolicanddiastolic vol- Pathophysiology • • • • Presentation resulting inretrogradefl ow intotheleftventricle duringdiastole. Abnormalitiesintheleafl Defi

• • • • • ImmediateManagement

ValvularDisease:AorticRegurgitation

Congestive heartfailure Coronary arterydisease Pulmonary edema Other causesofdiastolicmurmurs(e.g.,mitralstenosis) Angina Palpitations Fatigue Dyspnea Angiogram Echocardiogram ECG Increase heartrate(goal90)tominimize diastolictime Administer ﬂuid tomaintainpreload. start at5mg/hr) Consider vasodilatoradministration(e.g.,nicardipineinfusion, forward ﬂ Mildly vasodilatethepatienttominimizeafterloadandpromote Avoid anesthetic induction with ketamine (may increase afterload). Avoid anestheticinductionwithketamine(mayincreaseafterload). nition

ow.

ets or supporting structures of the aortic valve ets orsupportingstructuresoftheaorticvalve

g ur g itation

51 CHAPTER 2 Cardiavascular Emergencies 52 CHAPTER 2 Cardiovascular Emergencies

insuffi Intra-aorticballoonpumpiscontraindicatedinthepatientwithaortic Backwardfl Forwardflow = cardiacoutput Totalflow =(end diastolicvol.–endsystolicvol.)×HR Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated BonowRO,CarabelloBA,ChatterjeeK,et al.2008focusedupdateincorporated FurtherReading Regurgitantfractioniscalculatedasfollows: SpecialConsiderations Earlydetectionandmedicalmanagementofsymptoms Prevention • • • • SubsequentManagement FrogelJ,GaluscaD. Anesthetic considerationsforpatientswith advancedval-

• • • • • • RiskFactors

Thoracic Surgeons. Society forCardiovascularAngiography andInterventions,Societyof heart disease).EndorsedbytheSocietyof CardiovascularAnesthesiologists, to revisethe1998guidelinesformanagement ofpatientswithvalvular Heart AssociationTaskForceonPractice Guidelines(WritingCommittee vular heartdisease:areportoftheAmerican CollegeofCardiology/American into theACC/AHA2006guidelinesfor managementofpatientswithval- Mar;28(1):67–85. vular heartdisease undergoing noncardiacsurgery. Refer thepatientforvalverepairorreplacement. severe aorticinsufficiency anddecompensatedCHF. Consider pulmonaryarterycatheterplacementinthesettingof are anticipated. Consider centralvenouscathetherplacementifmajorfl Decrease afterloadwithvasodilators(e.g.,nicardipine5mg/hr) Bicuspid aorticvalve Aortic dissection Trauma Cystic medionecrosis Bacterial endocarditis Marfan syndrome Regurgitant FractionRegurgitant = ciency. ow =(totalfl ow –forwardfl

J AmCollCardiol

Backward flow

Total Flow

. 2008 Sep 23;52(13):e1–e142. . 2008Sep23;52(13):e1–e142. ow)

Anesthesiol Clin

uid shifts

. 2010;

severe (0.6–0.9cm

• • • DiagnosticStudies • • • • DIFFERENTIALDIAGNOSIS ops andincreasestheriskofsuddendeath. increasing workloadfortheLV.Pulmonaryedemaeventuallydevel- and LVhypertrophyfurtherincreasesenddiastolicvolume,thus LV enddiastolicpressureiscompensatory.Progressionofdilation and highLVsystolicpressuretoovercomestenosis.Anincreasein cases) followedbyrheumaticfeverandseniledegeneration. Acongenitalbicuspidvalveisthemajorpredisposingfactor(>75%of Pathophysiology • • • Presentation valvular, orsuprvalvularlevel.Normalvalvearea2.6–3.5cm Narrowing oftheaorticopening.Maybeeitheratvalvular,sub- Deﬁ stenosis isgradedasmild(1.5–2.5cm

• • • • • • ImmediateManagement

ValvularDisease:AorticStenosisV

Systolic Murmurs(mitralregurgitation) Congestive heartfailure Coronary arterydisease Pulmonary Hypertension Dyspnea Syncope Angina Chest radiograph Echocardiogram ECG Mildaorticstenosisiscompensatedbyventricularhypertrophy supraventricular dysrhythmias Preserve sinusrhythm—immediate cardioversionfor Decrease heartrate(goal50–70) and maintainafterload. If necessary,beginaphenylephrineinfusiontoaugmentpreload Avoid drugsthatdecreasesystemicvascularresistance. Maintain normovolemia. Treat hypotensionimmediatelywithavasoconstrictor. alvul nition a

r Disease:Aortic 2 ),orcritical(<0.6cm

S tenosis 2 ),moderate(1.0–1.4cm

2 ).

2 .Aortic 2 ), 53 CHAPTER 2 Cardiavascular Emergencies 54 CHAPTER 2 Cardiovascular Emergencies FrogelJ,GaluscaD.Anestheticconsiderations forpatientswithadvancedval-

BonowRO,CarabelloBA,ChatterjeeK,etal.2008focusedupdateincor- FurtherReading • • SpecialConsiderations Earlydetectionandmedicalmanagementofsymptoms Prevention • • • • RiskFactors • • • • SubsequentManagement

Mar;28(1):67–85. vular heartdisease undergoing noncardiacsurgery. to ischemia. ECG signsofleftventricularhypertrophymaymaskchangesdue ischemia. Myocardialischemiamaybedifficult todetectbecause Myocardial hypertrophyisariskfactorforsubendocardial Sep 23;52(13):e1–142. and Interventions,SocietyofThoracic Surgeons. Cardiovascular Anesthesiologists,Society forCardiovascularAngiography ment ofpatientswithvalvularheartdisease). EndorsedbytheSocietyof (Writing Committeetorevisethe 1998 guidelinesforthemanage- Cardiology/American HeartAssociation TaskForceonPracticeGuidelines patients withvalvularheartdisease:areportoftheAmericanCollege porated intotheACC/AHA2006guidelinesformanagementof hypertrophic subaorticstenosis(whichisadynamicstenosis). state, butitmaybebeneficial inapatientwithidiopathic stenosis, asitdecreasesthenecessaryheightenedcontractile Long-term betablockadeisusuallynotwelltoleratedinaortic hypertrophied myocardium. to maintainadiastolicpressurehighenoughperfusethe maintain systemicvascularresistance(SVR).SVRisimportant Administer alpha-adrenergicagents(e.g.,phenylephrine)tohelp resists forwardfl Afterload reductionisnothelpfulbecausethestenoticvalvestill risk forsuddendeath. LV dysfunction(CHF)withaorticstenosisisassociatedhigh Male >female Age >70 Rheumatic Fever Bicuspid Valve TEE forintraoperativemonitoring

ow.

J AmCollCardiol Anesthesiol Clin . 2010; . 2008

• • • DIFFERENTIALDIAGNOSIS • • • • Pathophysiology • • • Presentation • • • • Deﬁ

• • • • Toensureforwardﬂ ImmediateManagement

ValvularDisease:MitralRegurgitationValvula

acute-onset MR. Myocardial infarctionwithpapillarymuscledysfunctionpresentsas The mostcommoncauseofMRismitralvalveprolapse. Myocardial ischemia Primary pulmonaryhypertension heart failureensues. to 60%thehypertrophicanddilatedLVfailscompensate, absence ofsymptoms.Whentheregurgitantfractionincreases and normalpressurestothepulmonarycircuit;hence,relative hypertrophy andleftatrialdilationthatmaintainsforwardﬂ Chronic slow-onsetMRcausescompensatoryleftventricular oxygen consumption. tachycardia maintainscardiacoutputattheexpenseofincreased that aretransmittedtothepulmonarycircuit.Compensatory Acute MRleadstoincreasedleftatrialvolumesandpressures or secondaryduetoLVdilation. Mitral regurgitation(MR)canbeprimaryduetoadefectivevalve Orthopnea Dypnea Fatigue Severe MR:Regurgitantfraction>60% Moderate MR:Regurgitantfraction30–60% Mild MR:Regurgitantfraction<30% Cardiomyopathy systole. Regurgitant fraction = regurgitant volume/LV stroke volume systole. Regurgitantfraction=regurgitantvolume/LVstrokevolume Blood ﬂ owing fromtheleftventriclebackintoatriumduring (hypoxia, hypercapnia, acidosis) Avoid furtherincreases inpulmonaryvascularresistance Decrease afterload Avoid bradycardia(increasesLVand regurgitantvolume) Maintain preloadwithvolumeresuscitation nition

r Di sease:

ow:

t ral Re

g ur

itation

55 CHAPTER 2 Cardiavascular Emergencies 56 CHAPTER 2 Cardiovascular Emergencies FrogelJ,GaluscaD.Anestheticconsiderationsforpatientswithadvancedval-

• • • • Deﬁ BonowRO,CarabelloBA,ChatterjeeK,etal.2008focusedupdateincor- FurtherReading Atrialﬁbrillation isseeninabout75%ofcasesMR. SpecialConsiderations hence earlyinterventionisnecessary. OnceLVdysfunctionhasbecomeestablished,itmaybeirreversible; Prevention • • • SubsequentManagement • • DiagnosticStudies

• • • RiskFactors

ValvularDisease:Mitral Stenosis Valvula

Mar;28(1):67–85. vular heartdiseaseundergoingnoncardiacsurgery. Sep 23;52(13):e1–142. and Interventions,SocietyofThoracicSurgeons. Cardiovascular Anesthesiologists,SocietyforAngiography of patientswithvalvularheartdisease).EndorsedbytheSociety (Writing Committeetorevisethe1998guidelinesformanagement Cardiology/American HeartAssociationTaskForceonPracticeGuidelines patients withvalvularheartdisease:areportoftheAmericanCollege porated intotheACC/AHA2006guidelinesformanagementof Surgical intervention Consider prostaglandinE1(alprostadil) Nitric oxideisapulmonaryvasodilator Giant Vwaveonpulmonaryarteryocclusionpressuretracing Echocardiogram Incompatible with life<0.3cm Critical <1cm Symptomatic at1.5–2.5 cm Normal Valvearea4–6cm Bacterial endocarditis Myocardial ischemiawithpapillarymuscledysfunction Mitral valveprolapse nition

r Disease:MitralStenosis

2 2 (ValveIndex4–4.5cm (ValveIndex1–2 cm

Anesthesiol Clin J AmCollCardiol

2 /m 2 /m 2 ) 2 )

. 2010; . 2008

• • • SubsequentManagement • • DiagnosticStudies • • • DIFFERENTIALDIAGNOSIS septum towardtheLV,decreasingLVvolumes. RV furthercompromiseLVfunctionbyshiftingtheinterventricular tance andrightventriclepressure.Hypertrophydilationofthe Progression ofstenosisgraduallyincreasespulmonaryvascularresis- stenosis isnotusuallytransmittedtothepulmonarycirculation. atic. Theincreasedﬁ lling pressureintheleftatriumwithmildmitral commissures andprogressivescarring. Usuallysecondarytorheumaticheartdisease,withfusionofvalvular Pathophysiology • • • • • • Presentation

• • • • ImmediateManagement

Myocardial ischemia Other causesofdiastolicmurmurs(e.g.,aorticregurgitation) Primary pulmonaryhypertension Angina Hemoptysis Paroxysmal nocturnaldyspnea Palpitations Fatigue Dyspnea Beta-blockade be necessary. AV pacingwithlong PRintervals(toallowadequate ﬁ mitral valveisthelimitingfactor. Afterload reductionisnothelpful,as theproximalstenosisat Pulmonary arterycatheter—largeA waveonPAtracing Transesophageal echocardiogram(TEE) Milddiseasewithgoodphysiologiccompensationisasymptom- Immediate cardioversiontomaintainsinusrhythm acidosis) pulmonary vascularresistancebyhypoxia,hypercarbia,and Maintain pulmonaryvascularresistance(avoidincreasesin Slow heartrate(maximizetimespentindiastole) Maintain preload(increasescanprecipitatepulmonaryedema)

lling) may

57 CHAPTER 2 Cardiavascular Emergencies 58 CHAPTER 2 Cardiovascular Emergencies

• • • • • Presentation by penetratingblood. Dissectionoftheintimalandmedial layersofthethoracicaorticwall Deﬁ BonowRO,CarabelloBA,ChatterjeeK,etal.2008focusedupdateincorporated FurtherReading • • SpecialConsiderations intervention toavoidirreversibleventriculardysfunction. Earlydetectionandmedicalmanagementofsymptoms,early Prevention • • FrogelJ,GaluscaD.Anestheticconsiderationsforpatientswithadvancedval-

• • RiskFactors

ThoracicAorticDissection Th

Mar;28(1):67–85. Mar;28(1):67–85. Thoracic Surgeons. J AmCollCardiol . 2008Sep 23;52(13):e1–e142. Society forCardiovascularAngiographyandInterventions,of heart disease).EndorsedbytheSocietyofCardiovascularAnesthesiologists, to revisethe1998guidelinesformanagementofpatientswithvalvular Heart AssociationTaskForceonPracticeGuidelines(WritingCommittee vular heartdisease:areportoftheAmericanCollegeCardiology/American into theACC/AHA2006guidelinesformanagementofpatientswithval- vular heartdiseaseundergoingnoncardiacsurgery. Surgical intervention Maintenance ofsinusrhythm Elevated bloodpressure Pericardial tamponade Congestive heart failure withaorticinsufﬁ Back pain(oftendescribedas“ripping”) Chest pain replacement. 30% inﬁve years,theearlymorbidityislowerthanthatofvalve Even thoughmitralcommisurotomyresultsinarestonosisrateof important, andashigh30%ofthestrokevolume. Atrial contributiontotheLVstrokevolumeisextremely Rheumatic fever Female >Male nition o racic A

rtic Dissecti

o n

ciency Anesthesiol Clin

. 2010; . 2010;

• • • • • RiskFactors cal intervention. may manifestasmetabolicacidosis) areallindicationsforacutesurgi- deteriorating kidneyfunctionandgastrointestinalperfusion(which Assessmentoforganfunctionisimportant.Neurologicchanges, SubsequentManagement • • • • DiagnosticStudies • • • • DIFFERENTIALDIAGNOSIS minority ofcaseswithoutintimaltear. 70% ofalldissections.Vasavasorumrupturehasbeenimplicatedina wall aredilated.Tearsintheascendingaortaandaorticarchmakeup intima andmedia,unlikeananeurysmwhereallthreelayersofvessel Bloodmostcommonlypenetratesanintimaltearandseparatesthe Pathophysiology • • •

• • • • ImmediateManagement

Angiogram Transesophageal echocardiogram Chest CT Chest X-ray(mediastinalwidthgreaterthan8cm,) Thoracic outletsyndrome Pancreatitis Cardiogenic shock Acute MI Cardiac ischemia Hemoptysis duetotrachealerosion compression anddirecttracheal Dyspnea andhoarsenessduetorecurrentlaryngealnerve Pregnancy Marfan syndrome andotherconnectivetissuedisorders Male >Female Age >60 Hypertension Surgical correction Transfuse packedredbloodcellsand/orfactorsasnecessary. to maintainHR60–80 Administer betablockers(e.g.,labetaloloranesmololinfusion) Administer vasodilatorstomaintainsystolicBP105–115mmHg

59 CHAPTER 2 Cardiavascular Emergencies 60 CHAPTER 2 Cardiovascular Emergencies SubramanianS,RoselliEE.Thoracicaorticdissection:long-termresultsof

• • • • DIFFERENTIALDIAGNOSIS such ashypoxiaandacidosis. Usuallysecondarytomyocardialischemia orunderlyingconditions Pathophysiology Eitherawitnessedcardiacarrest,ornotedontheECG Presentation coordinated electricalactivity. A nonperfusingrhythmoftheventricleswith disorganized andnon- Deﬁ KohlBA,McGarveyML.Anesthesiaandneurocerebralmonitoringforaortic FurtherReading involved. ascending aorticdissections,astherightsubclavianarterymaybe vessels. ing aortaisinvolved,soastoallowforperfusionofthemajor hemodynamic stabilityisrequired. sequence inductionandslow,controlledtomaintain tion ofdissectionintoheadvesselsandassociatedmentalchanges. the patientisnecessarytobeablemonitorforpropaga- 90%. untreated 2-daymortalityof50%and6-monthashigh Surgicalmortalitygreaterthan30%isconsiderablybetteran SpecialConsiderations AggressiveBPcontrol. Prevention

VentricularFibrillationVe endovascular andopenrepair. dissection. Acidosis Hypoxia Pulmonary embolism Drug toxicity(cocaine,digitalis,antidepressants) Leftradialarteryispreferredforthearteriallineplacementwith Femoralarterycannulationmayberequirediftheentireascend- Abalancebetweenfull-stomachprecautionsrequiringrapid Judicioususeofpreoperativepainmedicationsoasnottoobtund nition n t r icula Semin ThoracCardiovascSurg.

r F i br

i llat

Semin VascSurg. io n

2005;17(3):236–246. 2009;22(2):61–68.

Earlydetectionof precipitatingunderlyingconditions andtherapy. Prevention • • • • • SubsequentManagement • • • • • DiagnosticStudies • • • •

• • RiskFactors

• • • • ImmediateManagement

repeat toa3mg/kgmax.loadingdose Lidocaine (ifamiodaroneunavailable)1.0–1.5mg/kgIV,may persists) Amiodarone 300mgIV(repeat150in3–5minutesifVF/PVT ACLS secondarysurvey Airway management Echocardiogram Cardiac enzymes Arterial bloodgas Serum electrolytelevels ECG Shivering Hypovolemia Electrolyte abnormalities(hyper/hypokalemia) Cardiac tamponade hypomagnesemia in waterfortorsadesdepointesorsuspected/known Magnesium sulfate1–2gIVdilutedin10mL5%dextrose Advanced diseasestates Cardiac comorbidities vasopressin (one-timedose) Epinephrine 1mgIV(repeatevery3–5minutes)OR40U pausing tocheckrhythmorpulse CPR aftershocktomaintain30:2ratiofor2minuteswithout Endotracheal intubation every 2minutesifnecessary( 360 J*monophasic(200biphasic)cardioversion—mayrepeat before airwaymanagement )

avoid delay—administershocks

61 CHAPTER 2 Cardiavascular Emergencies 62 CHAPTER 2 Cardiovascular Emergencies

AmericanHeartAssociation.Guidelinesforcardiopulmonaryresuscitation FurtherReading cardioversion an escalatingenergytocardiovert.Currentguidelinesrecommend early cardioversion;hence,therecommendationof360Jinstead ACLSguidelineshavebeenupdatedtoemphasizetheimportanceof SpecialConsiderations Circulation and emergencycardiovascularcare.Part7.2:Managementofcardiacarrest. . 2005;112:IV-58–IV-66). before deﬁnitive airwaymanagement.

Chapter 3

Equipment Problems James B. Eisenkraft

Breathing Circuit Malfunction: Low Pressure Condition 64 Electric Power Failure 66 Oxygen Pipeline Failure 69 Ventilator Failure 72

63 64 CHAPTER 3 Equipment Problems • • • • DIFFERENTIALDIAGNOSIS transmitted tothelungsduringinspiration. gas mixtureproducedbythemachine,andthatpositivepressureis Breathingsystemmustbegastighttoensurethatpatientreceives Pathophysiology • Presentation ventilate thepatient’slungs Failuretogenerateorsustainapositivepressurethatissufﬁ Deﬁ • • • • • • • ImmediateManagement

Pressure Condition BreathingCircuitMalfunction:Low

less thanintended,leadingtolowFIO but lungsdonotinfl During bag-assistedventilation,bagemptieseasilywhensqueezed may beobviousorconcealed Breakage of,orleakagefrom,abreathingsystemcomponentthat Breathing systemdisconnectionormisconnection Leak inanesthesiamachinelow-pressuresystem Breathing systemfailspre-usecheckout. • During positivepressureventilationbyventilator: mask airway(LMA)) Leak aroundairwaymanagementdevice(trachealtube,laryngeal During spontaneousventilation,reservoirbagempties;FIO • • • Leak frombronchialtree(e.g.,bronchopleuralfi Properlyset breathingsystemlowpressurealarmis Capnogram isabnormalorabsent(apnea)leadingtoalarm. Spirometry alarmforlowtidalvolume(TV)/minute Ventilatorstanding bellowsfailstofi ll; sinkstobottomof disconnect patient frombreathingsystematY-piece/elbow and If theleakcannot be compensatedforbyincreasing FGF, If theleakissmall,increasefreshgas flow (FGF)to compensate site ofleakandcorrectifpossible. Inspect anesthesiaworkstation/breathing systemforobvious annunciated duringcase. (MV) isannunciated. bellows housing. nition

C C ondition ircuit Mal

ate.

f unction: Low

2 alarm.

stula)

cientto 2 is

Anyconnectioncan becomedisconnectedormisconnected. SpecialConsiderations • Prevention • • • SubsequentManagement • • DiagnosticStudies • •

• • RiskFactors (continued) Immediate Management

• •

including pre-usecheckout. Educate personnelinthecorrectoperation oftheworkstation, Refer toauthorizedservicepersonnel. and/or workstation. If sourceisnotdetermined,replaceanesthesiabreathingsystem If sourceofleakhasbeendetermined,correctifpossible. poorly seatedLMA). difference indicatesleakdistaltoY(e.g.,trachealtubecuffleak; Measure inspiredandexpiredtidalvolumesatY-piece.A airway device),towastegasscavenging. breathing circuitcomponents(includingtrachealtubeorother gas pathwayfrommachinecommonoutlet,throughall point ofleakage,i.e.,bagcircuit,ventilatororboth.Trace manufacturer-recommended pre-usecheckouttoidentifylikely If possible,disconnectpatientfrombreathingsystemandrepeat detection andinterventionwillavoid anadverseoutcome. Use allavailablebreathingsystemmonitors andalarms.Early TVs? Does setventilatorTVagreewithinspiredandexpired Failure tocorrectlyassemblebreathingsystemcomponents by manufacturer Failure toperformpre-usecheckoutproceduresrecommended air. connected toanO ventilate lungswithself-inﬂating resuscitation(e.g.,Ambu)bag patient. Call forhelptorepairtheleakwhilecontinuingcare Maintain anesthesiawithintravenousagents.

sourceifavailable—otherwiseuseroom

65 CHAPTER 3 Equipment Problems 66 CHAPTER 3 Equipment Problems RaphaelDT,WellerRS.Aresponsealgorithmforthelowpressurealarm EisenkraftJB.Hazardsoftheanesthesiadeliverysystem.In:RosenblattMA ASASub-CommitteeonEquipmentandFacilities.Recommendationsfor • Presentation • Deﬁ AdamsAP.Breathingcircuitdisconnections. FurtherReading • • • • • • • •

Electric PowerFailureElectri condition. & Wilkins;2009:37–55. (ed.). 14, 2010). clinical/FINALCheckoutDesignguidelines02-08-2008.pdf pre-anesthesia checkoutprocedures(2008).Availableat: Room lightingfails. within thefacility. failure ofelectricutilitycompanysupplytothefacility,or Failure ofdeliveryelectricalpowertotheOR.Maybedue earthquakes, terrorismact,etc. fail duringaﬁre orduringnaturaldisasterssuchasstorms, when autilitycompanysupplyfailureoccurs.Thisbackupmay Most facilitieshavebackupgeneratorsthatturnonautomatically power supply,UPS. backup powersupplyorareconnectedtoanuninterruptible All wall-poweredelectricaldevicesturnoff,unlesstheyhavea operate, dependingonthemodel. Some orallfunctionsofanelectronicworkstationmayceaseto robotic systems,etc.willfail. Cardiopulmonary bypassmachine, cell saver,electrocautery, Local telephoneandpagingsystems mayshutdown. other computersshutdown. Anesthesia informationmanagement(record-keeping)systemand (NIBP), pulseoximeter,gasmonitoring,capnograph. Physiologic monitoringfails(ECG,noninvasivebloodpressure supply; theseare usually identiﬁed witha red wallplate. and lightsintheOR areenergizedfromtheemergency power may needtopower upand/orbereset.Onlycertain outlets of time.Duringthetransition,computer-based equipment are activated,electricityshouldresume withinashortperiod If failureisinthesupplytofacility andemergencygenerators nition ASA refreshercoursesinanesthesiology

c Anesth Analg.

Power Failure

1988;67:876.

Br JAnaesth. ,Vol.37.Lippincott,Williams 1994;73:46–54. . (AccessedMarch www.asahq.org/

• • DIFFERENTIALDIAGNOSIS

• • • • • • • • • • • • • ImmediateManagement

devices. circuit breaker)causingshutdownofoneormoreelectrical circuits intheOR(e.g.,turnedoffaccidentally,orbyatripped Unannounced constructionworkortofailureofindividual natural disasters,fire, earthquake,constructionwork). demand onutilitycompany,weather-relatedpowerlinefailure, Failure ofsupplyoutsidethefacility(e.g.,excessivepower Phasein EMMA)to monitorCO Consider usingcolorimetric CO BP. Palpatethepulse. Obtain amanualBPcuffandsphygmomanometer tomonitor ventilation Use aprecordialoresophagealstethoscope tomonitor defi ECG canbemonitoredusingthemonitoring modeofa be available. oximetry. Otherwise,individualbatterypoweredmonitorsmay powered transportmonitorforECG,NIBP,capnography,pulse Re-establish patientmonitoring.Ifpossible,obtainabattery procedure ifpossible.Awakenpatientornot? Discuss thesituationwithsurgeon/proceduralist.Abort resuscitation bag. ventilation bybreathingsystemreservoirbag,orself-infl the patient’slungsarebeingventilated.Ifnot,switchtomanual Check thattheanesthesiaworkstationisfunctioningand failure. functioning; otherwisefollowprotocolforoxygenpipeline Check thatoxygenpipelinegassupplyandsuctionare connected toemergencypoweroutletsinOR Ensure thatallessentialelectricallypoweredequipmentis breakers. If anelectricalpanelisintheroom,checkfortrippedcircuit electrocution. Ensure thatpowerlossisnotduetopatientorpersonnel telephone. Call forhelp.IftheORtelephonesystemfails,useacellular light, emergencyflashlights mountedonwallinmostORs) Obtain emergencyportablelighting(fl semi-quantitative CO brillator

2 mainstreamanalyzer (e.g.,Statcap,

2 2

detectororbattery powered ashlight, laryngoscope

ating

67 CHAPTER 3 Equipment Problems 68 CHAPTER 3 Equipment Problems • • Prevention Refertoauthorizedengineeringandservicepersonnel. DiagnosticStudies • • •

• • • RiskFactors (continued) Immediate Management

• • • • •

status ofthebackup battery. During checkoutoftheanesthesia workstation, notethecharge safety. how toreactapowersupplyfailure, andaboutelectrical Educate ORpersonnelaboutthe power supplytotheOR, Service andrepairasneeded. that automatictransfertothissourceoccurswithoutdelay. Regularly testemergencypowersupplytoinstitutionensure Replace backup batteriesas necessary. that thebatteries are chargedandcanmaintaintheir charge. Regularly checkall anesthesiadevicesandmonitors to ensure construction). interruption ofelectricalpowersupply (e.g.,maintenanceor Provide adequatewarningtoallstaffofanyplanned ORs Unannounced constructionormaintenanceinthevicinityof institution Unannounced constructionormaintenanceinthevicinityof systems andtomaintain/repairasrequired. Failure toregularlycheckemergencybackuppowersupply workstation, switchto“AlternateOxygen”ﬂ Apollo®, DragerFabius®GS,GES5/ADU®).IfaAisys® reliable electricalsupplyhasbeenrestored. Elective surgicalproceduresshouldbepostponeduntila machine). ventilating patient’slungs;crankingthecardiopulmonarybypass Reassign personneltoprovidemanualpower(e.g.,hand- Maintain anesthesiausingintravenousagents. ﬂ On workstationsthatnormallyhaveelectronicdisplayofgas lowest possiblesetting. the reservoirbag.Adjustscreenbrightnesscontrolto by switchingofftheventilatorandmanuallyventilateusing supply powerfor30–45minutes.Conservebattery Most electronicworkstationshaveabackupbatterythatwill ows, revertto100%O

2 frombackuprotameter(Drager

owmeter.

YasnyJ,SofferR.Acaseofpowerfailureintheoperatingroom. • • • Pathophysiology • • • Presentation tion oftheanesthesiaworkstation. or belowtheminimumoxygenpressurerequiredfornormalfunc- Oxygenpipelinesupplypressuretotheworkstationiseitherabsent Deﬁ EichhornJH,HessellEA.Electricalpowerfailureintheoperating FurtherReading • • WelchRH,FeldmanJM.Anesthesiaduringtotalelectricalfailure,orwhat CarpenterT,RobinsonST.Responsetoapartialpowerfailureintheoperat- •

OxygenPipelineFailureOxy 2005;52:65–69. room: aneglectedtopicinanesthesiasafety. 1519–1521. would youdoifthelightswentout? ing room. Other gasessuppliedtomachine(N oxygen fl alarms forapnea(lowpressure,absent capnogram). Oxygen-powered pneumaticventilator stopsworking,leadingto fl • pressure systemandthensupplies the following: Pipeline supplyofoxygenat50psig entersworkstationhigh alarm soundsattheORcontrolcenter. If duetoacentralsupplyproblem,lowoxygenpressure Low oxygensupplypressurealarmisannunciatedinworkstation. Workstation failspre-usecheckout. backup battery. anesthesia informationmanagementsystems(AIMS)thathaveno for electricallypowereddevicessuchasORcomputersand Consider obtaininguninterruptiblepowersupply(UPS)units anesthetizing location. fl Regularly checkthatbattery-poweredlighting/emergency O owing. ashlights arepresent,obvious,functioning,andchargingineach Highpressurediameterindexed safetysystem(DISS) device) oxygen take-off(to drivejetventilator,venturisuction 2 nition fl ow atmainandauxiliaryfl ow metersdecreasesorceases; g en Pi

ush fails. Anesth Analg

eline Failure

. 2010;110:1644–1646.

J ClinAnesth

2 O,heliox,possiblyair)stop

1989;1:358–362. Anesth Analg

. Anesth Prog. 2010;110:

69 CHAPTER 3 Equipment Problems 70 CHAPTER 3 Equipment Problems • • • DIFFERENTIALDIAGNOSIS • • • •

• • • • • • ImmediateManagement

• • • • • • • Debris inpipelinesystemobstructingwalloxygenoutlet workstation Obstruction/kinking ofhosebetweenwalloxygenoutletand Leak inanesthesiamachinehigh-pressuresystem workstation. debris), orobstructioninhoseconnectingoxygenwalloutletto (empty, leaking),pipelinesystemclosedofforobstructed(e.g.,by Failure ofcentraloxygenstoragesupplyorpipelinetoOR • pipeline system Failure ofconnectionbetweenbulkoxygenstoragevesseland Unannounced maintenanceofpipelinesystem Shutoff valveoutsideORisinOFFposition Intheabsence ofanopencylindersupply,thelatterfunctions Pneumatically poweredventilator O Fail-safe mechanism Lowoxygen pressurealarm Auxiliary fl Alternateoxygen fl ow meter(GEAisys®workstation) Mainoxygen fl • • oxygen. Open reserveO pipeline supplypressuregaugeonworkstation.CheckO Confi tolerate alowerFIO If workstationhas pipelinesupplyofairandthepatient will department. Alert surgeon,personnelinotherORs, andtheengineering oxygen tanks. Announce thefailure,callforhelpand foradditionalbackup • Take stepstominimizeoxygenuse operation. Ensurethatauxiliaryoxygenfl ow isoff. Switchoffapneumaticventilator;usespontaneousormanual UselowestO fail. ventilation. possible). 2 fl rm lossofpipelineoxygensupply/pressurebychecking ush

owmeter (fornasalcannula,etc.)

ow meter 2 ﬂ 2 cylinderonworkstation ow possible(closed-circuittechniqueif 2

,considerdecreasing FIO

2 toconserve

2 ﬂ ush • • • • • • SpecialConsiderations • • Prevention • DiagnosticStudies • meit aaeet (continued) Immediate Management • •

• • • RiskFactors •

3000 psigandcontain 1000litersofgaseousO Refer toauthorizedengineeringandservicepersonnel. Ensure adequateSpO Consider, forbackup supply,EsizeO have practicedchanging theoxygentankonworkstation. Ensure thatallanesthesiapersonnel havebeeninstructedand backup tankoxygensupply. oxygen willbedrawnfromanopen tank,silentlydepletingthe yoke. Ifthepipelinepressuredecreases tolessthan45psig, left open,oxygenmayleakoutbetween thetankandhanger Ensure thatthetankisfull,andthen turnoffthetank.Iftankis workstation istightlysecuredinthehangeryoke. Before startingacase,ensurethatbackuptankofoxygenonthe Check fornormalpipelinepressure. pre-use checkout. Educate personnelincorrectoperationofworkstation,including Ensure adequateFIO workstation. Check adequacyofallhoseconnectionsbetweenwalland

agents. resuscitation bagandmaintainanesthesiausingintravenous is notpossible,ventilatewithroomairusingaself-infl backup oxygencylindersconfi oxygen supplyhasbeenrestored,andanadequateof Elective surgicalproceduresshouldbepostponeduntilpipeline If theventilatorisdrivenbyO Unannounced pipelinemaintenance Unannounced constructioninvicinityofOR by manufacturer Failure toperformpre-usecheckoutproceduresrecommended Filling ofbulkoxygenstoragevesselbyunqualifi

2 2 byoxygenanalyzer. .

rmed. 2 anduseofcompressedair

2 tanksthatareﬁ

2 ,andthathavea ed personnel.

lled to ating

71 CHAPTER 3 Equipment Problems 72 CHAPTER 3 Equipment Problems WellerJ,MerryA,WarmanG,RobinsonB.Anaesthetistsmanage- SchumacherSD,BrockwellRC,AndrewsJJ.Bulkliquidoxygensupplyfailure. • Pathophysiology • • Presentation ume tothepatient’slungs Inabilityoftheanesthesiaventilatortodeliversetinspiredvol- Deﬁ LorrawayPG,SavoldelliGL,JooHS,ChandraDB,ChowR,NaikVN. FurtherReading • • • • •

VentilatorFailure Ventil 2007;62:122–126. ment ofoxygenpipelinefailure:roomforimprovement. Anesthesiology. riculum? Management ofsimulatedoxygensupplyfailure:isthereagapinthecur- pressure outletonthetank. disconnected fromthewalloutletandconnectedtohigh- at 50psig.Ifthepipelinesupplyfails,oxygenhosecanbe regulator andDISSoxygenconnectionthatcanprovide resulting infailure toventilate. uneducated usermay inadvertentlyselectanincorrect mode, Ventilator operationmaynotbeintuitively obvious;the an electricmotor.Inbothdesigns, the controlsareelectronic. oxygen, orinsomecasesair);piston ventilatorsaredrivenby Bellows ventilatorsarepoweredpneumatically (bycomp Ventilator cannotbeturnedon. Workstation failspre-usecheckoutforventilator. auscultation, andpatientattempting tobreathespontaneously. to movenormallywithventilation,absenceofbreathsoundson Clinical signsofhypoventilation/apneaincludefailurechest inspiration. Ventilator doesnotsoundnormalduringpositivepressure absent. Ventilator bellowsmovementisabnormal(irregular,sticking)or end-tidal carbondioxide;lowSpO Physiologic monitorsindicateinadequateventilation(low/high TV, MV;low/high/continuingpressure). Ventilator/ventilation alarm(s)is/areannunciated(e.g.,low/high nition Anesth Analg. ator Failure

2004;100:186–189.

2006;103:865–867.

2 ).

Anaesthesia. r essed

• DIFFERENTIALDIAGNOSIS • • • • • • • • • • • • ImmediateManagement • • •

Ventilator turnedoff Breathing systemorairwayobstruction decrease inthoraciccompliance Change inventilatoryneedsduringtheprocedureassociatedwith in thebreathingsystem No freshgasflow, orfl ow isinadequate toovercomeasmallleak confi The ventilatormustbeconnectedcorrectlytoaproperly Obstruction toinspiratorysideofcirclesystem system) leak; stuckclosed,causinghighpressureconditioninbreathing Failure ofventilatorpressurereliefvalve(stuckopen,causing computer controlsystem,orpneumatic) Failure ofaventilatorcomponent(maybemechanical,electronic, workstation Failure ofpneumaticand/orelectricalpowersupplytothe ventilators (e.g.,GEAisys®Carestation). fl Failure ofbreathingsystemflow sensor.Properlyfunctioning

Anestar®) decoupling (e.g.,DragerFabius®GS,Apollo®,Datascope Failure ofdecouplingvalveinaworkstationthatusesfreshgas

ow sensorsarerequiredforthenormaloperationofsome ventilation. breathing systemreservoirbag.Ifthisissuccessful,continuebag oxygen flush control, andattempttoventilateusingthe Change fromventilatortobagcircuit,fill thecircuitusing while youcareforthepatient. anesthesia caregivertroubleshootandcorrecttheproblem Call forassistance.Haveananesthesiatechnicianorother functioning; ifnot, switchtobackupcylindersupplies. sites ofgasleakage.Checkthatthe pipelinegassupplyis Check circuitfordisconnections,misconnections, andother fl If thebreathingcircuitcannotbefilled byoperatingtheoxygen necessary. equipment, mouth-to-trachealtube ventilationmaybe circuit maybeused.Intheabsence ofback-upventilation (“Ambu”) bag.Ifasourceofoxygen orairisavailable,aBain patient cannotbe ventilated,reverttothe“Ambu” bag, Bain, If thecircuitdoes fill fromtheoxygen fl ush, ventilatethepatientwithaself-infl gured breathingsystem.

ush/ﬂ

ating resuscitation

owmeters, butthe

73 CHAPTER 3 Equipment Problems 74 CHAPTER 3 Equipment Problems • • • • Prevention • DiagnosticStudies • • • RiskFactors (continued) Immediate Management • • • •

Refer toauthorizedengineeringandservicepersonnel. Ensure adequateSpO changes intidalvolume whenfreshgasﬂow rate,respiratory Some newerworkstations usefreshgasdecouplingto prevent the ventilator. The anesthesiacaregivermustbeadequately trainedintheuseof Ensure adequateFIO of theworkstation/ventilator. Inadequate educationofanesthesia caregiverintheoperation manufacturer’s recommendations Failure tomaintain/serviceworkstationaccording by manufacturer Failure toperformpre-usecheckoutproceduresrecommended service personnel. from clinicaluseuntilrepairedbymanufacturer-authorized or anesthesiatechnician,theworkstationshouldbewithdrawn If theproblemcannotbecorrectedbyananesthesiacaregiver identiﬁ the backupsystemifnecessary,untilfailurehasbeen Ensure thatventilationandoxygenationaremaintainedusing technique. be maintainedusingatotalintravenousanesthesia(TIVA) If inhalationalagentscannotbeadministered,anesthesiashould tension pneumothorax). or bronchialtree,endobronchialintubation,bronchospasm, kinked trachealtube,herniatedcuff,foreignmatterinthetube system, consideranobstructionto/inthepatient’sairway(e.g., If unabletoventilatewiththeAmbu,Bain,orotherbackup wrapping). of theinspiratorylimbmaybeobstructed(e.g.,byplastic inspiratory unidirectionalvalvecouldbestuck,orthelumen obstruction ontheinspiratorysideofcirclesystem.The or otheralternativeventilationsystem,andlookforpossible ed andtheproblemcorrected.

2 2 byoxygenanalyzer. .

SandbergWS,KaiserS.Novelbreathing circuitarchitecture:newconse- RaphaelDT,WellerRS,DoranDJ.Aresponse algorithmforthelowpressure OrtegaRA,ZambrickiER.Freshgasdecoupling valvefailureprecludesmech- EisenkraftJB.PotentialforbarotraumaorhypoventilationwiththeDräger • • • • • ASASub-CommitteeonEquipmentandFacilities.Recommendationsfor FurtherReading • SpecialConsiderations • •

quences ofoldproblems. alarm condition. 2007;104:1000 anical ventilationinaDraegerFabiusGS anesthesiamachine. AV-E ventilator. 14, 2010). clinical/FINALCheckoutDesignguidelines02-08-2008.pdf pre-anesthesia checkoutprocedures(2008).Availableat: formula: To estimatethetimeremainingatagivenflow rate,usethe proper functionofbag/ventilatorselectorswitch. system inbothmanual/bagandautomatic/ventilatormodes, form ofareservoirbag)connectedattheY-piececircle unidirectional valves,andabilitytoventilateatestlung(inthe Confi Perform properpre-usecheckoutoftheworkstation/ventilator Educate personnelinthecorrectoperationofworkstation. to manufacturer’srecommendations. Equipment shouldbeproperlymaintainedandservicedaccording systems. the differencesbetweenthisdesign,andthatoftraditional or I:Eratioarechanged.Itisimportantthattheuserunderstand psig andcontain684litersofO Standard Ecylindersontheanesthesiamachinearefilled to2200 immediately availableandfunctioning. Ensure thatanalternativemeanstoventilatethepatient’slungsis 50 psigoutletontheO can bedisconnectedfromthewalloutletandconnectedto 50 psig.Ifthepipelinesupplyfails,workstation’soxygenhose regulator andDISSoxygenconnectionthatcanprovideat 3000 psig(containing1000litersofgaseousoxygen),andhavea Consider, forbackupsupply,Esizeoxygentanksthatarefi Time remaining (hours) = Pressure (psig)/(200flow rate ×(l/min)) O rm correctassemblyofthebreathingcircuit,function

J ClinAnesth. Anesth Analg.

Anesthesiology. 2 tank.

1989;1:452–456. 1988;67:876–883.

2 . 2004;100:755–756.

. (AccessedMarch www.asahq.org/

Anesth Analg. lled to

75 CHAPTER 3 Equipment Problems This page intentionally left blank Chapter 4

Ethical Considerations Robert B. Schonberger and Stanley H. Rosenbaum

Informed Consent 78 Refusal of Blood Transfusion 80 Organ Harvesting and the Declaration of Brain Death 81

77 78 CHAPTER 4 Ethical Considerations • TheEthicalStandard ofCare • • InformedConsent KeyPoints • • OrganHarvestingandBrainDeath • • RefusalofBloodTransfusion • •

InformedConsent Inform obtained priorto the performanceofanyinvasiveprocedure. As bothalegaland ethicalmatter,informedconsent mustbe

person wouldconsidertobeinthebestinterestsofpatient. physicians shouldactinaccordancewithwhatareasonable In anemergencyinwhichnodecisionmakerisavailable, invasive procedures. As ageneralrule,informedconsentisrequiredpriortoall has beenarranged. undergo organharvestingunlessdonationaftercardiacdeath spontaneous respiratoryeffortsarenotbraindeadandmay are persistentlyvegetative,minimallyconscious,orexhibit death oftheentirebrain,includingbrainstem.Patientswho In theUnitedStates,declarationofbraindeathrequires cardiac orbraindeath. donor, organharvestingmayoccuronlyafterthedeclarationof With theexceptionofacompetentandconsentingliving recombinant factorVII(ifindicated). treatments suchaserythropoietin,desmopressin(ddAVP),and circuit withthepatient,cellsaversystems,andpharmacologic hemodilution, removalofbloodthatiskeptinacontinuous refuses transfusion.Somemajormodalitiesincludedeliberate There arenumerousstrategiesformanagingapatientwho transfusion foranyreason. With fewexceptions(seebelow)patientsmayrefuseblood the criticallyillpatientshouldresume. the organharvestdoesnotproceed,andappropriatecareof does notbecomeapneicandpulselesswithinaspeciﬁ institutional protocolsgovernsuchprocedures.Ifthedonor support inanticipationofdeathwithinashorttime.Strict Donation aftercardiacdeathinvolvestheremovaloflife individual acceptancevaries. Speciﬁ c strategiesshouldbediscussedwiththepatient,as e

d Consent

ed time,

• Competent patients may refuse to give such consent for any procedure for any reason. • For competent patients, informed consent must be obtained from the patient and must include an explanation of the purpose of the proposed procedure as well as the major risks, beneﬁ ts, and alternatives to the procedure. • In the case of incompetent patients who were formerly competent, a surrogate decision maker must be sought. The

essential elements and requirements of the informed consent Ethical Considerations process are the same when dealing with surrogates, as with patients themselves. The surrogate’s role is to act in substituted judgment, i.e., to authorize what the patient’s wishes would be if

the patient were in a position to express them. CHAPTER 4 • In the case of a minor child, or individual who has never been competent, informed consent must be obtained from the legal guardian or conservator whose role is to represent the best interests of the incompetent person. • For emergency situations in which delay would result in the loss of life, limb, or other serious morbidity, and in which a competent decision maker cannot be located, physicians have an ethical 7979 duty to act in accordance with what a reasonable person would hold to be in the best interest of the patient until such time as informed consent can be sought. Exceptions to the Need for Informed Consent • Patients may be incapable of informed consent due to acute injury, chronic brain disease, medication, intoxication, mental impairment, mental illness, or young age. In all of these cases, the physician’s obligation to obtain informed consent does not go away; the process simply transfers from the patient onto the surrogate decision maker. • Physical disability or language barrier may make obtaining consent inconvenient, but has no impact on a patient’s competency or on the obligation of the caregiver to obtain consent from the patient. • The emergency exemption to obtaining informed consent may be conceptualized as a reasonable presumption of consent. If the presumption of consent is later contravened by the patient or a surrogate, the emergency exemption no longer applies. • In the case of minor children, some treatments may be mandated by the courts despite the parents’ refusal to give informed consent. Keeping in mind the emergency exemption, it is prudent for a care provider to seek institutional administrative support in such situations. 80 CHAPTER 4 Ethical Considerations • • Transfusion TreatmentModalitiesforPatients WhoRefuse • ExceptionstotheRefusalofBloodTransfusion • • TheEthicalStandardofCare WhitneySN,McGuireAL,McCulloughLB.Atypologyofshareddeci- Foradiscussionofthetypologyinformedconsentasdistinctfromshared FurtherReading • • • •

RefusalofBloodTransfusionBl 2004;140(1):54–59. sion making,informedconsent,andsimpleconsent. decision makingandsimpleconsent,see: sustained advocacy onbehalfofthepatient. insurance carriers willnotpayforthistreatmentwithout in anefforttoincreasehemoglobin concentration.Some Preoperatively, patientsmayreceive recombinanterythropoietin blood transfusion. A varietyoftechniquesmayreduce risktopatientswhorefuse behalf oftheirminorchildren. preadolescent childrenmayNOTrefusebloodtransfusionson United Statescaselawgenerallyholdsthatparentsof should behonored. any objectionstoreceivingbloodproducts.Anysuchwishes Patients shouldbeaskedbeforetheirsurgerywhethertheyhave treatment wouldentaildeath. any othertreatmentforreason,evenifwithholdingsuch Competent adultpatientsmayrefusebloodtransfusionor ethics consultmaybewarranted. dilemma forwhichconflicting caselawexists,andforwhichan Gravid patientswithviablefetusespresentanotherethical fall intoagrayareainwhichanethicsconsultisbestpursued. Older adolescentchildrenwithobjectionstobloodtransfusion their ownobjections. exist, physiciansmayhaveanobligationtoprovidecaredespite patient’s autonomy.Incaseswherealternativeprovidersdonot products maydefercaretoacolleaguewhoisablehonorthe A careproviderwhoobjectstowithholdingappropriateblood patient’s preferencesshouldbeclarified priortosurgery. systems andextracorporealbloodcircuits.Thespecifics ofa Individual patientpreferencesmaydifferregardingcellsaver o

od Transfusion

Ann InternMed.

• Occasionally, patients who refuse anonymous-donor banked blood may still consent to autologous blood banking. • Patients who refuse autologous blood banking may sometimes consent to the withdrawal of blood if it is kept in a continuous circuit with the body. Such patients may undergo intraoperative withdrawal of blood into a blood donation bag that is left connected to the IV circuits. The blood can be slowly reinfused until a transfusion is needed.

• Deliberate hemodilution techniques are commonly used, but Ethical Considerations evidence-based guidelines have yet to be developed. • Steps to reduce blood loss include modiﬁ cations of surgical technique, controlled hypotension, use of ddAVP, and use of recombinant factor VII. CHAPTER 4 • Cell saver systems can be useful if patients consent to them. In situations, such as oncologic surgery, where cell saver is normally contraindicated, surgical blood loss may still be collected in a cell saver system. This blood should then be discarded unless the need for blood becomes critical. • Postoperative recombinant erythropoietin has been used. In addition, there are case reports of salvage therapy using 8181 hypothermia, sedation, and neuromuscular blockade to reduce oxygen consumption in patients with otherwise fatal anemia.

Further Reading For a discussion of some relevant case law, see: Benson KT. The Jehovah’s Witness patient: considerations for the anesthesiologist. Anesth Analg. 1989 Nov;69(5):647–656.

Organ HarvestingHarvesting and the Declaration of BrainBrain DDeatheath

The Ethical Standard of Care • Outside the domain of the consenting living donor, organ harvesting may occur either after the declaration of cardiac or brain death. • The declaration of brain death in the United States requires documentation that the entire brain, including the brain stem, has permanently ceased to function. • The declaration of brain death must generally be made by at least one physician who is not connected to the transplantation process. 82 CHAPTER 4 Ethical Considerations • • • be diagnosedevenifanyofthefollowingarepresent: AccordingtotheAmericanAcademyofNeurology,braindeathmay PitfallsintheDeclarationofBrainDeath • TheDeterminationofBrainDeath • • • • • • • • • • •

other brainstemactivityisnotlegallydead. A patientwhoshowsevidenceofspontaneousrespirationor Intercostal expansionwithoutsignificant tidalvolumes or extension Spontaneous movementsoflimbsotherthanpathologicfl must beconsideredand,whereappropriate,treated. intoxication, hypothermia,andresidualneuromuscularblockade history andexam.Specifically, severemetabolicderangement, Reversible causesofapparentcomamustberuledoutbothby donation aftercardiacdeathhasbeenarranged. of braindeathandmaynotundergoorganharvestingunlessa persistently vegetativepatients,donotmeetthelegaldefi Comatose patientswithresidualbrainfunction,including 3) 2) Deep tendonrefl Absence ofdiabetesinsipidus Hemodynamic stability Sweating, blushing,ortachycardia 1) The clinicaldeterminationofbraindeathrequires: brain bloodfl activity, oronperfusionstudiesthatdemonstratetheabsenceof brain deathmayalsobebasedonanEEGshowingabsent tests forthedeterminationofbraindeathcannotbeperformed, In caseswherethereremainssomedoubt,ortheclinical neurophysiologic testing. the determinationofdeathwithoutneedforfurther determination ofbraindeathissufficient inadultsfor Most UnitedStatesjurisdictionsholdthattheclinical Babinski refl physician oratmorethanonepointintime. determination ofbraindeathbeperformedbymorethanone Legal andinstitutionalguidelinesvarybutmayrequirethe refuse aneurologicalstandardofdeathentirely. Some UnitedStatesjurisdictionsallowforthenextofkinto apneainresponsetoahypercarbicchallenge. theabsenceofallbrainstemrefl

territories; unresponsiveness, includingtopainfulstimuliincranialnerve ex

ow.

exes

exes;

nition exion Donation after Cardiac Death (DCD) DCD refers to the practice of removing a severely ill patient from active life support in the expectation that the patient will have a cardiac arrest within a few minutes. This is distinct from donation after brain death, in which asystole is not required. In a DCD situation, when asystole has lasted for a speciﬁ ed period (usually taken to be 5 minutes), the patient is pronounced dead. Subsequently, the transplant team removes organs, generally just the liver and kidneys, for transplantation. This procedure must satisfy strict constraints: Ethical Considerations • The patient’s surrogate decision makers must have given formal consent for withdrawal of active life support. • To avoid any potential conﬂ icts of interest, there must be a sharp separation between the medical team caring for the patient and CHAPTER 4 the transplant team. • There must be a formal institutional protocol describing the details of the process, including the acceptable participants, the venue for the withdrawal of active support, the waiting duration for the patient to expire, and the period of asystole needed for the declaration of death. • If the patient does not become apneic and pulseless during the 8383 waiting time after withdrawal, generally chosen to be one hour, the patient is returned to regular hospital care appropriate for a standard end-of-life patient.

Further Reading American Academy of Neurology, Quality Standards Subcommittee. Practice parameters: Determining brain death in adults, Neurology. 1995;45:1012–1014. Van Norman GA. A matter of life and death: what every anesthesiologist should know about the medical, legal, and ethical aspects of declaring brain death. . Anesthesiology. 1999;91(1):275–287.

This page intentionally left blank Chapter 5 Metabolic and Endocrine Emergencies Lewis J. Kaplan

Acidosis 86 Adrenocortical Insufﬁ ciency (AI) 88 Alkalosis 90 Anaphylaxis 91 Coagulopathy 93 Diabetic Ketoacidosis (DKA) 96 Hypercalcemia 99 Hyperkalemia 101 85 Hypermagnesemia 102 Hypernatremia 104 Hypocalcemia 105 Hypokalemia 107 Hypomagnesemia 109 Hyponatremia 110 Hypothermia 112 Malignant Hyperthermia (MH) 114 Pheochromocytoma 116 Porphyria 119 Sickle Cell Crisis 121 Thyroid Storm 123 TURP Syndrome 125

86 CHAPTER 5 Metabolic and Endocrine Emergencies

• • • • • DIFFERENTIALDIAGNOSIS Pathophysiology • • • Presentation BloodpHlessthan7.36(normal=7.36–7.45) Deﬁ bolic states(e.g.,malignanthyperthermia). commonly fromrespiratoryfailure.Mayalsooccurinhypermeta-

ketoacids, toxins)fasterthantheliverorkidneyscaneliminatethem.

• • • • • ImmediateManagement

Acidosis Acidosis

vasodilation, narcosis,andpossiblycyanosis. Respiratoryacidosis spontaneously breathingpatient depression anddysrhythmias,compensatoryhyperventilationina Metabolic acidosis:hypotension,vasodilation,myocardial Respiratory acidosis:signsofCO Finding onarterialbloodgasanalysis Continue tomonitorandtreattheunderlyingcause. Subsequent management studies todeterminetheunderlyingcause(ifunknown) Arterial bloodgasanalysis,lacticacidlevel,plasmaelectrolytes, Diagnostic studies Laboratory error Metabolicacidosis • 0.08 inpH • 10 torrdecreaseinPaCO PaCO Plasma VolumeExpansion Consider intra-arterialandcentralvenouscatheterplacement. Establish large-boreIVaccess.

nition change inpHand calculate thenecessarychangeinPaCO respiratory alkalosistoraisethepH. Determinethedesired Metabolic acidosiscanbebuffered acutely byinducinga content reducestheriskofhyperchloremic acidosis. 0.9% normalsalinesolutionNSSbecauseitslowerchloride Generally lactatedRinger’ssolution(LR)ispreferredto then adjustthepatient’s minuteventilation. 2 Regulation

iscausedbyaccumulationofacids(e.g.,lacticacid,

iscausedbyanacuteincreaseinPaCO

2 resultsinanapproximateincrease of

retention,including

2 ,most 2 ,

• • • SpecialConsiderations Nospeciﬁc prevention. Aggressivetreatmentofunderlyingcause. Prevention Immediate Management(continued)

• • •

• • RiskFactors

extravascular space.) volume plasma expansionisrequired.(lessshift intothe Consider usingcolloid solutions(e.g.,hetastarch)when large- hypocarbia-induced vasoconstriction andischemia. Do notreducePaCO cause alkalosiswhentheseizureends). (e.g., aggressivetreatmentoflactic acidosis afteraseizuremay disorders andadjusttreatmentfor a changeinclinicalstatus. Monitor thepatientcloselyduring management ofacidbase • • • NaHCO NaHCO Maintenance IVFElectrolytePrescription

• • • • • • • • Metabolic acidosis: • Respiratory acidosis:

blood gas(ABG): (pH <7.2)usingthebasedeﬁcit derivedfromanarterial in 30minutestodeterminetheneedforadditionaltherapy. Administer onlyhalfthecalculateddoseandrepeatABG Administer NaHCO volume. appropriate tomaintainnormalcirculatingblood Administer isotoniccrystalloidsorcolloidsolutionsas Diabetic ketoacidosis Severe diarrhea Hypothermia (normal saline) Massive resuscitationwithhyperchloremicﬂ Hypermetabolic states(e.g.,thyrotoxicosis) Hypoperfusion states(e.g.,shock) Malignant hyperthermia Acute illness Respiratory failure 3 3 (mEq)=0.5×weight(kg)(24-HCO Administration

2 tolessthan25torr,asthismayproduce 3 torapidlycorrectsevereacidosis

uids 3 −

(mEq/L))

87 CHAPTER 5 Metabolic and Endocrine Emergencies 88 CHAPTER 5 Metabolic and Endocrine Emergencies NeliganPJ,DeutschmanCS.Perioperativeacid-basebalance.In:MillerRD

• • DIFFERENTIALDIAGNOSIS pituitary disease,orexogenoussteroids. caused bydestructionoftheadrenal cortex(autoimmuneorHIV), ative feedback,inhibitingtherelease ofCRHandACTH.AIcanbe causes theadrenalglandstorelease cortisol.Cortisolprovidesneg- amus andstimulatesthepituitary toreleaseACTH.ACTHthen Corticotrophin-releasinghormoneisreleasedfromthehypothal- Pathophysiology • • • Presentation tex, adrenalsuppression,orpituitaryinsuffi Primaryadrenalinsuffi ciency duetodestructionoftheadrenalcor- Defi FidkowskiC,HelstromJ.Diagnosingmetabolicacidosisinthecriticallyill: FurtherReading • • •

AdrenocorticalInsuffiInsu 2010:1557–1572. (ed.). 2009 Mar;56(3):247–256. bridging theaniongap,Stewart,andbaseexcessmethods. An awakepatientmaypresentwithabdominalpainandvomiting. administration andD Use of½NSS+75mEqNaHCO respiration. generation, andanaerobicmetabolismisreplacedwithaerobic levels decreasefrombothhepaticmetabolismandreduced As plasmavolumeexpansioncorrectshypoperfusion,lacticacid lower molecularweight. of injury,inflammation, andcapillaryleak.Thisisduetoalbumin’s retained intheintravascularspacethanalbuminpresence Synthetic colloidsandfreshfrozenplasma(FFP)arebetter content relativetoplasma. acidosis) maybebeneficial becauseofitsreducedchloride acidosis (especiallywithpreexistinghyperchloremicmetabolic Acute abdomen Septic shock Hyponatremia, hyperkalemia,andhypoglycemia Hypotension orshockrefractorytofluids andvasopressors nition Miller’s Anesthesia

. 7thed.Philadelphia:ElsevierChurchillLivingstone; 5 W+75mEqNaHCO

fﬁ ciency ciency (AI) 3

forplasmavolume ciency. ( AI 3 /Linpatientswith )

Can JAnaesth .

• • SpecialConsiderations Carefulhistoryshouldbetakenforsteroidusebeforesurgery. Prevention ManagetheunderlyingcauseofAI. SubsequentManagement • • • • DiagnosticStudies • • • RiskFactors

• • • • ImmediateManagement

Imaging studiestoruleoutacuteabdomen Plasma electrolytesandglucose the OR Dexamethasone suppressiontestmaybeappropriateoutsideof Baseline cortisolandACTHlevels(draw when hypotensionislife-threatening!) steroids whenthereissufficient time,butdonotdelaytherapy ischemia. intra-abdominal sepsis withfeculentperitonitis,and mesenteric acute AIincludethose withnecrotizingsofttissueinfection, common presentingfinding. Examplesofpatientsat riskfor surgery forinfection-relateddisorders. Septicshockisa Acute AIismorecommonwithpatients undergoingemergency large dosesofglucocorticoidiscontroversial. The efficacy ofprovidingamineralocorticoidinaddition tothe Patients beingtreatedfordiagnosedAI equivalent) formorethan4weekswithintheprecedingyear) Corticosteroid use(morethanprednisone20mg/dayor (e.g., transplantpatients) Corticosteroid useforconditionsotherthanprimaryAI units/min) resistant tocatecholamines,considervasopressin(0.01–0.04 Support bloodpressurewithinotropesorvasopressors.If Administer dextrose(D replete Na Administer fluids toexpandplasmavolume.(NSSorLR Follow with50mghydrocortisoneevery6hours. Administer aninitialdoseof100mghydrocortisoneintheOR.

usingisotonicﬂ

Wbolus)tocorrecthypoglycemia.

uids)

before

administering

89 CHAPTER 5 Metabolic and Endocrine Emergencies 90 CHAPTER 5 Metabolic and Endocrine Emergencies

reducing PaCO hypochloremia), excessiveHCO Alkalosisiscausedbylossofacidfromtheextracellularspace(e.g., Pathophysiology Vasoconstriction,pallor,lightheadedness,paresthesias Presentation BloodpHgreaterthan7.45(normal=7.36–7.45) Deﬁ ConneryLE,CoursinDB.Assessmentandtherapyofselectedendocrinedis- FurtherReading • •

• • • • ImmediateManagement

Alkalos Alkalosis

orders. therapy mayalsohaveacuteAI. Septic patientswithhypotensionunresponsivetovasopressor volume resuscitation. dependent aftergeneralsurgicalproceduresdespiteadequate Suspect acuteAIinolderpatientswhoarevasopressor • • PaCO cannulation. central venousaccessandisareasonablealternativetoarterial Venous bloodgasanalysismayalsobereliableinpatientswith (pH >7.5)(facilitatesABGanalysis). Consider intra-arterialcatheterplacementforseverealkalosis efﬁ amount ofchloride usinghypertonicsalineisequally thosewhocannottoleratethevolume, providinganidentical administration of0.9%normalsaline solution(NSS).For For patientswhoareabletotolerate volumeloading,bolus •

nition safe physiologicrangewhileensuring adequateoxygenation. Use permissivehypercapniaasnecessary torestorepHa decrease of0.08pH A10torrincreaseinPaCO PaCO desired pH. respiratory acidosis.Adjustminuteventilationtoattaina Buffer metabolicalkalosisbyinducingadeliberateacute cacious. Anesthesiol ClinNorthAm 2 Regulation 2 isinverselyrelatedtopHbythefollowingformula:

i s

2 .

. 2004Mar;22(1):93–123. 2 3 producesanapproximate -

loads,orhyperventilationacutely

antibiotic orlatex. Anacute,severe, hypersensitivityreactiontoatrigger suchasan Deﬁ NeliganPJ,DeutschmanCS:Perioperativeacid-basebalance.In:MillerRD KhannaA,KurtzmanNA.Metabolicalkalosis. FurtherReading • • SpecialConsiderations Avoidinadvertenthyperventilation. Prevention Investigationtodetermineunderlyingcauses. SubsequentManagement Arterialbloodgasanalysis. DiagnosticStudies

• • • • • • • RiskFactors

A Anaphylaxis

2010:1557–1572. (ed.). too longtoactbeofbeneﬁt intheacutesetting. anhydrase inhibitors(e.g.,acetazolamide)butthesedrugstake Metabolic alkalosisiscommonlytreatedintheICUwithcarbonic Regardless ofcause,alkalosisgenerallyrespondstoeitherPaCO Apr;19(Suppl 9):S86–S96. regulation orchlorideadministration. • 2 • • Iatrogenic causes • Hypochloremia Volume contraction Hypocarbia Severe hypoproteinemia Loop diureticadministration na

nition nd Proximal entericﬁ Administration ofweakions(acetate,citrate) Hyperventilation ofpatientswithchronicrespiratoryfailure Vomiting mostcommonacid-basedisorderinhospitalizedadults p Miller’s Anesthesia h y

laxis

. 7thed.Philadelphia:ElsevierChurchill Livingstone; stula

J Nephrol.

2006Mar-

91 CHAPTER 5 Metabolic and Endocrine Emergencies 92 CHAPTER 5 Metabolic and Endocrine Emergencies

• • DIFFERENTIALDIAGNOSIS ening vasodilation,myocardialsuppression,andbronchoconstriction. response toreleaseofIgEfrommastcells,causingpotentiallylife-threat- Massivereleaseofleukotrienes,histamine,andprostaglandinsin Pathophysiology • • • • • Presentation

• • • • • • • • • ImmediateManagement

Flushing Wheezing Tachycardia Hypotension Urticaria • Nonimmunologic drugreaction Sepsis •

• • • If mildanaphylaxis Search fortriggeringagent Treat bronchospasm(inhaledalbuterol4–8metereddoses) Establish large-boreIVaccess Supplemental O Ensure anadequateairway Inform thesurgeons; considerterminatingtheprocedure antibiotics, latex, and neuromuscularblockingagents. immediately priortotheanaphylactic event,including Perform acarefulevaluationofagents administered • If severeanaphylaxiswithhypotension • • • • • •

“Red mansyndrome”withvancomycin Morphine-induced histaminerelease Fluid resuscitatewithisotoniccrystalloid orcolloidsolutions H Epinephrine 0.1mg-0.5SQorIVevery10–20minutes Above interventions begin advancedcardiaclifesupport (ACLS). If cardiacarrestoccurs,administer epinephrine 1mgIVand Epinephrine infusion(titratetosystolic bloodpressure) Diphenhydramine 50mgIV(H Hydrocortisone 100mgIV Consider intubationandmechanicalventilation Arterial bloodgasforpH,PaCO 2 antagonist(e.g.,famotidine20mgIV) 2 (FiO 2 100%ifsevere) plus

1 antagonist) 2 andPaO

assessment

ence ofaninhibitor, orthedeficiency ofionsincluding Mg change. Thiscanbe duetoadeficiency ofoneormorefactors, thepres- thelium, andtheplatelet surfacethatmustundergoa conformational Failureofacomplexinteractionbetween clottingfactors,theendo- Pathophysiology ter insertionsites,orotherlocations. retroperitoneum), raworgansurfaces afterpartialresection,cathe- Diffusehemorrhagefromthesurgical wound,areasofdissection(i.e., Presentation cascade. Uncontrolledbleedingresultingfromafailureofthecoagulation Defi MertesPM,LambertM,Guéant-RodriguezRMetal.Perioperativeanaphy- FurtherReading • • SpecialConsiderations • • Prevention • • • SubsequentManagement Clinicaldiagnosis—nodiagnosticstudies DiagnosticStudies

• • • RiskFactors

C Coagulopathy

laxis. common thanisreportedinthemedicalliterature. Latex andperfumeallergy(undisclosed)isprobablymore the perioperativeperiod. Neuromuscular blockingagentsarethemostcommontriggerin Limit theuseoflatexproductsinoperatingroom. Review eachpatient’schartcarefullyforknownallergies. If thetriggerisunknown,considerskintesting the samedrug(ifidentiﬁ Prominently documenttheeventtopreventanotherexposure Careful reviewofthepatient’schartforknowndrugallergies oa Prior exposuretocertaindrugs(e.g.,intravenouscontrast) History ofallergicrhinitis History ofatopy nition g Immunol AllergyClinNorthAm ulopathy

able)

. 2009Aug;29(3):429–451.

andCa

2+ . 93 CHAPTER 5 Metabolic and Endocrine Emergencies 94 CHAPTER 5 Metabolic and Endocrine Emergencies

• • • • • • • DIFFERENTIALDIAGNOSIS

• • • • • ImmediateManagement

chronic renalfailure thrombocytopenic purpura,heparin-inducedthrombocytopenia, coagulation, immunethrombocytopenia,thrombotic Acquired coagulationdisorders:disseminatedintravascular hemophilia Congenital bleedingdisorder:vonWillebrand’sdisease, Renal disease:chronicrenalfailure Liver disease Herbal preparations:ginkobilboa,ginseng,sawpalmetto,garlic nonsteroidals Medications: warfarin,heparin,ﬁsh oil,vitaminE,aspirin,all Surgical bleeding • • • • • • • • frozen plasmaandplatelets). immediately available,considerempiricadministrationoffresh Correct factordeﬁciencies (iflaboratorystudiesarenot Review medicationsandhistory. Establish large-boreIVaccess. unknown, support theentirecascadeincludingclotting factors, If diffusemicrovascular hemorrhageoccursorthecause is clopidogrel use) bleeding fromsmallvessels.(Maybe duetoaspirinor Consider platelettransfusionforunexpected andpersistent

procedures such as laparotomy with partial colectomy). procedures suchaslaparotomywith partialcolectomy). procedures suchascatheterinsertions) or<100,000/µL(major Transfuse plateletsifplateletcount less than50,000/µL(minor cryoprecipitate. If ﬁbrinogen level is lessthan100mg/dl,administer10unitsof vitamin K10mgIVfollowedby4unitsFFP. If PTiselevatedorliverdiseasesuspected,administer If PTandaPTTareelevated,administer4unitsFFP. If renalinsufﬁciency, administer0.3mcg/kgddAVP. µL). platelets (deliversapproximately100,000functionalplatelets/ If aspirinorNSAIDuseissuspected,transfuse10unitsof heparin. (HeparinandLMWHareclearedbythekidney.) Protamine maypartiallyreverselowmolecularweight hypersensitivity reactionsoranaphylaxis! ) Vitamin K10mgIV.( If warfarinuseissuspected,administer4unitsFFPand

Caution: VitaminKmaycausesevere

• Prevention • • SubsequentManagement • • • • • DiagnosticStudies

Immediate Management(continued)

• •

• • • • • • • • RiskFactors

activated andfactorVIIisadministered coagulopathy isunknownorifthemassivetransfusionprotocol Obtain ahematologyconsultationifthecauseof Continue tomonitorcoagulationstudies. Consider thromboelestographyifequipmentisavailable. Activated clottingtime Fibrinogen level PT, aPTT Complete bloodcountwithplatelets 1:1:1 ratio. use ofplasma,packedredbloodcells (PRBCs)andplateletsina traumatic injuryincludeminimaluse ofcrystalloidsolutionsand Current recommendationsformassive transfusiontherapyin (if hypoﬁbrinogenemia ispresent). platelets, calcium,magnesium,andﬁ Hemorrhage, Chapter14.) protocol thatmayincludeactivatedfactorVII.(SeeMassive stabilize thepatient.Considerinitiatingamassivetransfusion a “damagecontrol”typeofproceduretocontrolbleedingand If massivecoagulopathyoccurs,stronglyconsiderconvertingto protamine inpatientswithoutasalmonallergy. after intraoperativeheparintherapy.Reversewith Use ActivatedClottingTime(ACT)toassesscoagulopathy Use of“herbal”preparations Unreported useofaspirinorNSAIDs Disseminated intravascularcoagulation Congenital bleedingdisorder Fibrinolysis Platelet dysfunctionorconsumption Consumption ordilutionofcoagulationfactors Uncontrolled surgicalhemorrhage

brinogen

95 CHAPTER 5 Metabolic and Endocrine Emergencies 96 CHAPTER 5 Metabolic and Endocrine Emergencies SpinellaPC,HolcombJB.Resuscitationandtransfusionprinciplesfortrau- SpahnDR,RossaintR.Coagulopathyandbloodcomponenttransfusionin diuresiscausesa severefree-waterdefi cit inalmostallpatients. Fluid, electrolyte, andacid-basebalanceareaffected. Osmotic DKAisgenerally causedbyactualorfunctionalinsulin defi Pathophysiology • • Presentation inducing condition(mostofteninfection). betic withpoorcompliance,oracompliantdiabeticstress- Thefailureofglucosehomeostasisinanundiagnoseddiabetic,adia- Defi RossaintR,DuranteauJ,StahelPF,SpahnDR.Nonsurgicaltreatmentofmajor FurtherReading • • • SpecialConsiderations • •

DiabeticKetoacidosis(DKA) matic hemorrhagicshock. trauma. bleeding. consultation isoftenhelpful. other conditionshasyettobeestablished,andHematology been reported.Theoptimaldosefortraumaandmany with measuredPTandaPTT,undesirableclottinghas and isextremelyexpensive.Effi cacydoesnotcorrelate severe coagulopathy.Thisisan“off-label”useofthedrug Consider recombinantactivatedfactorVIIinunexplained interpret, andisneitheruniversallyacceptednorcommonlyused. all aspectsofclottingbutistimeconsuming,maybediffi Thromboelastography issensitivemeasureoftheinteraction hypothermia impliesapoorprognosis. Coagulopathy thatoccursinassociationwithacidosisand the extentthatclinicalconditionspermit. enzyme kinetics.Maintainnormothermiaformostproceduresto Hypothermia createsafunctionalclottingdeficit byreducing replacement duringandaftersurgery. those factorsreplacedbeforesurgeryandmayneedongoing Patients withspecific clottingfactordefi ciencies shouldhave Hyperglycemia, ketosis,andacidemia nausea, vomiting,andabdominalpain. 2–3 dayhistoryofgradualdeterioration, includingpolydipsia, nition Br JAnaesth Anesthesiol Clin

. 2005Aug;95(2):130–139. . 2007Mar;25(1):35–48.

Blood Rev

. 2009Nov;23(6):231–240. ( DKA

)

cult to ciency.

• • • • • Otherconditionsthatcancauseseveremetabolicacidosisinclude: DIFFERENTIALDIAGNOSIS buffering. Severe

• • • • • • • • • ImmediateManagement

Alcoholic ketoacidosis. Aspirin overdose Hyperosmotic coma(markedlyelevatedglucose,noketones) Renal failure Sepsis (lacticacidosis) If pHislessthan7.2,calculaterequiredNaHCO defi • • Insulin Defi • Water andelectrolytes measurements. Management isguidedbyserialbloodgasandketone abnormality andtheunderlyingcause. patient presentswithDKAinordertocorrectthemetabolic Strongly considercancellinganyelectiveprocedureithe care setting. surgery toresuscitateandimprovepHperfusioninacritical If theclinicalsituationpermits,considerbriefly delayingurgent metabolic acidosis. large-volume fluid resuscitationmayinduceahyperchloremic certainly reasonableinpatientsrequiringemergencysurgery,as Correction oflesserdegreesacidosisiscontroversialbut Correct acid-basestatus. Assess airway,breathing,circulation,andlevelofconsciousness. • • •

Assess electrolytestatushourly. author’s preference). (Suggested initial dose 0.1 unit/kg bolus, then 0.1 unit/kg/h.) (Suggested initialdose 0.1unit/kgbolus,thenunit/kg/h.) Establish acontinuous intravenousinfusionofshort-acting insulin. Establish largeboreIVaccess. “designer” fluids suchas½NSS+75mEq/LNaHCO defi Avoid colloidsbecausetheydonot correctthefreewater times theirmaintenancefl Normotensive patientsshouldreceiveapproximately2–3 normotonic fluids asboluses. Rapidly resuscitatehypotensivepatientswithdextrosefree, cit andgive50%IVpriortosedationforETTplacement. acidosis increasestherequiredminuteventilationforpH cit. Appropriatefl uids include0.9%NSS,LR,and ciency

uid rate.

3 loadusingbase 3 (the

97 CHAPTER 5 Metabolic and Endocrine Emergencies 98 CHAPTER 5 Metabolic and Endocrine Emergencies

• • SpecialConsiderations and/or undergoingsurgery. with insulineveninnon-insulin-requiring diabeticswhoareacutelyill Earlydetectionandtreatmentofdiabetes mellitus.Earlyintervention Prevention • • SubsequentManagement • • • DiagnosticStudies

• • • • RiskFactors Immediate Management(continued)

•

electrolyte levels and replacement,glucose,urine,ABGs. Record andmanage onanhourlybasis:insulininfusion rate,ﬂ because absorptionisvariable. Avoid subcutaneousinsulinadministration inpatientswithDKA Begin subcutaneousinsulinslidingscalewhenstable. 250 mg/dl. appropriate formaintenanceﬂuid whentheglucosefallsbelow Add dextrosetoIVsolutionandreducestandardas • To determinepossibleetiology: Serial plasmaelectrolyteandketonelevels Serial arterialbloodgasanalysis,lacticacidlevel •

Discontinuation ofinsulininadiabeticpatient diabetics whenunderstress Usually occursintypeIdiabetics,butmayoccurII Emergency surgery Acute illnessinadiabeticpatient • • • • • Electrolyte Disorders

Troponin (myocardialischemia) Complete bloodcount,cultures(sepsis) required. Consider replacingsomepotassiumasKPO Check electrolytelevelsatleasthourly hypophosphatemia. Assess glucoseandK Replace Mg Administer KCl40mEqslowIVifK+islessthan3.0mg/dl.

2+ asMgSO

+ atleasthourlyandadjustinfusionas

4 1gIV

4 toavoid

uids,

• DIFFERENTIALDIAGNOSIS ium toxicity. hyperparathyroidism, paraneoplastic syndrome,immobility,orlith- Hypercalcemiaismostcommonly amanifestationofsecondary Pathophysiology • • • • • • • • • Presentation • • • Deﬁ KohlBA,SchwartzS.Surgeryinthepatientwithendocrinedysfunction. FurtherReading • • • •

Hyp Hypercalcemia Renal calculi Polyuria Vomiting Bradycardia Hypertension Hyperrefl Mental statuschanges Incidental laboratoryfi Severe: Greaterthan14mg/dL Mild: 11–14mg/dL Normal calciumis8.5–10.5mg/dL(ionized2.0–2.5mEq/L) Delivering totalsof200mEqK when phosphatelevelislessthan1mg/dL. by hypophosphatemia.Acuterespiratorycompromiseoccurs Hypocalcemia mayalsooccurbutisovershadowedinfrequency K Severe hypokalemiamayinducelife-threateningdysrhythmias. often artifactualandinsignifi Hyperglycemia anddehydrationmayinducehypernatremiathatis Laboratory error Oliguric renalfailure atypical insevereDKA. Clin NorthAm repleted. + nition andMg ercalcemia exia

2+ arecotransportedandshouldbesimultaneously . 2009Sep;93(5):1031–1047.

nding

cant.

and12gramsofMg

2+ isnot

Med 99 CHAPTER 5 Metabolic and Endocrine Emergencies 100 CHAPTER 5 Metabolic and Endocrine Emergencies

• • • SpecialConsiderations ing ﬂuids invulnerablepatients. Maintainadequatehydrationandurine outputwithsodium-contain- Prevention • • • • • SubsequentManagement • • • • DiagnosticStudies

• • • • RiskFactors

• • • • • ImmediateManagement

Hypercalcemia can causepancreatitis. neuromuscular blocking agents. Patients withmuscleweaknessshould receivereduceddosesof Avoid thiazidediureticsinpatients at riskforhypercalcemia. Follow amylaselevelsuntilCa • Investigate underlyingcauseifunknown Calcitonin therapy Calcimimetic agents(i.e.,cinacalcet), Bisphosphonate therapy Electrocardiogram Amylase Metabolic panel(includingliverfunctiontests) Plasma electrolytelevels •

Hyperparathyroidism Granulomatous diseases:tuberculosis,sarcoid Kidney failure lymphoma) Malignancy (breast,lung,kidney,multiplemyeloma, Beta-blockade (e.g.,metoprolol,labetolol) Calcium channelblockade(e.g.,diltiazem,nicardipine),or Hemodyalisis inpatientswithrenalfailure 40 mgIV In patientswithnormalrenalfunction,administerfurosemide IV ﬂuid resuscitation(generallyNSS) Parathyroid hormonelevels Workup formalignancy

returnstonormal

• • DiagnosticStudies • • DIFFERENTIALDIAGNOSIS tion andmaypotentiallyresultincardiacarrest. Highplasmaconcentrationofpotassiumimpairsmyocardialconduc- Pathophysiology • • • • Presentation • • • • Deﬁ KayeAD,RiopelleJM.Intravascularﬂ uid andelectrolytephysiology.In: FurtherReading

• • • • ImmediateManagement

H Hyperkalemia

Livingstone; 2010:1711–1712. Miller RD(ed.). thrombocytosis May beartiﬁcially elevatedinsevereleukocytosisor Improper samplehandling(celllysis) T waveelevation. degree ofhyperkalemialooselycorrelateswiththeheight Peaked TwavesonECGindicateimpendingcardiacarrest.The Muscle weakness,paresthesias Nausea, vomiting Incidental laboratoryﬁ Severe: Morethan7.0mEq/L Moderate: 6.0–7.0mEq/L Mild: 5.5–6.0mEq/L Normal potassiumis3.5–5.5mEq/L. Electrocardiogram Plasma electrolytes (usedtofollowtreatmentprogress) • • Force renalexcretion Administer 10unitsofregularinsulinIVwith50ccD Administer CaCl Establish IVaccessandECGmonitoring yperkalemia

nition between the1stand2ndlitersofsaline Furosemide 20–40mgIV(depending onbaselinecreatinine) 0.9% NSS2000cc

Miller’s Anesthesia

2 (

not calciumgluconate

nding

. 7thed.Philadelphia:ElsevierChurchill

) 1IV

50 WIV

101 CHAPTER 5 Metabolic and Endocrine Emergencies 102 CHAPTER 5 Metabolic and Endocrine Emergencies

mEq/L.) • • • Presentation Mg Deﬁ KayeAD,RiopelleJM.Intravascularﬂ uid andelectrolytephysiology.In: FurtherReading • • SpecialConsiderations • • Prevention ReducethetotalbodyK SubsequentManagement Induction ofdiarrheaindicateseffectivetherapy. this therapyinpatientswithabnormalrenalfunctionorfailure. sodium polystyrene[Kayexelate])suspendedinsorbitol.Consider

• • • • • RiskFactors

Hyperma Hypermagnesemia

Livingstone; 2010:1710 Miller RD(ed.). Hypotonia Bradycardia with widened QRScomplex,prolonged PRinterval Muscle weakness hyperkalemia (generallyK Consider acutehemodialysisinpatientswithlife-threatening body potassiumload. plasma spacetotheintracellularspace;and(3)reducingtotal polarization anddepolarization;(2)relocatingpotassiumfromthe Therapy addressesthreemajoraims:(1)supportingmyocardial Monitor K Avoid iatrogeniccauses massive hemolysis Cell destruction:skeletalmusclecrush,massivetissuenecrosis, disorders orsevereburninjury Succinylcholine useinpatientswithuppermotorneuron Diabetic ketoacidosis Renal failure Iatrogenic (inadvertentoverdose,massivetransfusion) 2+ nition levelgreaterthan2.5mEq/L.(Normal Mg

+ carefullyinpatientswithriskfactors

nesemia Miller’s Anesthesia.

+ loadwithacationexchangeresin(e.g.,

+ >7.0mEq/L)orrenalfailure.

7thed.Philadelphia:ElsevierChurchill

2+ level1.5-2.0

transmitter release. levels depressthecentralnervoussystemandinterferewithneuro- tives) inpatientswithrenalimpairment.Highmagnesium • • • SpecialConsiderations MonitorMg Prevention MonitorMg SubsequentManagement PlasmaMg DiagnosticStudies • DIFFERENTIALDIAGNOSIS MostcommonlycausedbyexcessiveintakeofMg Pathophysiology • •

• • • • • • ImmediateManagement

• • RiskFactors

Acute respiratoryfailure Hyporeﬂ Mg Mg Magnesium andcalciumantagonize eachothers’effects. myasthenia gravisorLambert-Eaton syndrome. Laboratory error Administer furosemide20mgIV. Expand plasmavolumewithanisotonicsolution(LRorNSS). with renalfailure. Acute hemodialysisinseverehypermagnesemiaorpatients Administer CaCl Control theunderlyingcause(i.e.,stopinfusion). Intubate andinitiatemechanicalventilationifindicated. effects ofMg Use ofMg Aggressive treatmentofpre-ecclampsia 2+ 2+ prolongstheaction ofneuromuscularblockingagents. willproduceprofoundmuscleweakness inpatientswith exia 2+ 2+ 2+ ,electrolytes,BUN,creatinine 2+ levelscarefullywhenusingittherapeutically. levelsasappropriate.

containingantacidsorlaxatives

2+ ).

1gIVover5minutes(temporarilyreverses

2+ (especiallylaxa-

103 CHAPTER 5 Metabolic and Endocrine Emergencies 104 CHAPTER 5 Metabolic and Endocrine Emergencies WhangR,HamptonEM,DD.Magnesiumhomeostasisandclin-

• • DIFFERENTIALDIAGNOSIS Free waterlossisthemostcommoncause. Eitherexcessivefreewaterlossorsodiumadministration. Pathophysiology • • • • Presentation • • • • Deﬁ KayeAD,RiopelleJM.Intravascularﬂ uid andelectrolytephysiology.In: FurtherReading

• • • ImmediateManagement

Hypernatrem Hypernatremia

ical disordersofmagnesiumdefi Feb;28(2):220–226. Livingstone; 2010:1713–1714. Miller RD(ed.). Acute liverfailure(useoflactuloseormannitol) Laboratory error hemorrhage Severe hypernatremia:brainshrinkagecausingintracerebral neurologic defi Central nervoussystemsymptoms:confusion,seizures,focal Laboratory fi Profound dehydration Severe: Greaterthan160mEq/L Moderate: 150–160mEq/L Mild: 145–150mEq/L Normal sodiumis135–145mEq/L • • Hypervolemic hypernatremia: • Normovolemic hypernatremia: • Hypovolemic hypernatremia: • •

nition Correct underlyingcause(DDAVP fordiabetesinsipidus) Discontinue Na Free water(.45%salineorD Administer ﬂuids tocorrecthypovolemia patient’s renalfunction Consider furosemide 20mgIVorasappropriatefor the .45% salineorD

nding cits Miller’s Anesthesia

+ 5 i containingsolutions WtocorrectNa a

. 7thed.Philadelphia:ElsevierChurchill 5 WtocorrectNa

cec. ciency.

Ann Pharmacother

+ ) . 1994

Calciumlessthan 8.5mg/dl(ionizedlessthan2.0mEq/L). Defi KayeAD,RiopelleJM.Intravascular fl uid andelectrolyte physiology.In: BagshawSM,TownsendDR,McDermidRC.Disordersofsodiumandwater FurtherReading • • SpecialConsiderations quantities ofsodium-containingfl Followplasmaelectrolytelevelscloselywhenadministeringlarge Prevention • • SubsequentManagement • • DiagnosticStudies

• • • RiskFactors

Hyp Hypocalcemia

Livingstone; 2010:1706–1709. Miller RD(ed.). balance inhospitalizedpatients. equation: Free waterdeﬁcit maybecalculatedusingthefollowing • over thesubsequent16hours NOTE: Correcthalfofthedeﬁcit over8hoursandtheremainder Determine thecauseofhypernatremiaandtreatappropriately. Monitor electrolyteintakecarefully. Urine electrolytesandosmolality Plasma electrolytesandosmolality

Hypervolemic patients:iatrogenic(NaHCO lithium toxicity Euvolemic patients:diabetesinsipidus(nephrogenicorcentral), conjunction withasaltrestricteddiet ACTH, excessivemannitoladministration,loopdiureticusein Hypovolemic patients:openwounds,GIlosses,insufﬁ saline administration) Na Free H Estimate bodywateras0.6L/kginmalesand0.5females. nition + ocalcemia /140)-1) 2 odeﬁcit =Body water(L/kg)×weight(kg)((serum

Miller’s Anesthesia.

Can JAnaesth

uids. 7thed.Philadelphia:ElsevierChurchill

. 2009Feb;56(2):151–167. 3 orhypertonic cient

105 CHAPTER 5 Metabolic and Endocrine Emergencies 106 CHAPTER 5 Metabolic and Endocrine Emergencies

• • SubsequentManagement • • • DiagnosticStudies • DIFFERENTIALDIAGNOSIS Ca Pathophysiology • • • • • • • Presentation the transportandsecretionofﬂuids andelectrolytes.

• • • • • • • • RiskFactors • • ImmediateManagement

Dysrhythmias Prolongation ofQ–Tintervalorheartblock Hypotension Laryngospasm Chvostek andTrousseausigns Tetany Mental statuschanges continuous infusion(lessirritatingtoveins). Maintain normocalcemiawithcalciumgluconategIVbybolusor Investigate thecauseofhypocalcemiaifunknown. Parathyroid hormonelevel Metabolic panel(includingproteinandliverfunctiontests) Plasma electrolytes Laboratory error 2+ Repeat asneededtoreturnionizedCa Administer CaCl Hypomagnesemia Acute panhypopituitarism Thyroidectomy orparathyroidectomy Sepsis Hyperparathyroidism renal failure) Low albuminlevels(criticallyillpatient, sepsis,burns,acute Rapid transfusionofcitratedblood products(1.5mL/kg/min) Acute hyperventilation for symptomstoabate. mediatesmusclecontraction,multipleendocrinefunctions,and

2 1gIVover5minutes

levelstonormal,or

• • • DIFFERENTIALDIAGNOSIS includes atrialfi brillationandprematureventricularcontractions. Arrhythmiaisthemostcommonconsequence ofhypokalemia,and Pathophysiology • • Presentation • • • • Defi KayeAD,RiopelleJM.Intravascularfl uid andelectrolytephysiology.In: FurtherReading • • • SpecialConsiderations • • Prevention

Cor

Hy Hypokalemia necessary. Livingstone; 2010:1711–1712. Miller RD(ed.). CaCl 8–10 unitsofPRBCduringrapidtransfusion. Severe weakness. Severe: Lessthan2.5mEq/L Moderate: 2.5–3.0mEq/L Mild: 3.0–3.5mEq/L Normal potassiumis3.5–5.5mEq/L. albumin causesa0.8mg/dLdropintotalCa hypoalbuminemia usingtherelationshipthata1g/dLdecreasein If ionizedcalciummeasurementisunavailable,correctfor caused bylarge-volumeresuscitationwithisotonicsaline. Hypocalcemia maybeaccompaniedbyhypomagnesemiawhen Alternatively, measureionizedCa Common practiceisempiricadministrationof500mgCaCl Cushing syndrome (manifestationsofhypercortisolemia) Hypomagnesemia Hypocalcemia inverted Twaves,orUwaves. ECG mayshowprolongedPRinterval,STsegmentdepression, available. requires degluconationbeforethecalciumisbiologically nition etdC (gd)=Maue a m/L 08 (-lui(gd) (4-albumin( g/dL)) × 0.8 + (mg/dL) MeasuredCa = (mg/dL) rectedCa p okalemia 2 providesimmediatelyavailablecalcium.Calciumgluconate

2+ Miller’s Anesthesia.

7thed.Philadelphia:ElsevierChurchill 2+

2+ every5unitsandtreatas

;therefore:

2 per 107

CHAPTER 5 Metabolic and Endocrine Emergencies 108 CHAPTER 5 Metabolic and Endocrine Emergencies

• • • SpecialConsiderations hypokalemia. Monitorplasmaelectrolytescarefullywhenpatientsareatriskfor Prevention • SubsequentManagement • DiagnosticStudies

• • • • • • • • RiskFactors

• • • • • ImmediateManagement

treatment, althoughK Mild ormoderatehypokalemiararely requiresemergency transmembrane raises plasmalevels. levels implythatthe intracellularstoreisdepletedbecause Potassium isprincipally anintracellularcation.Lowplasma require severaldaysofintravenous therapytocorrect. potassium torestorenormalplasma andintracellularmay Severe hypokalemiamayrequireas muchas200–300mEqof potassium havebeenadministered. Consider postoperativetelemetrymonitoringafterlargedosesof Plasma electrolytesincludingmagnesium(renalcotransport) Beta-agonist use Salt-wasting nephropathies GI losses(diarrhea,vomiting,intestinalsuction,ilealbladder) hyperventilation) Alkalosis (includingrespiratoryalkalosisdueto Insulin administration Diuretic administration Normal postoperativediuresis Plasma volumeexpansion (e.g., spironolactone). (e.g Consider withholdingpotassium-wastingdiuretics because KCl-containingsolutionsareextremelyirritating. Consider administrationthroughacentralvenouscatheter The patientmusthaveECGmonitoring. monitoring. of life-threateningdysrhythmiaswithcarefulECG Limit KClinfusionto20mEq/hexceptinthesetting Slowly administerKCl20mEqIV. . , furosemide)orswitchingtopotassium-sparingdiuretics

isgenerallyapartofIVmaintenance ﬂ

uids.

DiagnosticStudies PlasmaMg • DIFFERENTIALDIAGNOSIS with large-volumeplasmavolumeexpansion. Hypomagnesemiaiscommonlyassociatedwithhypokalemiaand Pathophysiology • • • • Presentation Mg Deﬁ KayeAD,RiopelleJM.Intravascularﬂ uid andelectrolytephysiology.In: FurtherReading

• • • ImmediateManagement The amount of replacement can be estimated from the plasma level: Theamountofreplacementcanbeestimatedfromtheplasmalevel:

H Hypomagnesemia

Torsade despointes,ventriculartachycardia,ﬁ Livingstone; 2010:1710. Miller RD(ed.). Laboratory error Dysrhythmias Hypertension andangina(coronaryarteryspasm) and Trousseausigns Central nervoussystem:mentalstatuschange,tetany,Chvostek 2+ Administer MgSO To correctadeﬁcit foundonlaboratorystudies: • • For acutearrhythmias: ypomagnesemia

nition levellessthan1.5mEq/L.(NormalMg Administer MgSO Monitor bloodpressureandheartrate 1.0–1.24 1.25–1.49 1.5–1.74 1.75–1.9 2.0–2.25 Mglevel 2+ level,plasmaelectrolyte levels Miller’s Anesthesia.

4 2–4gIVover15minutes.

4 2–4gIVover5minutes.

10.0 gm 8.0gm 6.0gm 4.0gm 2.0gm Replacementdose(IV) 7thed.Philadelphia:ElsevierChurchill

level1.5-2.0mEq/L.)

brillation

109 CHAPTER 5 Metabolic and Endocrine Emergencies 110 CHAPTER 5 Metabolic and Endocrine Emergencies WhangR,HamptonEM,DD.Magnesiumhomeostasisandclinicaldisor-

total bodyNa Mostsurgicalpatients haveadilutionalhyponatremia andnottrue Pathophysiology ataxia, alteredmentalstatus,nausea, vomiting. Dependsonpatient’sfl Presentation • • • • Defi KayeAD,RiopelleJM.Intravascularfl uid andelectrolytephysiology.In: FurtherReading • • • SpecialConsiderations Monitormagnesiumlevelscarefullyduringresuscitation. Prevention FollowMg SubsequentManagement

• • • • • RiskFactors

Hyponatrem Hyponatremia

ders ofmagnesiumdeﬁ Livingstone; 2010:1712–1713. Miller RD(ed.). Hypomagnesemia increasestheriskofperioperativearrhythmias. Severe: Lessthan120mEq/L Moderate: 120–124mEq/L Mild: 125–134mEq/L Normal sodiumis135–145mEq/L. Maintaining plasmaMg with reactiveairwaydisease. constriction. Supplementationmaybeausefulmodalityforthose Hypomagnesemia isassociatedwithbronchialsmoothmuscle atrial dysrhythmiamanagementaswell. Renal losses: loop diuretics, diuretic phase of acute tubular necrosis Renal losses:loopdiuretics,diureticphaseofacutetubularnecrosis Common incriticallyillpatients other hypermetabolicstates. Mild hypomagnesemiaisnormalinathletes,pregnancy,and Large volumeplasmaexpansion Hypokalemia nition 2+

levelandmaintainwithinnormalrange.

+ deﬁ ciency. Dilutionalhyponatremia ischaracterized Miller’s Anesthesia. i a ciency. uid status.Symptomsmayinclude headache,

2+ approximately2.5mg/dLishelpfulin

Ann Pharmacother

7thed.Philadelphia:ElsevierChurchill

. 1994Feb;28(2):220–226.

Measureplasmaelectrolytes frequently Prevention causes permanentneurologicinjury. myelinolysis, anirreversibledemyelinatingdisorderthat CAUTION:Rapidcorrectionmayleadtocentralpontine correction shouldbelimitedto0.5mEq/Lperhour. Afteracutecorrectionto125mEq/Lovertheﬁrst 8hours,additional SubsequentManagement Plasmaelectrolytelevels DiagnosticStudies • • • DIFFERENTIALDIAGNOSIS by lowNa normal tohighurineNa

Sodiumdeﬁcit (mEq)=0.6×bodyweight(kg)(pt’sNa

• • • • • • RiskFactors • • • • ImmediateManagement

Hyperglycemia hyponatremic fl Sample dilution(drawingfromthesamearmasanIVwith Laboratory error Calculate sodiumdeficit usingtheformula: • In patientswithdilutionalhyponatremia: Monitor ECGorhemodynamicsifindicated. Establish IVaccess. Liver failure Syndrome ofinappropriateantiduiretic hormone(SIADH) Adrenocortical insuffi Thiazide diureticadministration or GYNprocedures) Absorption ofirrigationfluid (TURPsyndrome,endoscopic GU Excess freewateradministration(resuscitationwithD5½NS) • •

Na Free waterrestriction hypertonic saline For severe,symptomatichyponatremia,consider3% Furosemide 20–40mgIVifpatientishypervolemic. + ) + butnearlynormalCl

uid)

+ ciency

− accompaniedbydiluteurineanda

+ -desired

111 CHAPTER 5 Metabolic and Endocrine Emergencies 112 CHAPTER 5 Metabolic and Endocrine Emergencies

Myxedematouscoma (hypothyroidism) DIFFERENTIAL DIAGNOSIS induced diuresismayleadtoprofound intravascularvolumedepletion. during surgerythroughradiation,evaporation, andconvection.Cold- the peripheryduetoanesthesia-induced vasodilation.Heatisalsolost or drugoverdose).Duringsurgery,heat istransferredfromthecoreto Heatislostinapatientwithimpaired thermalregulation(e.g Pathophysiology • • • Presentation Amild(32–35°C)orsevere(lessthan32°decreaseintemperature. Deﬁ BagshawSM,TownsendDR,McDermidRC.Disordersofsodiumandwater FurtherReading • • SpecialConsiderations KayeAD,RiopelleJM.Intravascularﬂ uid andelectrolytephysiology.In:

Hypotherm Hypothermia induces freewaterlosswithminimalchangesinsoluteexcretion. in theUS,thoseagentswillreplacefurosemide,becauseADH When ADHantagonisttherapy(i.e.,aquaretics)isreadilyavailable balance inhospitalizedpatients. Livingstone; 2010:1706–1709. Miller RD(ed.). Total bodywateris0.6L/kginmalesand0.5females • • • • Less than28°C • • 28–32° C • 32–35° C • • • •

Ventricular ﬁbrillation orcardiacarrest Electrically silentEEG(iflessthan18°C) Metabolic acidosis(maygetworseonrewarming) Unconsciousness Dysrhythmias Myocardial depression Lethargy andconfusion Coagulopathy Hyperkalemia Shivering Weakness nition

Miller’s Anesthesia. i a

Can JAnaesth 7thed.Philadelphia:ElsevierChurchill

. 2009Feb;56(2):151–167.

. , after injury ,afterinjury

• • SubsequentManagement • • DiagnosticStudies

• • • • • • RiskFactors • • • • • • • • ImmediateManagement

patients whoarrivewithordevelophypothermia. Consider limitingintraoperativetimetolessthan2hoursin biracbonate duringrewarming. It maybenecessarytobuffer“washoutacidosis”withsodium Send thyroidfunctiontestsifhypothyroidismissuspected. Monitor coretemperature. • • • Consider Mg temperature reaches30°C .) guidelines. ( If necessary,beginresuscitationaccordingtoACLS Establish anairwayandventilatewith100%O Airway, breathing,circulation. Major tranquilizers (suppressshivering) Acute alcoholintoxication trauma, craniofacial procedures,extensivebodycavity surgery) Failure toactivelywarmthepatient duringsurgery(especially Impaired levelofconsciousness. Immersion incoldwater. injury). Prolonged exposuretocoldambient environment(e.g.,after setting ofhypovolemiamayleadtolife-threateninghypotension. dangerous. Warming-inducedperipheralvasodilationinthe In severehypothermia,activesurfacewarmingmaybe • Severe hypothermia: • Mild tomoderatehypothermia: Actively rewarmthepatient. • •

( Consider cardiopulmonarybypasssupportandrewarming abdomen) Body cavitylavage(inparticularbladder,andonoccasion GI lavageviaNGT In additiontoabove: Warm IVﬂ Forced-air warmers. Warming blankets best option )

NOTE: Thepatientmaynotresponduntilcore uids 2+ fordysrhythmias.

2 .

113 CHAPTER 5 Metabolic and Endocrine Emergencies 114 CHAPTER 5 Metabolic and Endocrine Emergencies

hypertension. production, itmaybeaccompaniedbycardiovascularcollapseor

• • • • • Presentation Characterized byhyperthermia,bodyrigidity,andincreasedCO a hypermetabolicresponsetotriggeringanestheticagent. Arelativelyrareinheriteddisorderofskeletalmusclethatcauses Deﬁ InslerSR,SesslerDI.Perioperativethermoregulationandtemperaturemoni- FurtherReading • • • • SpecialConsiderations • • • • • • Prevention

MalignantHyperthermia(MH)M warm) toring. Hyperthermia isa latesign. Muscular rigidity(especially massetermusclespasm) Increased CO Hypertension Tachycardia Use activewarmingdevicesforﬂ Use aforcedairwarmingdeviceduringthesurgicalprocedure. Place warmingpadsontheORbed. Cover thepatienttoextentpossible. Warm theOR. area. Use activewarmingdevicesintheORandpreoperativeholding Guidelines onIntraoperativeMonitoring. Temperature monitoringisrecommendedaspartoftheASA norepinephrine, epinephrine,orothervasoactivedrugs. Separation fromcardiopulmonarybypassmayrequire response tohypothermia)andneuromuscularblockingagents. seen intheORduetouseofanesthetics(whichblunt Shivering, acommonsignofcorehypothermiaisnottypically prevent furtherheatloss. acute hemorrhage.Ineachcircumstance,takeprecautionsto suffering fromsepsis,environmentalexposure,orinjurywith Patients whoarehypothermiconarrivalintheORgenerally alignant Hyperthermia nition Anesthesiol Clin

2 production(absorbentcanistermay become

. 2006Dec;24(4):823–837.

uids.

(

)

• • • SubsequentManagement • • DiagnosticStudies • • DIFFERENTIALDIAGNOSIS Inbornerrorofcalciummetabolisminskeletalmuscle. Pathophysiology

• • • • • • • • • • ImmediateManagement

production) at aseparatesitting. caffeine halothanecontracturetesting(CHCT)orgenetic Diagnosis maybeconﬁrmed obtainingamusclebiopsyfor Frequent arterialbloodgasandplasmaelectrolytedetermination Thyrotoxicosis Light anesthesia(hypertensionandtachycardiawithoutCO the episode,because therecurrencerateis25%. Continue dantrolene1mg/kgevery 4–6hoursfor36after bicarbonate. Severe metabolicacidosismayrequire managementwithsodium tubular injuryfromrhabdomyolysis. Maintain urineoutputatleast2mL/kg tominimizeriskofrenal intravenous anestheticsonly. Terminate thesurgicalprocedureasquicklypossibleusing with ice-coldsolution. cold irrigatingsolution.Insertanasogastrictubeandirrigate surgeon tolavageanyopenbodycavity/woundsurfacewith Cool thepatientaggressivelywithcoldIVsolutions.Ask symptoms arecontrolled). Administer sodiumdantrolene(2.5mg/kgIVuntilsignsand ﬂ Expand plasmavolumewith15cc/kgperbolus×3usingcool frequent bloodgasmeasurementsforacid-basestatus). Insert anarterialcatheter(bloodpressuremonitoringand Establish large-boreIVaccess. Hyperventilate thepatientwithanewanesthesiacircuit. Increase FiO (succinylcholine andpotentvolatileanesthetics—N Immediately discontinuetriggeringanestheticagent(s) Call forhelp! uids.

to100%.

2 oissafe)

115 CHAPTER 5 Metabolic and Endocrine Emergencies 116 CHAPTER 5 Metabolic and Endocrine Emergencies

• • • Presentation adrenal medulla. Acatecholaminesecretingchromafﬁn celltumorusuallyfoundinthe Deﬁ BencaJ,HoganK.Malignanthyperthermia,coexistingdisorders,and FurtherReading • • • SpecialConsiderations MH orasuggestivefamilyhistory. Avoidtheuseoftriggeringagentsinpatientswithaknownhistory Prevention •

• • • • RiskFactors

Ph Pheochromocytoma

Oct;109(4):1049–1053. enzymopathies: risksandmanagementoptions. dantrolene, these drugs may cause hyperkalemia and cardiac arrest. dantrolene, thesedrugsmaycausehyperkalemiaandcardiacarrest. Do notadministercalciumchannelblockers.Inthepresenceof Hyperthermia AssociationoftheUnitedStates( to theMHnationaldatabasemaintainedbyMalignant Discuss theepisodewithpatient’sfamilyandaddpatient Myocardial ischemia History ofheadaches, chestpain,andpalpitations tachydysrhythmias Sustained orparoxysmalhypertension, tachycardia,and members forsusceptibility. Because MHisaninheriteddisorder,considertestingfamily concentration. reticulum, andthusservestorestoreanormalmyocytecalcium Sodium dantroleneinhibitscalciumegressfromthesarcoplasmic Rate ofoccurrenceisapproximately1in10,000patients. triggering agents. MHmayoccurdespiteprioruneventfulexposureto during ananesthetic. Family history,especiallyanunexplaineddeathofarelative anesthetics) inapatientwithknownhistoryofMH. Use oftriggeringagents(succinylcholine,potentvolatile nition eoc h

romocytoma

Anesth Analg www.mhaus.org ).

. 2009

• • • • • DIFFERENTIALDIAGNOSIS induced myocarditis. due toincreasedmyocardialoxygendemandorcatecholamine- tachycardia andvasoconstriction.Cardiacmanifestationsmaybe Excessivecatecholaminessecretedbyachromafﬁn celltumorcause Pathophysiology •

• • • • • • ImmediateManagement

Thyrotoxicosis (fever,acidosis,tachycardia) Cocaine oramphetamineuse(toxicologyscreen) Malignant hypertension acidosis) Malignant hyperthermia(fever,mixedrespiratoryandmetabolic Light anesthesia manipulation ofthetumor. Acute crisismayoccurduringinductionofanesthesiaorsurgical • • nitroglycerine should beusedwithcaution. If myocardialischemia refractorytobeta-blockadeis suspected, Discontinue surgeryassoonpractical. Administer ﬂuids asnecessary. • • Return thebloodpressuretoasafelevel. pressure). myocardial depression,whichwillhelptolowertheblood anesthetics (volatilecausevasodilationand Deepen theanestheticwithopioidsorpotentvolatile Immediately discontinueanynoxiousstimulation.

patient’s baseline. Titrate medicationstoreturntheblood pressuretothe vasoconstriction. adrenergic activitymayleadtosevere hypertensionand Beta blockadecombinedwithunopposedalpha- rate onlyafteradequatecontrolofbloodpressure . heart rate). infusion (500mcg/kgIV,then50mcg/kg/mintitratedto Labetalol (20–40mgIVevery10minutes),oresmolol (start at5mg/h). fenoldopam infusion(0.2–0.8mg/kg/min),nicardipine Sodium nitroprussideinfusion(startat1mcg/kg/min), Insert anintra-arterialcathetertomonitorbloodpressure. Use beta-blockingagentstocontrolheart

117 CHAPTER 5 Metabolic and Endocrine Emergencies 118 CHAPTER 5 Metabolic and Endocrine Emergencies

ConneryLE,Coursin DB.Assessmentandtherapyofselected endocrinedis- FurtherReading • • • • SpecialConsiderations • • Prevention • • • • • • DiagnosticStudies

• RiskFactors

orders. and vasodilatoreffects.) (Magnesium inhibitscatecholaminereleaseandhasantiarrhythmic Consider Mg transfer totheSICU) Careful postoperativebloodpressuremonitoring(consider Subsequent management Urinary vanillylmandelicacid(highestspecifi metanephrines (highestsensitivity) Plasma freemetanephrinesandurinaryfractionated adequate circulatingbloodvolume. resection ofaknownphoechromocytoma generallyhavean Patients whohaveundergonepreoperative preparationfor diuresis maybeineffective. and water.Reducingpreloadwithvenodilationorattempted reduced intravascularvolumeduetorenalexcretionofbothsalt pheochromocytoma patient.Thesepatientsgenerallyhave Avoid venodilatorsanddiureticsintheunanticipated preferred overmetoprololorothercardiospecifi Labetalol isavasodilatorinadditiontoitscardiaceffectsand pheochromocytoma. Careful manipulationoftheadrenalglandsinpatientswithknown symptoms suggestiveofpheochromocytoma. Careful preoperativeworkupinpatientswithunexplained collection forfreecatecholamines. Endocrine workuptoconfirm diagnosis,including24–hoururine Hydralazine causesrefl ex tachycardiaandshouldnotbeusedalone. neurofi hyperparathyroidism), vonHippel-Lindausyndrome,or 2 (pheochromocytoma,medullarythyroidcarcinoma, Associated withmultipleendocrineneoplasia(MEN)type Anesthesiol ClinNorth Am bromatosis type1.

2+ (40–60mg/kgbolus),theninfusion2g/h.

. 2004Mar;22(1):93–123.

city)

c beta-blockers.

• • DIFFERENTIALDIAGNOSIS significant quantityinbetween attacks. acute attacksofporphyria.None of theseelementsaccumulatein ates inthehemebiosyntheticpathwaythatareincreasedduring vulinec acidandporphobilinogenaretwocharacteristicintermedi- Thehemeprecursorsarebelievedtobeneurotoxic;delta-aminle- Pathophysiology • • • Presentation of relevancetoanesthesiologists. phyria, andacuteintermittentporphyria(AIP).AIPisthe common typesareporphyriacutaneatarda,erythropoieticpor- (liver) dependingonwheretheaccumulationoccurs.Thethreemost precursors. Classifi ed aserythropoietic(bonemarrow)orhepatic ates thatcausepathologicaccumulationofporphyrinsorporphyrin Afamilyofrelatedenzymedisordershemepathwayintermedi- Defi

Porphyr Porphyria exposure. Porphyria cutaneatarda:skinblisteringrelatedtosun • • • • Acute IntermittentPorphyria: rarely liverfailure. Erythropoietic porphyria:skinlesions,occasionalhemolysis,and May mimicGuillain-Barresyndrome. Acute abdomen(maypresentwith severeabdominalpain). • •

long procedure) anesthetized patientmayfailtoregainmotorfunctionaftera acute postoperativerespiratoryfailureandreintubation.(An Progressive polyaxonalmotorneuropathythatmayleadto autonomic neuropathy CNS symptomsincludingconfusion,hallucinations,seizures, Sympathetic hyperactivity Abdominal pain(possiblyrelatedtoautonomicneuropathy) occurs duringanacuteattack. Reddish coloredurinethatdarkensafterexposuretolight particularly helpfulduringanattack. In betweenattacks,diagnosisisdifﬁcult, butlaboratorytestingis nition

i a

119 CHAPTER 5 Metabolic and Endocrine Emergencies 120 CHAPTER 5 Metabolic and Endocrine Emergencies

• • • • SubsequentManagement • • • DiagnosticStudies

• • • RiskFactors

• • • • ImmediateManagement

Frequent plasmaNa analysis, butisnotusefulintheacutesetting. Genetic testingishelpfulfordiagnosisconfirmation andfamily Admit patientswithacuteprophyria. central IVadministrationispreferred. mg/kg deliveredasasingledailydose.Large-boreperipheralor Administer hemin(Panhemin®);LundbeckInc.,Deerfield, IL,3–4 diagnosis andmanagement. A hematologyconsultationisstronglyrecommendedforacute OR orPACU. RBC, plasma,and/orurinewillhelptomakethediagnosisin Measurement ofbothporphyrinprecursorsandporphyrinsin Urine porphobilinogen(diagnosticofanacuteattack). Dehydration Reduced caloricintake(especiallycarbohydrates) LIST) progesterone, sulfonamideantibiotics channel blocker( anticonvulsants exceptgabapentin), barbiturates,calcium Drugs: Alcohol,angiotensinconverting enzymeinhibitors, Begin aggressivehydrationwithdextrose-containingfl • • • • If atriggeringdrughasbeenused: Anticipate cardiovascularinstability. Withdraw anytriggeringagents. •

at least3Lperday. and maydecreaseALAsynthetaseactivity). Consider beta-blockade(treatshypertensionandtachycardia Administer abolusofD Give oralcarbohydratesorintravenousD Immediately discontinueuseofthatdrug. Monitor closely,withdailyurineporphyrinlevels. kCal/24 h).

especially nifedipine

+ ,K

+ ,andMg

W.BeginD

2+ levelsduringacuteattack.

), ergots,etomidate, (NOT ACOMPLETE 10 W1mL/kg/htodeliver

Winfusion(200

uids.

• • • • • Presentation resulting inacharacteristicsickleshape tothecells. ture thatundergoesaconformational changeatlowoxygentension, Aninheriteddisordercharacterizedbyabnormalhemoglobinstruc- Deﬁ JamesMF,HiftRJ.Porphyrias. FurtherReading • • • • • • • • • SpecialConsiderations • • • Prevention

SickleCellCrisisS Attacks may last for days, generally followed by complete recovery. Attacks maylastfordays,generallyfollowedbycompleterecovery. ALA synthetaseactivity. Anhematin restoresnormalhepatichemelevelsandsuppresses rare. laparoscopy orlaparotomy,althoughfrankperitonitisisquite A misseddiagnosisofporphyriamayleadtoanontherapeutic Acute bloodlossdoesnotseemtoprovokeaporphyricattack. considered tobeunsafe. tolerated, butrepeatexposureoruseduringanacuteattackis In general,asingleexposuretoevenpotentinducersmaybe Morphine, fentanyl,andsufentanilaresafe. widely consideredtobesafebutshouldusedwithcaution. Neuromuscular blockingagents(includingsuccinylcholine)are Inhaled anesthetics,includingN Propofol, ketamine,andbenzodiazepinesareprobablysafe. local anestheticscantriggeranacuteattack. patient’s neurologicstatus.Thereisnoevidencetosuggestthat Consider regionalanesthesiaiffeasibleandafterevaluatingthe elective procedures. early inthedayandundergoplasmavolumeexpansionpriorto Patients withafamilyhistoryofporphyriashouldbescheduled Avoid useofknowntriggeringagents. Priapism Jaundice, hematuria, gallstones Abdominal pain(GIdysfunction,liver orspleeninfarction) Chest painwithpossiblerespiratory failure Painful crisis(especiallybonesorjoints) i c nition k le

ell

C ri s

i s

Br JAnaesth

2 oareconsideredsafe. . 2000Jul;85(1):143–153.

121 CHAPTER 5 Metabolic and Endocrine Emergencies 122 CHAPTER 5 Metabolic and Endocrine Emergencies

• • SpecialConsiderations • • • • Prevention be indicatedinthesettingofsevereanemiaoracuteCNSischemia. Exchangetransfusionstoreducethehemoglobin-Sconcentrationmay SubsequentManagement • • • DiagnosticStudies abdomen. Acuteabdomen(e.g.,appendicitis).Sicklecrisismaycauseanacute DIFFERENTIALDIAGNOSIS occlusive disease. lysis andcapillarythrombosis.Thisleadstochronicanemiavaso- DeoxyhemoglobinSpolymerizes,distortingRBCsandcausinghemo- Pathophysiology

• RiskFactors

• • • • ImmediateManagement

be habituatedtoopioids. Highdosesofmultipleanalgesics are Patients withsickle celldiseaseoftenhavechronicpain andmay trait) mayalsohave crises. more likelytohave anacutecrisis,heterozygouspatients (sickle Although patientshomozygousfor Hgb-S(sicklecelldisease)are improvement inoutcome. Preoperative exchangetransfusion is controversial,withno Avoid acidosis. Maintain adequatehydration. Maintain normothermia Chest X-ray Urinalysis Complete bloodcount(sicklebodies) trait. Approximately1in600hassicklecelldisease. 8% ofAfrican-Americansareheterozygousandhavesicklecell Plasma volumeexpansionwithcrystalloidorcolloidsolutions necessary tocontrolpain. Administer analgesics(morphineorhydromorphone)as Increase FiO as wellenhancingO Therapy isdirectedatrestoringplasmavolumeandRBCﬂ

2 to100%

2 delivery.

• • Diagnosticstudies • • DIFFERENTIALDIAGNOSIS thyroidism, generallyprecipitatedbythestressofsurgeryorinfection. Astateofseveresympatheticoveractivityinthesettingclinicalhyper- Pathophysiology • • • • • • Presentation and release. cathecholamines drivenbyexcessivethyroidhormoneproduction Ahypermetabolicstatecharacterizedbyhighlevelsofcirculating Deﬁ FirthPG.Anesthesiaandhemoglobinopathies. FurtherReading •

• • • ImmediateManagement

ThyroidStormTh

Jun;27(2):321–336. concentration ofmethemoglobin. may bedifﬁcult andrequiremultimodaltherapy. usually requiredforoptimalanalgesia.Postoperativepaincontrol Pheochromocytoma (nofever) acidosis, creatinekinaseiselevatedinMH) Malignant hyperthermia(mixedmetabolicandrespiratory Diaphoresis High fever(105–106F) Tremulousness Hypertension Tachycardia (withorwithoutdysrhythmiaandischemia) Hyperthermia Pulse oximetrymayunderestimateSaO Plasma electrolytes T 80 mgover5minutes, then150mcg/kg/mininfusion. 10 minutes,metoprolol 5mgIVevery10minutes,or esmolol Administer betablockers: labetalol20–40mgIVevery Begin ﬂ Establish large-boreperipheralIVor centralvenousaccess. 3 nition ,freeT y roid Storm uid resuscitation. 4

,TSH

2 by2%duetoahigh

Anesthesiol Clin

. 2009

123 CHAPTER 5 Metabolic and Endocrine Emergencies 124 CHAPTER 5 Metabolic and Endocrine Emergencies

• • SpecialConsiderations response. thyroidism toavoidanexaggerated sympatheticnervoussystem Establishanadequatedepthofanesthesiainapatientwithhyper- Prevention • • • • SubsequentManagement

• • • • • • • RiskFactors Immediate Management(continued)

• • • •

vasoconstrictor (e.g., phenylephrine). Intraoperative hypotension shouldbetreatedwitha direct-acting of theend-organeffectsexcess thyroidhormone. Emergency therapyconsistsofcirculatory supportandblockade An endocrinologistshouldguidesubsequentmanagement. Begin elementaliodineafterstartingantithyoidmedication. methimazole. (Bothareoralpreparations.) Load withanti-thyroidmedication:propylthiouracil(PTU)or intubation andmechanicalventilation If thepatientisalreadyintubated,considerpostoperative surgery Excessive manipulationofahypertrophicthyroidglandduring Excessive thyroidhormonereplacement Preeclampsia Trauma patient withpreexistinghyperthyroidism Infection orseriousillness(e.g.,myocardialinfarction)ina Cessation ofantithyoidmedications contrast agents) Recent iodinetherapy(radioiodineoriodine-containing 6 hours. mg IVevery6hoursorhydrocortisone100 since theymightcauseshivering). If necessary,institutetopicalcoolingmethods(lessdesirable Administer acetominophenorNSAIDstodecreasefever. Supplement Mg glucocorticoids blockconversionofT Administer glucocorticoids(possibilityofadrenalinsufﬁ

asneeded.

3 toT

4 ): dexamethasone4 ciency;

• • DiagnosticStudies • DIFFERENTIALDIAGNOSIS neuro toxicity(ifglycine-containingsolutionisused). of irrigatingsolutionleadstohyponatremia,circulatoryoverload,or the circulationthroughopenvenoussinuses.Excessiveabsorption Nonionicirrigatingsolution(mannitol,glycine,orsorbitol)enters Pathophysiology • • Symptomsofhyponatremia,including: Presentation 2% ofpatients. transurethral resectionofaprostatemass.Occursinapproximately Systemicabsorptionofﬂ uids usedforbladderdistensionduringa Deﬁ ConneryLE,CoursinDB.Assessmentandtherapyofselectedendocrinedis- FurtherReading

• • • • ImmediateManagement

TURPSyndrome

orders. • • • Congestive heartfailure(CHF) • Cardiovascular symptoms: • CNS manifestations: Plasma electrolytes CBC •

within 6hourspost-op). TURP syndromeisusuallytime-limited (generallyresolves creatinine. Administer furosemide(20mgIV); adjust doseforpreoperative Send bloodforplasmaelectrolytelevels.(Na Discontinue administrationofirrigationﬂ Myocardial ischemiaanddysrhythmia Bradycardia Nausea andvomiting Hypertension Confusion Diplopia nition Anesthesiol ClinNorthAm S yndrome

. 2004Mar;22(1):93–123.

uid.

+ )

125 CHAPTER 5 Metabolic and Endocrine Emergencies 126 CHAPTER 5 Metabolic and Endocrine Emergencies

MalhotraV.Transurethralresectionoftheprostate. FurtherReading • • SpecialConsiderations changes) Consideruseofregionalanesthesia(permitsearlydetectionCNS Prevention • • SubsequentManagement

• • • • RiskFactors

solution maycausetransientblindness. hyponatremia (<120mEq/L,orthosewithneurologicsymptoms). Consider hypertonic(3%)salineinpatientswithsevere Careful postoperativemonitoringuntilsymptomsabate. Careful attentionshouldbepaidtoreplacementofbothK space. Acutecellswellingandlysismayoccur. and intotheinterstitiumaswellextravascularintracellular water alongitsconcentrationgradientoutoftheplasmaspace Acute reductioninplasmasodiumcontentforcesmigrationof and Mg Am Glycine-containing solution(maycausetransientblindness) Large prostate,extensiveresection High irrigatingpressure(heightofbagabovepatient) absorbed per40minutesoperatingtime) Prolonged operativetime(Approximately1literofﬂ . 2000Dec;18(4):883–897. 2+ ifdiureticsareadministered.Useofglycine-containing

Anesthesiol ClinNorth uid

Chapter 6 Miscellaneous Problems Keith J. Ruskin

Acute Transfusion Reaction 128 Bone Cement Implantation Syndrome (BCIS) 130 Burns 131 Drug Extravasation 133 Intra-arterial Injection 135 Occupational Exposure 137 Operating Room Fire 139

127 128 CHAPTER 6 Miscellaneous Problems • DiagnosticStudies • • DIFFERENTIALDIAGNOSIS intrinsic systemofcoagulation. commonly occurswhenRBCproductsarereleasedandactivatethe in thedistaltubules.Disseminatedintravascularcoagulation(DIC) versial, buttheprevailinghypothesisisthathemoglobinprecipitates body andcomplement.Theprecisecauseofrenalfailureiscontro- Intravascularhemolysisofredbloodcellscausedbyrecipientanti- Pathophysiology • • Presentation type mismatch. body andcomplement.Usuallyoccursinresponsetoamajor(ABO) Intravascularhemolysisofredbloodcellscausedbyrecipientanti- Deﬁ • • • • • • ImmediateManagement • • • •

AcuteTransfusionReactionTrans

patient’s bloodfor repeatcrossmatch. Send suspectedunittobloodbank withanothersampleof Delayed transfusionreaction(transfusionswithin2–21days) Sepsis Hypotension Variable symptoms,manyofwhicharemaskedbyanesthesia. Febrile transfusionreaction(directantiglobintest) and ﬂ An awakepatientmaycomplainofnausea,fever,chills,andchest Bleeding diathesis Hemoglobinuria administration. Maintain urineoutputat75–100cc/hourwithgenerousIVﬂ Stop thetransfusion. Consider mannitol12.5–50gIV. Consider furosemide20–40mgIV. Maintain bloodpressureasneeded. then additionaldosesasnecessaryto achieve urinepHof8). Alkalinize theurinetopHof8withsodiumbicarbonate.(0.5–1mEq/kg, nition ank pain.

i on React

uid

MillerRD.Transfusiontherapy.In: RD(ed.). FurtherReading patients. undetectable. Severehemolyticreactionsarefatalin20%–60%of vent, sincetheyrequireverylowlevelsofantibodythatmaybe ally manifestasadropinhematocrit.Theyaredifﬁ cult topre- days and3weeksafteradministrationofbloodproducts,usu- Delayedhemolytictransfusionreactionsmayoccurbetween2 SpecialConsiderations Useextracautionwhenadministeringbloodproducts. Prevention • SubsequentManagement • • • • • • • • RiskFactors

necessary) toensureadequaterenalbloodfl Maintain normotension(usingfluids andvasoactivedrugsas Send urineforhemoglobinuria. and hemoglobinemia. Send abloodsampletobankfordirectantiglobulintest, Philadelphia: ElsevierChurchillLivingstone; 2005:1815–1817. Send urineandserumsamplesforhemoglobinconcentration. Consider ahematologyconsult. time, andfi Send bloodsamplesforplateletcount,partialthromboplastin serial numbercarefully. Labeling errors—checkthepatient’sunitnumberandblood loss ortraumasurgery. Rushed orincompletecheck-in,especiallyduringrapidblood nurses. have leftthebloodbankandarecommittedbyphysicians incompatibility. MosterrorsoccurAFTERthebloodproducts The majorityoftransfusionreactionsareduetoABO

brinogen level.

Miller’s Anesthesia. ow.

6thed.

129 CHAPTER 6 Miscellaneous Problems 130 CHAPTER 6 Miscellaneous Problems • • • SubsequentManagement • DiagnosticStudies • DIFFERENTIALDIAGNOSIS activation hasalsobeenproposedasamechanism. release ofvasoactiveorpro-inﬂ ammatory mediators.Complement include embolicshowerscausingeitheradirectmechanicaleffector ThepathophysiologyofBCISisunknown.Proposedmechanisms Pathophysiology • Presentation implantation. nary vascularresistancefollowingmethylmethacrylatecement Hypoxia,hypotension,cardiacdysrhythmias,orincreasedpulmo- Deﬁ • • • • • ImmediateManagement • •

Syndrome (BCIS)S BoneCementImplantation anesthesia Dyspnea and/oralteredmentalstatusinpatientsunderregional patients vasopressors) ultrasonography mayrevealthepresence ofemboli. Transesophageal echocardiography orprecordialDoppler whether toproceed ifasecondjointreplacementis planned. Advise thesurgical teamoftheeventandmakeadecision asto diagnostic studies. BCIS isaclinicalsyndromewithout speciﬁ Anaphylaxis Decreasing end-tidalcarbondioxide(ETCO Cardiac dysrhythmiasorcardiacarrestmayoccur. hypotension, pulmonaryedema,minimalresponsetoﬂ Myocardial infarctionorcardiacfailure(ECGchanges,prolonged Massive pulmonarythromboembolus(prolongedhypoxemia) BCIS isusually transientand resolvesspontaneously

yndrome Increase FiO phenylephrine orepinephrineinfusion. phenylephrine (100µgIV)boluses.Ifrefractory,consider Support bloodpressurewithephedrine(5mgIV)or Initiate aggressiveresuscitationwithIVﬂ nition C ement Implantation

2 to100%. ( B

I S)

uids. c conﬁ rmatory 2 )inventilated

uids or

• Presentation degree burnsinvolvemuscle,fascia, andbone. destruction ofthedermisandmustbeexcisedgrafted.Fourth- require excisionandgrafting.Third-degreeburnsinvolvecomplete spontaneously. Second-degreeburnsinvolvethedeepdermisand First-degreeburnsinvolveepidermisandupperdermisheal Deﬁ DonaldsonAJ,ThomsonHE,HarperNJ,KennyNW.Bonecementimplanta- FurtherReading sion orhypoxemia. dic prostheses.Someofthesepatientsdeveloptransienthypoten- transesophageal echocardiographyduringimplantationoforthope- Intravascularemboliofair,bonemarrow,orfatcanbeseenon SpecialConsiderations ing inhigh-riskpatients. implantation, andconsiderationofinvasivebloodpressuremonitor- tration, increasedvigilanceduringandimmediatelyafterprosthesis TheseverityofBCISmaybereducedbygenerousﬂ Prevention • • • • • • RiskFactors •

B Burns

tion syndrome. Thermal traumaafterexposureto ﬂames inanenclosed space drugs. venous catheterformonitoringandadministrationofvasoactive ventricular failure.Inthiscase,considerplacementofacentral Prolonged episodesmayoccurandshouldbetreatedasright insensate. spontaneously. Full-thickness burnsdonotblanchand are Partial-thickness burns arered,blanchwhentouched, andheal Chemical burnsafterindustrialaccidents accidents Thermal traumaafterairplane,motor vehicle,orindustrial More commoninelderlyordebilitatedpatients Rare inhealthypatients May beassociatedwithsurgicaltechnique u nition r ns

Br JAnaesth

. 2009Jan;102(1):12–22.

ud adminis- uid

131 CHAPTER 6 Miscellaneous Problems 132 CHAPTER 6 Miscellaneous Problems • • • • DiagnosticStudies may causehypovolemicshock. edema. Extensiveﬂ uid lossfromtheinjuryandmassiveﬂ Hypoxemia mayresultfromlunginjury,atelectasis,andairway suppression, sepsis,multipleorganfailure,andproteincatabolism. of interleukinsandtumornecrosisfactor,resultinginimmuno- Severeburnscausemultiplesystemicreactions,includingrelease Pathophysiology • • • • • ImmediateManagement • • • •

from burningplastics). Lactic acidlevel(lactic acidosismayindicatecyanide poisoning carboxyhemoglobin level Arterial bloodgas,includingco-oximetry todetermine Blood electrolytes and back18%each. each upperextremity9%;lower extremity18%;torsofront Surface areacanbeestimatedbythe RuleofNines:Head9%; apparent) and airwayobstruction(airwayinjurymaynotbeimmediately Airway injuryfromsmokeinhalationpresentwithdyspnea

Fluid Requirements=TBSAburned(%)×Wt(kg)4mL injury. EstimaterequirementsaccordingtotheParklandformula: resuscitation ispreferredinthefi greater than15%totalbodysurfacearea(TBSA).Crystalloid Begin aggressivefluid resuscitationinpatientswithburns toxicity. half overnext16hours. Administer 1/2oftotalrequirementinfirst 8hours;givesecond considered. severe facialorairwayinjury,butothertechniquesmaybe intubation withtopicalanesthesiaispreferredinpatients Secure theairwaywithanendotrachealtube.Awakefi patent airway. Immediately administer100%O pulmonary arterypressures. Fluid managementisguidedbyurineoutput,CVP,or After intubation,maintainahighFiO sodium nitrate3%solution,andhydroxycobalamin. If cyanidetoxicityissuspected,administersodiumthiosulfate, contamination ofunitorstaff. If achemicalburnissuspected,usecautiontoprevent

2 rst 24hoursfollowingburn byfacemaskinpatientswitha 2 duetotheriskofCO

beroptic uid shifts uid

HettiaratchyS,PapiniR.Initialmanagementofamajorburn:II—assessment • • Presentation sue orperivascularspace. Unintentionalinjectionofdrugsor ﬂ uids intothesubcutaneous tis- Deﬁ HettiaratchyS,PapiniR.Initialmanagementofamajorburn:I—overview. FurtherReading • • SpecialConsiderations See“OperatingRoomFires”Onpage139. Prevention • SubsequentManagement • • • toxic smoke. resistant” plasticdrapeswillburninthepresenceofO Firesintheoperatingroomduetoelectrocauteryorlasers.“Fire Riskfactors

DrugExtravasationDru and resuscitation. BMJ Discomfort, swelling orhyperemiaatthesiteof catheter. Pain oninjectionor duringinfusionoffl the burninjury. after aburn,butthatmustbeavoidedfor12months Succinylcholine isgenerallysafetousewithinthefirst fewhours be confusedwithunburntskin.Fullthicknessburnsdonotbleed. Full-thickness burnsappearwhite,waxy,orleatherlikeandmay temperature ashighpossible. air warmers,fluid warmersasnecessary.Keeptheroom Maintain normothermia.Usewarmingblankets,forced- may occurforupto10weekspostinjury. Resistance tonondepolarizingneuromuscularblockingagents suspected. a pressurechamberisavailable,andsevereCOpoisoning Consider hyperbaricoxygentherapyifthepatientisstable, Use topicalantibioticstopreventinfection. nition . 2004Jun26;328(7455):1555–1557. g Ex

travasation

BMJ 2004Jul10;329(7457):101–103.

uids.

2 andrelease

133 CHAPTER 6 Miscellaneous Problems 134 CHAPTER 6 Miscellaneous Problems there isanydoubt, administerasmalltestdoseofdrug ﬁ throughout thesurgical procedure.Avoidusing“positional” IVs.If Whenever possible,placeIVswhere theycanbevisuallyinspected AvoidplacingIVcathetersover joints(e.g.,antecubitalfossa). Prevention • DiagnosticStudies of pulsedistaltoinjectionsite) Intra-arterialinjection(severeburningpain,discoloration,orabsence DIFFERENTIALDIAGNOSIS pressure, ﬂuid osmolalityorcytotoxicity,vasoconstriction. Tissueinjuryoccursforavarietyofreasons,includinghydrostatic Pathophysiology • • • • • • ImmediateManagement • • • • • • RiskFactors • • •

Clinical diagnosis—nodiagnosticstudiesarenecessary. injury. Severe cases:Compartmentsyndrome;muscle,tendon,ornerve Paresthesias orlocalindurationoftheskin(latesigns). Document theinjuryinpatient’schart. Subsequent management Observe thesitecarefullyforatleastseveraldays.

There isnodefinitive treatmentforextravasationinjury. complains ofseverepainorsignsextravasationarenoted. Stop druginjectionorfluid administrationifthepatient fl In thecaseofvesicants(e.g.,adriamycin),stabincisionsand Specifi Consider vascularorplasticsurgeryconsultation. phentolamine infi Extravasation ofvasopressorshasbeentreatedwith Location ofcatheter High infusionpressure Access sitesincloseproximitytotendons, nerves,orarteries Multiple puncturesofthesamevein ushing with500mLofnormalsalinehasbeenrecommended. c treatmentdependsontheextravasatedsubstance.

ltration.

rst.

• • DIFFERENTIALDIAGNOSIS arteritis, ordrug-inducedtissueinjury. Pallor,ischemia,andpainmayoccurduetovasospasm,chemical Pathophysiology • • Presentation tally insertinganintravenouscatheterintoartery. injection intoanindwellingintra-arterialcatheter,orafteracciden- Unintentionalinjectionofdrugsorﬂ uids intoanartery,usuallyby Deﬁ SchummerW,C,BayerO,MüllerA,BredleD,KarzaiW. FurtherReading should thereforebegiventhroughthedistallumen. sel ifthecatheteriswithdrawnevenafewcentimeters.Vessicants venous catheterisusedbecausetheproximalportmayexitves- port thesepractices.Extravasationcanoccurevenwhenacentral presses arecommonlyrecommended,thereislittleevidencetosup- Althoughelevatingtheextremityandapplyingwarmorcoldcom- SpecialConsiderations • • ImmediateManagement

Intra-arterialInjectionInt Mar;100(3):722–727. Extravasation injuryintheperioperativesetting. be associatedwithdistalblanching or mottlingoftheskin. Some drugs(e.g.,propofol)causepain oninjection.Thiswillnot of theskin) of thecatheter;latesignsincludeparesthesiasorlocalinduration Drug extravasation(discomfort,swellingorhyperemiaatthesite site inanawakepatient. Anesthesia ormuscleweaknessmayoccurdistaltotheinjection distribution ofthevessel. Pain oninjectionorduringinfusionofﬂuids, possiblyinthe Skin pallororcyanosisdistaltotheinjectionsite. complains ofpain, ordistalpallorisnoted. Stop druginjection orﬂuid administration ifthepatient nition r a-arterial In

ection

Anesth Analg.

2005 135 CHAPTER 6 Miscellaneous Problems 136 CHAPTER 6 Miscellaneous Problems • • • • • • Prevention • • • DiagnosticStudies • • • meit aaeet (continued) Immediate Management • • • • • RiskFactors • •

Observe thesitecarefullyforatleastseveraldays. Consider intra-arterialthrombolyticinjection. extremity). continuous brachialplexusblock(ifcatheterislocatedinupper Consider sympatholysiswithastellateganglionblockor risk ofcompartmentsyndrome. Extremity shouldbeelevatedtodecreaseedemaandreducethe Document theinjuryinpatient’schart. in apatientwithanarterialcatheter. Always verifythatdrugsarebeinginjected intothecorrecttubing Subsequent management arteriovenous fistula, thistestisnondiagnostic.) implies thatthecatheterisintra-arterial.(Ifpatienthasan Transduce thecatheter.Highpressuresoranarterialwaveform Clinical diagnosis of blood. Before injectinga drug, carefullyobserveIVtubingfor backfl not besotightas to occludearterialbloodfl When insertinganintravenouscatheter, thetourniquetshould location. Never assumethatanindwellingcatheter isinthecorrect

Consider anticoagulationwithintravenousheparininfusion. the cathetercanbeﬂushed andthereisnoclot. and treatment.Beginaslowinfusionofisotonicsalinesolutionif Leave thecatheterinplaceforsubsequentdiagnosticstudies (30 mg). Consider intraarteriallidocaine2mg/kgandpapaverine Darkly pigmentedskin Morbid obesity Pre-existing vascularanomaly rotation ofthearm) Thoracic outletsyndrome(pulsedecreaseswithinternal

ow.

care worker. Exposuretoblood-bornepathogensresultsininfectionofahealth Pathophysiology • • Presentation needle) orsplashingfl uids intoexposedmucosa. body fl uids bypuncturingtheskinwithacontaminated object(e.g., Inoculationofahealthcareworker(HCW)withinfectiousbloodor Defi SenS,ChiniEN,BrownMJ.Complicationsafterunintentionalintra-arterial FurtherReading outcome. and rapidinitiationoftreatmentofferthebestchanceagood diate recognitionoftheproblem,discontinuationirritant, are basedonindividualcasereportsorsmallseries.Vigilance,imme- none havebeendefi nitively proven towork.Allrecommendations Althoughmanytreatmentstrategieshavebeenrecommended, SpecialConsiderations • • • • • ImmediateManagement

OccupationalExposureOccu

Proc injection ofdrugs:risks,outcomes,andmanagementstrategies. wound. Blood orbodyﬂuids splashedintotheeyes,mouth,oranopen Injury withaneedleorothersharpobject. pathogen. Post-exposure prophylaxis dependsonthetypeofsuspected followed. Federal (US)andstatereportingrequirements mustalsobe protocol; thisprotocolshouldbefollowed. All healthcareinstitutionshaveanoccupational exposure should beirrigatedcopiouslywithnormal saline. If exposurewasthroughexposedmucous membranes,they use willreduceriskofinfection. antiseptics isnotcontraindicated,buttherenoevidencethat Wash thewoundliberallywithsoapandwater.Useof nition . 2005Jun;80(6):783–795. p ation

a l Ex

osure

Mayo Clin 137 CHAPTER 6 Miscellaneous Problems 138 CHAPTER 6 Miscellaneous Problems • • Prevention • DiagnosticStudies • • • • • • • • • • • • • RiskFactors

handed techniqueshouldbeused. Do notrecapneedlesifpossible.If recappingisnecessary,aone- Always usestandardprecautions. unknown. Testingusuallyrequirespatientconsent. antibody (anti-HCV),andHIVantibody)ifhisorherstatusis pathogens hepatitisBsurfaceantigen(HBsAg),Cvirus The patientshouldbetestedforthepresenceofbloodborne available. Needleless orprotectedneedledevices shouldbeusedwhen 6–12 weeksand6months. undergo baselinetestingforHIVantibodyandfurtherat If exposuretoHIVissuspected,thehealthcareworkershould aminotransferase withfollow-upin4–6months. should undergobaselinetestingforanti-HCVandalanine If exposuretoHCVissuspected,thehealthcareworker Needles shouldnot beheldwhiletyingsutures. systems shouldbe usedwhenpractical. Sharp objectssuch asneedlesorscalpelswithengineered safety There isnoprophylaxisforexposuretohepatitisC. active immunity. hours, andthehepatitisBvaccineshouldbeofferedtoconfer hepatitis Bimmuneglobulinshouldbeadministeredwithin24 If exposurewastohepatitisBandtheHCWissusceptible, Subsequent management tolerated. 24 hoursofexposureandbecontinuedfor4weeksif of HIVtransmission.Prophylaxisshouldbeginwithin placed ona2-or3-drugregimendependingtherisk If thesourcepatientisHIVpositive,HCWshouldbe personnel. increase theriskofneedlestickinjuriesinmedical Long workhoursandfatiguehavebeenreportedto study) Two-handed recappingofneedles(13%exposuresinone devices Use ofstraightsutureneedlesforsecuringvascularaccess protection Use oflarge,hollowboreneedleswithoutengineered

chloride (HCl),and cyanide. Burning plastic(e.g., surgicaldrapes)canproduce CO,hydrogen smoke, butnotenough heattoactivateoverheadsprinkler systems. Operating roomfi res canproducesignifi cant amounts oftoxic dizer (O Threeelementsmustbepresent: fuel (e.g.,alcoholorplastic),oxi- Pathophysiology • • • • Presentation head andneck,oranyotherportionofthesurgicalfi Aninfrequentbutcatastrophiceventthatcaninvolvetheairway, Defi FismanDN,HarrisAD,RubinM,SorockGS,MittlemanMA.Fatigue BerryAJ.Needlestickandothersafetyissues. FurtherReading patient careresponsibilitiesasrecommendedbytheCDC. worker whodevelopshepatitisBorCshouldmodifyhisher tissue duringthepostexposurefollow-upperiod.Ahealthcare Exposed healthcareworkersshouldnotdonateblood,plasma,or exposed individualshouldbecounseledregardinginfectioncontrol. who hasbeenexposedtohepatitisBorCHIV,althoughthe no needtomodifythepatientcareresponsibilitiesofanindividual this documentshouldbeavailableatallclinicallocations.Thereis tocol ismaintainedinthepolicyandproceduresmanual.Acopyof Acopyofthehealthcareinstitution’soccupationalexposurepro- SpecialConsiderations • •

OperatingRoomFireOperatin Appearance ofsmokeonthesurgicalﬁ eld orfromunderthedrapes A puffofsmokeandpossiblyaﬂ ash oflightinanendotrachealtube Jan;28(1):10–17. results fromacase-crossoverstudy. increases theriskofinjuryfromsharpdevicesinmedicaltrainees: solutions) isthefuel. Flames maynotbevisible,especially ifalcohol(fromprep A “popping”soundmaybeheard. whenever riskofexposureispresent. Barrier precautions(gloves,masks,eyeshields)shouldbeused secure vascularaccessdevices. Staples shouldbeusedinsteadofsutureswithstraightneedlesto Sep;22(3):493–508, vii. nition 2 orN

g 2 O),andanignitionsource(electrocautery orlaser).

R oo

m Fire

Infect ControlHospEpidemiol

Anesthesiol ClinNorthAm eld. . 2007 . 2004

139 CHAPTER 6 Miscellaneous Problems 140 CHAPTER 6 Miscellaneous Problems • • • Prevention • SubsequentManagement immediately. mine theignitionsource,fuel,oxidizer,andlocationoffire Thereisnotruedifferentialdiagnosis.Itimportanttodeter- DIFFERENTIALDIAGNOSIS • • • • RiskFactors • • • • ImmediateManagement • • • • •

extinguishers and fi brought intotheoperating room.Knowthelocation offi A responseplanshould beformulatedbeforethepatient is from thepatientbeforeusingelectrocautery. Be certainthatflammable prepsolutionshavebeen removed Minimize FiO Subsequent managementdependsonthelocationoffi Abort thesurgicalprocedureassoonitissafetodoso. necessary. Determine whetherevacuationoftheoperatingroomis into contactwithotherfl Bringing hotitems(i.e.,halogenlampsorcameralightsources) Use oflasersurgicaldevices discontinue O (Disconnect anesthesiacircuitfrompatientforairwayfi Contain thefire byremovingtheoxidizerfromfuel. alarm. Rescue patentsorstaffinimmediatedanger.Activatethefi RACE: Rescue,Alert,Contain,Extinguish. of fuelandoxidizer. Specifi Extinguish flames ifitissafetodoso. Use ofO solutions Use ofelectrocauteryafterapplicationalcohol-basedprep of thefi back andforthacrossthefi Evacuate theroomifnecessary. PASS: c actionsdependuponthelocationoffi re andsource Pull re, 2 enrichedgasadjacenttoelectrocauteryorlaser thepintoactivateextinguisher,

Squeeze 2 wheneversurgerywilltakeplacenear theairway. 2 .) re blankets.

thetrigger,and

ammable items re.

Sweep

theextinguisher

Aim atthebase re, re re.

RinderCS.Firesafetyintheoperatingroom. EhernwerthJ,SiefertHA.Electricalandfi re safety.In:BarashPG,CullenBF, FurtherReading ABC (canbeusedonallfi guisher forthefire inprogress.MostextinguisherstheORaretype B (liquidsorgrease),andC(electrical).Besuretousetherightextin- Therearethreetypesoffire extinguishers:A(paper,cloth,plastics), SpecialConsiderations Dec;21(6):790–795. Wilkins; 2006:169–173. Stoelting RK. Clinical Anesthesia

res).

, 5thed.Philadelphia:LippincottWilliams& Curr OpinAnaesthesiol. 2008 141 CHAPTER 6 Miscellaneous Problems This page intentionally left blank Chapter 7 Neurosurgical and Neurologic Emergencies Ira J. Rampil

Autonomic Hyperreﬂ exia 144 Closed Head Injury 145 Dystonic Reactions 148 Intracranial Hypertension 150 Penetrating Head Injury 152 Spinal Cord Injury 155 Subarachnoid Hemorrhage (SAH) 157 Venous Air Embolism (VAE) 161 143

144 CHAPTER 7 Neurosurgical Emergencies

• • • DIFFERENTIALDIAGNOSIS occur whentheinjuryisaslowT10. when thespinalinjuryisaboveT6level,buthyperrefl the bowelorbladder.Severehyperrefl exia iscommon(50–90%) commonly, thisrefl ex istriggeredbystretchofa holloworganlike of sensorystimulusmaycauseamassivesympatheticdischarge.Most below thelesion.Insomecases,arefl ex arcdevelopsandanyform plantar reflex) asnewsynapticcircuitsformintheindependentcord the rostralCNS.Aseriesofabnormalrefl exes develop(e.g.,the neurons belowthelevelofinjuryfromdescendingcontrolby Spinalcordinjuryreleasesspinalpreganglionicsympatheticmotor Pathophysiology • • • • • Presentation nal cordinjury. charge ofsympatheticspinalneuronsbelowthelevelchronicspi- Amedicalemergencythatiscausedbymassiveautonomousdis- Defi

• • • • ImmediateManagement

AutonomicHyperreﬂ

subarachnoid block. in patientswithanoldspinalcordinjury.Itisunlikelyduring Autonomic hyperreflexia canoccurduringgeneralanesthesia Light anesthesia Essential hypertension Pheochromocytoma Blurred orspottyvisioninawakepatients Headache inawakepatients spinal injury Diaphoresis, erythemaandpiloerectionabovethedermatomeof associated baroreceptor-refl Sudden significant increaseinsystolicbloodpressurewith infusion. swallow; ifnotawake, considernitroprussideornitroglycerine If thepatientisawake, considernifedipine10mg,bite and hyperrefl If anesthesiaisplannedforapatient withahistoryof volatile agent. If thepatientisanesthetized,increase concentrationofpotent Insert aFoleycathetertoemptythe bladder. nition exia, considerneuraxiallocalanesthesia.

ex bradycardia exia

exia may exia

nal dysfunction.More forcefulinjuriesmaycausea cerebral surface lead todetectible anatomicinjury,butmaycausetransient neuro- Injuryisproportional toforceofimpact.Asmallimpact maynot Pathophysiology • • • • • • Presentation lead todelayedneuronalnecrosisandsecondaryarterialvasospasm. leading toischemia.Biochemicalderangementssuchasexcitotoxicity ity, respiratorydepression,andincreasedintracranialpressure(ICP) ries occurasaresultofvascularinterruption,cardiovascularinstabil- Abruptconcussiveorshearinginjurytobraintissue.Secondaryinju- Deﬁ Karlsson AK.Autonomicdysfunctioninspinalcordinjury:clinicalpresentation ParalyzedVeteransofAmerica/ConsortiumforSpinalCordMedicine.Acute FurtherReading concentration toprovidemotorblockade. consider asubarachnoidblockwithlocalanestheticofsufﬁ Ifsurgeryinvolvesanareaenervatedbelowthecordinjurylevel, Prevention ide, mecamylamine,orphenoxybenzamine. Iflong-termtherapyisrequired,consideroralwithdiazox- SubsequentManagement

• • RiskFactors

ClosedHeadInjury

of symptomsandsigns. guidelines.gov of America(PVA);2001Jul.29p.[138references].Availablefrom presenting tohealth-carefacilities.WashingtonDC:ParalyzedVeterans management ofautonomicdysreﬂ History ofimpactorsharpaccelerationhead May havesluggishpapillarylightreﬂ hypotension Possible autonomicsignsincluding bradycardia, pallor, Possible seizure Lethargy Brief lossofconsciousnessor“seeingstars” Male gender(4:1) Spinal cordinjuryaboveT6 nition

Prog BrainRes

exia: individualswithspinalcordinjury . 2006;152:1–8. ex

cient http:// 145 CHAPTER 7 Neurosurgical Emergencies 146 CHAPTER 7 Neurosurgical Emergencies

• • DiagnosticStudies • • • DIFFERENTIALDIAGNOSIS supply. shear theneuropilandwhitemattertractsalongwiththeirvascular tentorial duraandbrainstemarefi xed inposition.Thesemotions tively free-floating cerebrummovesintheskullwhilefalcineand Increasing theforceofimpactwillleadtodeeperinjuriesasrela- confi ischemia andedema.Injuredareaswilloftenbeinacoup-contrecoup contusion withlocaldestructionofneurons,petechialhemorrhage,

• • • • • • • • • • • ImmediateManagement

Chronic subduralhematoma Serial arterial bloodgasanalysis Plasma electrolytes, completebloodcount,toxicology screen Penetrating headinjury(includingany skullfracture) Subarachnoid hemorrhage from vascular malformation or aneurysm. Subarachnoid hemorrhagefromvascular malformationoraneurysm. rapid-sequence inductioniftheclinicalsituationpermits. contraindicated becauseofriskbasilarskullfracture.Consider with axialcervicalspinestabilization.Nasalintubationis Defi intracranial injury. Obtain anemergencyCTscantodetermineextentof clopidogrel orotheranti-plateletdruguse. Transfuse plateletsifpatienthasahistoryofNSAID, Obtain bloodfortypeandcrossmatch. mmHg. Useinotropesorvasopressorsasneeded. mean arterialbloodpressure(MAP)>90mmHgorCPP60 BP tomaintaincerebralperfusionpressure(CPP).Maintain Patients withsevereheadinjurymayrequirehigherthannormal Avoid glucose-containingorhypotonicsolutions. saline orcolloidsolutionstorestorenormalbloodpressure. Aggressively treathypotension:fluid resuscitatewithnormal Administer sedationwhenneurologicassessmentiscomplete. Initiate mechanicalventilationtomaintainPaCO Increase FiO and possibledrainageofcerebrospinal fl placement ofanintraventricularcatheter formonitoringICP Patients withsevereinjuryrequire evacuation ofhematomaor bridge todefi Administer mannitol0.5g/kgasneededtodecreaseICPa 30–35 mmHg. guration (skull-braininterfaceontheoppositesiteofimpact). nitive airwaymanagement:Oralendotrachealintubation 2 nitive therapy. tomaintainadequateoxygenation.

uid (CSF).

between

RopperAH,GorsonKC.Clinicalpractice:concussion. FurtherReading • • • SpecialConsiderations in thehospitalsetting. Patientstypicallypresentwiththisinjury;preventionisnotfeasible Prevention • • • • SubsequentManagement •

al . Table7.1

Obeyscommands MotorResponse None Topain Tosound Spontaneous EyeOpening • • • RiskFactors

patients with a history of head injury should be carefully evaluated. patients withahistoryofheadinjuryshouldbecarefullyevaluated. evolve intoalife-threateninglesionoverhourstofewdays.All Even minorheadtraumawithbriefalterationofconsciousnessmay injury days. The severityoftheinjurymayprogressoverfirst fewpost- intracranial hypertension. If surgeryisindicated,treatpatientswithprecautionsfor Rehabilitation ifneurologicaldefi 1 hour. Consider seizureprophylaxis:loadwithphenytoin15mg/kgover appears tobehypovolemicdespiteadequatefl injuries (e.g.,CTscan).Consideroccultbleedingifthepatient the patientisneurologicallystable,considerworkupforoccult Patients withsevereheadinjurymayhaveadditionalinjuries.If Supportive care Serial CTorMRIifsymptomsworsenovertime 2007;356:166–172. Shaken babysyndrome Lack ofhelmetduringmotorcycling cause ofbraininjury. Youth andmalegender.Motorvehicleaccidentsarealeading

Glasgow ComaScale

6 1 2 3 4

cits persist

uid resuscitation.

N EnglJMed .

147 CHAPTER 7 Neurosurgical Emergencies 148 CHAPTER 7 Neurosurgical Emergencies

ity ofdopaminergicreceptors(especially D Etiologyisunknown,butsomestudies suggestthatalteredsensitiv- Pathophysiology • • • Presentation neuroleptics, thataffectstriataldopaminergic(D reaction isasideeffectcommontoseveralclassesofdrugs,including mal postures,facialexpressionsorothermovements.Thedystonic Involuntary,sustained,orperiodicmusclecontractionscausingabnor- Deﬁ responsible. responsible.

• • ImmediateManagement impaired consciousness.Apracticalscale. ReprintedwithpermissionfromTeasdaleG,JennettB:Assessmentofcomaand Table 7.1

None Incomprehensiblesounds Inappropriatewords Confused Oriented VerbalResponse None Extension Abnormalﬂ Normalﬂ Localizespain DystonicReactions Dyston

agent. agent. Onset duringorwithin3monthsoftreatmentwithatriggering other dopaminereceptorantagonists. (prochlorperazine, promethazine,andmetaclopramide) prolixin), butyrophenones(haldol,droperidol),someantiemetics History ofexposuretophenothiazines(thorazine,thioridazine, repetitive movementsorabnormalpostures. Sustained musclecontractions,frequentlycausingtwistingand therapy (i.e.,atypical antipsychoticdrugs). Request apsychiatric consulttosuggestalternativedrug Taper ordiscontinue theoffendingdrug. nition

exion (withdrawal) exion (decorticate) i

(continued) c React i ons

1 2 3 4 5 1 2 3 4 5 Lancet 1974;304(7872):81–84.

2 andperhapsD

2 )transmission.

3 ) may be )maybe

• • Prevention • • SubsequentManagement • • • • • • DiagnosticStudies • • • • • • • DIFFERENTIALDIAGNOSIS

• • • RiskFactors (continued) Immediate Management

• •

or ocularmuscles. Botulinum toxin(Botox)mayprovidesymptomaticreliefforfacial Therapy forchronicdystoniaisproblematic. Detailed neurologicexamandpsychiatrichistory ANA (antinuclearantibodytiters),VDRL(syphilistest),HIVtiters Serum electrolytesincludingMg CNS imaging Serum ceruloplasminandslitlampexam Detailed drughistory Lesch-Nyhan syndrome Ataxia telangiectasia Lipid storagediseases Head trauma,stroke,braintumor Perinatal injury Disease, etc.) Degenerative CNSdisease(e.g.,Parkinson’s,Huntington’s Wilson’s Disease Use ofnewagents atminimumeffectivedosing Prophylaxis withanticholinergic drugs drugs. Risk increaseswiththedurationof treatment withneuroleptic patients Younger adultsaremorelikelytohave thisreactionthanolder newer atypicalneurolepticdrugs Use ofolderneurolepticdrugtherapy(about4:1)ratherthan propranolol. consider amantadineand/orabeta-blockersuchas For caseswithonsetbetweenoneweekand3months, anticholinergics). benztropine, trihexyphenidyl,ordiphenhydramine(i.e., In thecaseofacuteonset(within7days)dystonia,consider

,Ca

149 CHAPTER 7 Neurosurgical Emergencies 150 CHAPTER 7 Neurosurgical Emergencies

• DIFFERENTIAL DIAGNOSIS skull, causingherniation. may alsopushthebrainagainstavailable duralorbonyedgesinthe cerebral bloodfl owandmaycauseischemic injury.Increasedvolume and berefl If anycomponentincreasesinvolume, thepressureinvaultwillrise poorly compliantintracranialvault:Brain parenchyma,blood,andCSF. Therearethreemajorcomponents withinthenearlysealedand Pathophysiology • • • • • • Presentation imately 7–20mmHginsupineadults). Cerebrospinalfluid pressurethatexceedsthenormalvalue(approx- Defi vanHartenPN,HoekHW,KahnRS.Acutedystoniainducedbydrugtreat- FurtherReading do notrespondtoanticholinergictherapy. only inprolongedtreatmentwithtriggeringdrugs,anditssymptoms to preventnauseaandvomitinghavebeenreportedtriggerdystonia. been reportedtotriggerdystonia.Manyantiemeticdrugscurrentlyused antiemetic drugscurrentlyusedtopreventnauseaandvomitinghave to thepossibilityofdystonicdrugreactionsinrecoveryroom.Many Anesthesiaprovidersandpostoperativenursingpersonnelshouldbealert SpecialConsiderations

IntracranialHypertension Intracran ment. Headaches ofother etiology,e.g.,migraine,cluster,etc. • If anICPmonitorisinplace: be seeninseverecases. Systemic hypertension,bradycardia,andperiodicbreathingmay Depressed levelofconsciousness Blurred vision,diplopia Nausea, vomiting Headache Tardivedystoniacloselyresemblesacutedystonia,butitoccurs •

to 20minutes A waves:abruptincreasesinICPto50–100mmHgthatlastup several minutes B waves:abruptincreasesinICPto35mmHgthatlastfor nition Brit MedJ ected in the CSF pressure. Intracranial hypertension impairs ected intheCSFpressure.Intracranialhypertension impairs

i 1999;319(7210):623–626 al Hypertens

• • • • • SubsequentManagement • • • DiagnosticStudies • •

• • • • • • ImmediateManagement

• • • • • • • • • • RiskFactors

be indicated. If CSFcirculationisobstructed,aventriculoperitonealshuntmay monitoring. Consider ventriculostomytodrainCSFandallowcontinuousICP Treat feverifpresent. Consider mild(35°C)hypothermia. Control underlyingcause. Lumbar puncture(afterCTscanshowsNOmasseffect) Invasive ICPmonitoring mass effects,edema,hemorrhage,etc. CT scantoassessventricularsize,compressionofbasalcisterns, Idiopathic intracranialhypertension(pseudotumorcerebri) Drug intoxication osmotically reducebrainwatercontent. Mannitol 20%0.5–1.0g/kgIVrapidly,orhypertonicsalineto to ensureopenjugulardrainage. Optimizepositioning hematoma evacuation)orventriculardrainage Neurosurgical treatment(e.g.,decompressivecraniectomyor Avoid hyperglycemia. pressure between60and70mmHg.(CPP=MAP–ICP) Control systemicbloodpressuretomaintaincerebralperfusion and cerebralbloodﬂ mild hyperventilation,andtodecreasecerebralmetabolicrate Consider generalanesthesiaforairwayprotection,toallow Hydrocephalus (obstructive oridiopathic) Vasodilation (due todrugs,hypercapniaorhypoxia) Intracranial hemorrhage Cerebral edema Infection (brainabscess) Tumors Anoxic braininjury Chronic anticoagulanttherapy Prior subarachnoidhemorrhage(SAH) Neural tubedefects

ow.

: headup30°andlookingstraightahead

151 CHAPTER 7 Neurosurgical Emergencies 152 CHAPTER 7 Neurosurgical Emergencies

SDH tobeassociated withcontusionanddisruption of braintissue. followed bysecondary injuries.Epiduralhemorrhage is lesslikelythan promise, ischemia, andnecrosisthatcanpropagate and thatwillbe Bothofthesedisruptbraintissue and causeedema,vascularcom- 2) 1) Twomainagentsofinjuryare: • Pathophysiology • • • • • Presentation the skull. Anyinjurythatfracturesorotherwiseviolatesthecranialvaultof Deﬁ BershadEM,HumphreisIIIWE,SuarezJI.Intracranialhypertension. FurtherReading to ischemia. Initiatetreatmentrapidlybecausethebrainhasaverylowtolerance SpecialConsiderations

PenetratingHeadInjury Penetrat Chronic SDHisdefi ned aspresenting morethan21daysafterinjury. interpersonal violence. Associated with high mortality (> 50%). interpersonal violence.Associatedwithhighmortality(>50%). high-velocity impactssuchasmotorvehicleaccidents,fallsand Acute subduralhematoma(SDH)(Figure7.2)isalsocommonafter fi over thecourseofafewweekswilltransitiontoisodenseand Hematomas initiallyappearinCTimagingashyperdense,but abnormal reflexes, nuchalrigidity,andseizuresmayoccur. and depressedlevelofconsciousness(|40%).Papilledema, common (|90%)asisconfusion60%),hemiparesis If thepatientisconscious,severe,suddenheadachevery coma andtypicallyhaveapooroutcome. parenchymal damage.PatientswithEDHmayprogressrapidlyto high-energy impactsandusuallyareaccompaniedbydiffuse Epidural hematomas(EDH)(Figure7.1)arefrequentafter velocity involved Depends uponthetypeofimpactandkineticenergyor Neurol. nally hypodense. bullet, etc.)mayalsobepresentand causeadditionalinjury. the possiblyobjectthatcaused thetrauma(e.g.,knifeor Disruptionofvascularsupply.Adepressed bonefragmentsand the skull. Contusionandshearfrommechanical motionofbrainrelativeto nition 2008;28(5):690–702.

i ng HeadIn

j ury

Semin

Michele Johnson,MD) Figure7.2 Michele Johnson,MD) Figure7.1

A leftsidedsubduralhematomaandmasseffect. (Imagecourtesyof A leftfrontalepiduralhematomacausingmasseffect.(Imagecourtesyof

153 CHAPTER 7 Neurosurgical Emergencies 154 CHAPTER 7 Neurosurgical Emergencies

• • • • SubsequentManagement • • • DiagnosticStudies • • • DIFFERENTIALDIAGNOSIS

• • • • • • • • • ImmediateManagement

Serial CTorMRimagingstudies Serial arterialbloodgasanalysis Plasma electrolytes,completebloodcount,toxicologyscreen brain Hemorrhage intoexistingneoplasmorinfectiousmasslesionof malformation [AVM]) Leaking vascularmalformation(aneurysmorarteriovenous Brain contusion hypotension. over atlease1hour tominimizeriskofbradydysrhythmia and CAUTION: Ifintravenous phenytoinshouldbeadministered phenytoin 15mg/kg) Seizure prophylaxiswithanticonvulsants for7days(loadwith Consider ventriculardrainagetocontrol intracranialpressure. ensure adequatecerebralbloodflow foratleast7days Maintain cerebralperfusionpressure (CPP)>60mmHgto defi (0.5–1 g/kg)orhypertonicsalinetocontrolelevatedICPuntil fi shift >5mm,hematomathickness1cm,declineinGCSt2, Surgical decompression;guidelineindicationsincludemidline Use hyperventilation(PaCO Aggressively maintainC8 Initiate mechanicalventilationtomaintainPaCO Increase FiO management. Presume cervicalspineinstabilityduringacuteairway the clinicalsituationpermits. of basilarskullfracture.Considerrapid-sequenceinductionif stabilization. Nasalintubationiscontraindicatedbecauseofrisk indicated: oralendotrachealintubationwithaxialcervicalspine Defi airway. Assess thepatient’sGlasgowComaScorebeforemanaging presence ofcoagulopathy. Assess coagulation;delayedinjuryishighlycorrelatedwith and 35mmHg. xed pupils,orICP>20mmHg. nitive therapyisinitiated. nitive airwaymanagementifGCSlessthan8,orotherwise 2 tomaintainoxygenation.

60mmHgandS* P “

≈ 30mmHg)andmannitol

90mmHg. P “ 2 between30

sion byanexpanding hematoma. disruption ofthe spinal column,vascularcompromise, orcompres- Disruptionofspinal cordfunctionfollowingtraumatic, mechanical Deﬁ BrainTraumaFoundation,AmericanAssociationofNeurologicalSurgeons, FurtherReading • • • • • SpecialConsiderations Avoidrisk-takingbehavior. Prevention •

• • • RiskFactors

SpinalCordInjuryIn

severe traumaticbraininjury. Congress ofNeurologicalSurgeons.Guidelines forthemanagementof aneurysm oranAVM. brain parenchymaortoaleakingvascularmalformationlikean Subarachnoid hemorrhagecanbeduetotraumaticinjuryof extent bysuturelinesandareconcaverelativetothebrain. convex withrespecttothebrain,whereasSDHarenotlimitedin Epidural hematomasarelimitedbycranialsuturelinesand and patientsonanticoagulanttherapy(Figure7.2). SDH accumulatesmoreslowlyinagedpatients,ethanolabusers, and mayrapidlycompressthebrainitsbloodsupply.Chronic the bridgingveins.AcuteSDHoccursaftertraumaticheadinjury SDH collectbetweentheduraandarachnoidafterdisruptionof symptoms worsen(Figure7.1). may sometimespresentwiththeclassiclucidintervalbefore dura fromitsusualadherencetotheskull.Thesepatients Epidural hematomasforminthespacecreatedbystripping epidural hematoma(EDH). laceration ofthemiddlemeningealarteryandformationan Depressed fracturesofthetemporal-parietalareamayleadto indicated. Use ofhigh-dosecorticosteroidsincreasesmortalityandisnot Age over60yearsincreasesriskofSDH. Male gender deﬁ Preexisting coagulopathyincreasesriskofdelayedneuronal nition cits.

j ury

J Neurotrauma

. 2007;24(Suppl1):S1–S106.

155 CHAPTER 7 Neurosurgical Emergencies 156 CHAPTER 7 Neurosurgical Emergencies

• • SubsequentManagement • • DiagnosticStudies • • DIFFERENTIALDIAGNOSIS generators thatlocallycoordinatecomplexmotoractivity. areas thatperformlocalsensorysignalprocessing,andcentralpattern descending neuraltrafﬁ Thespinalcordcontainswhitemattertractsthatpassascendingand Pathophysiology • • • • • Presentation

• • • • • • ImmediateManagement

Hypotension andspinalshock bladder controlandsympathectomy. Lower thoracicandlumbarinjuriescancauselossofbowel of ventilationandmayalsoleadtobradycardia. Upper thoraciclevelinjurieswillcompromiseaccessorymuscles ventilation. Cervical injuriesaboveC4willcompromisediaphragmatic efferents, dependingontheextentofinjury Any combinationofsensoryandmotorlossincludingsympathetic Pressure ulcerprophylaxis Deep veinthrombosis (DVT)prophylaxis plain radiographsareofpoorquality CT scanifsuspiciousareasareseen onplainradiographs,orif 3-view cervicalspineradiographs(AP, lateral,odontoidviews) Vascular thrombosis,neoplasia,infection,etc. Soft tissueinjuryofneckleadingtomusclespasm especially ifadifficult airwayisanticipated. Glidescope ®videolaryngoscopeorafi fl in-line cervicaltractionorstabilization,avoidingextension If ventilatorsupportisrequired,intubatethetracheawith compromise. Maintain closemonitoringtodetectcardiopulmonary dose methylprednisoloneinfusion. Administer steroidstoreduceedema.Somecentersuseahigh- Maintain spinalalignmenttoavoidworseningtheinjury. Surgically decompresscordandstabilizespinalcolumn. days followinginjury. Maintain meanarterialpressure(MAP)85–90mmHgforfi exion. Consideruseofanindirectvisualizationdevicesuchasa

c. In addition, the central grey matter contains c. Inaddition,thecentralgreymattercontains

beropticbronchoscope,

rst 7

• • • • • • • or fromanarterialaneurysm(Figure7.3). Presentation secondary tobleedingfromanarteriovenousmalformation(AVM), ExtravasationofbloodintotheCSF.NontraumaticSAHisusually Defi StevensRD,BhardwajA,KirschJR,MirskiMA.Criticalcareandperiopera- MikoI,GouldR,WolfS,Afi FurtherReading in thehospital. Thisisasurgicalemergency.Therenospecific preventivestrategy Prevention • • •

• • • • • • RiskFactors

SubarachnoidHemorrhage(SAH)Hemorrha

2003;15:215–229. tive managementintraumaticspinalcordinjury. prognostic value. (World FederationofNeurosurgeons) system.Bothscoreshave SAH symptomsaregradedbytheHunt-Hess ortheWFNS often awarningthatcatastrophicbleedwillshortlyfollow. bleed, whichisasmallleakofbloodfromaneurysm.This About halfofSAHpatientspresentwithsymptomsasentinel Control hypothermia Monitoring forautonomichyperreﬂ Neuropathic painmanagement Cranial nervepalsy Hypertension and elevatedtemperaturearecommon signs. Photophobia Nausea, vomiting Acute, severeheadacheisaclassic sign ofSAH. In some cases, seizures or transient loss of consciousness may occur. In somecases,seizures ortransientlossofconsciousness mayoccur. 2009 Winter;47(1):37–54. Frequent falls Risk-taking behavior,especiallyinmotorvehicles Age 16–30years Male gender Sports injuries Violence nition

ﬁ

S.Acutespinalcordinjury.

exia g e

( SAH J NeurosurgAnesthesiol . )

Int AnesthesiolClin

157 CHAPTER 7 Neurosurgical Emergencies 158 CHAPTER 7 Neurosurgical Emergencies infectious masses,tumornecrosisandhemorrhage.(Figure7.4). Intraparenchymalhemorrhagefromnonvascularsourcesincluding DIFFERENTIALDIAGNOSIS regulation andintheetiologyofvasospasm. Extravasated bloodappearstoalsohavearoleinlocalnitricoxide CPP signiﬁcantly (possiblytozero)andcausesmajorischemicinjury. potentially reachsystemicarterialbloodpressure.Thisreducesthe Arterialbleedingmaysigniﬁ cantly increasetheICP,whichcould Pathophysiology reultant earlyhydrocephalus.(ImagecourtesyofMicheleJohnson,MD) Figure7.3

• • • • ImmediateManagement

fentanyl. Thesedrugs shouldonlybeusedinconsultation Sympathetic tone maybereducedwithmidazolamand/or increases ICPlessthannitroglycerine ornitroprusside. They arecerebralvasodilatorsand increase ICP.Hydralazine channel blockers(e.g.,nicardipine). Donotusenitrates. short-acting betablockers(e.g.,esmolol) and/orcalcium Reduce MAPtomaintainCPPof60–70 mmHgwithintravenous HR aslowconsistentwithCPPt 60mmHg. Stabilize thebloodpressure:Control MAP\ pressure monitoring. arterial catheterforbloodgasanalysisandcontinuous Obtain large-boreperipheralIVaccessandinsertanintra-

Diffuse subarachnoidhemorrhage,ﬁlling thebasalcisternsandcausing

130mmHgand o |

intraventricular hemorrhage. (ImagecourtesyofMicheleJohnson, MD) surrounding edema.There iscompressionoftheipsilateralventricle and Figure7.4

meit aaeet (continued) Immediate Management

• • • • • •

underlying neurologicclinicalexamination. with theneurosurgicalteambecausetheywillobscure Keep patienteuvolemicwhilemaintainingadequateCPP. normocapnic toslightlyhypocapnicventilation. Respiratory gasmonitoringshouldbeusedtoassure promptly treatanundesirablesympatheticresponse. have esmololdrawnupconnectedtotheIVlineinorder agent followedbyexpeditiouslaryngoscopy.Itisprudentto or thiopentalandarapid-actingneuromuscularblocking strongly advised,followedbyanappropriatedoseofpropofol Judicious premedicationwithmidazolamandfentanylare pressure mightcatastrophicallyrupturetheaneurysm. while intubatingthepatient.Anabruptincreaseinblood Maintain tightcontrolofbloodpressure,heartrate,andICP hypertension. or hyperventilationwillbeusedtomanageintracranial patient isobtundedandcannotprotecthisorherairway, Consider emergencyendotrachealintubationifthe intravascular therapy(e.g.,coilingorembolization). management (i.e.,aneurysmclippingorAVMresection) Current choicesfordeﬁnitive therapyincludesurgical Obtain anemergencyneurosurgicalconsult.

A largerighttemporo-parietal intraparynchemalhematomawith

159 CHAPTER 7 Neurosurgical Emergencies 160 CHAPTER 7 Neurosurgical Emergencies

MolyneuxAJ,KerrRS,YuLM.International subarachnoidaneurysmtrial FurtherReading • • SpecialConsiderations • • • • • SubsequentManagement • • • • • DiagnosticStudies

component toaneurysmformation. alcohol abuse.Recentdataindicatesthattheremaybeagenetic ranial aneurysmorarteriovenousmalformation.Tobaccoand Abruptincreaseinbloodpressureapatientwithknownintrac- RiskFactors 2005;366:809–817. of effectsonsurvival,dependency,seizures, rebleeding,subgroups. patients withrupturedintracranialaneurysms: arandomizedcomparison (ISAT) ofneurosurgicalclippingversus endovascularcoilingin2143 Rebleeding priortodefinitive therapyisoftenfatal. ECG (willoftenrevealrepolarizationabnormalities) Direct intravascularangiography CT scanwithoutcontrast,angiography Blood typeandcrossmatch arterial bloodgasanalysis Plasma electrolytes,completebloodcount,coagulationprofi needed totitrateHHHtherapy. defi Hemodilution). HHHtherapycanonlybeinstitutedafter classic triple-Htherapy(Hypertension,Hypervolemia,and consider bothintravascularangioplastyorstenting,and vasoconstriction andimpairscerebralperfusion. The presenceofbloodintheCSFdetrimentallycausescerebral Intraparenchymal hemorrhageisnotconsideredSAH. hydrocephalus. Patients withSAHhaveamoderateriskofdevelopingobstructive If symptomaticvasospasmoccurs nimodipine. Consider prophylaxisagainstcerebralvasospasmwithoral ischemia. Antifi nitive aneurysmaltherapy.Acentralvenouscatheterisusually brinolytics mayreducerebleeding,butincreaseriskof

after

aneurysmalrupture,

Lancet. le,

• • DIFFERENTIALDIAGNOSIS right-to-left shunt. cause ischemicinjuryinanyorganwhenthebubblespassthrougha tricular outﬂ sive rightheartfailure.Gasbubblescanalsocollectintheven- Gasbubblesmovetothepulmonarycirculationandcauseprogres- Pathophysiology • • • • • • • Presentation ventricle andthenbecomelodgedinvitalorgans. patients withanintracardiacdefect;gasbubblesmaymovetotheleft nary vasculature.Gasbubblesmayenterthesystemiccirculationin above theheartandtravelstorightsideoforpulmo- Airentersthevenouscirculationthroughanopenwoundlocated Deﬁ

• • • • ImmediateManagement

VenousAirEmbolism(VAE)

Thrombotic pulmonaryembolism Myocardial infarction collapse willoccur. If alargevolumeofgasisrapidlyentrained,cardiovascular The surgeonmaynoteintra-arterialbubbles. In awakepatients,acuteneurologicdeficits maybenoted. If systemicembolizationoccurs,ECGsignsofischemiamayoccur. End-tidal CO Arterial desaturation pain. In anawakepatient,theearliestsignsincludecoughingandchest not thecarotidarteries) pressure totheneckobstructflow inthejugular veins (but If VAEoccursduringcranialsurgery, applysuffi below thelevelofrightatrium Put theORtableflat orhead-downtoplacethesurgical wound soaking wetsponges. Tell thesurgeontoflood thefi eld orcoverthewoundwith Increase FiO nition ow tractandblockcardiacoutput.Gasembolicanalso

2 2 willdecreaseandend-tidalnitrogenincrease. to100%

( VAE

)

cient bilateral

161 CHAPTER 7 Neurosurgical Emergencies 162 CHAPTER 7 Neurosurgical Emergencies

• • Prevention • • SubsequentManagement • • DiagnosticStudies

meit aaeet (continued) Immediate Management

• • • •

• • • RiskFactors

risk ofright-to-left shuntingofbubbles. and decreasetheincidenceofVAE, butattheriskofincreased Use ofpositiveend-expiratorypressure (PEEP)mayincreaseCVP Preoperative ﬂuid loadingmaybeuseful. therapy. If systemicVAEoccurred,stronglyconsiderhyperbaricoxygen cerebral edema. Hemodilute tohematocritof30.Colloidsolutionsmitigate Hematocrit Arterial bloodgas in head-downandrolled-to-the-leftlateraldecubitusposition. If cardiovascularcollapseoccurs,performCPRwiththepatient pressure. to supportsystemicbloodpressureandincreaserightatrial Volume resuscitatewithisotoniccrystalloidorcolloidsolutions inotropes asneeded. Maintain systemicbloodpressurewithvasopressorsor entrainment usingbonewaxand/orelectrocautery. Ask thesurgeonstoﬁnd andoccludethepointofgas still occur. entrainment occurs,ischemicinjuryandrightheartfailurecan disappear morequicklythannitrogenoroxygen,butiflargegas venous system.Carbondioxidebubblesaremoresolubleand laparoscopic surgerymayalsocausegasembolizationintothe The CO total hiparthroplasty. Caesarean section,arthroscopicsurgeryoftheshoulder,and VAE isariskinmanyothersurgicalprocedures,including wound iselevatedabovethelevelofrightatrium. VAE classicallyoccursinsittingcraniotomywherethesurgical 2 tensionpneumoperitoneumthatiscreatedduring

effect. with bubblesrarelyrecoversenoughvolumetocauseatherapeutic Doppler andpulseoximetryarenotavailable,butaspirationofblood eters mayserveadiagnosticroleifend-tidalgasanalysis,precordial bubbles fromtherightatriumwasstronglyadvocated.Thesecath- In thepast,aspecialcentralvenouscatheterdesignedtoaspirate MirskiMA,LeleAV,FitzsimmonsL,ToungTJ.Diagnosisandtreatmentof FurtherReading the atrium,incm,isgreaterthanCVP(asmeasuredcmH Entrainmentofairoccurswhentheheightopenedveinabove SpecialConsiderations vascular airembolism. Anesthesiology.

2007;106:164–177.

2 O). 163 CHAPTER 7 Neurosurgical Emergencies This page intentionally left blank Chapter 8 Obstetric Emergencies Robert Gaiser

Accidental Dural Puncture 166 Breech Presentation 168 Embolism: Thrombus, Amniotic Fluid, Air 170 Failed Intubation 174 Fetal Bradycardia 177 Local Anesthetic Toxicity 179 Maternal Cardiac Arrest 181 Maternal Hemorrhage 184 Neonatal Resuscitation 187 Preeclampsia/Eclampsia 189 165 Shoulder Dystocia 192 Total/High Spinal Anesthesia 195 Umbilical Cord Prolapse 197 Uterine Rupture 199 166 CHAPTER 8 Obstetric Emergencies

injection. patchy, weakblock,unlikethedenseblockadefromintrathecal anesthetic (subduralinjection).Asubduralinjectionresultsina Hypotensionandhighsensorylevelfromasmallamountoflocal DIFFERENTIALDIAGNOSIS meninges. causing tractiononpain-sensitivestructuresincludingtheduraand epidural space.TheCSFleakagedecreasesintracranialpressure, dural punctureandiscausedbycerebrospinalfluid leakingintothe occurs. Headachetendstooccur24–48hoursafteraccidental high sensoryandmotorlevelsifunintendedintrathecalinjection of localanestheticusedforepiduralanesthesiacanproduce the dura,anaccidentalduralpunctureoccurs.Thelargeramounts spine averages4–6mm)orifthecatheterisadvancedthrough tance fromtheligamentumflavum totheduramaterinlumbar Ifanepiduralneedleisadvancedbeyondthespace(dis- Pathophysiology • • • • Anyoneofthefollowingsignsindicatesaccidentalduralpuncture: Presentation patient isatriskforcomplicationsfromtheduralpuncture. punctured bythecatheter.TheremaybenoCSFreturn,but dle. Theduramatermayalsobenickedbytheepiduralneedleor visible returnofcerebrospinalfl The majorityofaccidentalduralpuncturesareaccompaniedbythe Penetrationoftheduramaterwithanepiduralneedleorcatheter. Defi

• • ImmediateManagement

AccidentalDuralPuncture

Frontal-occipital headache24–48hoursafterepiduralanesthesia. Able toaspiratecerebrospinalfluid fromthecatheter; intrathecal block; Test dose(1.5%lidocainewithepinephrine,1:200,000)causes Free flowing cerebrospinalfl uid fromtheepiduralneedle; two coursesofaction: If accidentaldural puncturewiththeneedleoccurs,there are level fromatestdose. the epiduralcatheter,orbyobserving thepresenceofasensory observing CSFdrippingfromtheneedle, byaspiratingCSFfrom Identify thepresenceofanaccidental duralpunctureby nition

uid(CSF)throughtheepiduralnee-

never studied) or 3 mg epidural morphine, two doses 24 hours apart. never studied)or 3 mgepiduralmorphine,twodoses 24hoursapart. ture headache,intrathecal cathetershavebeenrecommended (but other thanmeticulous technique.Forpreventionof postdural punc- Therearenogoodmeanstoprevent anaccidentalduralpuncture Prevention • • • • SubsequentManagement • • DiagnosticStudies

Immediate Management(continued)

Forpostduralpunctureheadache: • • • • Foraccidentalduralpuncture: RiskFactors •

preventing furtherleakage. headache. Theinjectionofbloodformsaclotattheduralhole, cerebrospinal fluid cephaladandimmediatelyrelievesthe into theepiduralspace.Thiscompressesthecalsac,forcing an epiduralbloodpatch.20mLofautologousisinjected The definitive treatment forapostduralpunctureheadacheis caffeine 500mgIV,bedrest,andanalgesia. Conservative managementincludesintravenoushydration, of headache. Follow thepatientfor48hourspostoperativelypresence hole inthedura. Decrease theamountoflocalanestheticinjected,asthereisa a urinedipstick. Cerebrospinal fluid containsproteinwhichmaybedetectedwith CSF containsglucose,whichmaybedetectedwithaglucometer. • • manage asacontinuousspinalcatheter. or ifthetestdosesuggeststhatcatheterisintrathecal, If theprovideraspiratescerebrospinalfluid fromthecatheter Vaginal delivery Young age(10–40years) Female gender Previous accidentalduralpuncture

spinal catheter. Thread anintrathecalcatheterandmanageasacontinuous titrate thelocalanesthetic. Resite theepiduralneedletoplacecatheterandslowly

167 CHAPTER 8 Obstetric Emergencies 168 CHAPTER 8 Obstetric Emergencies nonvertex second twin,orifcesareandeliveryisrefused. to attemptavaginal breechdeliverysuchasforthe deliveryofa cumstances inwhich aparturientandherobstetrician willdecide decides whethertoproceedcesarean delivery.Therearecir- Theobstetriciandeterminesthetype ofbreechpresentationand DIFFERENTIALDIAGNOSIS hypoxia. the umbilicalcord,whichleadsto decreasedbloodfl ow andfetal abdomen todeliveryofthefetal head,thereiscompressionof partially dilated.Duringthetimeperiodfromdeliveryoffetal and maynotdeliverthroughthecervix,especiallyifcervixis entrapment. Theheadofthefetusislargestportion Themajorconcernwithdeliveryofthebreechfetusisfetalhead are lowermostinthebirthcanal. presentation, oneorbothhipsarenotfl exed, andoneorbothfeet tion, boththekneesandhipsareflexed. Inanincompletebreech fl mon typeofbreechpresentationandoccurswhenbothhipsare the legsandbuttocks.Afrankbreechpresentationismostcom- Breech presentationsareclassifi ed accordingtothepresentationof Presentation maternal pelvisbeforethefetalhead. Breechpresentationoccurswhenthefetalbuttocksdescendinto Defi AmorimJA,ValencaMM.Postduralpunctureheadacheisariskfactorfornew Al-metwalliRR.Epiduralmorphineinjectionsforpreventionofpostdural FurtherReading IV, andVI. cular musclesfromthetransientparalysisofcranialnervesIII, disturbances (diplopia)areduetothedysfunctionofextraoc- nausea, vomiting,visualdisturbances,andhearingalteration.Visual toms improvingwhenthepatientliesfl at.Othersymptomsinclude Postdural punctureheadachestendtobepositional,withsymp- Accidentalduralpuncturemayresultinpostoperativeheadache. SpecialConsiderations Pathophysiology exed andbothkneesareextended.Inacompletebreechpresenta- BreechPresentationPresentat postdural punctureheadache. puncture headache. nition

Anaesthesia.

Cephalgia. n 2008;63:847–850.

2007;28:5–8.

regional anesthesia. size. attempts havealowersuccessrate becauseoftheincreaseinfetal The procedureisdoneusuallyaround 36–37weeksgestation.Later cephalic presentationbyapplyingpressure tothematernalabdomen. The procedureinvolvesanattempt tomaneuverthefetusintoa Priortodelivery,theobstetricianmay attemptanexternalversion. Prevention of theroutedelivery. complications thanbabiesthathaveavertexpresentation,regardless skilled inneonatalresuscitation.Breechinfantshavemore Followingdelivery,theinfantshouldberesuscitatedbyindividuals Ultrasoundisusedtoconﬁrm physicalexamination. DiagnosticStudies SubsequentManagement

• • • RiskFactors • • • ImmediateManagement

Successforthis technique maybeimprovedwith theuseof • • • • • • anesthesia isusuallyadministered. Unless themotherhasanepiduralcatheterinplace,general prepared toperformrapidcesareandelivery. Both theanesthesiologistandobstetricianmustbe breech oraprematurefetus. Prepare foremergencycesareandeliveryininstancesoffootling • Placental • Fetal • Maternal

Oligohydramnios Polyhydramnios Neuromuscular disorders Pelvic tumors Microcephaly Multiparity Placenta Previa Anencephaly Uterine anomalies

169 CHAPTER 8 Obstetric Emergencies 170 CHAPTER 8 Obstetric Emergencies HannahME,WJ,HewsonSA,etal.Plannedcaesareansectionversus • • Presentation embolism isthemostcommoninparturients. otic ﬂ uid), orgas(air)intothematernalvascular system.Thrombo- States. Embolisminvolvesentryofsolid(thrombus), liquid (amni- EmbolismistheleadingcauseofmaternalmortalityinUnited Deﬁ DoyleNM,RiggsJW,RaminSM,etal.Outcomesoftermvaginalbreechdeliv- FurtherReading twin, oradvancedlaborwithabreechpresentation. tions exceptforanonviablefetus,deliveryofsecondnonvertex Cesarean deliveryisnowthepreferredrouteforbreechpresenta- neonatal morbidityandmortalitywithattemptedvaginaldelivery. or plannedbreechvaginaldelivery.Therewasanincreasedriskof at 37ormoreweeksgestationtoeitherplannedcesareandelivery performing acesareansection. how convertingtoavertexpresentationandthenallowinglabor,or two basicoptionsformanagementofabreechpresentation:some- risk ofinfectionandperineallacerationforthemother.Thereare nancies haveabreechpresentation.Breechdeliveryincreasesthe breech presentation.Atterm,however,only3–4%ofsingletonpreg- Before28weeksgestation,asmany40%offetusesareinthe SpecialConsiderations

Embolism:Thrombus,AmnioticFluid,Air Embol centre trial. planned vaginalbirthforbreechpresentationatterm:arandomizedmulti- ery. • • • • Amniotic ﬂ uid embolismincludesalloftheabove,and: • Common toall: TheTermBreechTrialrandomizedparturientswithbreechfetuses • • •

Disseminated intravascular coagulopathy Tachypnea Chest pain Bleeding Dyspnea Dilated externaljugularveins Increased centralvenouspressure Tachycardia nition Am JPerinatol. i sm: Thrombus,Amn

Lancet.

2005;22:325–328. 2000;356:1375–1383.

i ot

i c Flu i d, A i r

with hemorrhageoccurduringamnioticﬂuid embolism. resulting hypoxemia.Ananaphylactoidreactionandcoagulopathy tricular failure.Italsocreatesaventilation/perfusionmismatchwith pulmonary vascularbed.Thisobstructionmayproducerightven- Afterentryintothevenoussystem,embolibecomelodgedin Pathophysiology • • • ImmediateManagement

• • • • • Amniotic ﬂ • Thrombus • Air • • • • • • •

vasopressors Hemodynamic supportwithfl endotracheal intubationifrespiratoryfailureisimminent. vasopressors Hemodynamic supportwithfl endotracheal intubationifrespiratoryfailureisimminent. to aspirateairfromtherightatrium. Consider placementofamulti-orifice centralvenous catheter vasopressors. Hemodynamic supportwithfluids, inotropes,or Increase FiO site belowthelevelofheart. Inform theobstetricianandpositionpatientwithsurgical Increase FiO consider thrombolysisorsurgery. For episodeswithprofoundhemodynamiccompromise, Anticoagulation withunfractionatedheparin central venousaccess. Consider placementofarterialcatheterandestablishing available. Consider hyperbaric oxygenaftertheeventinsevere casesif cover openvenoussinuses. Request irrigationofthesurgicalfield withnormalsalineto cryoprecipitate, andplatelets. Correct coagulopathywithfreshfrozenplasma, medications toimproveuterinetone. Uterine atonyiscommonandrequiresadministrationof •

intubation.) Increase FiO uid 2 2

tomaintainoxygenation.Consider tomaintainoxygenation.Consider 2 tomaintainoxygenation.(Rarelyrequires

uids, inotropes,or uids, inotropes,or

171 CHAPTER 8 Obstetric Emergencies 172 CHAPTER 8 Obstetric Emergencies

• • • • SubsequentManagement Thrombus DiagnosticStudies • • • • • • • DIFFERENTIALDIAGNOSIS

Amnioticﬂ Air

Placental abruption Uterine rupture Peripartum cardiomyopathy Aspiration Sepsis Anaphylaxis Asthma intensive careunit. ﬂ The hemodynamic andhematologicconsequencesof amniotic analgesia. regional anesthesiamustbeconsidered whenprovidinglabor The appropriatetimeperiodsforwithholding thisdrugpriorto with low-molecular-weightheparin, aswarfarinisateratogen. If eventoccurspriortodelivery,the parturientisanticoagulated Parturients withthromboembolism shouldbeanticoagulated. thrombus. The mostcommoncauseofembolisminpregnancyis • • • • • • • • • uid embolismmandate thatthepatientbemanagedin the

require DopplerultrasoundorMRItolocatethesource The majorityofthrombioriginateinthelowerextremitiesand Spiral computedtomographicpulmonaryangiography V/Q scan Diagnosis ofexclusion pressure partial pressureandanincreaseincarbondioxide Arterial bloodgasanalysis,lookingforadecreaseinoxygen maternal circulation. for epithelialsquamouscells,lanugohair,ormucininthe Consider samplingbloodfromcentralvenouscatheterlooking partial pressureandanincreaseincarbondioxide Arterial bloodgasanalysislookingforadecreaseinoxygen person skilledintheinterpretation. speciﬁ Transesophageal echocardiographyisbothsensitiveand carbon dioxide. If generalanesthesia,thereisanabruptdecreaseinend-tidal c, butrequiresgeneralanesthesiaandthepresenceofa uid

to theembolismitself. lism syndromemay beduemoretotheimmunologic reactionthan complications islow.Thepathophysiology ofamnioticﬂ eries. Althoughairembolismisrelatively common,theincidenceof by transesophagealechocardiography in93–100%ofcesareandeliv- does notresultinclinicalconsequences. Aircanbedemonstrated Air embolismisalsocommonduring cesareandelivery,buttypically be thecauseofhighincidence thromboembolisminpregnancy. coagulation factorsI,VII,VIII,X,and XII.Thisincreaseisthoughtto Pregnancyresultsinahypercoagulablestatewithincreasedlevelsof SpecialConsiderations • • • Prevention • •

• • • RiskFactors

• • • Air • Amniotic fl • Thrombus irrigation. the surgicalteamtoflood theoperativesitewithnormalsaline the patientwithsurgicalsitelowerthanheartanddirect With airembolism,stopvascularentrainmentofair.Reposition accompanying amnioticfl Inhaled nitricoxidehasbeenusedforpulmonaryhypertension • •

closure ofhysterotomy),uterineexteriorization Air fetal macrosomia,augmentationoflabor tumultuous labor,trauma,multiplegestation,polyhydramnios, AmnioticFluid delivery, currentinfection,parity>3,immobility,thrombophilia Thrombus Maintenance ofsurgicalsitebelowthelevelheart with severalriskfactorsorahistoryofthrombus Antepartum pharmacologicthromboprophylaxisinpatients Mobility No provenmeansofprevention Use ofcompressionstockingsduringcesareandelivery Maintenance ofahighindexsuspicion Amniotic ﬂuid embolism tendstobeadiagnosisofexclusion. : Cesareandelivery(usuallybetweenofinfantto uid : Age>35years,obesity(BMI30),cesarean

: Advancedmaternalage,mulitparity, uid embolism.

uid embo- uid

173 CHAPTER 8 Obstetric Emergencies 174 CHAPTER 8 Obstetric Emergencies MarikPE,PlanteLA.Venousthromboembolicdiseaseandpregnancy.

anesthetic ifthepatientisextubated prematurely. etiologies. Lossoftheairwaymayalso occurattheendofageneral or maybecausedbyatotalspinalanesthetic, oversedation,orother Failedintubationmayoccurduringinductionofgeneralanesthesia DIFFERENTIALDIAGNOSIS profound decreaseinoxygensaturationduringperiodsofapnea. lad, causingadecreaseinfunctionalresidualcapacity,andmayresult accomplish it.Thegraviduterusdisplacesthediaphragm4–7cmcepha- only istheparturientmorediffi cult tointubate, butthereislesstimeto by 34%suggestinganincreasedpotentialfordiffi cult intubation.Not and trachea.At38weeks,theincidenceofgradeIVairwaysincreases respiratory tractcausesswellingofthenasalandoralpharynx,larynx, Duringpregnancy,capillaryengorgementofthemucosathroughout Pathophysiology • • • • • Presentation the postoperativeperiodthanduringatinductionofanesthesia. with intubation,airwayemergenciesareoccurringmorecommonlyin laryngeal, ortrachealedema.Duetoincreasedawarenessofdiffi Inabilitytointubatetheparturient,mostcommonlyduepharyngeal, Defi GistRS,StaffordIP,LeibowitzAB,BeilinY.Amnioticfl uid embolism. FurtherReading LowenwirtIP,ChiDS,HandwerkerSM.Nonfatalvenousairembolismduring • ImmediateManagement

FailedIntubation Fa

J Med. Surv. cesarean section:acasereportandreviewoftheliterature. Hypertension Tachycardia followedbybradycardia Difﬁ Difﬁ Hypoxemia Analg. • If intubationisnotpossible: •

nition i Call forhelp. Attempt maskventilation. led Intubat culty withintubation culty withmaskventilation 1994;49:72–76. 2009;108:1599–1602. 2008;359:2025–2033.

i on

Obstet Gynecol N Engl Anesth culty culty until airwayedemahasdecreased. resuscitation forhemorrhagemayrequirepostoperativeintubation bations haveresolved.Parturientswhoreceivedfl have recoveredsuffi ciently fromanesthesia and physiologicpretur- Patientswithdiffi cult intubationshouldnotbeextubateduntilthey SubsequentManagement • • DiagnosticStudies

examined previously. ined beforeinducinggeneralanesthesia,eveniftheairwayhadbeen way (includingoropharyngealstructures)mustthereforebeexam- with theamountofintravenousﬂuids orthelengthoflabor.Theair- a decreaseinupperairwayvolume.Thechangedidnotcorrelate may increaseaslaborprogresses,andthiscorrelateswith Examinetheairwayineveryparturient.TheMallampaticlassiﬁ Immediate Management(continued)

• • • • • • • RiskFactors

• Able tovisualize examination Mallampati classiﬁcation andotherfeaturesoftheairway • • •

• • • • • • Short neck Receding mandible Inability tovisualizeoropharyngeal structures Preeclampsia Diabetes mellitus Previous airwaysurgery Obesity

Class 1:faucialpillars,softpalate,uvula Class 3:softpalateonly Class 2:faucialpillars,softpalate Class 4:hardpalate Consider transtrachealoxygenation. Consider insertinganothertypeofsupraglotticairway. of agastrictube. Consider usingalaryngealmaskairwaythatallowsforpassage algorithm. (Insidefrontcover) If maskventilationisnotpossible,followthedifﬁ and maskventilationfortheprocedure. If maskventilationispossible,considerusingcricoidpressure Consider asurgicalairway.

cult airway uidorblood

cation 175 CHAPTER 8 Obstetric Emergencies 176 CHAPTER 8 Obstetric Emergencies ery units. should bereadilyavailableintheoperativeareaoflaboranddeliv- Inaddition,portableequipmentfordifﬁ cult airwaymanagement • SpecialConsiderations • • • • • • • • • • • • • the initialprovisionofregionalanesthesia,suchas: way managementequipmentshouldbeimmediatelyavailableduring personnel readilyavailabletomanageairwayemergencies.Basicair- ily available.LaborandDeliveryUnitsshouldhaveequipment has establishedanalgorithmforfailedintubationthatmustberead- catheter isfunctional.TheAmericanSocietyofAnesthesiologists ment inearlylaborofanepiduralcatheterandconﬁ rm thatthe from generalanesthesia.Forthosepatientsatrisk,considerplace- factors thatplacetheparturientatincreasedriskforcomplications Theobstetriccareteamshouldbealerttothepresenceofrisk Prevention

from failedintubation. training inemergencyairwaymanagement willimprovemortality for managementoftheunexpected difficult airway. Appropriate potentially difficult airways.Anesthesiologistsmustbe prepared consultation andearlyepiduralplacement inpatientswith Obstetricians shouldbeencouraged toprovideappropriate Topical anestheticsandvasoconstrictors Equipment suitableforemergencysurgicalairwayaccess Endotracheal tubeguides • ventilation. At leastonedevicesuitableforemergencynonsurgicalairway Laryngeal maskairwaysofassortedsizes Endotracheal tubesofassortedsize shape Rigid laryngoscopebladesandhandlesofalternatedesign hypnosis. Medications forbloodpressuresupport,musclerelaxation,and Self-infl Suction; Oxygen source; Endotracheal tubeswithstylets; Laryngoscope andassortedblades; • •

Retrograde intubationequipment ventilator Cricothryotomy kitwithorwithoutatranstrachealjet Hollow jetventilationstylet ating bagandmaskforpositivepressureventilation;

MhyreJM,RiesnerMN,PolleyLS,NaughtonNN.Aseriesofanesthe- compression). cental abruption),orfetal(umbilical cordocclusionfromknotor aortocaval compression,decreased hemoglobin),uterine(pla- oxia. Theetiologymaybematernal (hypoxemia,hypotension, in thebaselinelasting2–10minutes) isassociatedwithfetalhyp- variability orprolongeddeceleration (abruptt Fetalbradycardia,whenaccompaniedwithdecreasedbaseline Pathophysiology ClinicaldiagnosisbasedonFHRtracings. Presentation highly predictiveofabnormalfetalacid-basestatus. considered tobeindeterminate.Absenceofbaselinevariabilityis rate lessthan110bpm.Fetalbradycardiawithbaselinevariabilityis decelerations. Bradycardiaisdefi ned asanabnormalbaselineheart ing theFHRfora10-minutewindow,butexcludingaccelerationsor Thebaselinefetalheartrate(FHR)isdeterminedbyapproximat- Defi McDonnellNJ,PaechMJ,ClavisOM.Difficult andfailedintubationinobstet- KodaliBS,ChandrasekharS,BulichLN,TopulosGP,DattaS.Airwaychanges FurtherReading •

FetalBradycardiaBrad 2007;106:1096–1104. sia-related maternaldeathsinMichigan,1985–2003. Obstet Anesth. plications associatedwithgeneralanaesthesiaforcaesarensection. ric anaesthesia:anobservationalstudyofairwaymanagementandcom- during laboranddelivery. performed. failed regionalanesthetic,rapidsequenceinductionshouldbe induction. Ifgeneralanesthesiaisplanned,orinthecaseofa aspiration prophylaxis(sodiumbicitratesolution)before are thereforeatincreasedriskofaspirationandshouldreceive emptying mayalsobeprolongedinpregnancy.Allparturients junction, resultinginanincompetentGEsphincter.Stomach caused bythegraviduterus,whichchangesangleofGE Pregnancy isassociatedwithashiftinthepositionofstomach nition

2008;17:292–297. y cardia

Anesthesiology.

2008;108:357–362. 15bpmdecrease Anesthesiology.

Int J 177 CHAPTER 8 Obstetric Emergencies 178 CHAPTER 8 Obstetric Emergencies the amountoftime availableandthematernalairway examination. either generalorregional anesthesiaisadministered depending upon mental oxygenshouldbecontinued. Inthecaseofurgentdelivery, maintaining bloodpressure,leftuterine displacement,andsupple- Ifnon-urgentdeliveryisplanned, in-uteroresuscitationincludes SubsequentManagement Fetalheartratemaybeconﬁrmed withultrasonography. DiagnosticStudy • • • DIFFERENTIALDIAGNOSIS

• • • • • • ImmediateManagement

Maternal administrationofbeta-blockers Non-reassuring fetalheartrate Maternal heartrate • • • aortocaval obstruction. is administeredandmaternalpositionalteredtoprevent If non-urgentdeliveryisplanned,supplementalmaternaloxygen • If noepiduralcatheterisinplace,evaluatethematernalairway. achieve anappropriatesensorylevel). a satisfactorysensorylevel;lidocainerequires4–6minutesto the urgency(2-chloroprocainerequires2minutestoachieve level with3%2-chloroprocaineor2%lidocainedependingupon If afunctioningepiduralcatheterispresent,extendthesensory with sodiumbicitrate. If urgentdeliveryisrequired,consideraspirationprophylaxis • Treat factorsthatcouldbecontributingtofetaldistress: for urgentcesareansection. Consult theobstetricianregardingplanfordeliveryandprepare

Left uterinedisplacementtotreataortocavalcompression ephedrine 5mgIV Treat hypotensionwithfluid loadingandincrementaldosesof pressure. intubation, considerrapidsequenceinductionwithcricoid If airwayexamdoesnotsuggestapossibledifficult maternal injury. consider regionalanesthesiaorfiberoptic intubationtoavoid If airwayexamissuggestiveofpossiblediffi Administer supplementalO

cult intubation,

MaconesGA,HankinsDV,SpongCY,HarthJ,MooreT.The2008National ally duetooverdos oraccidentalintravascularinjection. Unintendedsystemic effectsoflocalanestheticadministration, usu- Deﬁ GrahamEM,PetersenSM,ChristoDK,FoxHE.Intrapartumelectronicfetal FurtherReading nonreassuring. should beconsideredinparturientsifthefetalheartratetracingis labor decreasesthepossibilityofanurgentgeneralanestheticand maternal mortality.Earlyplacementofepiduralanalgesiaduring elect toperformaregionalanestheticavoidfailedintubationand Despitethepresenceoffetalbradycardia,anesthesiologistmay SpecialConsiderations gen isdebatablebecausetheimpactonfetaloxygenationminimal. tension causedbyneuraxialanesthesia.Theuseofsupplementaloxy- phenylephrine (100mcgIV)orephedrine(5mgtotreatthehypo- to preventaortocavalcompression.Administerincrementaldosesof sion andfetaloxygendeliveryiscritical.Leftuterinedisplacementhelps Whilespeciﬁc preventionisnotpossible,maintenance ofuterineperfu- Prevention

• • • • • • • • • • RiskFactors

LocalAnestheticToxicityAnesthet

research guidelines. electronic fetalmonitoring:updateon deﬁ nitions, interpretation,and Institute ofChildHealthandHumanDevelopmentworkshopreporton Gynecol. heart ratemonitoringandthepreventionofperinatalbraininjury. Prematurity Rupture ofmembraneswiththefetalheadnotengaged Maternal trauma Maternal cocaineuse Maternal cardiacdisease Placental abruption Polyhydramnios Maternal asthma Hypovolemia Maternal hemorrhage nition 2006;108:656–666.

J ObstetGynecolNeonatNurs.

c Tox

i c i ty

2008;37:510–515.

Obstet 179 CHAPTER 8 Obstetric Emergencies 180 CHAPTER 8 Obstetric Emergencies

after injectionoflocal anesthetic,assumelocalanesthetic toxicity. Ifapatientseizes orhasventriculartachycardiaduring orshortly DiagnosticStudies • • • • • • • • DIFFERENTIALDIAGNOSIS dysrhythmias. ing thesodiumchannelsinheart,leadingtopotentiallyfatal central nervoussystem.Cardiovasculartoxicityresultsfromblock- the myocardium.Seizuresarecausedbylossofinhibitionin nervous system,myocardialmuscle,andtheconductionsystemin sodium channels.Thesedrugsactonthecentralandperipheral Localanestheticsreversiblyblocknerveconductionbyblocking Pathophysiology • • • rhythmias, andcardiovascularcollapse. CNStoxicity,includingseizures,andmyocardialdepression,dys- Presentation cardium andmyocardialdepression Cardiovasculartoxicity—impairedelectricalconductioninthemyo-

• • • • • ImmediateManagement

Ventricular ﬁ Ventricular tachycardia Higher bloodconcentration:Convulsions,coma Underlying cardiacdisease Myocardial infarction Thromboembolism Cardic arrest Alcohol/drug withdrawal Toxic/metabolic Underlying seizuredisorder Eclampsia •

symptoms persist. Bolus orinfusionof20%intralipidshouldbecontinuedif minutes. 1.5 mL/kgIVbolusfollowedby0.25mL/kg/minfor30–60 If bupivacainetoxicityissuspectedadminister20%Intralipid sodium thiopentalforseizures.Preparetosecuretheairway. Administer abenzodiazepine(e.g.,midazolam2mgIV)or Hyperventilate thepatient. Halt theinjectionoflocalanesthetic. lightheadedness, visualdisturbances Low bloodconcentration:Tonguenumbness,tinnitus, brillation

diac disease.Bupivacaine toxicitycanalsocausecardiac arrest.The include sepsis,amniotic fl uid embolism,trauma,andmaternalcar- Themostcommon causeisvenousthromboembolism. Othercauses Pathophysiology trical activity,ventricularfi brillation, orasystole. Nopalpablepulse.Theelectrocardiogram willrevealpulselesselec- Presentation resuscitation. Absenceofapalpablematernalpulserequiringcardiopulmonary Defi RosenblattMA,AbelM,FisherGW.Successfuluseof20%lipidemulsionto FurtherReading with instructionsforitsusereadilyavailable. should have20%intralipidinsuffi cient quantitiestotreattoxicity, Anyanesthetizinglocationinwhichlocalanestheticisadministered SpecialConsiderations intravascular injectionmaybedetectedpriortogivingalargedose. in 3–5mLincrements,waitingseveralminutesbetweendoses.An doses ofepiduralanesthesiashouldalsobefractionated.Administer tinnitus andcheckfortachycardiaduringtheinjection.Subsequent Fractionate thedoseoflocalanestheticandaskpatientabout rine 1:200,000priortoinjectionoflargevolumelocalanesthetics. Administeratestdoseof3mL1.5%lidocainewithepineph- Prevention • • • SubsequentManagement

Parturientsareatriskforintravascularplacementofepiduralcath- RiskFactors

MaternalCardiacArrest Anesthesiology. resuscitate apatientafterpresumedbupivacaine-relatedcardiacarrest. troponin levelstoruleoutmyocardialinjury. If cardiovasculartoxicityispresent,obtainaseriesofcardiac Perform neurologicexamination. Administer intralipidforpersistentsymptoms. eters duetodilationofepiduralveins. nition

2006;105:217–218.

181 CHAPTER 8 Obstetric Emergencies 182 CHAPTER 8 Obstetric Emergencies tion isgreaterthan 20weeks. the infantshouldbe deliveredbySTATcesareansection ifthegesta- Ifthematernalcirculation hasnotbeenrestoredwithin 4minutes, SubsequentManagement gases andtransesophagealechocardiography ifavailable. electrical activityshouldbedetermined byobtainingarterialblood diac rhythmistreatablewithelectricity. Theetiologyofpulseless Anautomatedexternaldeﬁbrillator willdeterminewhetherthecar- DiagnosticStudies • • • • • • • DIFFERENTIALDIAGNOSIS during theresuscitation. may complicatetheresuscitation.Thefetusmustalsobeconsidered signiﬁ anatomic andphysiologicchangesofpregnancylaborresultin

• • • • ImmediateManagement

Embolism Anaphylaxis Local anesthetictoxicity Total spinalanesthesia Hemorrhage Sepsis Maternal cardiacdisease used. compressions); and positive-pressure ventilation); primary survey. Diagnosis (identifypossiblereasonsforthearrest)follow access toadministerfluids andmedications), (assess theadequacyofventilation); Secondarysurvey Primarysurvey survey approach toemergencycardiaccarehasbeenthe uterine displacementtoimprovevenousreturn.Thetraditional algorithm. Duringresuscitation,considermaintainingleft circulation. FollowtheAmericanHeartAssociationACLS The goalofresuscitatingtheparturientisreturnmaternal recommended in the ACLS algorithm apply for pregnant patients. recommended intheACLSalgorithmapplyforpregnantpatients. not changesignifi cantly duringpregnancy.Theenergysettings The energyrequiredfordefi brillation energyprobablydoes cantly decreasedcardiovascularandpulmonaryreserves,which

followedbythe : A

, irway(opentheairway); A

irway (establishairwaycontrol); D

eﬁ secondary survey .

brillation (shockVF/pulselessVT) are

C irculation(givechest

C irculation (obtainIV B reathing(provide D ifferential primary B reathing

KatzV,BalderstonK,DeFreestM.Perimortem cesareandelivery:wereour KatzVL,DottersDJ,Droegemueller W.Perimortemcesareandelivery. FurtherReading resuscitation ofthemother. 23 weeksmaynotresultinaviableinfant,itenablesuccessful tation. Althoughemergencydeliveryperformedbetween20and expected fetalviabilityisconsideredtobearound24weekges- infants afterperimortemcesareandeliveries.Thethresholdfor gestational ageisanimportantfactorinpredictingprognosisfor venous returnandmoreeffectivechestcompressions.Estimated and inadequatechestcompressions.Deliveryallowsforimproved monary resuscitationiscompromisedbyaortocavalcompression of successfulmaternalresuscitation.Inlatepregnancy,cardiopul- of neurologicalinjuryintheinfantandmayimprovelikelihood should bedeliveredbyminute5.Earlydeliverydecreasestherisk ful. Ifthecirculationhasnotreturnedby4minutes,infant the earlydeliveryoffetusifresuscitationisnotsuccess- The mostimportantstepintheresuscitationofparturientis Theestimatedincidenceofcardiacarrestis1in30,000pregnancies. SpecialConsiderations disorders ofpregnancy. cion inparturientswithcardiacdisease,hemorrhage,orhypertensive complications arenottotallypreventable.Keepahighlevelofsuspi- dence oftotalspinalanesthesiaandlocalanesthetictoxicitybutthese Appropriatetestingoftheepiduralcathetermayreduceinci- Prevention thromboplastin timesaredecreased. factor concentrationsareincreasedandprothrombinpartial to behypercoagulableandatriskforthromboembolismbecause and VIIIincreasebymorethan100%.Parturientsarelikely and Hagemanfactor(FactorXII).TheconcentrationsofFactorsI VIII), Christmasfactor(FactorIX),Stuart-ProwerX), (Factor I),proconvertinVII),antihemophilicfactor with anincreaseincoagulationfactors,includingﬁ brinogen cardiac arrestduringlaboranddelivery.Pregnancyis Parturientswithcongenitalheartdiseaseareatparticularriskfor RiskFactors assumptions correct? ObstetGynecol.

1986;68:571–576. Am JObstetGynecol.

2005;192:1916–1920. associated

183 CHAPTER 8 Obstetric Emergencies 184 CHAPTER 8 Obstetric Emergencies soft, poorlycontracteduterusisreferredtoas myometrium, theuteruscannotcontract,resultinginhemorrhage.A through themyometrium(percreta).Ifplacentaisimplantedinto onto themyometrium(accreta),into(increta),or the birthoffetus. to separationoftheplacentaafter20weeksgestationandbefore proximate totheinternalosofcervix.

Presentation • • DIFFERENTIALDIAGNOSIS accreta. tum hemorrhageareuterineatony,retainedplacenta,andplacenta placenta previaandplacentalabruption.Themajorcausesofpostpar- postpartum. Thetwomajorcausesofantepartumhemorrhageare min. Hemorrhageduringdeliveryischaracterizedasantepartumor mL/min. Atterm,uterinebloodfl ow isapproximately500–700mL/ Inthenonpregnantstate,uterinebloodfl ow isapproximately50 Pathophysiology • • • • Parturientswithobstetrichemorrhage namic instability. maternal hemorrhageasanylossofbloodthatresultsinhemody- TheAmericanCollegeofObstetriciansandGynecologistsdefi Defi

• • • Managementofhemorrhage: ImmediateManagement

MaternalHemorrhage

Increased maternalheartrate cause ofpostpartumhemorrhageis uterineatony. anesthesia providerofretainedplacenta. Themostcommon Postpartum hemorrhage:Theobstetricianwillinformthe concealed. is verypainful,butthebloodlossmayberetroplacentaland vaginal bleedingwithnoconcealedbleeding.Placentalabruption Antepartum hemorrhage:Placentapreviaresultsinpainless Fetal tachycardia Maternal hypotension Sinus tachycardia Initiate ﬂ Obtain large-bore intravenousaccess Type andcrossmatchpackedredblood cells. nition Placenta previa uid resuscitation

Placenta accreta isaplacentaoverlyingthecervicalos,or

deﬁ nes implantationdirectly

Placental abruption uterine atony .

refers nes

• • SubsequentManagement • • • DiagnosticStudies Immediate Management(continued)

Managementofplacentaaccreta: • • • • • • • Managementofuterineatony:

• • RiskFactors

radiology consultationforarterialembolization. instability, theobstetricianmayrequestaninterventional For continuedbleedingthatdoesnotcausehemodynamic avoiding dilationandevacuation. the obstetriciantoexploreuterusmanually,potentially intravenous nitroglycerinprovidesuterinerelaxationandallows to maintaincontraction.Ifretainedproductsaresuspected, is required.Theadministrationofoxytocinmaybecontinued If uterinecontractilityismaintained,nofurtherintervention Uterine atonyisadiagnosisofexclusion. transabdominal ultrasonography. Placental abruptionandretainedplacentaarediagnosedby Placenta previaisdiagnosedbytransvaginalultrasonography.

the sametime. would havetomanagetheairwayandﬂuid resuscitationat may beperformedunderregionalanesthesia,theprovider Consider generalanesthesia.Althoughagravidhysterectomy Prepare forsigniﬁ Obstetrician willdoagravidhysterectomy. Prostaglandin F contraindication Methylergonovine 0.2mgIM.Preeclampsiaisarelative IV. Maycausehypotension Administer oxytocin20–40unitsin1litercrystalloidsolution Consider activatingthemassivetransfusionprotocol Placental Abruption • Placenta Previa • • •

Previous cesareansection Previous uterinesurgery Older maternalage Multiple pregnancy

2α 0.25mgIM.Asthmaisacontraindication cant hemorrhage.

185 CHAPTER 8 Obstetric Emergencies 186 CHAPTER 8 Obstetric Emergencies SewellMF,Rosenblum D,EhrnebergH.Arterialembolus duringcommon OyeleseY,SmulianJC.Placentaprevia, placentaaccreta,andvasaprevia. FranchiniM,FranchiBergaminiV,et al.Acriticalreviewontheuseof FurtherReading described, butmayexacerbateapreexistinghypercoagulablestate. if available.TheuseofrecombinantFactorVIIainobstetricshasbeen Anesthesiologists guidelinesstatethatacellsavershouldbeconsidered College ofObstetriciansandGynecologiststheAmericanSociety oretical riskofinfectionoramnioticfl uid embolism.BothAmerican Theuseofacellsaverinobstetricsiscontroversialbecausethethe- SpecialConsiderations uterus, decreasingbloodloss. eters maybeinfl ated afterdeliverytodecreasebloodfl ow tothe by interventionalradiologypriortocesareandelivery.Thesecath- accreta, considerplacementofballooncathetersintheiliacarteries blood fortransfusionshouldbeavailable.Inpatientswithplacenta factors. Inpatientsatriskforhemorrhage,large-boreIVaccessand Optimal managementincludespreparationandidentifi cation ofrisk Therearenospecifi c meanstopreventobstetrichemorrhage. Prevention Risk Factors(continued) • •

2006;108:746–748. iliac ballooncatheterization atcesareanhysterectomy. ObstetGynecol. rhage. recombinant FactorVIIainlife-threatening obstetricpostpartumhemor- • • • • • • • • • Uterine Atony • Placenta Accreta • •

Trauma Cocaine History ofplacentalabruption Hypertension Preeclampsia Magnesium Infection Multiple gestation Multiparity Previous cesareansectionandplacentaprevia Polyhydramnios Fetal macrosomia Semin ThrombHemost. 2006;107:927–941.

2008;34:104–112.

Obstet Gynecol. given totheinfant ifthemotherhasreceivedopioids withinthepast does notchange the needforresuscitation.Naloxone 0.1mg/kgis Maternalopioidconsumption maycauseneonatal apnea, butthis DIFFERENTIALDIAGNOSIS rial blooddoesnotbecomeoxygenated. pulmonary arteriolesmayremainconstricted,andthesystemicarte- air andusingthelungsforoxygen.Ifthissequenceisinterrupted, constrict. Atthecompletionoftransition,babyisbreathing fl tance, resultinginincreasedpulmonarybloodfl ow anddecreased pressure. Pulmonaryvasodilationdecreasespulmonaryarteryresis- ing thelow-resistanceplacentalcircuitandincreasingsystemicblood replaced byair.Theumbilicalarteriesandveinareclamped,remov- transition, thefluid inthealveoliisabsorbed intothelungtissueand After birth,thelungsbecomeonlysourceofoxygen.Duringthis Beforebirth,thefetusdependsuponuterinebloodflow foroxygen. Pathophysiology • • • Presentation tive measures. respiration, whileabout1%ofnewbornsneedextensiveresuscita- Approximately 10%ofnewbornsrequiresomeassistancetoinitiate neonate isforcedtomakerapidandprofoundphysiologicchanges. Duringthetransitionfromintrauterinetoextrauterinelife, Defi WatersJH,BiscottiC,PotterPS,PhillipsonE.Amnioticfl ShimJY,YoonHK,WonHS,KimSK,etal.Angiographicembolizationfor restart respiration. of secondaryapnea.During apnea,stimulationwillnot gen deprivationcontinues,thebaby gaspsandthenentersaperiod such asdryingtheinfantwillcause a resumptionofbreathing.Ifoxy- breathe, thereisaperiodofprimary apneaduringwhichstimulation, deprived ofoxygen.Afteraninitialperiodrapidattemptsto ow throughthe ductusarteriosus.Thearteriosusbeginsto

NeonatalResuscitationNe ActaObstetGynecolScand. obstetrical hemorrhage:effectivenessandfollow-upoutcomeoffertility. Total bodycyanosis Heart ratelessthan100bpm Failure toinitiateventilationafterbeingstimulated Respirationsaretheﬁ rst vitalsigntoceasewhenanewbornis during cellsalvageinthecesareansectionpatient. 2000;92:1531–1536. nition o natal Resuscitati

2006;85:815–820.

o n

Anesthesiology. ud removal uid

187 CHAPTER 8 Obstetric Emergencies 188 CHAPTER 8 Obstetric Emergencies neonatal ICUfor further monitoring. compression ormedications,theinfant shouldbeadmittedtothe and requirespositivepressureventilation. Iftheinfantrequireschest immediately afterbeingstimulated, theinfanthassecondaryapnea no furtherwork-upisnecessary.If ababydoesnotbeginbreathing Iftheinfantrespondstodryingor topositivepressureventilation, SubsequentManagement pink lipsand,inlight-skinnedinfants,atrunk). umbilical cordorwithastethoscope)andcolor(infantshouldhave heart rate(shouldbemorethan100bpmdeterminedbypalpating Managementisbaseduponphysicalexam,evaluatingforrespirations, DiagnosticStudies aspiration, andneonatalsepsis. mother, congenitalhearddefectsorothermalformations,meconium 4 hours.Othercausesincludegeneralanesthesiaadministeredtothe

• • • • • • • • • • ImmediateManagement

minute. compression, foratotalof30breathsand90compressionsper 0.1–0.3 mL/kgisadministeredintravenously. If theheartrateiflessthan60bpm,epinephrine1:10,000 breathe spontaneously,positiveventilationisstopped. If theheartrateisgreaterthan100bpmandbabybeginsto stopped butventilationiscontinued. If theheartrateisgreaterthan60bpm,chestcompressionsare The rateofcompressionisonebreathafterevery3 or ringfinger ofonehandareusedtocompressthesternum.) two finger technique,thetipsofmiddlefi nger andtheindex encircle thetorsoandfingers supportthespine.With (Two thumbsareusedtodepressthesternumwhilehands despite 30secondsofeffectivepositivepressureventilation Initiate chestcompressionsifheartrateislessthan60bpm accurate). Assess heartrate(listeningwithastethoscopeismost breaths perminuteatapressurenogreaterthan20cmH If apneic,initiatepositivepressureventilationatarateof40–60 Dry andstimulatetheinfantfor20seconds. Place theinfantonaradiantwarmer. lactated Ringer’ssolutionat10mL/kg. If theinfantispale,replacevolumewithnormalsalineor

2 O. blood pressureof 90mmHg.Eclampsiaincludesthese findings aswell systolic bloodpressure ofatleast140mmHgorasustained diastolic Obstetricians andGynecologistsdefines preeclampsiaasasustained increased bloodpressure,andproteinuria. TheAmericanCollegeof Amultisystemdisorderuniqueto pregnancy thatcancauseedema, Defi TreviasanutoD,MicaglioM,PittonM.Laryngealmaskairway:isthemanage- SaugstadOD,RootweltT,AgleaO.Resuscitationofasphyxiatednewborn FurtherReading should beventilatedwiththelowestFiO have beenshowntobeeffectiveforventilatingnewborns.Neonates tation shouldbepresentateverydelivery.Laryngealmaskairways responsibility istheneonateandwhocapableofinitiatingresusci- Atleastoneperson(nottheanesthesiaprovider)whoseprimary SpecialConsiderations the infantwillnotrequireresuscitation. resuscitation. Theabsenceofariskfactordoesnotguaranteethat Beawareofriskfactorsthatplacetheneonateatforrequiring Prevention quate oxygenation. quate oxygenation.

• • • • • • • • • • • RiskFactors

Preeclam Preeclampsia/Eclampsia

Resuscitation. ment ofneonatesrequiringpositivepressureventilationatbirthchanging? 2 study. infants withroomairoroxygen:aninternationalcontrolledtrial:theResair Instrumental delivery(forcepsorvacuum) Prolonged ruptureofmembranes Emergency cesareansection Non-reassuring fetalhearttracingduringdelivery Meconium Fetal malformation Post-term gestation Maternal drugoverdose Maternal infection Preeclampsia Maternal diabetes nition Pediatrics.

2004;62:151–157.

p sia/Eclam 1998;102:130–137.

sia

2 requiredtoproduceade-

189 CHAPTER 8 Obstetric Emergencies 190 CHAPTER 8 Obstetric Emergencies genic proteinsproducedbytheplacenta. pregnancies. Mosttheoriesimplicateanabnormalresponsetoangio- patients withmolarpregnanciesandalsoinabdominal appear andseemstoinvolvetheplacenta.Preeclampsiaisseenin seems tobeginatimplantation,wellbeforetheclinicalmanifestations Theetiologyofpreeclampsiaremainsunknown,butthedisease Pathophysiology • • Presentation mal convulsionsnotrelatedtoothercerebralconditions. as centralnervoussysteminvolvementleadingtoseizuresorgrand

• • • • ImmediateManagement

• Severe Preeclampsia • Preeclampsia

postpartum. the bestmedicationforprevention ofseizuresintra-and cesarean delivery. Consider epidural laboranalgesiaorregionalanesthesia for Check theplateletcountbeforeattempting regionalanesthesia. preeclamptic patients.Magnesiumsulfate (MgSO is difﬁcult, soprophylacticanticonvulsantsareusedin all to preventeclampsia.Predictingwho isatriskforeclampsia Anticonvulsants areadministeredto womenwithpreeclampsia cesarean section. is anindicationfordeliveryeitherbyinductionoflaboror Preeclampsia atterm,orthepresenceofseverepreeclampsia, Presence ofonethefollowing Requires both: • • • • • • • • • • • •

Intrauterine growthretardation Diastolic bloodpre[ Systolic bloodpre[ Hemolysis, elevatedliverenzymes,lowplatelets(HELLP) Pulmonary edema ProteiV OliO Epigastric pain Visual changes ProteiV Headache pressure Systolic bloodprM ra|400mLina24-hourperiod uria | ra“5000mgina24-hourcollection uria “ ra“300mgina24-hourcollection uria “ t 90mmHg

sr 140mmHgordiastolicblood ssure “ ue“160mmHg sure “ ue“110mmHg sure “

4 )remains

• • • • • SubsequentManagement • • • • DiagnosticStudies • • • • • • • • DIFFERENTIALDIAGNOSIS

• • • • • • • RiskFactors

function, loadwith4gmfollowedbyaninfusionof1–2gm/h. hours postpartum. until theplateletcountbeginstonormalize. thrombocytopenia, considerdelayedremovalofthecatheter In parturientswithepiduralcatheterswhodevelop hours. PatientsmustbemonitoredandMgSO eclampsia inthepostpartumperiod,especiallyduringﬁ Parturients withpreeclampsiaareatriskforthedevelopmentof and isanindicationfordelivery. The diagnosisofseverepreeclampsiaindicatesorganinvolvement Start MgSO anatomic causesoftheseizure. If thepatientseizes,aheadCTscanmaybeobtainedtoruleout intravascular volume,oritmaybedecreasedifthereishemolysis. The hemoglobin/hematocritmaybeincreasedwithadecreasein Complete bloodcounttoruleoutthrombocytopenia. a 24-hourperiodisabnormal. in a24-hourperiodisnormal.Proteinuriagreaterthan300mg important test.Ina24-hourcollection,proteinuriaupto300mg In ahypertensiveparturient,urinalysisforproteinisthemost Alcohol/drug withdrawal Toxic/metabolic Preexisting kidneydisease Pain Acute cocainetoxicity Hypertension Preexisting seizuredisorder Local anesthetictoxicity Platelet countstendtonormalizewithin60hourspostpartum. Asthma Diabetes mellitus Previous pregnancywithpreeclampsia First pregnancy Hypertension beforepregnancy Multiple births Maternal age(<20yearsor>40years) 4

forseizureprophylaxis.Inpatientswithnormalrenal

4 continuedfor24

rst 24

191 CHAPTER 8 Obstetric Emergencies 192 CHAPTER 8 Obstetric Emergencies VisalyaputraS,RodanantO,Somboonviboon W,etal.Spinalversusepidural RanaS,KarumanchiSA,LevineRJ,etal.Sequentialchangesinantiangiogenic romuscular blockers. extreme caremustbeusedinthedosingofnon-depolarizingneu- ade. Ifthepatientreceivesgeneralanesthesiaforcesareandelivery, to result indeliveryofthe shoulders.The mostcommonetiology Gentledownward tractiononthefetalheadbyobstetrician fails Deﬁ BaumannMV,BersingNA,SurbeckDV.Serummarkersforpredictingpreec- FurtherReading upon theclinicalsituation.MgSO with preeclampsia.Thelowestacceptableplateletcountwilldepend be checkedpriortoneuraxialanalgesia/anesthesiainaparturient absence ofplacentalabruption.Aplateletcountshouldtherefore dence dependsontheseverityofdiseaseandpresenceor most commonhematologicabnormalitywithpreeclampsia.Itsinci- increase theriskofpulmonaryedema.Thrombocytopeniais out ahigherincidenceofhypotension.Spinalanesthesiadoesnot cated, spinalanesthesiahasproventobeareliabletechniquewith- develop eclampsia.Whileonceconsideredabsolutelycontraindi- ductive age.Ofthoseparturientswithpreeclampsia,1%ofthem pregnancies andismorelikelytooccuratbothextremesofrepro- Inindustrializedcountries,preeclampsiacomplicates4.5–11.2%of SpecialConsiderations indicated. symptoms. Aspirindoesnotpreventpreeclampsiaandisnolonger to predictthosewhowilldeveloppreeclampsiabeforetheonsetof discovery oftheangiogenic/antiangiogenicproteins,itmaybepossible Thereisnoknowninterventionthatpreventspreeclampsia.Withthe Prevention Risk Factors(continued)

• • •

ShoulderDystociaD

domized multicenterstudy. anesthesia forcesareandeliveryinsevere preeclampsia:aprospective,ran- 2007;50:137–142. factors inearlypregnancyandriskofdevelopingpreeclampsia. lampsia. Scleroderma Systemic lupuserythematosis Kidney disease nition Mol AspectsMed.

stocia

2007;28:227–244. Anesth Analg.

4 potentiatesneuromuscularblock- 2005;101:862–868.

Hypertension.

for thedelivery. shoulders, thearrival timesofteammembers,andmaneuvers used The recordshould includethetimesofdelivery theheadand resuscitation team. Themothershouldbeinformed oftheevent. Followingdelivery,theinfantshould beresuscitatedbyaneonatal SubsequentManagement Clinicaldiagnosisismadebytheobstetrician. DiagnosticStudies • • DIFFERENTIALDIAGNOSIS into thepelvisandperformanurgentcesareandelivery. maneuvers torelievethisimpactionormustreturnthefetalhead pelvic bone.Theobstetricianmustbepreparedtoperformseveral entering thepelvis,shouldersmaybecomeimpactedon shoulder shouldrotateintotheanterior-posteriordiameterbefore allow foritsdescentandpassagethroughthematernalpelvis.If Duringanormaldelivery,thefetalheadandshouldersrotateto Pathophysiology • • • Presentation promontory. commonly, theposteriorshoulderbecomesimpactedonsacral is impactionoftheanteriorshoulderabovepubicbone.Less

• • • • ImmediateManagement

Absence ofuterinecontraction Poor maternalpushingeffort plexus injury. The obstetricianmustavoidexcessiveforcetopreventbrachial fails toresultindeliveryoftheshoulder. Following deliveryofthefetalhead,gentletractiononhead Prolonged secondstageoflabor. injury. Delivery mustberapidinordertopreventhypoxicbrain Prepare foremergencycesareandelivery. Provide analgesiafordelivery. maternal pelvisandperformingcesareandelivery) do theZavenelliManeuver(returningfetalheadinto If attemptstodelivertheneonatefail,obstetricianmay

193 CHAPTER 8 Obstetric Emergencies 194 CHAPTER 8 Obstetric Emergencies DeeringS,PoggiMacedoniaC,Gherman RB,SatinAJ.Improvingresident CroftsJF,BartlettC,ElliseD,HuntLP,FoxR,DraycottTJ.Managementof FurtherReading • • complicates anestimated0.6–1.4%ofdeliveries. anesthesia ifurgentcesareandeliveryisrequired.Shoulderdystocia provide analgesiaifanepiduralcatheterispresentandto from theentireteam.Theanesthesiaprovidermustbepreparedto Shoulder dystociarequiresanimmediateandcoordinatedresponse SpecialConsiderations to improvethemanagementofshoulderdystocia. Training, especiallysimulation-basedtraining,hasbeendemonstrated elective cesareandeliveryinpatientsatriskforshoulderdystocia. Fetalpositionshouldbeassessedduringlaboranddelivery.Consider Prevention

• • • • • • • RiskFactors

ing. competency inthemanagementofshoulder dystociawithsimulationtrain- shoulder dystocia. • • Potential neonatalcomplications: • Potential maternalcomplications: • • • •

Vacuum orforcepsassisteddelivery Precipitous laboranddelivery Prolonged secondstage Maternal diabetes Maternal obesity Fetal macrosomia Previous shoulderdystocia Brachial plexusinjury Fractured clavicle 4 Pubic symphysealseparation Birth asphyxiawithneurologicimpairment Hemorrhage Femoral neuropathy th Obstet Gynecol. degreelaceration

Obstet Gynecol. 2004;103:1224–1228.

2007;110:1069–1074.

• • • • DIFFERENTIALDIAGNOSIS the cranialnerves,patient’spupilsmaybefixed anddilated. blockade ofthecardiacacceleratorfibers. Iftheblockadeextendsto extent ofblockade.LevelshigherthanT1causebradycardiadueto a head-upposition.Symptomsoftotal/highspinaldependuponthe position, orwhenahypobaricsolutionisusedandthepatientin hyperbaric solutionisusedandthepatientplacedinTrendelenburg recognized bytheprovider.Atotalorhighspinalmayoccurwhena occur whenanepiduralcatheterislocatedintrathecallyandnot amounts oflocalanestheticintotheintrathecalspace,suchasmay Totalorhighspinalanesthesiamayresultfromtheinjectionoflarge Pathophysiology • • • • • • Presentation spread. caused byanexcessivevolumeoflocalanesthesiaorhighrostral Extensivespreadoflocalanestheticwithintheintrathecalspace Defi

• • ImmediateManagement

Total/HighSpinalAnesthesiaTotal/Hi

respiration Respiratory arrestfrommotorblockadeofmuscles pupils. Patients withatotalspinalanestheticmayhavefixed anddilated Hypotension higher thanT1) Bradycardia fromblockadeofcardiacacceleratorfi The patientisunabletomoveupperextremities. patient maybeunconscious. The patientmaybeconsciousbuthavedifficulty speaking,orthe Intracerebral bleed Hemorrhage Local anesthetictoxicity Myocardial infarction Increase FiO2tomaintain oxygenation. Recognize thatthepatienthasatotal/high spinalanesthetic. nition

g h SpinalAnesthesia

bers (level

195 CHAPTER 8 Obstetric Emergencies 196 CHAPTER 8 Obstetric Emergencies

• • Prevention • • • • • SubsequentManagement • • DiagnosticStudies

• • • • • ImmediateManagement

• • • RiskFactors

parturients Reduce thedose of intrathecallocalanesthesiainshort orobese Maintain vigilance whileperformingneuraxialblocks. perform othertasksifthisapproachischosen. but thismayincreasetheriskofaspirationandmakeitdiffi mask ventilationuntilthepatientisabletoprotectairway, Some practitionerschoosetomanagetheairwaywithassisted further decreasevenousreturntotheheart. further rostralspread,asitwillonlyworsenvenouspoolingand Reverse Trendelenburgpositionisnotrecommendedtoprevent performed. If fetalbradycardiaoccurs,urgentcesareandeliveryshouldbe provide amnesiaduringsurgery. Small amountsofvolatileanestheticagentsshouldbeusedto continuous administrationofavasopressor. Hypotension resultingfromsympatheticblockademayrequire is indicated. following theintrathecalinjection,acomputedtomographyscan If thepatientdoesnotrespondwithinexpectedtimeframe spinal. No diagnosticstudiesareindicatedforthediagnosisoftotal/high hypotensive patient. Use cautionwhenadministeringaninductionagentina Increase Fio Recognize thatthepatienthasatotal/highspinalanesthetic. Administer additionalintravenousfl relatively contraindicated. the levelofblockextendsbeyondT1,makingphenlyephrine or epinephrine)totreathypotension;bradycardiamayoccurif respiratory insufficiency. Administervasopressors(ephedrine Prepare forurgentairwaymanagementinthesettingof Spinal anesthesiafollowingfailedepidural anesthesia Maternal obesity Short stature

2 to maintainoxygenation.

(continued)

uid.

cult to

• • • • DIFFERENTIALDIAGNOSIS pelvis priortoruptureofthemembranes. require rupturedmembranesanda fetuswhoisnotengagedinthe Whilethesetwopostulatedmechanisms arecontradictory,both 2. 1. Twomechanismshavebeenpostulated: Pathophysiology membranes. dycardia orseverevariabledecelerationsinthesettingofruptured Umbilicalcordprolapsetypicallypresentswithpersistentfetalbra- Presentation uterine wall. ity ofcases.Itmayalsobecomecompressedbetweenthefetusand during labor,protrudingintoorthroughthecervixinvastmajor- Theumbilicalcorddescendsinadvanceofthefetalpresentingpart Deﬁ KoppSL,HorlockerTT,WarnerME,etal.Cardiacarrestduringneuraxial FurtherReading The mostcommonsignprecedingthearrestisbradycardia. Cardiacarrestinmayoccurpatientswithhigh/totalspinalanesthesia. SpecialConsiderations • • • Alwaysadministeratestdoseoflocalanestheticthroughan

UmbilicalCordProlapseProla AnesthAnalg. anesthesia: frequencyandpredisposingfactorsassociatedwithsurvival. soliciting thepatientforsymptomsofintrathecalinjection Fractionate thedoseofepidurallocalanestheticandalways epidural catheter. epidural anesthesia Reduce thedoseoflocalanesthesiainpatientswithfailed Oligohydramnios Maternal hypotension Placental abruption Fetal bradycardia prolapse. then leadstodecreasedadaptabilityandpredisposescord Fetalacidosisincreasesthestiffnessofumbilicalcord,which and canmoreeasilyprolapse. Theumbilicalcordbecomeslimpafterrepeatedcompression nition

2005;100:855–865.

197 CHAPTER 8 Obstetric Emergencies 198 CHAPTER 8 Obstetric Emergencies

• Prevention • • • SubsequentManagement • • DiagnosticStudies

• • • • • • • • • RiskFactors

• • • ImmediateManagement sider generalanesthesiausingrapid-sequenceinduction. Iftheparturientdoesnothaveanepiduralcatheterinplace,con-

pelvis. rupture ofmembranes toinsurethatthefetusisengaged inthe A carefulvaginalexaminationshould beperformedpriorto the infantisacidoticandhypoxic. skilled inneonatalresuscitation,asthereisahighpossibilitythat Following delivery,theinfantshouldberesuscitatedbyindividuals decision-making process. The obstetricianmustfollowthefetalheartrateandassistin Prepare foremergencycesareandelivery. vaginal examination. The diagnosisisconﬁrmed bypalpationofumbilicalcordduring bradycardia andrupturedmembranes. Suspect umbilicalcordprolapseinaparturientwithfetal Preterm delivery Fetal malpresentation Amniotomy Twin gestation Polyhydramnios Amnioinfusion Multiparity Contracted pelvis Low birthweight Prepare foremergencycaesareandelivery. delivery. umbilical cordpulsationsanddeterminetotheurgencyof The obstetricianshouldassessthefetalheartratebyfeeling moving itawayfromtheumbilicalcord. Ask theobstetriciantoelevatepresentingpartoffetus,

2%, andwithaninverted T-shapedorclassicincision, the riskis4–9%. verse scarisapproximately 1%.Withalowvertical scar,theriskis cesarean section,theriskofuterine rupturewithapriorlowtrans- anomalies orconnectivetissuedisease. Inparturientswithaprevious Inwomenwithanunscarreduterus, uterineruptureisdueto Pathophysiology • • • • uterus. Uterineruptureusuallypresentswith: scar, althoughitmayoccurinanunscarred(noprevioussurgery) Uterineruptureusuallyoccursinparturientswhohaveauterine Presentation uterine muscle.Adehiscenceisalsoknownasawindow. of theuterinewall,usuallywithserosaoverlyingdefectin abdominal cavities.Uterinedehiscenceisanincompletedisruption ine wall,resultinginfreecommunicationbetweentheuterineand Uterineruptureisthecompleteseparationofalllayersuter- Deﬁ DilbasB,OzturkogluE,S,OzturkN,SivasliogluAA,HaberalA.Risk FurtherReading vagina. to positionthepatientwithobstetrician’shandinpatient’s Although spinalanesthesiamaybepossible,itistechnicallydifﬁ agement forumbilicalcordprolapseisemergencycesareandelivery. of perinatalmortalityislow(0–3%).Thecurrentlyacceptedman- prolapse occursinahospitalandmonitoredsetting,theincidence 0.62% andhasaperinatalmortalityrateof50%.Ifumbilicalcord Theincidenceofumbilicalcordprolapsevariesbetween0.14%and SpecialConsiderations •

UterineRuptureUter ArchGynecolObstet. factors andperinataloutcomesassociatedwithumbilicalcordprolapse. with uterinerupturewillexperiencebreakthroughpain.) Abdominal pain;(Ifanepidurallaboranalgesiaisinuse,parturient umbilical cord. examination shouldbeperformedtocheckforthepresenceof If thereisbradycardiaafterruptureofthemembranes,vaginal Abnormal fetalheartrate(usuallybradycardia). Loss offetalstation; Vaginal bleeding; nition i ne Rupture

2006;274:104–107.

cult 199 CHAPTER 8 Obstetric Emergencies 200 CHAPTER 8 Obstetric Emergencies

blood resuscitationismandatory. hysterectomy isperformed,closeattentiontoadequateﬂ pregnancy mustbemanagedwithelectivecesareandelivery.Ifgravid terectomy. Usuallytheuteruscanberepaired,butanysubsequent Thepresenceofuterinerupturedoesnotnecessitategravidhys- SubsequentManagement with urgentcesareandeliveryifuterineruptureissuspected. Ultrasoundmaybeused,butgenerallytheobstetricianwillproceed DiagnosticStudies • • • • DIFFERENTIALDIAGNOSIS the onsetoflabor. ally occursduringlaborwithuterinecontractions,itcanoccurbefore Uterine rupturemayoccurfollowingmyomectomy.Whileitgener-

• • • • • • • RiskFactors

• • • • • ImmediateManagement

Uterine tetany Fetal bradycardia Placenta previa Placental abruption Induction oflabor inparturientwithpreviouscesarean section Fetal macrosomia Advanced maternalage Pregnancy within2yearsofprevious cesareandelivery Type ofscar(verticalincisionhasthe highestrisk) Maternal obesity number ofsurgeries) Prior uterinesurgery(riskincreases indirectcorrelationwith anesthesia isalsoanoption. long asadequateﬂuid resuscitationismaintained.General Epidural anesthesiamaybeusedforgravidhysterectomyas Consider useofaﬂuid warmerandrapidinfusionsystem. Send amaternalbloodspecimenfortypeandcrossmatch. hemorrhage. Establish large-boreintravenousaccessinanticipationof performed. If uterineruptureissuspected,expeditiouscesareandelivery

uid and uid

AmericanCollegeofObstetriciansandGynecologists.ACOGPractice AmericanCollegeofObstetriciansandGynecologists.ACOGcommittee FurtherReading vaginal birthaftercesareandelivery. provider mustbeimmediatelyavailablewhenaparturientattempts Gynecologists guidelinesstatethatanobstetricianandanesthesia trial oflaborhasdecreased.AmericanCollegeObstetriciansand nal birthaftercesareandelivery,thenumberofwomenattemptinga Despitethelowincidenceofuterineruptureduringattemptedvagi- SpecialConsiderations • • • • Prevention

2004;104:203–212. Bulletin #54:vaginalbirthafterpreviouscesarean. ObstetGyencol. opinion no.342:inductionoflaborforvaginalbirthaftercesareandelivery. rupture occurs. attempted vaginalbirthaftercesareansectionincaseuterine An anesthesiologistandobstetricianmustbepresentduringany Prolonged useofoxytocinisassociatedwithuterinerupture. should notundergoinductionoflaborwithprostaglandins. A parturientconsideringavaginaldeliveryaftercesarean Uterine ruptureisarareevent. 2006;108:465–468.

Obstet Gyencol.

201 CHAPTER 8 Obstetric Emergencies This page intentionally left blank Chapter 9 Pediatric Emergencies Jessica L. Wagner

Anaphylaxis 204 Asthma, Status Asthmaticus 206 Burns 209 Drowning and Near Drowning 212 Epiglottitis 215 Inhaled Foreign Body 217 Major Trauma 219 Neonatal Resuscitation 223 Pediatric Basic Life Support 227 Pediatric Advanced Life Support 230 203 Stridor 234

204 CHAPTER 9 Pediatric Emergencies

systemic vascularresistanceandtissuehypoperfusion. hypovolemia andshock.Arterialvasodilationproducesdecreased ability causestransudationoffl uid intotheskinandviscera,causing tryptase, andplatelet-activatingfactor.Increasedvascularperme- including histamine,prostaglandins,leukotrienes,cytokines,heparin, tion andreleaseofmultipleinfl gen inapreviouslysensitizedperson.Exposuretriggerstheproduc- activation ofmastcellsandbasophils,followingexposuretoanaller- AnaphylaxisisanimmediatehypersensitivityreactioncausedbyIgE Pathophysiology • • • • • • • • • • Presentation immunoglobulin E(IgE). rapid releaseofinflammatory mediators.Anaphylaxisismediatedby a specifi c antigenwith multisystemicmanifestationsresultingfrom Acute,potentiallylifethreatening,typeIhypersensitivityreactionto Defi

• • • • • ImmediateManagement

Anaphylaxis Anaphylax

Dyspnea anesthetized patient ) Cardiac arrest(rare,usuallyreversible) Dizziness oralteredmentalstatus Hypotension ( Nausea, vomiting,andabdominalpain Facial, lip,andtongueedema Erythematous rash,urticaria,andpruritis Tachypnea withuseofaccessoryrespiratorymuscles Hoarseness orstridorcausedbylaryngealedema Bronchospasm withwheezing Establish large-bore IVaccess. and repeatasnecessary. Epinephrine 1–10mcg/kgIV,depending onseverityofreaction, Support ventilationandoxygenation withFiO intubation orcricothyroidotomyimpossible). immediately (laryngealedemamay make endotracheal Maintain apatentairway;ifairwayobstruction occurs,intubate Identify anddiscontinueanypossible antigen. nition

may betheonlysignofanaphylaxisin i s

ammatoryandvasoactivemediators,

2 100%.

• • • • • SubsequentManagement • • DiagnosticStudies • • • • DIFFERENTIALDIAGNOSIS

Immediate Management(continued)

• • RiskFactors • • •

response totreatment. to whetherproceed;terminatetheprocedureifthereisno Advise thesurgicalteamofeventandmakeadecisionas Antihistamines (diphenhydramineIV1mg/kg) methylprednisone 2mg/kgIVbolus) Corticosteroids (dexamethasone0.2mg/kgIVbolus,or mast celltryptase. If thediagnosisisunclear,abloodsampleshouldbeanalyzedfor manifestations butarenotimmunologicallymediated) Anaphylactoid reactions(presentwithsimilarclinical Aspiration ofaforeignbodyorgastriccontents Acute asthmaexacerbation anaphylaxis Cutaneous manifestationsofallergicreactionnotassociatedwith Follow-up evaluationbyanallergy specialist required forseveralhoursafterseverereactions. Continuous infusionofepinephrine(0.01–0.2mcg/kg/min)maybe diagnosis. at leasttwoorgansystemsmustbeinvolvedtomakethe Anaphylaxis isdiagnosedbasedonclinicalmanifestations; inhaled anestheticconcentrationwillalsotreatbronchospasm. albuterol). Ifthepatientishemodynamicallystable,increasing Treat bronchospasmwithinhaledbronchodilators(e.g., pressure. Stop ordecreasedoseofanestheticagentstomaintainblood pressure stabilizes). intravascular volume(10–20mL/kg,repeatuntilsystolicblood Begin aggressiveresuscitationwithIVﬂuids tosupport Drug allergies(especially penicillin) most commoncauseofanaphylactic reactionsinchildren. Food allergies,particularlytopeanuts, eggs,anddairy,arethe

205 CHAPTER 9 Pediatric Emergencies 206 CHAPTER 9 Pediatric Emergencies SampsonHA.Anaphylaxisandemergencytreatment. airway instrumentation. lower airways.Occurs inresponsetoavarietyofstimuli including This airwayobstruction increasesresistancetoair fl ow withinthe constriction, mucosaledema,airway infl ammation, andsecretions. Reversibleairwayobstructioncaused bybronchialsmoothmuscle Defi MelvilleN,BeattieT.Paediatricallergicreactionsintheemergencydepart- FurtherReading instability ismorecommonlyseen. anaphylaxis inchildren,contrastwithadultswherecardiovascular tion. Respiratoryabnormalitiesarethepredominantfi have arecurrenceofanaphylaxis8–12hoursafterinitialpresenta- cardia, orventriculardysrhythmias.Between5%–20%ofpatientswill nephrine canleadtoseverehypertension,supraventriculartachy- doses recommendedfortreatingcardiacarrest.Overdosingepi- Dosesofepinephrineusedtotreatanaphylaxisarelowerthanthe SpecialConsiderations anaphylactic reactions. an allergyspecialistisimportanttoreducetheincidenceoffuture tion anddelayimmediatediagnosistreatment.Follow-upwith phylaxis arenotrecommendedbecausetheymaymaskatruereac- a latex-freeenvironment.Prophylacticmedicationstopreventana- asthma. Ifthereisanyquestionofalatexallergy,treatthechildin Obtainadetailedhistoryofpreviousallergicreactions,atopy,and Prevention

• • • • Risk Factors(continued) Asthma,StatusAsthmaticus Asthma

111:1601–1608. 111:1601–1608. ment: areview. Higher incidenceofanaphylaxisinchildrenwithasthma Insect bites(bees,wasps)orcontactwithanimals surgical procedures) congenital genitourinaryabnormalitieswhohavehadmultiple Latex allergy(morecommoninchildrenwithspinabiﬁ during anesthesia(evenwithnopreviousexposure). Muscle relaxantsarethemostcommoncauseofanaphylaxis nition

, StatusAsthmaticus

Emerg MedJ.

2008;25:655–658.

Pediatrics.

nig with nding da or

2003;

• • • • DIFFERENTIALDIAGNOSIS mast cellsandoveractivityoftheparasympatheticnervoussystem. ators, immunemechanismsthatleadtodegranulationofbronchial Acuteasthmaiscausedbythelocalreleaseofvariouschemicalmedi- Pathophysiology • • • • • • Presentation

• • • • • • • • ImmediateManagement

that wheezingisnolongerheard. As thechildfatigues,airmovementmaydecreasetopoint Chest painortightness Increasing coughwithsputumproduction Hypoxemia resultingfromventilation-perfusionmismatch Dyspnea and/ortachypneawithprolongedexpiratoryphase Expiratory wheezingcausedbyairwayobstruction neck orchestradiograph) while eatingwith persistent cough,objectmaybeidentifi Foreign bodyaspiration (tracheaoresophagus;history ofchoking hypotension) Anaphylaxis (suddenonset,exposure toallergen,urticaria, Inhalation injury(basedonexposure history) tachypnea, retraction,wheezing) Bronchiolitis (viralinfection,infants lessthan1yearold, glycopyrrolate) shouldbegivenfirst todecreasesecretions. an inductionagent,butanticholinergicagent(atropine, Ketamine actsasabronchodilatorandmaybebenefi for afullstomach. standard anestheticagents;considerarapid-sequenceinduction For emergencysurgery,anesthesiamaybeinducedwith endotracheal intubationandmechanicalventilation. Asthma refractorytoinitialmedicaltherapymayrequire may alsobeusedinthemanagementofsevereasthma. Parasympathetic antagonists(atropine,nebulizedipratropium) given, butareconsideredasecond-tiertreatment. Methyxanthines (e.g.,theophyllineoraminophylline)maybe 1–2 mg/kg)toreduceinfl Intravenous ororalcorticosteroids(e.g.,methylprednisolone continuous useat5–10mg/hmayberequired Administer anebulizedβ2-agonist,suchasalbuterol; Increase FiO 2 to100%maintainoxygenation.

ammation

cial as

ed on

207 CHAPTER 9 Pediatric Emergencies 208 CHAPTER 9 Pediatric Emergencies

reduce theincidence ofacuteattacks.Childrenwith chronicasthma Medicalmanagement andminimizingexposureto triggerscan Prevention • • • • • • SubsequentManagement • • DiagnosticStudies • • • • •

• • • • RiskFactors

patients). dioxide elimination(onlynecessaryforseverelycompromised Arterial bloodgaswillhelpassessoxygenationandcarbon chest radiograph. Hyperinfl Vocal corddysfunction Mediastinal mass Bronchial stenosis Tracheomalacia/bronchomalacia Recurrent pulmonaryaspirationofgastriccontents stomach andextubateunderdeepanesthesia. If noriskfactorsforaspirationarepresent,suctionthepatient’s β-agonist therapy. Monitor forhypokalemia,whichisasideeffectofhigh-dose completely awakeandupperairwayreflexes arerestored. stomach), extubationshouldonlyoccuroncethechildis Following emergencysurgery(orinthepresenceofafull oxygenation maybebenefi of potentvolatileanestheticsorextracorporealmembrane If conventionaltherapiesfailintheintubatedchild,administration considered. Intravenous bronchodilators,suchasterbutaline,mayalsobe A shortcourseoforalsteroids(prednisone)maybenecessary. children whohaveasthmaalsoallergies) dander, orotherairbornesubstances(approximately80%of Sensitivity orallergiestopollens,dusts,pollutants,animal parent hasasthma,70%chanceifboth parentshaveasthma). developing thedisease(6%general population,30%ifone Children ofparentswithasthmaare atmuchhigherriskof Upper respiratoryinfections cigarette smoke)canprecipitateanasthmaexacerbation. excitement, andexposuretostrongodors(chemicalsor Exercise (especiallyincold,dryconditions),emotional ation ofthelungsduetoairtrappingmaybeseenon

cial.

• • • Pathophysiology • • • • • • Presentation full-thickness. second-degree burnsinvolvethedermis,andthird-degreeare electrolyte balance.First-degreeburnsarelimitedtotheepithelium, temperature, provideabarriertoinfection,andmaintainfl Thermalinjurytotheskinthatdisruptsbody’sabilityregulate Defi DohertyGM,ChisakutaA,CreanP,ShieldsMD.Anesthesiaandthechild FurtherReading Anear-normalorincreasingPaCO SpecialConsiderations inhibitors (suchasmontelukast)andcromolynsodium,needed. and long-actingbronchodilators(salmeterol),alongwithleukotriene are treatedwithdailyinhaledcorticosteroids(suchasfl tachypnea isasignofimpendingrespiratoryfailure.

Burns Burns with asthma. (electrical burns) Small surfaceinjurywithmassiveunderlyingtissuedamage coma) hypoxic encephalopathy(hallucinations,delusions,seizures, CNS dysfunctioncausedbyinhalationoftoxicchemicals,or poisoning. Pulse oximetryvaluesmaybenormaldespitecarbonmonoxide monoxide poisoning,orairwayedemaandobstruction Inhalation injurythatmaybeassociatedwithhypoxemia,carbon tissues causingsignificant hemoconcentrationandedema Massive fluid shifts fromvascularcompartmentintotheburned Variable injuriestotheskinordeepertissues Myocardial depression alsooccursafterextensiveburns. if resuscitationisinadequate hypoperfusion, hypotension,metabolic acidosis,andrenalfailure Decreased preloadanddecreased cardiac outputcausing losses due tosequestrationoffluid intheburnedareaand evaporative Generalized increaseinvascularpermeability andhypovolemia nition

Paediatr Anaesth.

2005;15:446–454.

2 inthepresenceofsigniﬁ

uticasone)

uid and uid cant 209 CHAPTER 9 Pediatric Emergencies 210 CHAPTER 9 Pediatric Emergencies

• • • • • • DIFFERENTIALDIAGNOSIS • •

• • • • • • ImmediateManagement

inhaled fromburningplastics. Severe unexplainedmetabolicacidosismaybeduetocyanide poisoning (evenintheabsenceofexternalinjuries) Severe smokeinhalationandcarbonmonoxideorcyanide are alsocommon. Sepsis, metabolicderangements,andneurohumoralresponses of surfactant,andnecrotizingbronchitis. impairment ofnormalmucociliaryfunction,bronchialedema,loss epithelium, resultinginsloughingofrespiratorytractmucosa, Smoke inhalationandthermalinjurydirectlydamagesrespiratory immersion inhotwater) Non-accidental burns(“gloveandstocking”appearancedueto following arespiratoryinfection the skinandmucousmembranescausedbyallergicreactionor Stevens-Johnson Syndrome:severeinflammatory eruptionof tissue damageandnecrosis,myoglobinuria Electrical burns:smallsurfaceinjurywithmassiveunderlying have extensiveunderlyinginjury Chemical injury:painornumbness,blistersnecroticskin,may give halfinfirst 8 hoursandremainderduringnext16hours) formula, crystalloidfluids: 4mL/kg×percentburnwt(kg); Aggressive resuscitationwithIVfluids (estimatewithParkland facial burnsorpotentialinhalationinjury Early intubationandmechanicalventilationforanychildwith carboxyhemoglobin concentration Administer of100%humidified oxygentodecrease relaxant, andanopioid orinhalationagent Maintenance ofanesthesia withoxygen,nitrousoxide, muscle profound hyperkalemicresponse). 24 hoursandforaprolongedperiodthereafterdueto 24 hoursafteraburn(succinylcholineiscontraindicated induction withsuccinylcholineisappropriatewithinthefi immediately followingthermalinjury).Rapidsequence Full stomachprecautions(decreasedgastrointestinalfunction decreases (if continued postoperative intubation is planned). decreases (ifcontinued postoperativeintubationisplanned). (with littleornocuffinfl ation) donotneed replacementasedema children withcompromisedairway.Cuffed endotrachealtubes inhalation inductionwithsevofl ketamine maybepreferredifhypovolemia issuspected.Slow Induction ofanesthesiawiththiopental, propofol,orketamine;

urane and ﬁ

beroptic intubation for beroptic intubationfor

rst

injury. Theonlypreventive strategyistoavoidoperating roomﬁ Childrenareadmitted andpresenttotheoperating roomwiththis Prevention • • • • • • SubsequentManagement • • • DiagnosticStudies

• • RiskFactors Immediate Management(continued)

• •

sodium nitrate3%solution,and/orhydroxycobalamin. Treatment forcyanidetoxicityincludessodiumthiosulfate, is notwheezinganddoesrequireongoingburnresuscitation. symptomatic COpoisoninginahemodynamicallystablechildwho Hyperbaric oxygentreatmentisonlyindicatedforacute, wound sepsis) Topical antibioticandantibacterialtherapy(topreventburn tissue edema).Administerbloodproductsasnecessary. (excessive fluids may resultinpulmonaryedemaandincreased urinary output(0.5–1mL/kg/h),centralvenouspressure,andpH Fluid resuscitationisguidedbysystolicbloodpressure,heartrate, urine output) Placement ofurinarycatheter(withhourlymeasurements be morehelpfulthanamultilumencatheter. blood lossandfluid shifts);large-boresinglelumencathetersmay Establish arterialandcentralvenousaccess(tomonitorformajor Chest radiographifinhalationinjuryissuspected ventilation, oxygenation,andresuscitation) Serial bloodgasmeasurements(tomonitorforadequacyof the blood(toguidetreatment) Direct measurementofcarboxyhemoglobinandcyanidelevelin burn injuryinchildren. Scalding causedbyreachingforhot liquidsisthemostcommon candles, campfires, electricalcords,andotherhot appliances. Inadequate supervisionofsmallchildren aroundhotliquids, Children lessthan5yearsold(50% ofburnpatients) (minimize histaminerelease),ketamine,andmidazolam. Analgesia andsedationwithIVopioids,suchasfentanyl ambient roomtemperature,andforced-airwarmingdevices. use warmingblankets,warmintravenousfl Aggressive warmingtomaintainnormalbodytemperature—

uids, elevated

res.

211 CHAPTER 9 Pediatric Emergencies 212 CHAPTER 9 Pediatric Emergencies ShankES,SheridanRL,CoteCJ,JeevendraMartynJA.BurnInjuries.In: drowning’). Laryngospasm without aspiration of water may also occur drowning’). Laryngospasm withoutaspirationofwater mayalsooccur 90%ofpatientsaspirate waterorsomeotherdebrisinto thelungs(“wet Pathophysiology • • • • • • • Presentation of time. suffocation whilesubmergedwithrecoveryforatleastsomeperiod Suffocationbysubmersioninaliquid,usuallywater.Neardrowningis Deﬁ CampoTD,AldreteJA.Theanestheticmanagementoftheseverelyburned FurtherReading factor orcauseofdeathinpatientswithmajorburninjuries. and corrected.Pulmonarycomplicationsareamajorcontributing Chronic ionizedhypocalcemiaiscommonandshouldbemonitored demonstrate markedresistancetonondepolarizingmusclerelaxants. and sedativeseventuallyrequirehigherdoses.Burnpatientsalso Children withburninjuriesrapidlydeveloptolerancetomostopioids wound debridement,skingrafting,andcorrectionofcontractures. common indicationsforsurgicalinterventioninburnpatientsinclude air, butdecreasesto90minuteswhenbreathing100%oxygen.Most Thehalf-lifeofCOHbisapproximately5hourswhilebreathingroom SpecialConsiderations

DrowningandNearDrownin Children CJ, LermanJ,TodresID(eds.). patient. hypothermia, oracidosis) Dysrhythmias orcardiacdysfunction (duetohypoxemia, than 15%ofsubmersionvictims Clinically signiﬁcant alterationsinﬂ uids andelectrolytesinless production earlyinsubmersion) Hypovolemia duetobriskdiuresis(hypothermiadecreasesADH Metabolic acidosis was inverycoldwater) Hypothermia (mayprovidesomebrainprotectionifthepatient Hypoxemia duetointrapulmonaryshunting organ impairment Varies greatly,rangingfromnosymptomstocomaandmultiple nition . 4thed.Philadelphia:SaundersElsevier;2009:715–733. Intensive CareMed.

g andNearDrownin

1981;7:55–62.

A PracticeofAnesthesiaforInfantsand

• SubsequentManagement • • DiagnosticStudies Spinalcordinjury(mayoccurafterdivinginshallowwater) DIFFERENTIALDIAGNOSIS syndrome (ARDS)commonlydevelopafterresuscitation. fusion mismatch.Acutelunginjury(ALI)andacuterespiratorydistress cause hypoxemiaduetointrapulmonaryshuntingandventilation-per- washout (saltwater)alsooccurs.Alveolarinjuryandpulmonaryedema iologic process.Lossofsurfactantduetodenaturation(freshwater)or ing ofbloodthroughpoorlyventilatedareas,istheprimarypathophys- (“dry drowning”).Pulmonaryinjury,particularlyintrapulmonaryshunt-

• • • • • • • • • ImmediateManagement

warming techniques. 32° usegastriclavage, cardiopulmonarybypass,orother core blankets orradiant warmer.Ifbodytemperatureisless than If patientishypothermic,rewarmover afewhourswithheating Chest radiographtoevaluatepulmonary involvement. electrolytes, arterialbloodgas,and toxicologyscreens. Diagnosis ismadebyhistory;useful laboratorydatainclude signs ofpoorperfusion. boluses ofbalancedsaltsolutionifchildishypotensiveorshows Obtain large-boreIVaccess;administer20mL/kgfl compressions. Assess adequacyofcirculation;ifchildispulselessbeginchest the airway. aspirating gastriccontents)unlessaforeignobjectisobstructing Avoid abdominalthrusts(whichmayincreasetheriskof airway isprotected. Perform nasogastricsuctioningtoemptythestomachafter with severehypoxia. (PEEP) improvesventilation-perfusionmismatchinginchildren pressure ventilationwithpositiveend-expiratory Continuous positiveairwaypressure(CPAP)or Increase FiO has lossofprotectiveairwayrefl Intubate thepatientifapneic,insevererespiratorydistress,or Remove debrisorfluid fromtheairway. Cervical spineimmobilizationforallsuspecteddivingaccidents

2 tomaintainoxygenation.

exes.

uids;

213 CHAPTER 9 Pediatric Emergencies 214 CHAPTER 9 Pediatric Emergencies

ModellJH.Drowning. BurfordAE,RyanLM,StoneBJ,Hirshon JM,KleinBL.Drowningand FurtherReading • • • SpecialConsiderations unit, oroperatingroomwiththiscondition. Patientsareadmittedtotheemergencydepartment,intensivecare Prevention • • • • • •

• • • • • RiskFactors

2005;21(9):610–616. near-drowning inchildrenandadolescents. admitted andobservedforprogressiverespiratoryfailure. Children withanylowerrespiratoryinvolvementshouldbe prior todischarge. or resuscitationshouldbeobservedforaminimumof4hours Children whoareasymptomaticbuthaveahistoryofsubmersion Correct electrolyteandmetabolicabnormalities. (e.g., albuterol). Bronchospasm maybetreatedwithbronchodilators temperature hasreached37°. Continue advancedcardiaclifesupport(ACLS)untilthecore peripheral vasodilationandprofoundhypotension. Surface warmingusingblanketsorradiantwarmersmayinduce management ofthepatient. The typeofwater(freshversussalt)makeslittledifferenceinthe Alcohol ordrugsareinvolvedin50%ofcases. Adolescents drownmostcommonlyinrivers,lakes,andcanals. bathtubs, buckets,ortoilets. Infants lessthanoneyearofagearemostlikelytodrownin very coldwatercantriggerafatalarrhythmia) Patients withcongenitalprolongedQTsyndrome(swimmingin retardation inapoolornearwater,especiallyifunsupervised Children withseizuredisorders,historyofsyncope,ormental Use ofalcoholwhileparticipatinginwateractivities More commoninmalesallpediatricagegroups 0–4 yearsold Most commoninpreviouslyhealthypatients,especiallyages

N EnglJMed.

1993;328:253–256.

Pediatr EmergCare .

β-hemolytic infl uenzae zae Themostcommoncausativeorganismwas Pathophysiology • • • • • • Presentation and stiffeningthatcanrapidlyleadtocompleteairwayobstruction. ing thearytenoids,aryepiglotticfolds,andepiglottis,causingswelling Suddenonsetinflammatory edemaofsupraglotticstructures,includ- Defi

pathogens arenowmorefrequentcausesofthisrareinfection.

• • • • • • ImmediateManagement

E Epiglottitis

Cough isusuallyabsent. Slow tonormalrespiratoryrate Mouth maybeopenwithdroolingandprotrudingtongue. in asniffi Child willappeartoxicandinsistonsittingupleaningforward Inspiratory stridorwithlittleornohoarseness swallowing Abrupt appearanceofhighfever,severesorethroat,anddiffi without touching or traumatizingtheepiglottis. gentle cricoidpressure. Carefullyliftthebaseof tongue Endotracheal intubationfollowingdirect laryngoscopywith established. Establish IVaccessaftersurgicalanesthesia hasbeen cause apnea. Avoid useofIVinductionagentsor musclerelaxantsthatmay induction andspontaneousventilation shouldbemaintained. halothane). Childshouldbekeptinthesittingpositionduring Inhalation inductionofgeneralanesthesiawithsevofl establishing asurgicalairwayifneeded. OR setupshouldincludeequipmentandpersonnelcapableof equipment toimmediatelyestablishanairway. Patient shouldbetransportedbyaphysicianandwithadequate OR), notintheemergencydepartment. should onlybeperformedinacontrolledsetting(ideally,the the diagnosisismade.Examinationofpharynxandlarynx Transport patienttotheoperatingroomorICUassoon p typeB;however,sincethewidespreadadministrationof nition i glott vaccine,theincidencehasdrasticallydecreased.GroupA ng position.

streptococcus i t

i s

staphylococcus

candida,

Haemophilus inﬂ uen-

andotherfungal urane (or

culty H. 215 CHAPTER 9 Pediatric Emergencies 216 CHAPTER 9 Pediatric Emergencies

• • • • • SubsequentManagement • • DiagnosticStudies • • • • DIFFERENTIALDIAGNOSIS

Immediate Management(continued) • • • RiskFactors •

while eating;sudden,persistentcough) Foreign bodiesintheairwayoresophagus(historyofchoking respiratory rate) Croup (gradualonset,barkingcough,hoarseness,rapid decreased). the supraepiglotticandperiepiglotticswellinghassignifi The childcanusuallybeextubatedwithin1–3days(when spontaneously. opioids andbenzodiazepines.Ideally,childshouldbebreathing Transport thechildtoICUpostoperatively;sedationwith Obtain bloodculturesandbeginaggressiveantibiotictherapy. Ventilation withhumidifi intake) Ringer’s solution(childmaybedehydratedfromdecreasedoral IV hydrationwith10–30mL/kgofnormalsalineorlactated management immediatelyavailable. room withairwayequipmentandphysicianskilledin direct laryngoscopyshouldonlybeattemptedintheoperating Defi children). required fordiagnosis,shouldonlybeattemptedinstable Lateral neckradiographwillshowthumbprint-likemass(not Retropharyngeal abscess(airwayobstruction,stridor) drooling) Bacterial tracheitis(barkingcough,nodysphasia,sorethroat,or Nasotracheal intubationispreferred. intubation thoughpartiallyobstructedglottisaperture. risk ofpressurenecrosis).Astyletmaybehelpfulinfacilitating ETT shouldbeone-halfsizesmallerthannormal(todecrease Occurs rarely(0.63 per100,000in1990) Most commonlyseen inchildrenage3–6years H.infl uenzae Decreased occurrencewiththewidespread useofthe nitive diagnosisismadeondirectvisualization;however,

vaccine

ed gases

cantly

aspirated intothetracheaorbecomes lodgedintheesophagus. (e.g., beads,coins,toys,etc.)mayresult inairwayobstructionifitis children, butanysmallobjectthat canbeputintoachild’smouth glottic. Foodisthemostcommon foreign bodyaspiratedbyyoung Acuteonsetairwayobstructionmaybesupraglottic,glottic,orsub- Pathophysiology • • • • • • • Presentation esophagus. compression ofthetracheacausedbyanobjectobstructing Aspirationofaforeignbodyintotherespiratorytract,orposterior Defi VergheseST,HannallahRS.Pediatricotolaryngologicemergencies. FurtherReading over therisksassociatedwitha“fullstomach.” The urgencyofsecuringtheairwayinthissituationtakesprecedence obstruction canoccurduringthetimeittakestoobtainfi Useoflateralneckfi lms iscontroversialsincecompleteairway SpecialConsiderations cautiously inordertopreventexacerbationofairwayobstruction. Patientsareadmittedwiththiscondition.shouldbemanaged Prevention

• • ImmediateManagement InhaledForeignBodyForei

bodies obstructingbothbronchi) Cyanosis (suggestsforeignbodyintracheaormultiple hypoxemia) Emotional distress,agitation(maybeduetounderlying Absent breathsoundsononeside Monophonic wheezingorstridor Sudden onset,persistentcough Respiratory distress,tachypnea,andtachycardia History ofchokingandcyanosiswhileeating Clin NorthAmerica. agitation. Keep childcalmto preventairwaycollapseassociated with Administer 100% oxygen tocorrecthypoxemia. nition

2001Jun;19(2):237–256. g n Body

Anesthesiol lm. 217 CHAPTER 9 Pediatric Emergencies 218 CHAPTER 9 Pediatric Emergencies

• SubsequentManagement • DiagnosticStudies • • • • • • DIFFERENTIALDIAGNOSIS

• • • • • • •

Immediate Management(continued)

decrease postoperative wheezing. Administer abeta agonistbronchodilator(e.g.,albuterol) to hyperinfl confi Chest andneckradiographswithlateral viewswillhelp Retropharyngeal abscess(airwayobstruction, stridor). hypotension). Anaphylaxis (suddenonset,exposuretoallergen,urticaria, prolonged expiratoryphase). Acute asthmaexacerbation(wheezing,respiratorydistress, Epiglottitis (acuteonset,toxicappearance,sorethroat,stridor). Foreign bodyintheesophagus(drooling,dysphasia,dyspnea). respiratory rate). Croup (gradualonset,barkingcough,hoarseness,rapid cough). muscle relaxant(ensurethatthepatientdoesnotmoveor state ofanesthesiaindependentventilation),withorwithout foreign body. Intubate withanETTfollowingbronchoscopicremovalof Maintain anesthesiawith100%O careful endotrachealintubationandfl inhalation inductionisfollowedbyrigidbronchoscopy,or For subglotticobstruction,arapid-sequenceinductionor sevofl respirations andperformaninhalationinductionwith For supraglotticandglotticobstruction,maintainspontaneous distally toallowforadequateventilationandoxygenation. be immediatelyremovedbyrigidbronchoscopy,ordislodged If completeairwayobstructionoccurs,theforeignobjectshould rigid bronchoscope. management andemergencyairwayequipment,including operating room,accompaniedbyaphysicianskilledinairway life-threatening, immediatelytransportthechildto Ifthereisanydoubtastowhetherairwayobstruction and localizetheforeignbody. If thechildisstable,radiographicexaminationmayhelpidentify rm thepresenceandlocationofforeign body;distal urane. ation fromairtrappingoratelectasismaybeseen.

andpropofolinfusion(steady exible bronchoscopy.

• • • • • Presentation resulting indeath. involves aconstellationofthemostcriticalandsevereinjuries,often depending onmechanismandseverityofthetrauma.Majortrauma The“diseaseofinjury,”usuallyaffectingmultipleorgansystems, Deﬁ VergheseST,HannallahRS.Pediatricotolaryngologicemergencies. FurtherReading reaction ifaspirated. or severebronchospasm.Peanutscancauseanintenseinﬂ nia orbacterialinfection,airwayrupture,hemoptysis,pneumothorax, mainstem bronchus.Complicationscanincludeaspirationpneumo- Themajorityofforeignbodies(95%)becomelodgedintheright SpecialConsiderations goscopy. Carefullaryngoscopyandremovaloflooseteethpriortolaryn- Prevention •

• • RiskFactors MajorTraumaMa

necessary totreatsevereairwayedema. to 1:6)orsteroidtherapy(dexamethasone0.5–1mg/kg)maybe Nebulized racemicepinephrine(0.5mLof2.25%solutiondiluted Acute bleeding(internal orexternal) or spleenarecommon) Blunt orpenetratingabdominal thoracic injury(rupturedliver Potentially unstablespinalcordinjury presenting withamajortraumahave concomitantheadinjury) Altered levelofconsciousness,confusion (75%ofchildren Extremely variabledependingontype andextentofinjury Clin NorthAmerica particularly dangerous) tend toputobjectsintheirmouths(popcornandpeanutsare More commonininfantsortoddlers(age1–3yearsold)who manipulation. May beassociatedwithdislodgementofteethduringairway nition j or Trauma

. 2001;19:237–256.

ammatory Anesthesiol

219 CHAPTER 9 Pediatric Emergencies 220 CHAPTER 9 Pediatric Emergencies

• • • • • DIFFERENTIALDIAGNOSIS electrolyte ormetabolicdisturbances,intracranialhematomas. local orglobalbrainischemia,hypercapnia,hyper-hypotension, tion and/ordecelerationofthehead. fuse axonalinjuryandduraltearswhicharecausedbyacuteaccelera- lopathy arecommon. catecholamines. Metabolicderangements,hyperglycemia,andcoagu- the sympatheticnervoussystem,increasinglevelsofcirculating Thestressresponseassociatedwithmultisystemtraumastimulates Pathophysiology • • • •

• • • • • ImmediateManagement

Severe pain(especiallyfromunstablefractures) Hypotension (latefinding, onlyaftersignifi cant bloodloss) Tachycardia (initialsymptomwithacutebloodloss) pneumothorax) Hypoxia (frompulmonarycontusions,aspiration,or intracranial bleeding,ribfractures,eyecontusions). Child abuse(injuriesinconsistentwithhistory,multipleburns, Vascular ororthopedicinjuries. Intraperitoneal orretroperitonealinjurybleeding. hematoma). Traumatic braininjury(includingintracranial,subdural,orepidural Spinal cordinjury. SecondarybraininjuryiscausedbycomplicationsofPBIsuchas Primarybraininjury(PBI)resultsfromcontusions,lacerations,dif- inadequate, beginbag-valve-maskventilation. immobilization beginsimultaneously. Primary survey,initialresuscitation,andcervicalspine agent dependson individualcircumstances.Etomidate is response tointubation. Selectionofaspecifi avoid bradycardia, andlidocainetoreducehemodynamic administer analgesic(fentanyl),vagolytic, (e.g.,atropine)to Rapid-sequence intubationindicated foralltraumapatients; children withsufficiently depressedconsciousness. obstruction (blood,foreignbody,vomitus) andinfantsor Awake intubation(nomedications) forinfantswithairway at thescene,confirm properETTsizeandplacement. (Glasgow ComaScore[GCS]<8);ifthepatientwasintubated Endotracheal intubationisrequiredforseverelyinjuredchildren Provide 100%oxygenbyfacemasktomaintainSaO

c induction

>90%;if

• • SubsequentManagement • • • DiagnosticStudies Immediate Management(continued)

• • • • • • •

indicated. CT scans,ultrasonography(FASTscan),orangiographymaybe Depending oninjuriesandhemodynamicstability,skeletalsurvey, irregular respirations). symptoms, orCushing’sresponse(bradycardia,hypertension, Head CTisindicatedforGCS<9,skullfractures,anyneurologic Chest radiographforallpatientswithmajortrauma hyperventilation (PaCO Decrease intracranialpressure(ICP), ifnecessary,through perfusion pressure(>60mmHg). brain injury.Preventhypotensionand maintainadequatecerebral The goalofmanagementinheadtrauma istopreventsecondary (CSF), diuretictherapy (furosemide),sedation,analgesia, administration (0.25–1 g/kg),drainageofcerebrospinal fl kg) orrocuronium(1.2mg/kg). head injury.Musclerelaxationwitheithersuccinylcholine(2mg/ recommended forhemodynamicallyunstablepatientswith edema). mL/kg (overhydrationcanworsenpulmonaryandcerebral bleeding issuspectedorifinfusionofIVfluids surpasses80–100 to stabilizesystolicbloodpressure.Considerproductsif Begin IVfluid boluseswithabalancedsaltsolution,20mL/kg clavicle, orsternum)scalpveinsinneonatesandinfants. consider intraosseouscannulation(tibia,femur,iliaccrest, in theantecubitalfossaandfemoralveins);ifdiffi Obtain vascularaccess,atleast2large-boreIVlines(usually Insert orogastrictubetodecompressthestomach. intervention). Assess andcontrolbleeding(mayrequireemergentsurgical If difficult airway,considerfi Intubate withmanualin-linestabilization. catheter) andbladdercatheter. Placement ofinvasivemonitors(arterialline,centralvenous or tracheostomymayberequired. to definitively securetheairway.Emergencycricothyroidotomy LMA orlightwand(emergencysituation).Useasaconduit GlideScope ®,orBullard®laryngoscopeblindplacementof

2 between25–35mmHg),mannitol

beroptic bronchoscope,

cult access,

uid

221 CHAPTER 9 Pediatric Emergencies 222 CHAPTER 9 Pediatric Emergencies

mal changeinvital signs;therefore,hypovolemicshock mayensue sustain majorbloodloss(>25%of theirbloodvolume)withmini- decreased cerebralbloodﬂ ow mayworsenoutcome)Childrencan hypertension isseverebecausethe resultingvasoconstrictionand treatment (e.g.,surgery)andshould beavoidedunlessintracranial tance. Hyperventilationshouldbeused onlyasabridgetodeﬁ extension ofinjury(i.e.,controlling ICP)areofparamountimpor- injury inallagegroups.Optimizingcerebral perfusionandminimizing Traumaticbraininjury(TBI)isthemostcommoncauseofdeathfrom SpecialConsiderations ventable injuries. and theirfamiliesarethebestwaystoreduceincidenceofpre- Governmentpolicies,roadsafetycampaigns,andeducatingchildren Prevention • • • • • •

• • • • RiskFactors

serum Na+is<150andosmolality<300mOsm/L). pentobarbital, orbolusadministrationofhypertonicsaline(if dL. The optimalrangeforplasmaglucoseisbetween80and120mg/ brain orspinalcordinjuries)unlesshypoglycemiaisdocumented. Avoid usingglucose-containingsolutions(especiallyfortraumatic blood loss. disturbances, metabolicacidosis,coagulationdisorders,andacute Carefully monitorandcorrectforongoingelectrolyte Corticosteroids areindicatedforspinalcordinjuries. Seizure prophylaxisforheadinjuries(phenobarbitalorphenytoin) for children5yearsorolder. injuries). Patient-controlledanalgesia(PCA)maybeappropriate or regionalanesthetictechniques(particularlyfororthopedic drugs (NSAIDS),acetaminophen,low-doseketamineinfusions, Manage acutepainwithopioids,nonsteroidalanti-inﬂ warming devices,andincreasedambientORtemperature. Maintain normothermiawithforced-airwarmingsystems,blood- abuse) isthemostcommoncauseofheadinjury. For infantsunderoneyearofage,non-accidentalinjury(child Homicide, suicide Home accidents(falls,electricalinjuries,burns,drowning) use Motor vehiclecollisions,particularlywhenseatbeltsarenotin

ammatory

nitive

• • • DIFFERENTIALDIAGNOSIS isoimmunization. tered drugs(opioids,barbiturates,etc.), andanemiasecondarytoRh eases, prematurity,maternalfeverorinfection,maternallyadminis- for neonataldepressionincludecongenitalcardiacorpulmonarydis- leading toprogressivefetalhypoxiaandlacticacidosis.Othercauses hypoxia, umbilicalcordcompression,oruteroplacentalinsuffi asphyxia duringlabor,whichmaybeduetomaternalhypotensionor Neonataldepressionismostcommonlycausedbyintrauterine Pathophysiology • • • • • • • Presentation resuscitation duringthefi rst fewweekstomonthsoflife. ine toextrauterinelife;anynewbornrequiringcardiopulmonary Resuscitationofaneonateundergoingthetransitionfromintrauter- Defi LamWH,MackersieA.Paediatricheadinjury:incidence,aetiology,andman- FairgrieveR,LermanJ.Anaestheticcareoftheinjuredchild. FurtherReading ulopathy, andhypothermia(the“fataltriad”). with littlewarning.Goalsofcareincludeavoidinghypovolemia,coag-

NeonatalResuscitationN agement. Congenital abnormalitiesorsyndromes Hypothermia (duetolargesurfaceareaandthinskin) brain) Intracranial hemorrhage(duetoimmaturebloodvesselsinthe Bradycardia (lessthan100bpm) Cyanosis (duetohypoxia) level ofpulmonarysurfactant) Respiratory distressorapnea(causedbyimmaturelungslow Preterm delivery(lessthan37weeksgestation) Hydrops fetalis(leading tohemolyticanemia) bowel soundspresent inthechest) Diaphragmatic hernia(difﬁcult toventilate,scaphoid abdomen, hypotension, lossofpalpablepulse) Neonatal asphyxiaorhypovolemia (latedecelerationsinutero, Anaesthesiol e nition o natal Resusc Paed Anaesth.

. 2000;13:141–145. 1999;9:377–385.

i tat

Curr Opin ciency 223 CHAPTER 9 Pediatric Emergencies 224 CHAPTER 9 Pediatric Emergencies

• • •

• • • • • • • • • ImmediateManagement

alcohol) the motherpriortodeliveryormaternaladdictiondrugs Residual drugeffectsorwithdrawal(i.e.,opioidsadministeredto breath sounds) Pneumothorax (candevelopduringresuscitation,decreased not increaseabove60bpm) Congenital completeheartblock(suspectwhenratedoes improve orchestwallmovementisnotseen. higher pressuresmaybenecessaryifheartratedoesnot pressures. Useinitialinflation pressuresof20–25cmH place ETT).Avoidexcessivetidalvolumesandpeakairway is indicated(LMAmaybeusedasanalternativeifunableto If bag-maskventilationisunsuccessful,endotrachealintubation hypoxia doesnotimprove). room air,butoxygenshouldbereadilyavailableandusedif pressure ventilationisindicated(alsoreasonabletobeginwith Supplementary oxygenisrecommendedwheneverpositive 100 bpm,orpersistentcentralcyanosisispresent. infant isapneicorgasping,heartratebetween60and infl Begin positivepressureventilation(usingself-inflating bag,fl and color. 30 secondssimultaneouslyevaluatingheartrate,respirations, Allow 30secondsforinitialassessment;spendthenext and respiratoryeffort). vigorous (heartratelessthan100bpmwithpoormuscletone immediately afterbirth(notintrapartum)ONLYiftheyarenot Meconium-stained infantsrequireendotrachealsuctioning and stimulatethebaby. airway secretions(usingbulbsuctionorcatheter),dry, Position headin“sniffing” positiontoopentheairway,clear preterm babiesshouldbecoveredinplasticwrapping). Warm thepatientimmediatelyafterbirth(radiantheatsource, via ETT)ifheartrate remainsbelow60bpmdespite adequate Give epinephrine (0.01–0.03 mg/kgIVispreferred,or 0.1mg/kg recommended. each breath.Thetwothumb-encircling handstechniqueis of 120bpm.Threechestcompressions shouldbegivenfor third theanterior-posteriordiameter ofthechestatarate Compress theloweronethirdof sternumtoadepthone despite adequateventilationwithoxygen for30seconds. Begin chestcompressionsifheartrate islessthan60bpm ating bag,orT-piece)atarateof40–60breathsperminuteif

2 O; ow-

• • • • • SubsequentManagement resuscitation. glucose level(maintainwithinthenormalrange)regularlyduring Monitorarterialbloodgas(monitoradequacyofventilation)and DiagnosticStudies

Immediate Management(continued) •

• • • • • • • RiskFactors

appropriate. and continuousresuscitation,discontinuingresuscitationis If nosignsoflifearepresentafter10minutesadequate possible). supplemental surfactant(mosteffectiveifadministeredasearly Most infantslessthan28weeksgestationwillrequire persists despiteadequateheartrateandcolor. Consider naloxone(0.1mg/kgIMorIV)ifrespiratorydepression resuscitative measures. if neonateappearstobeinshockorisnotrespondingother Consider volumeexpansionwithisotoniccrystalloid10mL/kg normothermia. Use plasticwrappingandradiantheattomaintain 30 seconds. Reassess respirations,heartrate,andcolorevery until spontaneousheartrateisgreaterthan60bpm. Continue coordinatedchestcompressionsandventilations every 3–5minutes. ventilation with100%oxygenandchestcompressions.Repeat General anesthetic requiredforcesareansection and alcoholuseduring pregnancy) Maternal opioidadministration neartimeofdelivery (ordrug respiratory distress,seizures,andcerebral palsy) Infants borntofebrilemothers(increased incidenceof to-twin transfusion,etc.) Fetal hypovolemia(duetomaternal hemorrhage,sepsis,twin- Thick meconiumpresentatdelivery decelerations anddecreasedheart rate variability) Fetal distress,hypoxia,andacidosis(notedbyprolongedlate Preterm orinstrumented(suction,forceps)delivery

225 CHAPTER 9 Pediatric Emergencies 226 CHAPTER 9 Pediatric Emergencies prematurity (less than 23weeksorbirthweightless 400grams), cal outcome.Withholding resuscitationisreasonable withextreme correlates withsurvival;the5-minute scoreisrelatedtoneurologi- chronic opioiduse(maycauseseizures). The1-minuteApgarscore should beavoidedinneonateswhose mothersmayhaveahistoryof ciﬁ balanced withriskofhypoxicinjury (nocleardatatosupportaspe- Potentialadverseeffectsof100% oxygen administrationshouldbe SpecialConsiderations to gestationandweight Table9.2 eprtr ae RespiratoryRate MuscleTone Stimulation Responseto (beats/minute) HeartRate Color ClinicalFeature Table9.1 40 37 35 33 30 27 26 23/24 Gestation(weeks) 50%weightbygestation c FiO c 2 ).Heartrateandpulseoximetryguide therapy.Naloxone

Endotracheal tubediametersandlengthsaccording Apgar Score

0 Limp,ﬂ None Absent Pale/blue Absent 3.5 3 2.5 2 1.5 1 0.75 0.5 (kg) Bodyweight accid

1 extremities Someﬂ Grimace <100 extremities Pinkbody,blue irregular Poor effort,slow, 3.5 2.5 2.5 Diameter(mm) the lip Tubediameterandlengthat 3–3.5 3 2.5–3 2.5 2.5 exion of 2 movement Active Pullsaway,crying >100 Pink Good,crying 6.5 6 Length(cm) 9 8.5 8 7.5 7 9.5 TheInternationalLiaisonCommitteeonResuscitation(ILCOR).Consensus

• • • • • DIFFERENTIALDIAGNOSIS cause ofcardiacarrestin7%to15%infantsandchildren. existing cardiacorrespiratorydisease—maycausehypoxia.VFisthe eign bodyairwayobstruction,drowning,inhalationalinjuries,orpre- arrest inchildren.Variousmechanisms—forexample,trauma,for- Asphyxialeadingtohypoxiaisthemostcommoncauseofcardiac Pathophysiology • • • • Presentation pulmonary resuscitation(CPR). age) orchild(age1yearuntilstartofpuberty),includingbasiccardio- Initialmanagementofsuddenarrestaninfant(lessthan1year Deﬁ AmericanHeartAssociation.Guidelinesforcardiopulmonaryresuscitation FurtherReading (trisomy 13or18). anencephaly, andchromosomalabnormalitiesincompatiblewithlife

PediatricBasicLifeSupportP patients: neonatalresuscitation. on sciencewithtreatmentrecommendationsforpediatricandneonatal lines. and emergencycardiovascularcare:Part13:neonatalresuscitationguide- (e.g., childsuddenlycollapsingatasportingevent) Ventricular ﬁbrillation orpulselessventriculartachycardia Sudden cardiacarrest(usuallycausedbyhypoxia) Sudden respiratoryarrest(choking,foreignbodyaspiration) with orwithoutapulse) Unresponsive infantorchild(mayhavenosignsofrespiration, Poisoning, exposure totoxicgases Anaphylaxis (suddenonsetrespiratory distress,urticarialrash) Cardiac arrest,VF,orpulselessVT injury) Traumatic injury(considerthepossibility ofbrainorspinalcord in thesettingofcompleteobstruction) Foreign bodycausingairwayobstruction (childunabletovocalize ediatric BasicLifeSu nition Circulation.

2005;112:IV-188–IV-195.

Pediatrics. pp

ort

2006;117(5):978–984.

227 CHAPTER 9 Pediatric Emergencies 228 CHAPTER 9 Pediatric Emergencies

• ImmediateManagement • • • • • • • • • • •

between ventilationandcompressions. intermammary line)techniquetofacilitaterapidtransition infant’s chestwithyourhands,usethe2-ﬁnger (placejustbelow forcefully squeezethethorax.Ifalone,orunabletoencircle recommended. Placethumbstogetheroverlowersternumand For chest tofullyrecoil. of 100compressionsperminute.Releasecompletelytoallow one halftheanterior-posteriordiameterofchest,atarate Chest compressionsshoulddepressthechestonethirdto 60 bpmwithsignsofpoorperfusion,beginchestcompressions. If nopulseispalpatedafter10seconds,oriflessthan minutes. deliver 12–20breathsperminuteandreassesspulseevery2 a child).Ifpulsesarepresentbutnotbreathing,continueto Check forpulse(brachialinaninfant,carotidorfemoral available. technique. Usebag-maskventilationwith100%oxygenif watch chestrise).Forinfants,usemouth-to-mouth-and-nose nose closed,andgive2breathsmouth-to-mouth(besureto If childisnotbreathing,maintainopenairway,pinchthe continue tomonitorforbreathing. If thechildisbreathing,turnontosideand listen, andfeelforbreathingnomorethan10seconds. without headtiltifcervicalspineinjuryissuspected).Look, Open airwaywithheadtilt—chinliftmaneuver(usejawthrust before beginningCPR(etiologyismostlikelytobeVF). If thecollapsewaswitnessed,callforhelpandapplyAED code teamandgetanautomatedexternaldeﬁ 5 cyclesofCPR,thencallEMS(ifoutsidethehospital)or If unresponsive,callforhelpandbeginCPR.alone,perform immediately. for help.Ifalone,leavethechildtocallassistanceandreturn If thechildisresponsivebutinneedofmedicalattention,call 1 yearold).Resume chestcompressionsimmediately after Apply theAEDand followtheprompts(forchildren over (8–10 perminute)onlyafteradvanced airwayisinplace. Simultaneous compressions(100per minute)andventilation by 2breaths.For2-rescuerCPR,the rationshouldbe15:2. If alone,performcyclesof30chest compressionsfollowed one ortwohands(donotpresson ribsorxiphoid). In a infants child , compressthelowerhalfofsternum withheelof , the2thumb-encirclinghandstechniqueis

brillator (AED).

• • • SubsequentManagement ECGwaveformorpromptsontheAED. DiagnosticStudies

• • • • RiskFactors • • • Immediate Management(continued)

available. Obtain IVaccess(forfluid anddrugadministration)ifnotalready and transfertoanintensivecareunit. If resuscitationissuccessful,continuetocloselymonitorthechild facility, initiatepediatricadvancedlifesupportifneeded. Transfer patienttoahospitaliftheeventoccursatanoutside initiated orpatientbeginstomove. shock andcontinueCPRuntilpediatricadvancedlifesupportis • a blindfi breath. Ifyouseeaforeignbody,removeit,butdonotperform If unresponsive,lookinthemouthbeforegivingarescue • sound): is abletocoughdonotinterfere.Ifsevere(unablemakea For foreignbodyairwayobstruction,ifincompleteandthechild continue giving12–20breathsperminute. If pulseispresent,butabsentorinadequaterespirations, surface, andsecond-hand smoke) (increased riskwith pronesleepingposition, onsoft Sudden infantdeath syndrome(SIDS)ininfants2–4 months old motor vehicle-relatedinjuries) (nearly halfofallpediatricdeathsin theUSarecausedby drinking anddriving,adolescentdrivers withteenpassengers Failure tousepropersafetyrestraints andseatbeltsincars, Primary respiratory,cardiac,ormetabolic disease supervision ofinfantsandchildren. fi Preventable injuries(motorvehicle,pedestrian,bicycle,and rearm injuries,burns,drowning);oftenduetoinadequate

becomes unresponsive. (Heimlich maneuver)untilobjectisexpelledorchild In a CPR). object isexpelledorinfantbecomesunresponsive(thenbegin followed by5chestthrusts(tolowersternum);repeatuntil In an child infant, nger sweep. , performsubdiaphragmaticabdominalthrusts

deliver5backblows(betweenshoulderblades)

229 CHAPTER 9 Pediatric Emergencies 230 CHAPTER 9 Pediatric Emergencies TheInternationalLiaisonCommitteeonResuscitation(ILCOR).Consensus

blood loss,compression ofgreatvessels,decreased venousreturn arrest in7–15%of infantsandchildren.Intraoperatively, extensive arrest inachild.Ventricularfi brillation (VF) isthecauseofcardiac disease—can leadtohypoxia,the mostcommoncauseofcardiac drowning, inhalationinjury,shock, or primarycardiacrespiratory Variousmechanisms—forinstance: trauma,massivehemorrhage, Pathophysiology • • • • • • Presentation Algorithmforresuscitationofaninfantorchildwithcardiacarrest. Defi AmericanHeartAssociation.Guidelinesforcardiopulmonaryresuscitation FurtherReading have apoorprognosis. with cardiacarrestcausedbyblunttraumaorsepticshocktendto associated withimprovedsurvivalandneurologicoutcomes.Children barotrauma, andincreasetheriskofaspiration. return andthereforedecreasecardiacoutput,causeair-trapping coid pressure.Avoidhyperventilation,whichwilldecreasevenous sive peakinspiratorypressures(ventilateslowly)andapplyingcri- injury issuspected.Minimizegastricinfl ation byavoidingexces- Stabilize theheadandneckminimizemovementifcervicalspine Anticipateairwayobstructionfrombrokenteethorotherdebris. SpecialConsiderations

PediatricAdvancedLifeSupportLi 2006;117(5):955–966. natal patients:pediatricbasicandadvancedlifesupport. on sciencewithtreatmentrecommendationsforpediatricandneo- Circulation. and emergencycardiovascularcare:Part11:Pediatricbasiclifesupport. sudden dropinETCO Under generalanesthesia,ECGwillindicateanonperfusingrhythm, Trauma drowning,burninjury,ortoxicingestion Hypotension, tachycardia(decompensatedshock) Respiratory failure(tachypnea,gasping,grunting,cyanosis) Cardiac arrest(usuallyduetohypoxia) Unresponsive child.Pulsesmayornotbepresent. ShortintervaltimefromcollapsetoinitiationofeffectiveCPRis nition 2005;112:IV-156–IV-166.

and oxygen saturation on pulse oximetry. andoxygensaturationonpulseoximetry.

f e S u pp

ort

Pediatrics.

• • • • • • DIFFERENTIALDIAGNOSIS arrest. to theheart,andvagusnervestimulationmayprecipitatecardiac

• • • • • • • ImmediateManagement

Vagal stimulation(duetosurgicalmanipulation) collapse) Anaphylaxis (urticaria,airwayobstruction,cardiovascular Metabolic diseaseorderangement(i.e.,DKA,hypothermia) disease) Primary cardiacorrespiratorydisease(i.e.,congenitalheart Shock (usuallyhypovolemic) etc.) Respiratory failure(causedbyairwayobstruction,asphyxiation, ETCO neck compression). that mightcausevagalstimulation(e.g.,ocularcompression, and circulation.Askthesurgicalteamtodiscontinueanyaction Initiate basiclifesupport(BLS);assessmentofairway,breathing, • Recheck rhythm— • • • • Assess rhythm— and defibrillator and obtainingIVaccess. interruptions inchestcompressions)whileattachingmonitors If pulselessarrest,continueCPR(strivetominimizeany tracheal tubes).Confirm ETTplacementwithETCO Intubate thetrachea(equalsafetywithcuffedanduncuffed Increase FiO of restoringanorganizedrhythm). airway (increaseddurationoffibrillation decreasesthechance Attempt defibrillation immediately;donotwaittosecurethe effective chestcompressions).

1 mg/kg). giving amiodarone (IV/IO:5mg/kg)orlidocaine If persistentVF/VT, giveanothershock(4J/kg)andconsider Repeat epinephrineevery3–5minutes. ETT) andimmediatelyresume5cycles ofCPR. and giveepinephrine(IV/IO:0.01mg/kg or0.1mg/kgthrough If ashockablerhythmispresent,give asecondshock(4J/kg) recheck rhythm. Resume 5cycles(approximately2minutes)ofCPRand AED ifavailableandpatientisgreaterthanoneyearold). If shockable(VT/VF),give1shock(manual,2J/kg,orapplyan 2 mayreﬂect either incorrectETTplacementorlackof

2 to100%.

2 (lackof

231 CHAPTER 9 Pediatric Emergencies 232 CHAPTER 9 Pediatric Emergencies Immediate Management(continued)

• • • • • • • • • •

epinephrine every3–5minutesorbeginaninfusion,ifneeded. compressions andgivestandarddoseofepinephrine.Repeat breathing, andcirculation.Ifpoorperfusionpersists,beginchest • for first dose,0.2 mg/kgforseconddose). chemical cardioversionwithadenosine(0.1mg/kgrapidbolus massage orValsalvamaneuverinolderchildren),thentry fi For hemodynamicallystableSVT,attemptvagalmaneuvers (SVT). Ifrhythmissinus,searchforandtreatreversiblecauses. differentiate sinustachycardiaandsupraventricular For narrow-complextachycardia,obtaina12-leadECGto seconds. wide-complex tachycardiahasQRSdurationgreaterthan0.08 complex tachycardiahasQRSlessthan0.08secondsand For tachycardiawithapulse,assesstheQRSduration;narrow- dysfunction. bradycardia duetocompleteheartblockorsinusnode Transcutaneous pacingmaybelifesavingforrefractory is duetovagalstimulationorprimaryAVblock. Give atropine(0.02mg/kg,minimumdose0.1mg)ifbradycardia compromise, increaseFiO For bradycardia(HRlessthan60)causingcardiovascular 5 cyclesofCPR,recheckrhythmtodetermineifitisshockable. Repeat epinephrinedoseevery3–5minutes.After give epinephrine(IV/IO:0.01mg/kgor0.1throughETT). If rhythmisnotshockable(asystoleorPEA),resumeCPRand defi CPR andgiveanotherdoseofamiodaronebeforerepeating If defibrillation issuccessfulbutVT/VFrecurs,continue shock. amiodarone (procainamideisanalternative) beforethethird subsequent dosesto4J/kg).Ifsecond shockisunsuccessful,give synchronized cardioversion(2J/kg, ifunsuccessful,increase Wide-complex tachycardiaismost likelyVT.Treatwith unsuccessful. Consider amiodaroneorprocainamideifothertreatmentsare kg forfirst shock, increaseto2J/kgifsecondshockisrequired). For unstableSVT,providesynchronizedcardioversion(0.5–1J/ rst (applytoicethefaceofyoungchildren,carotidsinus

pointes (polymorphicVTwithprolongedQTinterval). Administer magnesium(IV/IO:25–50mg/kg)fortorsadesde brillation.

2 to100%andsupportairway,

• • • • • • • SubsequentManagement • • DiagnosticStudies

• • RiskFactors

treated (post-arrestfeverisassociatedwithaworseoutcome). Hyperthermia intheperi-arrestperiodshouldbeaggressively outcome). to 32°C34°Cfor12–24hours(toimproveneurologic If patientremainscomatoseafterresuscitation,considercooling herniation arepresent. Avoid hyperventilation,unlesssignsofimpendingcerebral (myocardial dysfunctionaftercardiacarrestiscommon). Vasoactive drugsmaybenecessarytomaintaincardiacoutput any metabolicorelectrolyteabnormalities. Evaluate andtreatreversiblecausesofcardiacarrest,aswell pressure andallowforfrequentbloodsampling. Insert anintraarterialcathetertocontinuouslymeasureblood Give crystalloidﬂuid boluses(20mL/kg)totreatsignsofshock. pulmonary status). Obtain chestradiograph(evaluateETTplacement,heartsize,and screen andcarboxyhemoglobinlevel). and calciumfrequentlyduringresuscitation(considertoxicology Check arterialbloodgases(ABGs),serumelectrolytes,glucose, • • • arrest: Reversible causesofpulselesselectricalactivity(PEA)cardiac terminal eventofprogressiverespiratoryfailureorshock. Cardiac arrestisuncommoninchildrenandusuallythe • • • • • • •

Hydrogen ions(acidosis) Hypovolemia Hypoxia Toxins (drugingestion) Hypothermia Hypoglycemia Hypo- orhyperkalemia Thromboembolism, coronaryorpulmonary Tension pneumothorax Tamponade, cardiac

233 CHAPTER 9 Pediatric Emergencies 234 CHAPTER 9 Pediatric Emergencies

subglottic, ortracheal stenosis. from viralorbacterial infectionstocongenitaloracquired laryngeal, and mid-tracheal lesions causebiphasicstridor.Etiology canrange disease orinfl ammation maycauseexpiratorystridor.Intrathoracic lesions mostcommonlycauseinspiratory stridor,whilelowerairway on theleveloflesion.Upperairway obstructionorextrathoracic Stridorcanoccurduringinspiration, expiration,orboth,depending Pathophysiology • • • • • • Presentation bulent airfl Partialtocompleteobstructionoftherespiratorytractcausingtur- Defi TheInternationalLiaisonCommitteeonResuscitation(ILCOR).Consensus AmericanHeartAssociation.Guidelinesforcardiopulmonaryresuscitation FurtherReading for oragainstuseofvasopressinduringcardiacarrestinchildren. β-blocker overdose.Insufficient evidenceisavailabletorecommend it shouldonlybeconsideredinexceptionalcircumstances,suchas success rate.Thereisnosurvivalbenefit fromhigh-doseepinephrine; lower ribs.Biphasicdefibrillators havegreaterthana90%fi over rightsideofupperchestandtotheleftnipple touching (useadultpaddlesforchildrenover10kg).Place paddles orself-adheringelectrodesthatwillfit onthechestwithout given throughETT.Whenusingamanualdefi brillator, uselargest Lidocaine, epinephrine,atropine,andnaloxone(“LEAN”)maybe given thoughintraosseousaccessifIVcannotbeobtained. Allresuscitationdrugs,includingfl uids andbloodproducts,maybe SpecialConsiderations

S Stridor 2006;117(5):955–966. natal patients:pediatricbasicandadvancedlifesupport. on sciencewithtreatmentrecommendationsforpediatricandneo- port. and emergencycardiovascularcare:Part12:Pediatricadvancedlifesup- Suprasternal, intercostal,andsubsternal retractions Paradoxical movementofchestwallinwardwithinspiration Cyanosis Tachypnea andtachycardia Hypoxemia andhypercarbia(duetorespiratorydistress) Noisy breathing,usuallyhighpitched(duetoairwayobstruction) trido nition Circulation ow. r

. 2005;112:IV-167–IV-187.

rst shock

Pediatrics.

• • • DIFFERENTIALDIAGNOSIS

• • • • • • • • • • • • • • ImmediateManagement

Epiglottitis (sudden onset,highfever,dysphasia,drooling) to nebulizedepinephrine) Bacterial tracheitis (highfever,toxicappearance,poor response grade fever,hoarseness) Croup (usuallyunderage3,gradual onset,bark-likecough,low for allchildren).Repeatevery1–2hours,asneeded. racemic epinephrine(0.5mLof2.25%solutionisstandarddose If virallaryngotracheitis(croup)issuspected,beginnebulized possible etiologyofstridor. Obtain thoroughhistoryandphysicalexamtodetermine Humidify inhaledgasestopreventdryingofsecretions. hypoxemia. Administer 100%oxygenbyfacemasktocorrect expected ETTsizeduetosubglotticnarrowing). preferably usinganasotrachealETT(mayrequiresmallerthan After completionofrigidbronchoscopy,intubatethetrachea, observed, anestheticlevelmaybeincreased. After spontaneousmovementofthevocalcordshasbeen Obtain IVaccessafterinductionofgeneralanesthesia. immediately available. surgeon capableoftreatingtotalairwayobstructionshouldbe be discontinuedpriortoexamination).Rigidbronchoscopeand oxide maybeusedwithcautiontospeedinduction,butshould Inhalation inductionwithsevoflurane orhalothane(nitrous most comfortableforhimorher. Keep thechildbreathingspontaneouslyinwhateverpositionis cause respiratorydepressionandworsenairwayobstruction. Use cautionwhenadministeringsedatives.Deepsedationmay or bronchoscopy. Transport toORfordefinitive diagnosisbydirectlaryngoscopy and isofbenefit inthesettingofsevererespiratorydistress. Helium-oxygen mixture(Heliox)decreasesairfl airway segment. stridor byloweringthepressuregradientacrossobstructed Continuous positiveairwaypressure(CPAP)maydecrease 0.15–0.6 mg/kg). a singledoseisusuallysuffi Corticosteroids areindicatedforcroupandairwayedema;

cient (dexamethasone

ow turbulence

235 CHAPTER 9 Pediatric Emergencies 236 CHAPTER 9 Pediatric Emergencies

• • • SubsequentManagement • • • • DiagnosticStudies • • • • • • • • • •

• • • RiskFactors

aphonia, chroniccough,causedbyhumanpapillomavirus) Obstructive laryngealpapillomatosis(hoarseness,stridor, Large esophagealforeignbody(causingtrachealcompression) choking orcyanosiswhileeating) Aspiration offoreignbody(suddenonsetstridor,history II malformation). Vocal corddysfunction(possiblysecondarytoArnold-Chiaritype infection (URI),ormechanicalirritantsintheairway) Refl urticarial rash) Acute allergicreaction(rapidonsetofstridoranddysphasia, The childcanusuallybeextubatedin2–4days. bacterial superinfectionorabscessissuspected. Antibiotics arenotindicatedforcroup,butmaybeappropriateif IV hydrationtopreventthickeningoftrachealsecretions bronchoscopy. Defi Defer radiologicstudiesifthepatientisunstable. compressing thetrachea. Barium swallowstudymaybehelpfulinidentifyinglesions steeple” sign)ischaracteristicofcroup. narrowing ofthesubglotticairshadowonAPfi Anteroposterior andlateralchestradiographs;symmetric Tonsillitis orperitonsillarabscess Enlarged tonsilsoradenoids tracheostomy) Subglottic stenosis(historyofendotrachealintubationor Tracheomalacia/laryngomalacia (prematurity,priortracheostomy) endotracheal intubation Edema andinflammation following(usuallyprolonged) region May beassociatedwithcongenital narrowing ofsubglottic age Most commonlyduetocroupininfants lessthan6monthsof ex laryngospasm(inpatientswithGERD,activeupperairway nitive diagnosisisobtainedbydirectlaryngoscopyor

lm (“church

HolzmanRS.Advancesinpediatricanesthesia:implicationsforotolaryngol- BjornsonCJ,JohnsonDW.Croupinthepaediatricemergencydepartment. FurtherReading 2–3 hoursaftertreatmentwithracemicepinephrine. rebound edemamayoccur.Childrenshouldbeobservedforatleast airway obstructinglesion.Duetotheshorthalflifeofepinephrine, the bestviewforsurgeontomakeadiagnosisand/orcorrect AnapneicanesthetictechniquewithoutanETTtubeinplaceprovides SpecialConsiderations dence ofpostextubationstridor. (approximately thesizeofpatient’sﬁ Nospeciﬁc preventionfor croup.Appropriatelysized,uncuffedETT Prevention ogy. PaediatrChildHealth. Ear NoseThroatJ 2007;12:473–477. . 1992;71:99–105.

fthﬁ nger)mayreduceinci- 237 CHAPTER 9 Pediatric Emergencies This page intentionally left blank Chapter 10 Postanesthesia Care Unit Sean M. Quinn and Keith A. Candiotti

Altered Mental Status 240 Chest Pain 242 Hypoxia 244 Myocardial Ischemia 247 Oliguria/Acute Renal Failure 249 Postoperative Hypertension 251 Postoperative Hypotension 253 Postoperative Nausea and Vomiting 255 Prolonged Neurologic Impairment after Regional Anesthesia 257 239 Respiratory Depression or Failure 259 Severe Postoperative Pain 261 Stroke 263

240 CHAPTER 10 Postanesthesia Care Unit • DIFFERENTIALDIAGNOSIS hypothermia, andpooranalgesia. delirium mayalsobeduetometabolicandelectrolytederangements, painful andmaycauseagitationorcombativeness.Confusion drains, andcatheters,aswellgastricurinarydistentionare and aggressivebehaviorduringemergence.Endotrachealtubes, result oforganicbraindisease.Painmaycauseagitation,confusion, Changesinmentalstatusfollowingsurgeryaregenerallynotthe Pathophysiology • Presentation iors, rangingfromemergencedeliriumthroughdelayedawakening. Aclinicalspectrumthatincludesinappropriateorunexpectedbehav- Deﬁ • • • • • • • • • • • •

• • • ImmediateManagement

AlteredMentalStatusM

Hypoxia orhypocarbia mental sluggishnessimmediatelyafteremergence. Many patientsexhibitsomesomnolence,disorientation,and wild thrashingthatisresistanttotreatment. Emergence excitationmayresultinahighlyagitatedstatewith Hypotension with noobviousunderlyingcause. respond tostimulationwithin60minutesfollowinganesthesia Delayed awakeningissaidtooccurwhenapatientfails hypoxia. Combativeness, confusion,anddisorientationmaybesignsof Hypoglycemia Electrolyte derangement(i.e.,hyponatremia,hypercalcemia) Hypothermia Acidemia Stroke Central cholinergicsyndrome Infection Seizure PaCO tidal volume. Ensure thatthepatient hasanadequaterespiratoryrate and Increase FiO Consider drawing anarterialbloodgastomeasure PaO nition 2 .

2 e

tomaintainoxygensaturation. n tal S

tatus

2 and ence somedegree ofpostoperativeconfusion,delirium, orcognitive Ahighpercentage ofelderlypatients(upto30–50%) mayexperi- SpecialConsiderations ing postoperativeexcitationanddelirium inasusceptiblepatient. into thepostoperativeperiod.There isnoclearstrategyforprevent- hemodynamic andmetabolicstability throughouttheanestheticand Ensureadequatepaincontrolinthe postoperativeperiod.Maintain Prevention • SubsequentManagement • • DiagnosticStudies • • • • • •

• • • • • Immediate Management(continued)

• • • • RiskFactors

patient. Continue toprovidereassurancetheagitatedorcombative Fingerstick forbloodglucoselevel Arterial bloodgasanalysis emergence. adequate neuromuscularreversalforpatientswithdelayed If indicated,administernaloxoneand/orﬂumazenil, andensure Correct allmetaboliccausesandensurenormothermia. CT ofbrain(ruleoutacutebleed,stroke) Plasma electrolytemeasurementsToxicologyscreen MRI, EEG)ifmentalstatusdoesnotimprove. Consider furtherneurologicalconsultationandworkup(CTscan, underlying cause. haloperidol 2.5mgIM)totreatagitationwithoutanobvious Consider judiciousadministrationofabutyrophenone(e.g., Restrain patientonlyiforstaffsafetyisatrisk. cholinergic syndromeissuspected. Consider administrationofphysostigmine0.5mgIVif Provide adequateanalgesiaandanxiolysisifindicated. Verbally reassureandreorientthepatient. Assess thepatient’sbloodpressureandheartrate. History ofsubstanceintoxicationorwithdrawal Mental retardation Organic braindysfunction Age (childrenandelderly)

241 CHAPTER 10 Postanesthesia Care Unit 242 CHAPTER 10 Postanesthesia Care Unit • DIFFERENTIALDIAGNOSIS duce sharp,pleuriticpainthatvarieswithrespiration. chest pressureorburning.Pulmonarythromboembolismmaypro- skin dermatomes.Gastroesophagealreﬂ arms, epigastricarea,back,shoulders,neckorjaw,andmayfollow ischemia orinfarction.Cardiacchestpainmayalsoradiatetothe symptoms ofchestpainandtightnessmaybeduetomyocardial Postoperativechestpainiscommonandhasavariedetiology.Classic Pathophysiology • Presentation localized. Intensitymayvarywithrespiration. as heavyorpressing,substernalwithpossibleradiation,andisrarely gies, maybecardiacorrespiratoryinnature,frequentlydescribed Painlocatedinthethoracicregion,attributabletomultipleetiolo- Deﬁ ChangYL,TsaiYF,LinPJ,etal.Factorsforpostoperativedeliriuminacardio- FurtherReading PACU ormayoccurdaysaftersurgery. Postoperative cognitivedysfunctionmaybeseenimmediatelyinthe preexisting cognitiveabnormalitiesmayallexacerbatethisproblem. decline. Generalanesthesia,combinedwiththestressofsurgeryand • • • • • • • • •

ChestPainC vascular intensivecareunit. Myocardial ischemiaorinfarction(MI) frequent radiationtoarmorjaw,describedassqueezingpressure Acute presentationofsubsternalchestpainorpressure,with Pericarditis Cardiac arrhythmia elevated). Blood pressurechangesmayalsobenoted(decreasedor Pneumothorax Pericardial tamponade cyanosis, ordiaphoresis May beassociatedwithtachypnea,shortnessofbreath,dyspnea, Pulmonary embolism(PE) Gastroesophageal reﬂ Pneumoperitoneum h nition es t Pa

i n

ux disease

Am JCritCare

. 2008Nov;17(6):567–575. ux mayalsobereportedas

• SubsequentManagement • • • DiagnosticStudies • • • • • • • • •

• RiskFactors • • • • • • ImmediateManagement

pain, patientcardiachistory,baselineECG,andriskindex. ECG interpretationshouldtakeintoaccountthequalityofchest CPK-MB) Cardiac enzymes(troponin,creatinephosphokinase(CPK), Chest X-ray 12-lead electrocardiogram Anxiety Thoracic aneurysm Esophageal spasmorrupture pericardial tamponade(pericardiocentesis). Treat signiﬁcant pneumothorax (tubethoracostomy)or but risksofbleedingneedtobeconsidered. resolution CT,orangiography.Anticoagulationmaybeindicated, If aPEissuspected,obtainpulmonaryperfusiontest,high- mg IVq5min). and hypertension(labetalol5mgIVq2minormetoprolol1–2 Consider administeringabeta-blockerforcontroloftachycardia MI issuspected. Consider administeringaspirinand/orsublingualnitroglycerinifan Treat hypotensionwithﬂuids and/orvasopressors. intervention. If anMIissuspected,obtainacardiology consultationforpossible Aggressively treathypotensionorhypertension. Increase FiO sex, hyperlipidemia, obesity,anddiabetes. artery disease,peripheral vasculardisease,advanced age,male A cardiacetiologyismorelikelyin the presenceofcoronary Initiate reviewofsurgicalandanestheticprocedures. Obtain anelectrocardiogramandchestX-ray. (start at0.5mcg/kg/min). Consider sublingualnitroglycerinoranIVinfusion Provide analgesics(morphine)forreliefofpain.

2 tomaintainadequateoxygenation.

243 CHAPTER 10 Postanesthesia Care Unit 244 CHAPTER 10 Postanesthesia Care Unit • Presentation ative period. of atelectasisand/oralveolarhypoventilation intheearlypostoper- oximetry orarterialbloodgasanalysis, usuallytransientasaresult Decreasedarterialoxygencontent inbloodasmeasuredbypulse Defi EagleKA,BergerPB,CalkinsH,etal.Guidelineupdateforperioperative FurtherReading pathology mayalsomimiccardiacpain. toneum canoftencausereferredpainintothechest,andesophageal considered. Abdominallaparoscopicprocedureswithpneumoperi- ruled out,otheretiologies(e.g.,gastroesophagealrefl ux) maybe ening conditionsfi Theinitialevaluationofchestpainshouldalwaysruleoutlife-threat- SpecialConsiderations decrease theriskofpneumothoraxwithcentrallineplacement. incidence ofdeepveinthrombosisandPE.Theuseultrasoundmay DVT prophylaxisandearlyambulationisalsousefulinreducingthe ical optimizationidentifi Appropriatepreoperativeevaluation,cardiacriskstratifi Prevention • Risk Factors(continued)

• •

Hypoxia H

Task Forceonpracticeguidelines. report oftheAmericanCollegeCardiology/AmericanHeartAssociation cardiovascular evaluationfornoncardiacsurgery—executivesummary.A SpO agitated. Patient isfrequently lethargicandmaybeuncooperative or recent trauma. abdomen. Alsosuspectapneumothoraxinanypatientwith surgical proceduresinvolvingthechest,neck,andupper especially beconsideredaftercentrallineplacementand A pneumothoraxmayoccurinalmostanysetting,butshould and prolongedbedrest. advanced age,highrisk(e.g.,orthopedic)orlongprocedures thrombosis (DVT),hypercoagulablestates,malignancy, PE diagnosisissupportedinpatientswithknowndeepvein y nition p 2 oxia <90%orpO

rst.Oncethosecauseshavebeenconsideredand

2 <60mmHg es patients at risk for cardiac events. Appropriate es patientsatriskforcardiacevents.Appropriate

Anesth Analg

. 2002;94:1052–1064. cation, and med-

• • DIFFERENTIALDIAGNOSIS agents, canalsooccur. tion, fromresidualanestheticsorneuromuscularblocking mismatch mayalsoleadtoarterialhypoxemia.Alveolarhypoventila- left intrapulmonaryshunt(i.e.,atelectasis)orventilation/perfusion become hypoxicinthesettingofseverehypoventilation.Aright-to- result insigniﬁ canthypoxia.Ahealthypatientwithnormallungswill Inthepatientbreathingroomair,evenmildhypoventilationcan Pathophysiology • • • • • • • • • • • • • •

• • • • • ImmediateManagement

Methemoglobin (normalPaO capacity) Hypoventilation duetoresidualanesthetics Tachycardia andhypertensionmaybeassociatedwithhypoxia. Obstructive sleepapnea Inadequate FiO Atelectasis Hypercarbia Tissue cyanosismaybeseeninseverecases. aspiration) Impaired diffusion(pulmonaryedema,pulmonaryﬁ PE Increased oxygenconsumption(shivering) Pneumothorax Transfusion-related lunginjury Mainstem bronchialoresophagealintubation Acute respiratorydistresssyndrome Carboxyhemoglobin (normalPaO PaCO maintain adequateoxygenation. arterial hypoxia. Cardiovascular support maybenecessaryinextreme casesof Arterial bloodgasanalysisisuseful to determinePaO patient doesnotrespondtosupplemental O Intubation andmechanicalventilation mayberequiredifthe present. Insert anartiﬁcial airwayifobstructionis Provide supplementalO 2 . 2

2 vianasalcannulaorfacemaskto 2 butimpairedcarryingcapacity)

2 butimpairedcarrying

2 . brosis, 2 and

245 CHAPTER 10 Postanesthesia Care Unit 246 CHAPTER 10 Postanesthesia Care Unit ately afteremergence andduringpatienttransport. 10 minutes,emphasizing theneedforsupplemental oxygen immedi- nitrous oxideanesthetic, andmaypersistforupto approximately Diffusionhypoxiacancontributeto postoperativehypoxiaaftera SpecialConsiderations vent andtreatatelectasis. be preventedbyappropriatepostoperative respiratorycaretopre- of sedatives,narcotics,andﬂ right-to-left shunt.Caremustalsobe takentousejudiciousamounts and recruitmentmaneuversmayhelptodecreaseatelectasis ative period.Appropriatelevelsofpositiveend-expiratorypressure administration ofsupplementaloxygenintheimmediatepostoper- Preventionofpostoperativehypoxiaislargelybasedonappropriate Prevention • SubsequentManagement • • DiagnosticStudies • • • • • • •

• • • • • RiskFactors

Continue supplementaloxygen. Arterial bloodgas Chest X-ray hypoxia orhypercarbia. Consider intubationandmechanicalventilationforsigniﬁ Arterial co-oximetry anticoagulants. suspected. Consultthesurgicalteambeforeadministering Consider initiatingananticoagulant(e.g.,heparin)ifPEis overload causingpulmonaryedema. Administer diuretics(furosemide20mgIV)totreatvolume Insert achesttubetodecompresspneumothorax. Provide analgesiaifsplintingisthecauseofhypoventilation. benzodiazepines. Consider reversingopioids,residualneuromuscularblockade,and hyperthermia, shivering) Increased productionofcarbondioxide(i.e.,malignant Congestive heartfailure hypertension) Preexisting pulmonarydisease(emphysema,ﬁ Obesity Advanced age

uidsintraoperatively.Hypoxiamay also

brosis, pulmonary

cant

cardial ischemiaand/orinfarction. in oxygensupply(hypotension,hypoxia)canprecipitateacutemyo- den increaseinmyocardialoxygendemand(tachycardia)ordecrease blood flow. Inpatientswithischemiccoronaryarterydisease,asud- the siteofaplaqueincoronaryarterythatdecreasesorinterrupts Plateletaggregation,vasoconstriction,andthrombusformationat Pathophysiology • Presentation increased oxygendemand. ments. Ischemiacanbecausedbydecreasedregionalperfusionor Myocardialoxygensupplyinsuffi cient tomeetmetabolicrequire- Defi LumbAB. FurtherReading • • • • •

• • • • • • • ImmediateManagement

MyocardialIschemiaMyocard

Butterworth-Heinemann; 2005. Chest painorpressurereportedbyanawakepatient Dizziness, orsyncope Hypoxia, dyspnea Arrhythmias, congestiveheartfailure,acutemitralregurgitation Possible tachycardiaandhypertensionorprofoundhypotension ST-segment elevationordepressiononECG procedure. Request acardiology consultationforapossibleinterventional risk ofbleeding. Administer aspirinafterconsulting with surgeontodetermine Titrate toatargetheartrateof60 if possible. mcg/kg/min) fortreatmentoftachycardia andhypertension. esmolol IVinfusionstartedat50mcg/kg/min toamaxof300 Initiate beta-blockers(metoprolol1–2 mgIVq5minor hypotension. Aggressive ﬂuid resuscitationand/orvasporessorsfor Treat painwithnarcotics(morphineIV). Ensure adequateventilation. Increase FiO nition Nunn’s AppliedRespiratoryPhysiology

ia 2 tomaintainadequateoxygenation. l I

e m

. 6thed.Philadelphia:

247 CHAPTER 10 Postanesthesia Care Unit 248 CHAPTER 10 Postanesthesia Care Unit • • • ally becontinued on thedayofsurgery. (ACE) inhibitorsand diuretics,allcardiacmedications shouldgener- demand. Withpossible exceptionofangiotensinconverting enzyme ensure adequatemyocardialoxygen supplyandminimizemyocardial tive complications.Avoidinghemodynamic labilityisimportantto coronary arterydiseaseisessential forpreventionofpostopera- Preoperativeoptimizationofthepatient withknownorsuspected Prevention • • SubsequentManagement • • DiagnosticStudies • • DIFFERENTIALDIAGNOSIS • • • • • • • • RiskFactors

therapy. artery stentingandinitiationofanticoagulationantiplatelet important forpossibleinterventions,includingemergentcoronary Cardiology consultationanddiscussionwithsurgicalteamare Consider additionofnitroglycerinforcoronaryvasodilatation. infusion) forcontrolofheartrateandbloodpressure Beta-blockers (e.g.,labetalolormetoprololIVpushesmolol thrombus evaluation Echocardiography fornewwallmotiondefects,ejectionfraction, defects to assessforSTsegmentchanges,newQwaves,orconduction Continuous monitoringandserialECGscardiacenzymes Cardiac enzymes(troponin,CPK,CPK-MB) 12-lead electrocardiogram Pericarditis Coronary vasospasm Arterial bloodgas Complete bloodcount,metabolicproﬁ PE Aortic dissection Chest X-ray Anxiety carry thehighestriskofpostoperativemyocardialinfarction. Major abdominal,thoracic,vascular,oremergencysurgeries myocardial infarction,orsigniﬁcant riskfactorsofCAD Known historyofcoronaryarterydisease(CAD),previous

FeringaHH,BaxJJ,PoldermansD.Perioperativemedicalmanagementofisch- • DIFFERENTIAL DIAGNOSIS catheter. the ureters,surgicalinjurytoureter, andobstructionofaurinary renal insufficiency. Postrenalcausesofoliguriaincludeobstruction result inacutetubularnecrosis,particularly inapatientwithbaseline dye, hypotension,orexposureto nephrotoxicmedicationsmay Preoperative orintraoperativeinsults, suchasradiographiccontrast bleeding, third-spacefl uid loss,andinadequatefl Prerenalcausesofoliguriaincludehypovolemiaduetoongoing Pathophysiology • Presentation function duetoprerenal,renal,orpostrenaletiologies. Urineoutputlessthan0.5mL/kg/hthatmaysignifylossofkidney Defi BadnerNH,KnillRL,BrownJE,etal.Myocardialinfarctionafternoncardiac FurtherReading should alwaysbeperformedforverification andevaluation. of leadsIIandV5willdetect80%ischemicevents,a12-leadECG evaluation formyocardialischemiaorinfarction.Whilemonitoring risk patientswithSTsegmentchangesshouldundergoanimmediate lemia, andgenerallyonlyrequiresobservationinthePACU.High- more benigncausessuchasanxiety,hyperventilation,andhypoka- risk patientrarelyindicatesmyocardialischemia,butratherother, tory andcardiacrisk.STsegmentdepressionchestpaininalow- depression, mustbeinterpretedtakingintoaccountapatient’shis- InterpretationofECGchanges,includingSTsegmentelevationor SpecialConsiderations • • •

Oliguria/AcuteRenalFailureOli Anaesthesiol emic heartdiseaseinpatientsundergoingnoncardiacsurgery. surgery. Hypovolemia exacerbated byanintraoperativeevent. Often associatedwithapreexistingrenalinsufﬁciency thatis Low cardiacoutput acidosis, andrisingbloodureanitrogencreatinine. May beassociatedwithelectrolyteabnormalities(hyperkalemia), Urine outputlessthan0.5mL/kg/h. nition g uria/Ac Anesthesiology

. 2007Jun;20(3):254–260. u te RenalFailure

. 1998;88:572–578.

ud replacement. uid

Curr Opin 249 CHAPTER 10 Postanesthesia Care Unit 250 CHAPTER 10 Postanesthesia Care Unit • SubsequentManagement • DiagnosticStudies • • • • • • • • • • •

• • • • ImmediateManagement • • • • • RiskFactors

if volumestatusisunclear. Consider insertingacentralvenousorpulmonaryarterycatheter Basic metabolicpanel Acute tubularnecrosis Abdominal hypertension treatment. Consider hemodialysisforworseningrenalfailurerefractoryto present. Treat severemetabolicacidosisandhyperkalemiaif perfusion. low cardiacoutputorhypotensiontoensureadequaterenal Consider startingadobutamineornorepinephrineinfusionfor Arterial bloodgas Nephrotoxic agentexposure Urine electrolytes Chest X-ray Mechanical catheterobstruction. Ureter obstruction Discontinue administrationofnephrotoxicagents. 10–40 mgIV)afterrulingouthypovolemia. Consider diagnosticadministrationofadiuretic(furosemide Administer afluid challenge(10–20mL/kgcrystalloid). Insert aurinarycatheterandevaluateforpatency. Intraoperative hypotension Signifi Advanced age Left ventriculardysfunction Chronic renalinsuffi cant intraoperativebloodloss

ciency

NoorS,UsmaniA.Postoperativerenalfailure. heart rateresultsfromanincreasein beta-1receptorstimulation. vascular resistanceandvenousreturn.Increasedcontractility mediated byalpha-adrenergicstimulationcausingincreasedsystemic nervous systemactivity.Peripheralarterialandvenousconstrictionis vated peripheralvasculartone,andincreasedendogenoussympathetic ated bloodpressureresponseduetononcompliantvasculature,ele- Patientswithahistoryofpreexistinghypertensionhaveanexagger- Pathophysiology ing factorofhypertension,commonlyassociatedwithtachycardia. operative patients.Painisoftenpresentandtypicallytheprecipitat- Moderateelevationinsystolicand/ordiastolicbloodpressurepost- Presentation Elevatedsystemicbloodpressure,frequentlyseenwithtachycardia. Defi JosephsSA,ThakarCV.Perioperativeriskassessment,prevention,andtreat- FurtherReading tenance ofbloodpressureareusefulinpreventingfurtherrenalinsult. to postoperativerenalfailure.Aggressiveearlyrehydrationandmain- sible ureteralinjury,andotherintraoperativeeventsmaypredispose Aorticcross-clamping,severehypotension,massivetransfusion,pos- SpecialConsiderations postoperative renalfailure. tenance ofadequaterenalperfusionmayalsobeusefulinpreventing line renalinsuffi ciency. Avoidanceofnephrotoxicagentsandmain- Carefulperioperativefluid balanceisimportantin patientswithbase- Prevention • • • ImmediateManagement

PostoperativeHypertensionPostoperat

Nov;24(4):721–729 ment ofacutekidneyinjury. (midazolam 1–2mg) tocontrolpainandanxiety. Administer analgesics(morphine1–2 mgIV)orsedatives Ensure adequateventilation. Increase FiO nition

2 tomaintainadequateoxygenation. i ve Hype

Int AnesthesiolClin r

tens i on . 2009Fall;47(4):89–105.

Clin GeriatrMed

. 2008

251 CHAPTER 10 Postanesthesia Care Unit 252 CHAPTER 10 Postanesthesia Care Unit • • throughout theperioperative period(ACEinhibitors anddiuretics Antihypertensive medicationsshouldgenerally be continued Prevention • • SubsequentManagement dence ofrulingoutanunderlyingetiology(i.e.,acidosis,hypercapnea). Initially,noneindicated.Furtherworkupshouldbebasedonclinicalevi- DiagnosticStudies • DIFFERENTIALDIAGNOSIS • • • • • • • • Immediate Management(continued)

• • •

• • • • RiskFactors

clevidipine), invasive blood pressure monitoring, and ICU admission. clevidipine), invasivebloodpressuremonitoring,andICUadmission. beta blocker(e.g.,labetalol),continuousIVinfusionsnicardine, Persistent hypertensionmayrequireintermittentbolusesofa reserved forrefractoryorlife-threateninghypertension. Potent vasodilatorssuchasnitroprussideornitroglycerineare Resume usualantihypertensivemedicationassoonpossible. Continued assessmentandtreatmentofpostoperativepain. Preoperative essentialhypertension Hypercapnea Arterial hypoxemia Postoperative painandagitation Hypervolemia Increased intracranialpressure Gastric orbladderdistention arterial line. Inappropriately smallbloodpressurecufforimproperlycalibrated Emergence delirium clevidipine forcontrol. as intravenouslabetalol,esmolol,hydralazine,nicardipineor If hypertensionpersists,considerotherinterventionssuch Ensure abilitytovoidurine. Treat acidosisorhypoxemiaifpresent. Patients undergoingintracranialprocedures. Inadequate paincontrol,eitherduring oraftersurgery. period. Cessation ofantihypertensivemedications intheperioperative Presence ofessentialhypertension preoperatively.

hypotension. thetic techniquesmayalsoleadtoa lossofsympathetictonecausing systemic vascularresistance,andvenoconstriction. Neuraxialanes- and cardiacoutput,sympathetic-mediated tachycardia,increased and bloodloss.Thesefactorslead todecreasedventricularfi by decreasedpreloadandongoing fl uid lossesduetothird-spacing (decreased afterload).Hypotension inthePACUisusuallycaused (decreased preload),cardiogenic(pumpfailure),ordistributive Systemichypotensioncanbecategorizedaseitherhypovolemic Pathophysiology • • Presentation sion andhypoxia. Decreasedsystemicbloodpressurethatcancausetissuehypoperfu- Defi VaronJ,MarikPE.Thediagnosisandmanagementofhypertensivecrises. FurtherReading restore hemodynamicstabilityasquicklypossible. causes (i.e.,pain,hypoxia)rapidly,andthenusepharmacotherapyto cannot alwaysbefound,itiscrucialtotreatcommonpostoperative tension andbradycardia.Whiletheexactetiologyofhypertension cardia aremorepredictiveofanadverseoutcomethanhypo- frequent; however,postoperativesystemichypertensionandtachy- PostoperativehemodynamicinstabilityinthePACUissomewhat SpecialConsiderations niques, orotherformsofanalgesia. treated withjudicioususeofnarcotics,regionalanesthetictech- drawal mayprecipitatereboundhypertension.Painshouldbe are oftenheldonthemorningofsurgery)becauseabruptwith- • •

PostoperativeHypotensionPostoperat Chest May beassociatedwitheitherbradycardiaortachycardia. Decreased arterialbloodpressure. Alteration inmentalstatusmaybeseenseverecases. ischemia). (myocardial infarction,acuterenalfailure,hepatic Organ systemfailuremaybeseenafterprolongedhypotension nition . 2000;118:214–227.

i v e Hypotens

i on

lling 253 CHAPTER 10 Postanesthesia Care Unit 254 CHAPTER 10 Postanesthesia Care Unit (i.e., myocardialischemia orpneumothorax). drugs. Determination andtreatmentofprimaryetiology isessential ing maybeusefulforcontinuedmonitoring andinfusionofﬂ sors asnecessary.Arterialand/orcentral venouspressuremonitor- Continuesupportivecarewithﬂuids, bloodproducts,andvasopres- SubsequentManagement • • • DiagnosticStudies • DIFFERENTIALDIAGNOSIS • • • • • • • • • • •

• • • • ImmediateManagement

cardiogenic originissuspected. 12-lead ECGand/orechocardiogrammaybeusefulifa Complete bloodcount Chest X-Rayifclinicalsuspicionofpneumothorax. Hypovolemia loss). base status(hematocritmaybeinaccurateduringacuteblood Arterial bloodgasanalysistodeterminehematocritandacid- Hemorrhage Anaphylaxis Pulmonary embolus Tension pneumothorax Cardiac tamponade Cardiac arrhythmia Myocardial ischemia/infarction Drug-induced (betablocker,calciumchannelblocker) Sepsis Spinal shock (benefi Consider placingthepatientinTrendelenbergposition mcg/kg/min) inthesettingofrefractoryhypotension. phenylephrine (0.5–1mcg/kg/min)orepinephrine(0.03–0.05 or epinephrineboluses.Considerbeginninganinfusionof Support bloodpressurewithphenylephrine,ephedrine, challenge. colloids). Manypatientswilloftenrespondtoamoderatefl Initiate aggressiveresuscitationwithIVfluids (crystalloidor supplemental oxygenorventilatorysupportifnecessary. Ensure adequateoxygenationandventilation.Provide ts controversial).

uids and

uid after avolatileanesthetic technique. patients mayexperience postoperativenauseaandvomiting (PONV) after dischargefollowingsurgery. Without prophylaxis,10–80%of Signifi Defi BarashPG,Cullen,BF,StoeltingRK,CahalanMK,StockME(eds.). FurtherReading considered. often overlookedasacauseofhypotensionandshouldalwaysbe and maybelethalifnotimmediatelytreated.Finally,anaphylaxisis pulmonary embolus,orpericardialtamponademayoccursuddenly patient withunexplainedhypotension.Tensionpneumothorax, PACU, oftenwithoutobvioussigns,andmustbesuspectedinany be considered.Signifi cant hemorrhagecandeveloprapidlyinthe hypotension, shockresultingfrommorecatastrophiccausesmust Whilerelativehypovolemiaisusuallythereasonforsystemic SpecialConsiderations agents. to maintainnormotensionandmaybemoresensitiveanesthetic tension. Criticallyillpatientsrelyonincreasedsympathetictone prior toneuraxialanesthetictechniquesmayalsopreventhypo- often underestimatedinmanysurgicalprocedures.Afl uid load intraoperative volumereplacement.Bloodandfl uid lossesare Postoperativehypotensionismostoftenpreventedbycareful Prevention

• • • RiskFactors PostoperativeNauseaandPostoperat Vomiting

2009:1452–1456. ClinicalAnesthesia. hypotension. Neuraxial anesthesthictechniquesareoftenassociatedwith Pre-existing hypertensionandcardiacdisease. bleeding. (bowel preparation,gastrointestinallosses)orsignifi Inadequate replacementoffluids fromongoingfl nition cant nauseaand/oremesisexperiencedeither inthePACUor

i 6thed ve Nausea

. Philadelphia:Lippincott,Williams&Wilkins;

a nd Vom i

t i uid losses ng cant

255 CHAPTER 10 Postanesthesia Care Unit 256 CHAPTER 10 Postanesthesia Care Unit • • DiagnosticStudies • • • • DIFFERENTIALDIAGNOSIS cholinergic, substanceP,andserotonergic. to targetspeciﬁ c receptorsincluding dopaminergic, histaminergic, reticular formationofthemedulla.Pharmacologicaltreatmentaims chemotactic centers.Theemeticcentersarelocatedinthelateral vation, autonomicimbalance,pain,andtheanestheticeffectson PONVistheresultofmultipleperioperativefactorssuchasstar- Pathophysiology • Presentation • • • • • • • • • • • ImmediateManagement

out othermoresevere etiologies. Perform additional diagnosticstudiesasclinicallyindicated torule Clinical diagnosis Hypoxia Anxiety Pain Anesthetics (narcotic,inhalationalagents) the postoperativeperiod. Range ofsymptomsfrommildnauseatoretchingandvomitingin Hypotension abdominal oringuinalsuturelines. Associated withincreasedintra-abdominalpressure,andmayrisk Hypoglycemia hypertension andtachycardia. Increased sympatheticnervoussystemresponse,producing protective reﬂexes arenotcompletelyintact. Increased riskofgastricaspiration,especiallywhenairway Increased intracranialpressure Bowel obstruction Gastric bleeding increased intracranialpressure). potentially seriouscausesofPONV(i.e.,impendingshock, prophylaxis. In general,donotrepeatthesameclassofagentsusedfor Administer medicationforrescue(i.e.,ondansetron4mgIV). Ensure adequatehydrationwithintravenouscrystalloids. Increase FiO 2 toensureadequateoxygenation.Exclude

nique, which may have resulted from the anesthetic, its contaminants, nique, whichmay have resultedfromtheanesthetic,its contaminants, Prolongedparalysis orsensorydeficit afteraneuraxialanesthesia tech- Defi GanTJ,MeyerTA,ApfelCC,etal.Societyforambulatoryanesthesiaguide- FurtherReading oxide maybepossiblewithatotalintravenousanesthetictechnique. is required,limiteduseofnarcotics,volatileanestheticsandnitrous reduce theincidenceofPONVsignifi cantly. Whenageneralanesthetic addition totheusualprophylactictreatment.Regionaltechniqueswill lactic therapy,maybenefi t fromanalterationinanesthetictechnique PatientswithahistoryofprotractedPONV,despiteadequateprophy- SpecialConsiderations low riskmaynotbeindicated. ally receivetripleagentprophylaxis,Prophylaxisinpatientsatvery Patients whohavethehighestriskofdevelopingPONVshouldide- ProphylaxisofPONVisoftenmoreeffectivethanrescuetherapy. Prevention • • • • SubsequentManagement

• • • • • • RiskFactors

Regional AnesthesiaR ProlongedNeurologicImpairmentProlon after

Analg. lines forthemanagementofpostoperativenauseaandvomiting. nausea. Propofol (10–20mg)maybealsobeneﬁcial forrefractory warning forQTcprolongation. Droperidol (0.625mg)ishighlyeffectivebutcarriesa“black-box” Continue totreatseverePONVwithmultimodaltherapy. Phenothiazines (phenergan, compazine) are good second-line agents. Phenothiazines (phenergan,compazine)aregoodsecond-lineagents. Opioid-based andnitrousoxideanesthetic Strabismus andmiddleearsurgery Laparoscopic surgery Prior historyofmotionsicknessorPONV Nonsmoking status Female sex e nition g ional Anesthesia 2007;105:1615–1628 ge

d Neurolo

ic Impairmentafte

Anesth

257 CHAPTER 10 Postanesthesia Care Unit 258 CHAPTER 10 Postanesthesia Care Unit • SubsequentManagement EmergencyMRIofspinalcordafteranintrathecalorepiduralblock. DiagnosticStudies • • • • • DIFFERENTIALDIAGNOSIS anesthetics orpreservatives. Neuro toxicitycanalsooccurasaresultofeitherintrathecallocal pression ofthecordbyanexpandingepiduralhematomaorabscess. ischemia orinfarctionmaybeduetoarterialhypotensioncom- is paraplegiaduetoischemia,infection,ordrugtoxicity.Spinalcord Themostseriousneurologicalcomplicationofneuraxialanesthesia Pathophysiology • Presentation condition. surgical procedure,positioning,orexacerbationofapreexisting • • • • •

• • • ImmediateManagement

hematoma orabscess. Perform emergencysurgicaldecompression ifthereisevidenceof Cauda equinasyndrome Toxicity ofanestheticoradditiveintheintrathecalspace Neuropathy duetopositioning(i.e.,lithotomyposition) Spinal/epidural abscess(notacute) Spinal/epidural hematoma local anestheticinjectedintothespinalorepiduralspace Prolonged motorandsensoryblockadegreaterthanexpectedfor Sensory deﬁcits suchasnumbnessandparesthesias Longer thanexpectedeffectofanestheticagents blockade). with noknownnerve damage(i.e.,clonidinepatchprolonging Numerous casereports showunexplainedprolonged block Most transientparesthesiasresolve overabout6months. signiﬁ Other thansurgicaldecompression, furthertreatmentof Emergency neurosurgicalconsultation other pathology. Emergency MRIofthespinalcordtoevaluateforhematomaor Neurological examinationtoevaluateextentofresidualeffect. cant neurologicinjuryislargelysupportive.

the normalventilatory responsestobothhypercarbia andhypoxemia. Theresidualeffects ofintravenousandinhalationalanesthetics blunt Pathophysiology • • • • Presentation in thepostoperativeperiod. variety ofmechanical,hemodynamic,andpharmacologicfactorsseen Impairedventilation,oxygenation,andairwaymaintenanceduetoa Deﬁ HorlockerTT,WedelDJ,BenzonH,etal.Regionalanesthesiainthe FurtherReading develops duringlocalanestheticinjection. safer tostoptheprocedureorrelocateneedleifaparesthesia rect aneedleifparesthesiadevelopsduringplacement,itmaybe of localanestheticshasbeensuggested.Whileitappearssafetoredi- Anassociationbetweenparesthesiasandradiatingpainoninjection SpecialConsiderations those whoareseverelyimmunocompromisedisrecommended. agulation, aswellpatientswithongoingsigniﬁ cant infectionsor agents (aspirinaloneisusuallyacceptable)andtherapeuticantico- regional anesthesiainpatientswhoaretreatedwithantiplatelet tant inlimitingthepotentialofcatastrophiccomplications.Avoiding spinal andepiduralanesthetics,properpatientselectionisimpor- Whileitisimpossibletopreventallneurologicalcomplicationsof Prevention

• • • RiskFactors

RespiratoryDepressionorFailureRes

May–Jun;28(3):172–197 anticoagulated patient:deﬁ ning the risks. Residual neuromuscularblockadewith muscleweakness Excessive sedationandsomnolence Decreased minuteventilationandpossible hypoxia Airway obstructionandlossofpharyngeal muscletone Traumatic ordifﬁcult needleplacement Antiplatelet therapyoranticoagulation Leukemia, blooddyscrasias,thrombocytopenia nition p irator

y De p

res

s i o n o

r Failure

Reg AnesthPainMed

. 2003 259 CHAPTER 10 Postanesthesia Care Unit 260 CHAPTER 10 Postanesthesia Care Unit • SubsequentManagement • • DiagnosticStudies • DIFFERENTIALDIAGNOSIS may leadtoairwayobstructionandrespiratorydepression. sure, thisfunctionisoftendecreasedinthesedatedpatient,which the diaphragmtoopenairwayduringnegativeinspiratorypres- the upperairway.Whilepharyngealmusclesnormallycontractwith Residual neuromuscularblockademaycausefurthercompromiseof the ventilatorydrive,andcancauseupperairwayobstruction. Benzodiazepines andnarcoticsactsynergisticallytofurtherdecrease • • • • • • • • • • • • • • • • ImmediateManagement

the appropriateantagonist(i.e.,naloxone orﬂ Reverse residualopioidsorbenzodiazepines withjudicioususeof Arterial bloodgas Chest X-ray anesthetics) Residual anesthetics(benzodiazepines,opioids,inhaled reactive airwaydisease. Administer beta-2agonistsfortreatment ofbronchospasmor Reverse residualneuromuscularblocking agents. Assessment forthepresenceofresidualneuromuscularblockade Residual neuromuscularblockers Mechanical ventilation Initiate continuous positiveairwaypressure(CPAP). Laryngospasm Upper airwayobstruction,edema,orhematoma Bronchospasm PE Pulmonary edema Pneumothorax Obstructive SleepApnea with theaboveinterventions. complete airwayobstructionthatdoesnotimmediatelyresolve Intubate thetracheainsettingofrespiratoryfailureor to provideapatentairway. Provide jawthrust,artiﬁcial oral,nasal,orlaryngealmaskairway Increase FiO

2 tomaintainadequateoxygenation.

umazenil).

• Presentation to bluntautonomicandsomaticrefl ex responses to pain. in additiontoinhibitingtrauma-induced nociceptivesignalsinorder of treatmentforpostoperativepain istoprovidesubjectivecomfort trauma, visceraldistention,andongoing diseaseprocesses.Theaim Postoperativepainisacomplexphysiologicalresponsetotissue Defi ArozullahAM,DaleyJ,Henderdon,WG,etal.Multifactorialriskindexfor FurtherReading way inapatientwhohasjustundergonenecksurgery. ischemia. Considerthepossibilityofahematomaobstructingair- in severepain,tachycardia,hypertension,andpossiblymyocardial sion withoutaffectinganalgesia.Anoverdoseofnaloxonewillresult incremental doses)canreverseopioid-inducedrespiratorydepres- with localanestheticsolution).Slowtitrationofnaloxone(40mcg removal ofnoxiousstimuli(i.e.,extubationorinfiltration ofawound Hypoventilationandairwayobstructionmaybeseenafterthe SpecialConsiderations tive sleepapneaandmorbidobesity) prone topostoperativerespiratoryfailure(e.g.,thosewithobstruc- Titrate sedativesandopioidscarefully,especiallyinpatientswhoare anesthetic agents,opioids)areacommoncauseofhypoventilation. Thesynergisticeffectsofrespiratorydepressants(e.g.,residual Prevention •

• • • • • RiskFactors

SeverePostoperativePainP

surgery. predicting postoperativerespiratoryfailureinmenaftermajornoncardiac Constant painnearthesurgicalsite, andachinginnature activities suchascoughing, ambulating,dressingchanges Frequent acuteexacerbation ofpainwithnormalpostoperative Obstructive sleepapnea Severe asthma Chronic obstructivepulmonarydisease(COPD) Obesity Advanced age nition Ann Surgery.

op 2000;232(2):242–253 erative Pain

261 CHAPTER 10 Postanesthesia Care Unit 262 CHAPTER 10 Postanesthesia Care Unit • • SubsequentManagement Clinicaldiagnosis DiagnosticStudies • DIFFERENTIALDIAGNOSIS cyclooxygenase-2 inhibitors(COX-2),andlocalanesthetics. such asopioids,nonsteroidalanti-inﬂ ammatory drugs(NSAIDs), of thissignalmayoccuratanylevelthepathwaywithmedications spinal cordtothecontralateralcortexviathalamus.Modulation stimuli viaafferentsensorynervesthroughthedorsalhornof Nociceptioninvolvestherecognitionandtransmissionofnoxious Pathophysiology • • • •

• • • • • • ImmediateManagement

Wound complications(infection,hematoma,nerveinjury) lower-extremity orthopedic procedures. opioids mayprovide superiorpainreliefinmanyabdominal or Intrathecal orepidural administrationoflocalanesthetics and Inadequate analgesicregimen(inadequateorinfrequentdosing) over arelativelyshortperiodoftime Usually isaself-limitingconditionwithprogressiveimprovement Chronic paindisorder consumption, andincreasedsympathetictonemaybepresent. Hypertension, tachycardia,myocardialischemia,increasedoxygen Drug-seeking behavior opioids. should hypoventilationoccurfollowingadministrationof Provide supplementaloxygentoensureadequateoxygenation acceptable levelandpatientiscomfortable. Consider patient-controlledanalgesia(PCA)oncepainisatan score of3–4isusuallyacceptable. hydromorphone) untilpatientappearscomfortable.Apain Administer incrementaldosesofopioids(e.g.,morphineor therapy. For severepostoperativepain,opioidsarethemainstayof reevaluate thepatientandnotifysurgicalteam. If thepainissevereandrefractorytoappropriatemanagement, or similarmethod. Evaluate thequalityandlevelofpainusingavisualanalogscale

ately afteremergence orearlyinthepostoperativeperiod. an ischemicorembolic eventinthebrain,diagnosed eitherimmedi- Developmentofa newacutefocalneurologicaldefi Defi CaplanRA,CarrDB,ConnisRT.Practiceguidelinesforacutepainmanage- FurtherReading shown topredictpersistentpostoperativepain. and thromboembolicevents.Severityofpostoperativepainhasbeen cardial ischemiaorinfarction,impairedwoundhealing,atelectasis, a furtherbenefi t inimprovingclinical outcomebypreventingmyo- Inadditiontopatientcomfort,adequatecontrolofpainmayhave SpecialConsiderations postoperative pain. techniques canbeusedtodecreasetheintensityanddurationof postoperative paininmanypatients.Localandregionalanesthetic Preemptiveanalgesictherapymaysignifi cantly helpincontrolling Prevention • • •

• • • • • RiskFactors

S Stroke

ment intheperioperativesetting. the onlyCOS-2inhibitoravailableinUnitedStates. will notaffectplateletfunction.Atthepresenttime,celecoxibis inﬂ do notcauserespiratorydepression,butwilldecreaselevelsof NSAIDS andCOX-2inhibitorshavenohemodynamiceffects morphine tohydromorphone). Consider switchingopioidsifpaincontrolisinadequate(i.e., of pain. Transition tooralrouteassoonfeasiblewithadequatecontrol t Opioid addiction anxiety) Coexisting medicalconditions(substanceabuse,withdrawal, Prior historyofpoorpainmanagement Preoperative pain Male sex nition r ammatory mediatorsatthesiteoftissueinjury.COX-2agents o ke

Anesthesiology

. 2004;100:1573–1581. citduetoeither

263 CHAPTER 10 Postanesthesia Care Unit 264 CHAPTER 10 Postanesthesia Care Unit • • SubsequentManagement • • DiagnosticStudies • • • • • DIFFERENTIALDIAGNOSIS less commonintheperioperativesetting. to aneurysmorarteriovenousmalformationarealsopossible,butfar Embolic strokesmaybeofcardiacorigin.Hemorrhagicdue hypotension, athromboticevent,oranembolism(e.g.,thrombus). artery andsubsequentinfarctofbraintissueduetoeitherprofound Astrokemayoccurastheresultofanocclusionacerebral Pathophysiology • Presentation • • • • • •

• • • • ImmediateManagement

endovascular intervention Request aneurosurgical orneurologyconsultationfor possible continuous hemodynamicmonitoring. Consider insertionofanintra-arterial cathetertofacilitate CT ofbraintoruleoutbleeding Clinical diagnosis Gas embolism(throughapatentforemanovale) Intracerebral hemorrhage Hemorrhagic stroke Ischemic stroke Thrombo-embolic stroke Weakness orparalysisinonemoreextremities Cranial nervedeﬁcits and/ordysarthria Possible MRIofbrain Seizure antiplatelet therapyifthereisnosurgical contraindication Consider initiatingtissueplasmogen activator(t-PA)or Blurred visionordiplopia Severe confusionandalteredmentalstatus Emergency neurologyconsultation. needed fortighthemodynamiccontrol. Ensure hemodynamicstability,usingvasoactivedruginfusionsas Emergency CTofbrainwithoutcontrast. Ensure adequateoxygenationandventilation.

SelimM.Perioperativestroke. FurtherReading functioning priortodischargefromPACU. necessary toassurethatpatientsreturntheirexpectedlevelof awakening afterapotentvolatileanesthetic.Closeobservationis circumstances mightindicateaprimaryneurologiceventwhile Manypatientsexhibitslurredspeechorbehaviorthatunderother SpecialConsiderations hypoperfusion andischemia. at-risk patientsisalsoimportanttoreducetheriskofstrokedue arterial plaques,thrombus,orairentry.Avoidanceofhypotensionin ing cardiacandcarotidsurgeryisalsocrucialtopreventembolismof diogenic embolusmaybeofbeneﬁ Preoperativescreeningforsigniﬁ cant carotiddiseaseorriskofcar- Prevention

• • • • • RiskFactors

Signiﬁ Atrial ﬁ Cardiac, carotid,orneurosurgicalprocedure Transient ischemicattack(TIA)oramaurosisfugax Recent stroke cant hypotension brillation

N EnglJMed. t. Carefulsurgicaltechniquedur- 2005Feb;356:706–713.

265 CHAPTER 10 Postanesthesia Care Unit This page intentionally left blank Chapter 11 Procedures Ramachandran Ramani and Ala Haddadin

Anesthetic Implications of Pacemakers 268 Blind Nasal Intubation 270 Bronchial Blocker Placement 271 Cricothyroidotomy 273 Double Lumen Endotracheal Tube (DLETT) 276 Femoral Vein Catheter 278 Complications 279 Fiberoptic Intubation 279 Intubating Laryngeal Mask Airway 282 Retrograde Intubation 284 267 Transcutaneous Pacing 286 Transport of a Critically Ill Patient 288 Transvenous Pacing 290 Ultrasound-Guided Central Venous Access 292

268 CHAPTER 11 Procedures remember: patient withapacemaker, buttherearesomeimportant pointsto the operatingroom. the heart’sintrinsicrhythm.Thismode isnotgenerallyusedoutside may inhibitthispacemakerevenwhen nointrinsicrhythmispresent. ular rateisadequate.Extrinsicelectrical activity(e.g.,electrocautery) that theywillnotinterferewiththeintrinsicrhythmwhenventric- electrical activity.Theprimaryadvantageofdemandpacemakersis atrioventricular (AV)sequentialdemand. of pacing:asynchronous,single-chamberdemand,anddual-chamber functions. cates programmabilityandthefi fth letterindicatesanti-dysrhythmia T fortriggered,DdualandOnone).Thefourthletterindi- the responseofpacemakertosensedchamber(Iforinhibited, third letterrepresentsthemodeofpacemaker,alsodescribedas letter representsthechambersensed(A,V,DandOfornone).The chamber paced(Aforatrium,Vventricle,Ddual).Thesecond the first 3arecommonly used.Thefi conduction. nent pacingarefailureofimpulseformation,andcardiac atic bradycardiaofanyorigin.Thetwomajorindicationsforperma- Artifi 2002;25:260–264. BPEG GenericCodeforantibradycardia,adaptive-rate,andmultisitepacing. Source known astheHeartRhythmSociety)/BPEGRevised(2002) Table11.1 (A + V) D=dual V=ventricle A=atrium O=none PositionI AnestheticImplicationsofPacemakersIm Nospecialmonitoringoranesthetic techniqueisrequiredfora An A Thecompletepacemakercodecontains5letters,ofwhichonly Modernpacemakersareprogrammableintooneofthreemodes cial pacingisgenerallyindicatedforthetreatmentofsymptom- demand pacemaker : ReprintedwithpermissionfromBernsteinAD,etal.TheRevisedNASPE/ asynchronous pacemaker

Generic PacemakerCode(NBG)NASPE(now (A+V) D=dual V=ventricle A=atrium O=none PositionII p lications ofPacemakers dischargesonlywhenthereisnointrinsic O=none (T+I) D=dual T=triggered I=inhibited PositionIII dischargescontinuously,regardless of rst letterrepresentsthecardiac modulation R=rate O=none PositionIV (A+V) D=dual V=ventricle A=atrium O=none PositionV PACE

7. 6. 4. 3. 2. 1. • • • • • Ifthepacemakermalfunctions:

transplanted heartisnotinnervated. not affecttheheartrateintransplant patientsbecausethe the blockisnotbelowbundleof His.Anticholinergicsdo hypotension. Antimuscarinicdrugsmaybealsousedaslong dopamine. Isoproterenolisnotwidelyusedbecauseitmaycause or increasechronotropicity(orboth).Considerepinephrine malfunctions becausetheydecreasedepolarizationthreshold Sympathomimetic drugsmaybeusefulifthepacemaker transvenous, ortransesophagealpacingifnecessary. Be preparedtobegintemporarytransthoracic(transcutaneous), Check antiarrhythmic druglevels(e.g.,amiodaroneor digoxin). Correct acid-baseandelectrolytedisturbances. substantially increasetheenergyrequired forventricularcapture. Rule outmyocardialischemia.Myocardial ischemiacan generator-heart circuit. current-return padsothatelectricitydoesnotcrossthe IfamonopolarESUistobeused,placetheelectrosurgical generators arerelativelyimmunetospuriousreprogramming. an older(pre-1990)generator.Morerecentlymanufactured pacemaker behavior,butitmightalsoallowreprogrammingof Placingamagnetoverthegeneratormightpreventaberrant rate ( (EMI) andbeginpacingasynchronouslyataprogrammedlower generator maydetectsigniﬁcant electromagneticinterference which thepacemakermayinterpretasQRScomplexes.The return electrode a bipolarESUbecausethecurrenttravelsthroughbodyto Amonopolarelectrosurgicalunit(ESU)ismoreproblematicthan pacing ordeﬁ brillation (orboth)ifneeded. Appropriateequipmentmustbeonhandtoprovidebackup 5. been showntodetectlossofBiVpacingbehavior. echocardiography (TEE),nootherintraoperativemonitorhas cardiac output.Withtheexceptionoftransesophageal pacing foranyreasonwillcauseanimmediatedropin (BiV) pacingintheperioperativeperiod.Lossofventricular Thereislimitedexperiencewithintraoperativebiventricular plethysmography, orthearterialpressurewaveform. systole. Mechanicalsystoleisbestevaluatedbypulseoximetry, Ensurethatpacedelectricalactivityisconvertedtomechanical ability todetectpacingdischarges. Electrocardiographicmonitoringofapatientmustincludethe noise reversionmodepacing ). . PacemakerscanbeinhibitedbyESUcurrent,

269 CHAPTER 11 Procedures 270 CHAPTER 11 Procedures

StoneME,ApinisA.Currentperioperativemanagementofthepatientwitha • • • • • • • Procedure than thatrequiredforanorotrachealtube. ﬂ Theonlyequipmentnecessaryforblindnasalintubationisasoft, EquipmentChecklist Maxillofacialfracture Contraindications tion undervisionfail. Blindnasalintubationcanbedonewhenothertechniquesofintuba- Indication technique. laryngoscope andMagill’sforceps)oritcanbeperformedasablind Nasalintubationcanbecarriedoutunderdirectvision(e.g.,witha RoznerMA.Thepatientwithacardiacpacemakerorimplanteddeﬁ FurtherReading

exible endotrachealtube.Anasotrachealtube is2–4cmlonger

BlindNasalIntubation Bl Mar;13(1):31–43. cardiac rhythmmanagementdevice. Jun;20(3):261–268. tor andmanagementduringanaesthesia. oxymetazoline, or cocaine) to decrease the risk of bleeding. oxymetazoline, orcocaine)todecreasetheriskofbleeding. Spray thenasalpassageswithavasoconstrictor(e.g.,phenylephrine, into theglottis. Gently passtheETT intothenasopharynxandthen further down (prevents trauma to thenasalturbinates). it throughthenostrilwithbevel ofthetubefacinglaterally Lubricate a7.0or7.5mmcuffedETT withlidocainejellyandpass patients). larynx abovetheglottis(maynotbe necessaryinanesthetized Consider bilateralsuperiorlaryngeal blocktoanesthetizethe tracheal mucosa. the cricothyroidmembraneintotracheatoanesthetize Inject 2mLlidocaine2%througha25gneedleplaced fl Position thepatientsupineandinsniffing position,withslight spontaneously. This techniqueisonlypracticalifthepatientbreathing Skullbasefracturewithorwithoutcerebrospinalfl exion ofcervicaljointandextensiontheatlantooccipitaljoint. i nd NasalIntubat

i on Semin CardiothoracVascAnesth

Curr OpinAnaesthesiol

uid leak

. 2007 brilla- . 2009

sion ofamainstem bronchus. Adevicethatpermits one-lungventilation(OLV)by selectiveocclu- Deﬁ • • • SpecialConsiderations • • • • Complications • • • • • •

BronchialBlockerPlacementBr infection. Prolonged nasotrachealintubationcancausenasalsinus inspiration. gently point wherebreathsoundsareheardwithmaximumintensity, left handandthenasotrachealtubewithrighthand,at With gentlesidetomanipulationofthelarynxwith Always useasoft,well-lubricatedtube. unavailable. performed butmaybeinvaluablewhenmoreadvancedtoolsare bronchoscope, blindnasalintubationtechniqueisveryrarely With theavailabilityofintubatingdevicessuchasfi intubation incomparisontooralintubation. Respiratory tractinfectionismorecommonafternasotracheal nasotracheal intubation. are sprayedwithatopicalvasoconstrictorbeforeattempting intubation .Thiscomplicationislesslikelyifthenasalpassages Bleeding fromthenaresisnotuncommonfollowingnasotracheal tube backandredirectit. submucosal pocket.Ifresistanceisencountered,gentlypullthe Trauma tothemucosawithnasotrachealtubepassingintoa ETT positionisconfirmed withcapnographyandauscultation. holding. Entry ofthetubeintotracheamaycausecoughingorbreath- epiglottis awayfromthepathofnasotrachealtube. Gently pullthemandibleforwardandclosemouthto the proximalendofnasotrachealtube. With themouthclosed,spontaneousventilationwillbeaudibleat distal endofthenasotrachealtubewillbejustaboveglottis. When theETThaspassed15cmfromexternalnares, tube towardstheesophagus. larynx, impingingonthevallecula,and extremeflexion directsthe Overextension oftheneckdirectstubeanteriorto nition o nchial Bl advancethenasotrachealtubeintotracheaduring

o cker Placement

beroptic

271 CHAPTER 11 Procedures 272 CHAPTER 11 Procedures

• • • • Complications • • • • • • Technique • • Preparation • • • EquipmentChecklist • • • Contraindications • • • Indications

Presence ofabronchopleuralfi placed underdirectvision) Inability tousefiberoptic bronchoscope(thesedevicesmustbe Lung isolation(e.g.,hemoptysis,empyema) Selective lobarblockade OLV inapatientwithknowndiffi Inability toinsertadouble-lumenETT direct vision.) Malposition ordislodgement oftheblocker.(Reposition under trachea (e.g.,inabilitytoventilate,unexplained hypoxia) The inflated ballooncanmigrateproximallyandocclude the or bronchopleuralfi Rupture ofthebronchuswithcuff, causingapneumothorax Open thelumenofblockertoroomairdeflate thelung. manufacturer. Infl cuff isplacedwithinthebronchustobeoccluded. Pass thebronchialblocker,manipulatingitsuchthatentire Identify thebronchusinwhichblockeristobeplaced. Pass thefiberoptic bronchoscopethroughtheETT. Thoroughly lubricatethedevicepriortoinsertionintoETT. diameter 7.5mminmostcases.). a fiberoptic bronchoscopeandabronchialblocker(Internal Ensure thattheETTislargeenoughtopermitpassageofboth tube withsurgicalteam. Discuss useofabronchialblockervs.doublelumenendotracheal Lubricant Fiberoptic bronchoscope Blocker Univent®;Vitaid,Lewinston,NY) or othertype)enclosedbronchialblocker(TorqueControl Bronchial blockerdevice(Arndt®wireguided,tip-defl lung.) lung.) lungs todefl Slow deflation oftheoccludedlung.(Defl ate thecuffwithvolumeofairrecommendedby

ate, then inﬂ

stula

ate the cuff and re-expand the ventilated ate the cuffandre-expandtheventilated

stula

cult airway

ate the cuff, allow both ate the cuff,allowboth

ecting,

• • EquipmentChecklist • • • • Contraindications • • Indications CamposJH.Updateonselectivelobarblockadeduringpulmonaryresections. FurtherReading • • • SpecialConsiderations SlingerPD,CamposJH.Anesthesiaforthoracicsurgery.In:MillerRD(ed.).

C Cricothyroidotomy CurrOpinAnaesthesiol Miller’sAnesthesia impossible. trachea, makingcontrolledcollapseoftherightlungdifﬁcult or is variableandtherightupperlobemayevenoriginatein left lungisindicated.Thetakeoffoftherightmainstembronchus Bronchial blockersaremoreeasilyusedwhencollapseofthe Distorted anatomy Trauma LifeSupportcourse). receive formaltraininginthistechnique(e.g.,anAdvanced personnel whoplantoperformsurgicalcricothyroidotomy have receivedpropertraining.Theauthorsrecommendthat This procedureshouldonlybeperformedbypersonnelwho airway emergency. Cricothyroidotomyisthesurgicalairwayaccessofchoiceinan injecting saline. positive airwaypressure(CPAP).Thiscanbemanagedby of thebronchialblocker,preventingapplicationcontinuous Occasionally, secretions,blood,orpusoccludethesmalllumen lung. Bronchial blockersdonotallowforsuctioningofthedeﬂ syringe, jetventilator system(seeFigure11.2) Needle cricothyroidotomy: 14gintravenouscatheter, 10cc endotracheal tube. and containanumber11blade,tracheal hook,dilatorand6mm Many standardcommercialcriocothyroidotomy kitsareavailable younger than12years. Surgical cricothroidotomyisnotrecommended inchildren Laryngeal injury Transected airway ricothyroidotomy

. Philadelphia:ChurchillLivingstone;2010:1833–1841.

. 2009Feb;22(1):18–22.

ated

273 CHAPTER 11 Procedures 274 CHAPTER 11 Procedures cothyroidotomy must be placed in children less than 12 years of age. cothyroidotomy must beplacedinchildrenlessthan12 yearsofage. cannot ventilate” situation. Thisisalifesaving procedureinanypatienta“cannot intubate, NeedleCricothyroidotomy • • • • • • • • • • • • • • • • StandardSurgicalCricothyroidotomy roid cartilageandthecricothyroidmembraneisidentifi with theleftthumbandmiddlefinger, andwiththeindexfi breadth belowthethyroidcartilage.Thelarynxcanbeimmobilized Anatomicallandmarks:Thecricothyroidmembraneisonefi Procedure

PercutaneousCricothyroidotomy

retract the trachea in the upward, cephalad, and anterior direction. retract thetracheainupward,cephalad,andanteriordirection. Insert thetrachealhookalongsuperioredgeofincisionand skin andsubcutaneoustissueoverthecricothyroidmembrane. Stabilize thelarynxwiththumbandindexfinger andincisethe Palpate thelarynxandidentifycricothyroidmembrane. Clean anddrapetheanterioraspectofneck(iftimepermits). patient. Confi the dilator. Pass anumber6tracheostomytube overthedilatorandremove opening. Pass thedilatoroverguidewiretowidentracheal Ensure thatthewireisdirectedinferiorly. Remove thesyringeandpassaguidewirethroughneedle. of airconfirms that theneedleisintrachea. through thecricothyroidmembraneintotrachea.Aspiration Attach an18gneedletoasyringefilled withsalineandinsertit incision throughthecricothyroidmembrane. fi Make atransverseincisionoverthecricothyroidmembrane— the cricothyroidmembranewithindexfi Immobilize thetracheawiththumbandmiddlefinger andfeel Clean anddrapetheanterioraspectofneck. ventilating thepatient. tube. Removethedilatorandconfirm thepositionoftubeby Keep thetrachealdilatorinplaceandpasscricothyroidotomy inferior direction. Insert thetrachealdilatoranddilatetracheainasuperior- membrane. membrane. Makeahorizontalincisiononthecricothyroid Again palpatewiththeindexfinger andidentifythecricothyroid rst throughtheskinandsubcutaneoustissue,thenasmall rm thepositionoftracheostomytubeby ventilatingthe

Thisisalsothepreferred techniqueifacri-

nger.

ed. nger, thy-

nger-

• • SpecialConsiderations • • • • Complications • • • • • • • inserted intothetracheathroughcricothyroidmembrane. Figure11.1

soon asthepatient’schestbeginstorise. When jetventilationisbeingused,discontinueO (Figure 11.2) at theendofjetventilatorconnectsto14gcannula). Connect thecathetertoajetventilator(theLuerlockconnector into thetrachea. Tilt theneedletoa45°angleinferiorly,andthreadcatheter trachea. Aspiration ofairconfirms thepositionofneedlein membrane (SeeFigure11.1). Insert thecatheterintotracheathroughcricothyroid saline. Connect a14gintravenouscatheterto10mLsyringefi Palpate thecricothyroidmembrane. Percutaneous cricothyroidtomy requirespriorexperience. than atracheostomy . cricothyroidotomy providesadefinitive airway morequickly Ina“cannotventilate,cannotintubate” situation, Injury totheposteriorwalloftrachea Barotrauma orpneumothorax(jetventilation) Bleeding fromthecricothyroidarteryoranteriorthyroidvein subcutaneous space) subcutaneous space) Subcutaneous emphysema(high-pressure airforcedintothe

A 14gneedlewithcatheter(witha10mLsyringeﬁlled withsaline)is

2 insufﬂ ation as lled with

275 CHAPTER 11 Procedures 276 CHAPTER 11 Procedures

• • • • • EquipmentChecklist trachea, earlytakeoffoftherightupperlobebronchus). Abnormalityinthetracheobronchialtree(e.g.,highbifurcationof Contraindications • • • • Indications 14 gcannula. Figure11.2

DoubleLumenEndotrachealTube(DLETT) Suction catheters through thedouble lumentube. Conﬁ bronchoscope willpassthroughthe bronchiallumen.) Fiberoptic bronchoscope(A3.6mm or4.9mmpediatric Y connectors,Kellyclamps • • Appropriate sizedoublelumentubes: aorta, etc. Surgery ontheesophagus,thoracicspine,descending nonpulmonary thoracicsurgery. Elective lungsurgery,thoracoscopy,bronchopleuralﬁ lung ventilation. Control ofventilation:Giantunilateralcystorbulla,independent purulent bronchialsecretions. Lung isolation:Pulmonaryhemorrhage,unilaterallunglavage, •

39 Frispreferredinmalepatients 4 sizesareavailable:35Fr,3739 Fr,41Fr 35 Frispreferredinfemalepatients rm thatthebronchoscope islubricatedandthatitwillpass

Luer lockconnectorattheendofjetventilatorconnectsto

( DLETT stula,

)

• • Complications • • • • • • • • • • • • bronchial blocker). airway, consideralternativetechniques(e.g.,singlelumenETTwith double lumenendotrachealtube.Inpatientswhohaveadifﬁ procedures. here, sincethistubecanbeusedforbothleft-andright-sided Insertionofaleftsidedoublelumentubewillbedescribed Procedure

bronchial cuff(bluecolor)shouldbebarelyvisible. bronchoscope shouldemergeabovethecarinaandtopof Pass thebronchoscopethroughtracheallumen.The Air entryshouldbeheardonlyontheleftside. Occlude thetracheallumenandventilatebronchiallumen. the patientthroughtracheallumen). bronchial cuffisinthetrachea,itwillnotbepossibletoventilate lumen—air entryshouldbeheardonlyontherightside(if Clamp thebronchiallumenandventilatethroughtracheal Infl positioned correctly. for airentry.Bilateralentryconfirms thatthetracheallumenis connectors. Inflate thetrachealcuff,ventilatelungs,andcheck Connect theDLtubetobreathingcircuitusingY should beattheincisors. adult ofaverageheight(170–180cm)the29cmmarkontube Advance theDLtubeuntilslightresistanceisencountered.Inan bronchial orifice towardstheleftside). vocal cords.Rotatethetube90°toleft(thisturns Remove thestyletafterbronchialcuffpassesthrough curvature ofthetubefacinganteriorly. Pass alubricatedDLtubewiththestyletinplaceand Visualize thevocalcordswithalaryngoscope. Induce generalanesthesia. Preoxygenate thepatientpriortoinductionofanesthesia. trachea ispossible. Because ofitslarge sizeandlength,traumatothelarynx and confi Misplacement oftheDLtube.Listen tobreathsoundsand lumen. visible whenthebronchoscopeispassed throughthebronchial bronchus. Theentrytotheleftupper lobebronchusshouldbe tube sothatthebronchiallumeniscompletelywithinleft If necessary,deflate thebronchialcuffandgentlyadvance Assessthepatient’sairwaybeforeattemptingintubationwitha ate thebronchialcuffwith2mLofair. rm placementwiththefi

beroptic bronchoscope.

cult 277 CHAPTER 11 Procedures 278 CHAPTER 11 Procedures

• • Technique • • • EquipmentChecklist • • Contraindications • • • • Indications route isthataradiographnotnecessarytoverifyproperposition. recurrent laryngeal,andvagusnerves.Anotherbeneﬁ rax, arrhythmias,thoracicductlaceration,anddamagetothephrenic, cations associatedwithothersites,includingpneumothorax,hemotho- Vascularaccessthroughthefemoralveinminimizesriskofcompli- CamposJH.Lungisolationtechniques. FurtherReading • • SpecialConsiderations

FemoralVeinCatheter Fem Patient whowillnottoleratethesupineorTrendelenburgposition the sartorius muscles), where it lies medial to the femoral artery. the sartoriusmuscles),whereitlies medial tothefemoralartery. the inguinalligament,lateraltoadductor longus,andmedialto The femoralveinispuncturedinthe femoraltriangle(inferiorto with abronchoscope. Check thepositionofDLtubeafteranychangeinposition, Choose thecorrectsizeDLtubeandfi • femoral arterywith thelefthandwhileguidingneedle. Hands the ipsilateralhand toholdtheneedleandsyringe.Palpate the If thecatheteristo beplacedintotherightfemoralvein, use not haveanIVC fi Beforeattemptingthisprocedure, verifythatthepatientdoes Anatomy andpatientpositioning Central venouscatheterkit • Relative contraindications: Presence ofanIVCfi Introduction ofatransvenouspacemaker Diffi Emergency venousaccessforadministrationofdrugsorfl Sep;19(3):455–474. •

Trauma toipsilateralgroinorlowerextremity Infection, burn,orskindamageatpuncturesite cava (IVC) Suspected proximalvascularinjury,especiallyofinferiorvena cult peripheralvenousaccess o ral VeinCatheter

lter . lter

Anesthesiol ClinNorthAmerica

beroptic bronchoscope.

t of the femoral t ofthefemoral uids . 2001

Fiberoptic intubating scopes are smaller in diameter than bronchoscopes Fiberoptic intubatingscopes aresmallerindiameter thanbronchoscopes Fiberopticintubation canbedoneeitherorallyor nasotracheally. TsuiJY,CollinsAB,WhiteDW,Lai J, TabasJA.Videosinclinicalmedi- FurtherReading • • • • • • • • SpecialConsiderations • • • • •

FiberopticIntubationF Com Complications 26;358(26):e30. 26;358(26):e30. cine. Placementofafemoralvenous catheter. cannulated. (Thefemoralveinismedialtotheartery.) should beintheoppositepositionifleftfemoralveinisbeing catheter belowtheinguinalligament). Retroperitoneal hematoma.(Alwaysinsertafemoralvein Arterial bleeding. Infection. Always occludetheopenhubofneedletopreventairembolism. location ofthevessel. attached to5-mLsyringecanbeusednotethedepthand If thelocationofvesselisindoubt,afinder (25-gauge)needle abdominal injury. This willincreasetheriskofretroperitonealhematomaorintra- Do notattempttoinserttheneedleaboveinguinalligament. gown andgloves. the proceduremustwearacap,eyeshield,andmaskwithsterile Unless accessmustbeobtainedurgently,theoperatorattempting the procedureisdoneonanawakepatient. Always useadequatelocalanesthesiaatthepuncturesitewhen fi Excessive dilationincreasestheriskofbleedingandarteriovenous the depthatwhichbloodwasfirst aspiratedfromtheneedle. vessel. Thedilatorshouldonlybepassedslightlyfartherthan Pass thedilatoroverwire.Avoidexcessivedilationof Make astabincisionalongthewirewith#11blade. One handshouldholdtheguidewireatalltimes. if anyresistanceisencountered. Pass theguidewirethroughneedle.Donotadvancewire syringe. Verifythatbloodflow isnotpulsatile. Aspirate dark(venous)bloodfromtheveinandremove stula orpseudoaneurysmformation. i beropt p lications i c Intubat

i on

N EnglJMed

. 2008 Jun . 2008Jun

279 CHAPTER 11 Procedures 280 CHAPTER 11 Procedures

• • • • cussed first, followed byfi tive airwayanesthesia.Hencelocalanesthesiaoftheisdis- Thesuccessofanawakefi beroptic intubationdependsuponeffec- Procedure • • • • EquipmentChecklist • • Contraindications • • Indications fi possible inafi beroptic intubatingbronchoscope.Theeyepieceofthe used forprocedures.Onlyantero-posteriormovementofthetipis

beroptic scope must be rotated for side-to-side movement. beroptic scopemustberotatedforside-to-sidemovement.

scope. Appropriate sizeendotrachealtubethreadedoverthefi nasopharynx by placing cotton pledgets soaked in 2% lidocaine on nasopharynx byplacing cottonpledgetssoakedin2% lidocaine on If anasalintubation isplanned,anesthetizethenasalcavity and hypoxic andimmediateaccesstotheairwayisrequired. Consider othertechniquesorasurgicalairwayifthepatientis spine duringintubation). Unstable cervicalspine(tominimizemovementofthe Anticipated/unanticipated difficult endotrachealintubation. • • • Topical anesthesiashouldbeappliedtothreeregions: midazolam 0.5mgIVorfentanyl25mcgIV). the patientandoperator’schoice(e.g.,incrementaldosesof Consider mildsedationdependingontheclinicalstatusof mucosa andimprovetheefficacy ofthelocalanesthesia. Administer anantisialagogue(glycopyrrolate0.2mgIV)todrythe 2% lidocaineandviscouslidocaine. Equipment, Wheeling,IL,USA) Intubating airway(e.g.Ovassapianairway,RichardsMedical oxygen connectedtothesideport,andsuction. A workingfiberoptic bronchoscope(ideallywithavideodisplay), fi contraindication becausethisdistortstheviewthrough Excessive secretionsorbloodintheairwayisarelative beroptic scope.

the vagus nerve (superior laryngeal and recurrent laryngeal nerves). the vagusnerve(superiorlaryngealand recurrentlaryngealnerves). Hypopharynx, larynxandtrachea—innervated bythebranchesof the branchesofglossopharyngeal nerve. vallecula, lingualtonsilandpharyngeal wallareinnervatedby posterior thirdofthetongue,anterior surfaceofepiglottis, Oral cavity,posteriorthirdofthetongue andthepharynx— lesser palatinenervesandanterior ethmoidal nerves. Nasal cavityandnasopharynx—suppliedbythegreater

beroptic intubation.

beroptic

• • • •

through thecricothyroidmembrane)anesthetizestrachea. Transtracheal injectionof2%lidocaine(with25gneedleinserted ethmoidal nerve) bilaterally. ethmoidal nerve)bilaterally. the roofofnasalcavityclosetocribriformplate(anterior the middleturbinate(greaterandlesserpalatinenerves)in the posteriorwallofnasopharynxalongupperborder • • • Fiberoptic intubation: or abloodvesselandtheninject2%lidocaine2mL. injecting toensurethattheneedlehasnotenteredpharynx directed intheanteriorandcephalicdirection.Aspiratebefore it piercesthethyro-hyoidmembrane.Theneedleshouldbe posteriorly. “Walk”theneedleoffhyoidcartilageuntil being blockedwhiledisplacingthecarotidarterylaterallyand laryngeal nerve.Displacethehyoidbonetowardside If thepatientiscooperative,considerblockingsuperior glossopharyngeal nerveandsuppressthegagreﬂ inferior aspectofthepalatoglossalfoldtoanesthetize Cotton pledgetssoakedinlidocaineareplacedclosetothe Anesthetize theoropharynxwithviscous2%lidocaine. • • •

direction. O movement ofthetipscopeinanteriorposterior of thenondominanthandoperateslevercontrolling the dominanthandguidesshaftofscope.Thethumb The bronchoscopeisheldinthenondominanthandwhile pharyngeal wall. the tongueandopensspacebetween anesthetized patient,thedistalendofairwaygoesbehind ability totoleratetheairwayconfirms airwayanesthesia.Inan airway directsthescopetowardlarynxandpatient’s oral cavity(e.g.,Ovassapian,PatilSyracuse,Berman,etc.).The Insert anoralairwaydesignedforfiberoptic intubationintothe a pieceoftape. endotracheal tubeoverit,securingthewith Lubricate thebronchoscopeandthreadappropriatesize the glottiswith2% lidocaine. be threadeddown thesideportofbronchoscope tospray With thescopejust abovetheglottis,anepiduralcatheter can adjusted togetclearvisualizationof theglottis. cm markisatthelips.Theposition ofthetipscopeis the bronchoscopewillbejustabove theglottiswhen15 The epiglottisisvisualizedatadepth of10cm.Thetip airway. The bronchoscopeisthengentlyintroduced throughtheoral helps blowawayanysecretionsfromthetipofscope. channel. Thisenrichestheinhaledoxygenconcentrationand 2 fl owing at2L/minisconnectedtotheside

ex.

281 CHAPTER 11 Procedures 282 CHAPTER 11 Procedures

• • Contraindications • • • Indications icone endotrachealtubehasbeendesignedforusewiththeILMA. oriﬁ in lengthandhasahandlethatpermitsmanipulationoftheshaft diameter) andwasspeciﬁcally designedforthispurpose.Itisshorter LMA Fastrach®)isarigidwithwiderlumen(13mminternal tion inanemergency.TheintubatingLMA(ILMA,alsoreferredtoas Thelaryngealmaskairwaycanbeusedfororalendotrachealintuba- • • • SpecialConsiderations

IntubatingLaryngealMaskAirway Intubatin spine) diffi expected, butvisualizationofthevocal cordisexpectedtobe Intubation insituationswhengoodvisualizationofthelarynxis • • • Airway pathology involvingthetongue,pharynxorlarynx Severe trismusor inabilitytoopenthemouthforother reasons facilitate definitive airwaymanagement In a“cannotintubate,cannotventilate ”scenario,ILMAmay fail (e.g Diffi forward toopenapaththroughthepharynx. procedure isnoteffective,thetonguemayhavetobepulled away fromthepharyngealwallandopenspharynx.Ifthis In anesthetizedpatients,gentlyliftingthejawmovestongue intubation isplanned. oxymetazoline spray)andasmallerendotrachealtubeifnasal Always useatopicalvasoconstrictor(phenylephrineor when thecordsabduct. The endotrachealtubeshouldbeadvancedduringaninspiration

ce, whilelimitingmovementofthepatient’sheadandneck.Asil- passage ofthetube. propofol 20–30mgIVtosedatethepatientandpermit Before advancingtheendotrachealtube,consideradministering and willinducecoughinginanawakepatient. trachea. Avoidtouchingthecarinabecausethisisveryirritating The bronchoscopeisthenadvancedthroughthelarynxinto counterclockwise andattempttopassthetubeagain. is caughtonthearytenoidcartilage.Rotatetube90degrees resistance isfelt,themostlikelycausethattipoftube Gently passtheendotrachealtubealongbronchoscope.If cult (e.g cult intubationwhereconventionaltechniquesof

. , directlaryngoscopy,ﬁ . ,lingualtonsilarhyperplasiaorimmobility ofcervical g Laryn

eal MaskAirway beroptic intubation)

• • • • • • • • • • • • • Procedure • • • EquipmentChecklist

the laryngealorifi into thetrachea.ThismaneuversealscupofLMAagainst gently liftit(the“Verghese”maneuver)whileadvancingtheETT If resistanceisencountered,grasptheILMAbyitshandleand of theendotrachealtubefacestoleft). longitudinal blacklinefacingcephalad(thisensuresthatthebevel Pass thesiliconeendotrachealtubethroughILMAwith position oftheLMAbyventilatingpatient. Once thedeviceisinplace,inflate thecuffandconfi the levelofhypopharynx. the contourofpalateuntilsomeresistanceisencounteredat Exerting gentlepressureonthepalate,advanceILMAalong palate. wall, andcupoftheLMAorifice facingdownrestingagainstthe Insert theILMAwithhandleofparalleltochest mouth withtherighthand. Hold thedeviceinlefthandwhileopeningpatient’s position. Position thepatientsupinewithheadandneckinneutral water-soluble lubricant. Check thepatencyofcuffandlubricateILMAwitha The ILMAisgenerallyusedinanesthetizedpatients. LMA isbeingwithdrawnovertheendotrachealtube) Stabilizer rod(forstabilizingtheendotrachealtubewhen Cuffed siliconeendotrachealtube 4 inadults50–70kg,andsize570–100kg.) ILMA (Foursizesareavailable.Size3ispreferredinchildren,size patient. Confi removed overit. end oftheETtubetostabilize ET tube,andtheILMAisgently stabilizer rodisintroducedthrough theILMAintoproximal When theLMAisoverproximal endoftheETtube, the ILMAandwithdrawwhile holdingtheETTinplace. Remove theILMAoverendotracheal tube.Deflate thecuffof by ventilatingthepatientandobserving forCO Once theETTisinplace,inflate itscuffandconfi rm itsposition encountered, the ETT is gently advanced into the trachea. encountered, theETTisgentlyadvancedintotrachea. ET tubeliftsuptheepiglottiselevatorinLMA.Ifnoresistanceis tube) andthenadvanceitanother1.5cm.Atthispointthetipof Insert theendotrachealtube15cm(horizontalblacklineon rm thepositionofET tubeagainbyventilatingthe

ce.

2 return. rm the

283 CHAPTER 11 Procedures 284 CHAPTER 11 Procedures

• EquipmentChecklist • • • • Contraindications • • • • intubation eitherfailorarenotfeasible. Retrogradeintubationisindicatedwhenconventionaltechniquesfor Indications ETT isthenthreadedovertheguidewireintotrachea. cricothyroid membraneandretrievedfromthemouth(ornose).An Anintubationtechniqueinwhichaguidewireisinsertedthroughthe Deﬁ • • • SpecialConsiderations • • Complications

RetrogradeIntubation Retro reintroduce it. ILMA whilerotatingitalongtheaxisofairway,andthen occluding theairway.Ifthisoccurs,gentlywithdraw The epiglottismaybecomefoldedasILMAisadvanced,thus the device. Select theappropriatesizeILMAtoensurecorrectplacementof exert excessivepressureonthesurroundingtissues. Do notinflate theILMAforlongerthan15minutesbecauseitcan 18 gintravenouscatheter (orTuohyneedle) preferred techniqueinanemergency. Retrograde intubationisanelective procedureandisnota Tumor ortraumainvolvingthelarynx Coagulopathy, localinfection Inability toaccessthecricothyroid membrane intubation requiresthatthemouthopen3–4cm) Small mouthopening(directlaryngoscopyandfi Oropharyngeal malignancy Excessive secretionsorbloodintheairway Unstable cervicalspine until theendofsurgicalprocedure. removing theILMAitcanbeleftinplace(withcuffdefl ET tube.Ifthephysicianisunfamiliarwithprocedurefor Use thestabilizerdevicewhileremovingILMAover infl If thedistalendofLMAtendstogetfolded,insertitpartially nition ated. g

rade Intubation

beroptic

ated)

• • • • SpecialConsiderations • • • • • • • • • • Procedure • • • •

of theendotrachealtube. endotracheal tubetoprovidebettercontroloverthedistalend The guidewirecanbethreadedthroughtheMurphy’seyeof the ETTfurtherdownintotrachea. Remove theguidewirefromcricothyroidmembraneandpass the ETTisbeingpassed. Maintain tensionbygentlypullingonbothendsofthewirewhile Thread theETToverproximalendofguidewire. of theguidewiretopreventitfromslippingout. Remove thecatheterandplaceasmallclampoverdistalend proximal endoftheguidewire. laryngoscope andMagillforcepsmayberequiredtoreachthe through thecatheterandretrievedfrommouth.A Direct thecathetercephalad.The.035”guidewireisthreaded membrane. Conﬁrm itspositionbyaspiratingair. Insert the18gcatheterintotracheathroughcricothyroid inject 2mLof2%lidocaineintothetrachea. Puncture thecricothyroidmembranewitha26gneedleand lidocaine. subcutaneous tissueoverthecricothyroidmembranewith1% Identify thecricothyroidmembraneandinﬁltrate theskinand Clean anddrapetheanteriorpartofneck. performed forlaryngealanesthesia.) lidocaine. (Abilateralsuperiorlaryngealblockcanalsobe Spray theposteriorpartoftongueandpharynxwith4% Position thepatientsupinewithneckslightlyextended. Endotracheal tube Magill forceps 3 mLsyringe standard endotrachealtube) .035” guidewire(75cmlong—2–2.5timesthelengthofa rotate thetubewhile advancingit. cause isthatthetube isimpingingonthepyriformfossa. Gently If resistanceisencounteredwhenpassing theETT,mostlikely before advancingthetubefurtherinto thetrachea. Once theETTenterstrachea,a softbougiecanbepassed proximal end. is easiertoretrieveawirethanan epidural catheterfromthe An epiduralcathetercanbeusedinstead ofaguidewire,butit

285 CHAPTER 11 Procedures 286 CHAPTER 11 Procedures

• • Contraindications • • • Indications pacing). tem. Thisisabridgetomoredeﬁ with hemodynamiccompromiseduetoadisturbedconductionsys- Externalcardiacpacingisapotentiallylife-savingmeasureinpatients Deﬁ

TranscutaneousPacingPacin • • • • • • • • Acute myocardialinfarction: • • • • Relative: Absolute: None • Overdrive suppressionoftachyarrhythmias: • Not relatedtoanacutemyocardialinfarction: • •

After cardiacsurgery,especiallyvalvularheartsurgery pacemaker-dependent (Angio Jet®),orageneratorreplacementinpatientwhois rotational atherectomy(rotablation),rheolyticthrombectomy As aprecautioninpatientsundergoingpercutaneouscoronary New trifascicularblock block who haveahighriskofdevelopingacutethird-degreeheart As aprecautioninpatientsundergoingalcoholseptalablation Tachyarrythmias secondarytobradycardia block Symptomatic second-orthird-degreeatrioventricular(AV) Symptomatic sinusorjunctionalbradycardia Asystole of successfulresuscitation) Bradysystolic arrest formorethan20minutes(minimal chance Digoxin toxicity hypoperfusion) pulmonary edema,anginaorothersignsofend-organ Symptomatic secondorthirddegreeAVblock(hypotension, ventricular ﬁ Severe hypothermia(duetopropensity forinductionof To preventortreattorsadesdepointes Asystole Second orthirddegreeAVblockwithoutsymptoms terminated withrapidatrialpacing Certain atrialtachycardias,suchasﬂutter, canbe nition

brillation)

nitive treatment(e.g.,transvenous g

erally shouldbestarted inthesynchronousmode. complex issensed forapredeterminedamountoftime. Pacinggen- pacing isa“demand mode”inwhichthepacerﬁ res onlywhenno ing thevulnerableperiodofcardiac cycle(RonT).Synchronous activity. Thismodemayinducedysrhythmias ifstimulationoccursdur- electrical stimulusatpresetintervals, independentofintrinsiccardiac Intheasynchronous(ﬁ xed-rate) mode,thepacemaker deliversan Synchronous/AsynchronousModes needed tomaintaincapture. quickly achievecaptureandthen decrease theoutputtolevel unconscious patient,beginwithahighcurrentoutput(200mA)to is increasedin10-mAincrementsuntilcaptureachieved. is conscious.Thepacemakerunitthenturnedon,andthecurrent Settheheartrateto80bpm.current0mAifpatient PacemakerOperation electrical connectiontothepatient. It maybenecessarytoshaveexcessivebodyhairensureagood are appliedoverthecardiacapexandjustmedialtoleftscapula. Pacemaker pads,oftenlabeled“front/back”or “anterior/posterior,” PadApplication • • • EquipmentChecklist • • • • • • Complications

Assistants torollanuncooperativepatient 2 pacingelectrodepads External pacemaker(Mostdefibrillators havethiscapability.) (pneumothorax, chronicobstructivepulmonarydisease). current deliverymayincludefluid (pericardialeffusion)orair or improperlysetupequipment.Anatomicimpedimentsto pad looselyapplied),inadequatecurrentoutput,andfaulty placement, poorskincontact(excessivehair,wetskin,or Failure tocapture—potentialcausesincludeimproperpad Skin burnshavebeenreportedwithprolongeduse. diaphragm andthoracicmuscles. Coughing andhiccupsmayoccursecondarytostimulationofthe fl hemodynamic changesincludinglossofatrialkick,reverseblood activation oftheatriummayoccasionallyresultinundesirable of synchronybetweentheatriaandventriclesorretrograde Pacemaker Syndrome:Whentemporarypacingstarts,loss Atrial orventriculardysrhythmia and analgesics lowest effectivecurrent,andjudiciousadministrationofsedatives Pain. Maybeminimizedbyproperpadplacement,useofthe ow withcannonAwaves,anddecreasedcardiacoutput.

In the

287 CHAPTER 11 Procedures 288 CHAPTER 11 Procedures

• • • EquipmentCheck • • • • • • PrinciplesofManagement • • • • • ProblemsDuringTransport Intrahospitaltransportofacriticallyillpatient. Defi Confi confi pulses. Inthehypotensivepatient,echocardiographymaybeusedto widened QRScomplexthatshouldcorrelatewithpalpablecarotid ElectricalcaptureisdocumentedontheECGbypresenceofa

TransportofaCriticallyIllPatient Trans Infusion pumps Transport ventilator (O Transport monitor to thephysicianatpatient’sdestination. patient duringthetransportandhand overthecareofpatient Ideally, thephysiciancaringfor patient shouldmanagethe the patient’sdestination. continue theseinfusionsduringtransportandmakechangesat If thepatientisonhemodynamicsupport,itadvisableto avoid abruptchangesinventilationstatusduringtransport. Attempt tocontinuethesamemodeofventilationinorder transportation andpre-ﬁll syringesforrapidadministration. Anticipate whichdrugsandmedicationswillberequiredduring Checkbatterypower . (e.g., monitor,transportventilator,infusionpumps)isfunctional. Ensure thattheequipmentrequiredfortransportingpatient ventilation beforetransport. If possible,stabilizethepatient’shemodynamicstatusand to identify. the alarmsmaysounddifferent,makingsomeproblemsdifﬁ Equipment usedfortransportmayhaveuniquefailuremodesand new problemsastheyarise. hypotension, hypoventilation.Bepreparedtoidentifyandmanage Anticipate andbepreparedtomanageproblemssuchas Limited monitoringandventilationcapabilitiesduringtransport Need toprovidecriticalcareduringtransport continuous monitoring Critically illpatientrequiringcardiorespiratorycarethatinvolves nition rm cardiaccontractionthatcorrelateswithelectricalactivity. rmation ofCapture p ort ofaCriticall

tankshouldbefull—2200 PSI)

y IllPatient

cult

WhenthepatientreachesICU: TransferofCare

• • • • • • • • • • • • • PreparationforTransport Procedure • •

ChecklistforTransportation

intubated, check the position and security of the endotracheal tube. intubated, checkthepositionandsecurityofendotrachealtube. Airway: Ensurethatthepatient’sairwayissecure.Ifpatient have toremainfl end ofbedslightlyelevated.Patientswithanunstablespinemay Position inbed:Mostpatientscanbetransportedwiththehead route (e.g.,anelevatorgetsstuck). have adequatereservesintheeventthatthereisadelaywhileen that drugsandbatterypowerwilllastfortheentiretrip.Planto infusions (especiallyvasoactivedrugs)areflowing well.Becertain the infusionisfl signs beforetransport.Ifpatientisonvasopressors,confi Circulation: Totheextentpossible,stabilizepatient’svital adequately. transport ventilatorandmakesurepatientisbeingventilated Breathing: Ifthepatientisonrespiratorysupport,connect patient isenrouteandready. Confi To theextentpossible,stabilizepatientpriortotransfer. the patient. The transportteamshouldbefamiliarwiththeclinicalstatusof batteries wheneverpossible. transport time,plusagenerousreserve.Usefully-charged have enoughpowertolastatleastaslongtheanticipated Confi endotracheal tubeisdislodgedduringtransport.) equipment (Bereadytoreintubateormaskventilateifthe Endotracheal tube,laryngoscope,andotherairwaymanagement record). of themanagement ofthepatient(bothverbalaswell asawritten Hand overcareto theICUphysicianwithadetailed description transfer note. Check thevitalsignsandrecordone setofvitalsignsinthe Make surethatalltheinfusionsare fl Connect thepatienttoventilator onappropriatesettings. Connect thepatienttomonitor intheICU. administer these drug before transporting and bring an extra supply. administer thesedrugbeforetransportingandbringanextrasupply. If thepatientrequiressedationorneuromuscularblockade, rm thatthecareteamatdestinationknows rm thatallbattery-powereddevicesarefullychargedand

owing. Conﬁ at.

rm thatintravenousdrugandﬂ

owing.

rm that uid

289 CHAPTER 11 Procedures 290 CHAPTER 11 Procedures

• • • • • • • • • • • • Equipment • • • Contraindications • • • Indications quate cardiacoutput. being conducted,ortheheartrateistooslowtomaintainanade- when intrinsicstimulationisinsufﬁ cient, thenativeimpulsesarenot Invasiveelectricalpacingisusedtoinitiatemyocardialcontractions Deﬁ WaydhasC.Intrahospitaltransportofcriticallyillpatients. FurtherReading

TransvenousPacingPac Shoulder roll Alligator clipsand connectingwire Suture material Local anestheticsolution Cardiac monitor Percutaneous sheathintroducerkit Spare batteryforthepacemaker Pacemaker generator Flexible transvenouspacingcatheter Deﬁ “Crash cart”withresuscitativedrugs Airway managementequipment is notacandidatefortransvenouspacerplacement. A patientwhohasbeenasystolicforanextendedperiodoftime contact themyocardium) may predisposetoventricularﬁbrillation whenthepacingwires Hypothermia (increasestheirritabilityofmyocardiumand properly inapacemaker-dependentpatient As abridgewhenpermanentpacemakerisnotfunctioning pacing Patients whodonottolerateorarerefractorytotranscutaneous See TranscutaneousPacing(Page286). contraindications. irritability ofthemyocardiumareconsideredrelative Digoxin toxicityandotherdrugsthatmayincreasethe 1999;3(5):R83–R89. nition brillator

Crit Care .

• • • • • • • • • • • • Technique

catheters, theballoonshouldalwaysbedefl ated priortowithdrawal. the ballooniswithinvascularsystem.Aswithallballoon-tipped the introducer.Advancecatheter10centimeterstoensurethat Insert thepacemakercatheterthroughrubberdiaphragmof pacemaker generator. end ofthecathetertonegativeandpositiveterminals lead. Connectthepacemakercatheterterminalsonproximal the negativeterminalofpacemakercatheterfromECG Connect thepacemakergeneratortocatheter.Disconnect the rightventricularwall. elevation isobserved.Thisindicatesthatthecatheterabutting Defl with alarge-amplitudeQRScomplex. fl complex shouldappearnormalinV1.Whenthecatheteris to advancethecatheterrightventricle,whereQRS and theQRScomplexincreasesinamplitude.Nowcontinue As therightatriumisentered,Pwavebecomesupright seen. Continuetoadvancethecatheter. wave withanegativepolarityandsmallQRScomplexwillbe When thepacingcatheterreachesrightatrium,alargeP inverted), whiletheQRScomplexisunchanged. In thesuperiorvenacava,Pwaveincreasesinamplitude(still and theQRScomplexarebothsmallinamplitudeinverted. at alltimes.Inthesubclavianorinternaljugularvein,Pwave Slowly advancethecatheterwhileobservingECGmonitor balloon. SettheECGmonitortoleadV1. attach thecliptoV1leadonECGmonitor.Infl end. Attachonealligatorcliptothenegativepacemakerwireand This isdoneusinganinsulatedwirewithalligatorclipateach Attach V1leadtothepacemakercatheternegativeterminal. sheath introducer. Access thecentralvenouscirculationbyplacingapercutaneous prior tousingitinanemergencysituation. The physicianmustbefamiliarwiththepacemakergenerator complex inleadV1. on themonitor.Thisisindicatedby pacingspikesandawideQRS Turn onthepacemaker.Increase energyuntilcaptureisseen beats perminute.Startwith5mAof energyontheoutputdial. when aspontaneousbeathasnotoccurred) witharateof60–80 Set thepacemakergeneratorondemand mode(tofi is assessed by reducing the energy until the pacemaker fails to is assessedbyreducing theenergyuntilpacemaker failsto The energyneeded forsuccessfulpacing(thethreshold) oating freelyintherightventricle,Pwavewillbeupright ate theballoonandadvancecatheteruntilST-segment

re only ate the

291 CHAPTER 11 Procedures 292 CHAPTER 11 Procedures

nique canalsobe used toaccessperipheralveinsand arteries. thers intotheinternal jugular,subclavian,orfemoral veins. Thistech- Theuseofultrasonography tofacilitateplacementof vascularcathe- Deﬁ • • • • SpecialConsiderations • • • • • Complications • •

Ultrasound-GuidedCentral VenousAccess Ultras of the inferior wall could stimulate and pace the diaphragm. of theinferiorwallcouldstimulateandpacediaphragm. present asfailuretocaptureorcardiactamponade.Perforation increase inthepacingthresholdoccurs.Ventricularperforationcan changes fromalefttorightbundlebranchblock,orifanabrupt catheters. SuspectseptalperforationifthepatternonECG or thefreeventricularwall.Thisismorecommonwithrigid Perforation oftheventricularseptum,myocardiumatria, capture. capture. three timesthethresholdvaluetopreventinadvertentlossof stimulate contraction(lossofcapture).Theoutputisthensetat transferring thepatient. Firmly affix thepacingcathetertoinsertionsiteprior pneumothorax fromthecentralvenouscatheterplacement. stabilized toensurepropertipplacementandruleouta Chest radiographsshouldbeobtainedafterthepatientis myocardial injury. A flexible catheter shouldalwaysbeusedtodecreasetheriskof defl into therightventricleanddoesnotcurlupinatriumor internal jugularveinsothatthecathetertraversesastraightline capture willresult.Vascularaccessshouldbethroughtheright the tipwillencounterendocardiumofrightventricleand to thepowersourceandcatheteradvancedblindlysothat In atrueemergency,thepacemakerelectrodesareconnected complexes and/orPwaveswhenfluoroscopy isunavailable. Electrocardiographic guidanceisusefulinpatientswithnarrow of thepacingwireinrightventricle. Fluoroscopic guidancecanbeusedtoensureaccurateplacement Complications relatedtoobtainingcentralvenousaccess Air embolism Infection canbeadelayedcomplication. few centimetersandobservetherhythm. If cardiacarrhythmiasoccur,immediatelywithdrawthecathetera nition ect intotheinferiorvenacava.

und-Guided CentralVen

o us Access

• • • • • • Placement TechniqueforRightInternalJugularCentralLine • • EquipmentChecklist • • • • • • Anatomy None Contraindications

air) Subclavian vein(difﬁcult tovisualizeonultrasoundbecause of • • • Prepare theprobe: Clean anddrapetheareausingstandardaseptictechnique. Usual equipmentforcentrallineplacement • Ultrasound equipment: ultrasound. Fluid appearsblack,whileboneandairappearwhiteon is appliedwiththeprobe. manuver. Arteriesarenoncompressiblewhenmoderatepressure the patientisinhead-downpositionorperformsaValsalva Veins arenonpulsatile,easilycompressible,anddistendedwhen Antecubital vein Femoral vein Internal andexternaljugularveins probe inthetransverse orientation. down intothesupraclavicular fossausingthelinearultrasound Track theinternal jugularveinfromtheangleof mandible the bestsiteforneedlepunctureand centrallineplacement. Perform ultrasonographicexamination ofthenecktodetermine caudal totheneedleinsertionsite. will beplacedinatransverseposition onthepatient’sneck, Place theultrasoundmachineat headofthebed.Theprobe position ataround15degreestomaximize thevesseldiameter If possible,placethepatientinhead-down(Trendelenburg) •

included togetherinaset). Sterile sheathfortheprobewithgelandelasticband(usually 2–10 MHzareadequate. Vessels areusuallysuperﬁcial, somostfrequenciesbetween the sterilesheathwilldegradeimage. probe. Airbubblesbetweentheprobeandinnersurfaceof Place gelonthedistalendofsheathandgentlyrollover probes mayalsowork. Linear probesareusedmostcommonly,althoughcurved Secure withtheelasticband.

293 CHAPTER 11 Procedures 294 CHAPTER 11 Procedures

• • • • • • • Figure11.3

that thewirehas passed intothesuperiorvenacava. ultrasound. When thesubclavianveinisbeingcannulated, ensure the needleinto vein.Confirm position oftheguidewirewith Once bloodisaspirated,theguide wire canbepassedthrough possible. vein occurswithadistinct“pop”and aspirationofbloodwillbe Gently advancetheneedlein1cm increments; entryintothe and theneedleduringanyadjustments inneedleposition directly overthetargetvessel.Always lookatthepatient’sneck is alignedcorrectly,thissofttissuedepressionshouldbelocated depression oftheskinonultrasoundmonitor.Ifneedle probe. Duringinitialskinpuncture,theoperatorshouldnotea of theneckand1–2cmbackfrommiddleultrasound The needleshouldbeangledat40–60degreesfromtheplane Infi midline. (Increasedriskofarterialpuncture.) Do notturnthepatient’sheadmorethan30degreesfrom chance ofinadvertentarterialpuncture. minimally overliestheinternalcarotidartery.Thiswillreduce Attempt tofind a location wheretheinternaljugularveinonly an independentriskfactorforunsuccessfulvenouscannulation. its course.Internaljugularveinsizeoflessthan7mmmaybe Determine whethertheinternaljugularveinispatentthroughout lateral tothesmaller,thick-walledinternalcarotidartery Figure 11.3showsthelarger,thin-walledinternaljugularvein overlap withtheinternalcarotidartery,anddepthfromskin. vessel patency,diameter,degreeofcollapsewithrespiration, During theinitialscanofinternaljugularvein,makenote ltrate theskinwithlocalanesthesia(1%lidocaine).

The internaljugularveinlateraltothecarotidartery.

GrahamAS,OzmentC,TegtmeyerK,LaiS,BranerDA.Videosinclini- FurtherReading Aswithcentrallineinsertion • Complications • MaeckenT,GrauT.Ultrasoundimaginginvascularaccess.

cal medicine.Centralvenouscatheterization. Conﬁ technique. Continue placementofthecatheterusingSeldinger 24;356(21):e21. 2007 May;35(5Suppl):S178–S185. rm thepositionofcatheterwithchestx-ray.

N EnglJMed Crit CareMed .

. 2007May 295 CHAPTER 11 Procedures This page intentionally left blank Chapter 12 Regional Anesthesia Complications Raymond S. Sinatra and Dan B. Froicu

Bupivacaine Cardiotoxicity 298 Epidural Abscess 300 Epidural Hematoma 301 Globe Injury 304 Local Anesthetic Toxicity 305 Nerve Injury 308 Total Spinal Anesthesia 310 297 298 CHAPTER 12 Regional Anesthesia Complications • fatal arrythmiasandcardiovascularcollapse. of myocardialsodiumchannelsresultsindecreasedcardiacoutput, that affectsimpulseconductionandcardiaccontractility.Blockade tance ofsodiumchannelsthroughafast-in,slow-outmechanism tractile andconductingcardiaccells.Bupivacainedecreasesconduc- Bupivacaineishighlyprotein-boundandrapidlytakenupbycon- Pathophysiology • • Presentation uptake. Cardiaceffectsarelifethreatening. plasma concentrationsofbupivacaineandsubsequentmyocardial Profounddepressionofheartrateand/orcontractilitycausedbyhigh Deﬁ

• • • • • • • • ImmediateManagement

BupivacaineCardiotoxicity Bupivacaine

Hemodynamicchanges. ventricular ﬁbrillation andasystole. which maybequicklyfollowedbyventriculartachycardia, Cardiacdysrythmias followed bycardiovasculareffects. lethargy, coma.Thesesymptomsappearﬁrst, andarerapidly Neurotoxicity. continuous infusionof0.25mL/kg/min for30–60minutes. lipid emulsion20%1.5mL/kgover 1 minute,followedbya Administer lipidemulsion.Onerecommended protocolis epinephrine). ConsiderCaCl Begin advancedcardiaclifesupport(ACLS)ifindicated. Intubate thepatientandinitiatemechanicalventilation. Airway, breathing,circulation.Administer100%O unresponsive tointravenouslipidemulsion. Consider openchestmassageand/or cardiacbypassforpatients disturbances aggressively. Check arterialbloodgases(ABG)frequently. Treatacid-base Support bloodpressurewithvasopressors(e.g slow IV(maycausehypotension). Promptly treatventriculararrhythmias:amiodarone150mg nition

Tinnitus,perioralnumbness,tremors,seizures, C . InitiallywidenedQRSandbradyarrythmias, a rd Hypotension,cardiovascularcollapse.

i otox

2 . i c

i ty

. , vasopressin, 2 .

solution. plain bupivacainesolution,or2mg/kg withepinephrine-containing 0.25% bupivacaineatonetime.Do notexceed1.6–1.7mg/kgwith Donotadministermorethan3mL of0.5%bupivacaineor6mL SpecialConsiderations • • • Prevention • • SubsequentManagement and electrolyteabnormalities Arterialbloodgasanalysis,plasmaelectrolytestocorrectacidosis DiagnosticStudies • • DIFFERENTIALDIAGNOSIS • • •

• • • RiskFactors

essential. Careful monitoringofECGandongoingpatientassessmentis include a500mLvialof20%intralipid,and60syringe. regional anesthesiaareused.Thecartshould toxicity shouldbeavailablewhereverlocalanestheticsand 20% lipidemulsioninsufﬁcient quantitytotreatbupivacaine epinephrine 1:200,000. administration individeddoses.Alwaysuseatestdosecontaining Careful needleplacement,frequentaspirationandbupivacaine bypass. techniques, consideropenchestcardiacmassageand/or If thepatientdoesnotrespondtostandardresuscitation not discontinueresuscitationefforts! Myocardialdepressionmaynotresolvefor80–90minutes.Do Acute myocardialinfarction Vasovagal episode cardiac toxicity. Accidental intravenousinjectionisthemostcommoncauseof Profound hypotensioncausedbypreexistinghypovolemia. Intrathecal injectionandtotalspinalanesthesia Cardiac disease Hypokalemia, hypercarbia Pregnancy

299 CHAPTER 12 Regional Anesthesia Complications 300 CHAPTER 12 Regional Anesthesia Complications MulroyMF.Systemictoxicityandcardiotoxicityfromlocalanesthetics: WeinbergG.Intralipidforcontrolofbupivacainecardiotoxicity>Availableat: EmergencyMRIof lumbarand/orthoracicspine DiagnosticStudies • • DIFFERENTIALDIAGNOSIS that causespinalcordsymptoms(pain,incontinence,paresthesias). aureus, Localinfectionoftheepiduralneedle/cathetersite,mostoftenwith Pathophysiology • Presentation or successfulepiduralanesthesia. Epiduralabscessformation,eitherspontaneouslyorafterattempted Deﬁ FeliceK,SchumannH.Intravenouslipidemulsionforlocalanesthetictoxicity: FurtherReading • • • • • •

• • • ImmediateManagement

EpiduralAbscess Ep

incidence andpreventivemeasures. Dec;27(6):556–561. www.lipidrescue.org a reviewoftheliterature. Muscular orligamentousinjuryrelatedtoneedleplacement Epidural hematoma Back pain,painalongnerverootdistribution,weakness. Spinal arterythrombosis Residual localanestheticeffect Fever, tendernessatepiduralsite. Neck stiffness,headache,signsofmeningitis. untreated paraplegiacandevelop. Progressive weaknesswithabscessformation;ifleft weeks, orevenmonthsafterepiduralanesthesia. Leucocytosis, sometimespresentafteravariabledelayofdays, Emergency neurosurgical consultation for drainage of the abscess Emergency neurosurgicalconsultation fordrainageoftheabscess Emergency MRI Stop epiduraldrugadministration. nition i d causesanabscesswithassociatedinﬂ u ral

Ab scess

. Accessed:October5,2009.

J MedToxicol

Reg AnesthPainMed . 2008Sep;4(3):184–191.

ammation andmasseffect

. 2002Nov-

• • Presentation paralysis blood vesselthatcausesprogressive spinalcordcompressionand Anexpandingcollectionofblood related todamageanepidural Deﬁ PradillaG,ArdilaGP,HsuW,RigamontiD.EpiduralabscessesoftheCNS. FurtherReading Speciﬁ SpecialConsiderations • • Prevention • • SubsequentManagement • • •

• • • • • RiskFactors

EpiduralHematomaEp

LancetNeurol adjacent tothesite ofepiduralneedleorcatheterplacement. The initialsymptom isbackpainatthesiteorimmediately Presentation isoftenslow,insidious andprogressive. placement. Infection attheproceduresiteisacontraindicationforepidural Use carefulaseptictechniquewhenplacingneuraxialblocks. Repeat MRIifwarranted Close neurologicmonitoringuntilfunctionisrestored warranted. Antibiotic prophylaxisand/orbacterialﬁlter usemaybe noted. Promptly removethecatheteriferythemaorlocaldischargeis infection daily. Check theskinatsiteofindwellingcathetersforsigns Alcohol abuse Steroid use Cancer Diabetes mellitus Existing infection nition i cally informthepatientofrisksprocedure. dura

l . 2009Mar;8(3):292–300.

Hemat

301 CHAPTER 12 Regional Anesthesia Complications 302 CHAPTER 12 Regional Anesthesia Complications • DiagnosticStudies • DIFFERENTIALDIAGNOSIS toma andlasttobeaffected. conveys pain,temperature,andlighttouchisfurthestfromthehema- becomes paraplegic.Theanteriorlateralspinalthalamictractthat the corticalspinalmotortractsarecompromisedandpatient point discrimination,andpositionsense.Asthehematomaexpands, umns aretheﬁ rst structuretobeaffected,impairingvibration,two may eventuallycausespinalcordcompression.Theposteriorcol- nerve endingsintheepiduralspace,resultingacutebackpain,and or artery,resultinginhematomaformation.Theirritates Spinalorepiduralneedleplacementmaydamageanvein Pathophysiology • • • • • • •

• • • • ImmediateManagement

available andtheclinicalsituationpermits. epidural space.MRIismoresensitive, andisthepreferredstudyif MRI orCTtodetectcollectionsof bloodorabscessinthe Muscular orligamentousinjuryrelatedtoneedleplacement observed. tone andurinaryincontinenceorretentionmayalsobe (vibration sense,twopointdiscrimination).Lossofsphincter Worsening backpainwithlossofposteriorcolumnsensation touch arethelast sensorymodalitiestobeaffected. position inthelower extremities.Pain,temperature, andlight Physical examination:Assessability todetectvibrationand Assess rectaltone. Residual neuralblockade light touchsensationmayremainintactdespitemotordeﬁ Motor weaknessprogressingtoparalysis.Pain,temperature,and Spinal arterythrombosis Epidural abscess decompression. Emergency neurosurgicalconsultationforsurgical unexplained sensorydeﬁcits ormotorweakness. Emergency MRItoruleouthematomainpatientswith back painduringorfollowingepiduralcatheterplacement. Do notadministeropioidstopatientscomplainingofworsening permanent, devastatingneurologicinjury. Delayed recognitionofepiduralhematomamayresultin

cits.

SharmaS,KapoorMC, SharmaVK,DubeyAK.Epiduralhematoma complicat- GogartenW.Theinﬂ uence ofnewantithromboticdrugsonregional anes- FurtherReading • SpecialConsiderations • • • • • Prevention • • SubsequentManagement • • • • RiskFactors • • • • • •

JCardiothoracVascAnesth ing highthoracicepidural catheterplacementintendedfor cardiac surgery. thesia. emergency. placement ofanepiduralcatheterrepresentsatruesurgical The occurrenceofbackpainwithposteriorcolumndeﬁ Avoid removalofepiduralcathetersinanticoagulatedpatients. Minimize thedurationofepiduralcatheterplacement. Minimize needleplacementattempts. dose oflow-molecular-weightheparin. Do notinsertanepiduralcatheterwithin12hoursofthelast anticoagulants orwillreceivethemaftersurgery. Avoid epiduralplacementinpatientswhoaretreatedwith abnormal neurologicalassessment. Consider anearlyneurosurgicalconsultationinsettingsof carefully for24–36hours. After obtainingabaselineneurologicexamination,followpatients develops motordeﬁcits, ortheinjurymaybecomeirreversible. Surgical interventionmustbeperformedbeforethepatient team torecognizethesymptomsandtheirimplications. The anesthesiologistmaybetheonlymemberofpatientcare Herbal preparations:ginkgobilboa,sawpalmetto,andgarlic molecular-weight heparin Anticoagulation includingheparininfusion,coumadin,andlow- Pregnancy withengorgedepiduralveins Hypertension Epidural placementforpainfollowingcardiacsurgery NSAID use Spondolysthesis, spinalstenosis Hematoma mayoccurintheabsenceofriskfactors. Curr OpinAnaesthesiol

. 2004Dec;18(6):759–762.

. 2006Oct;19(5):545–550.

cits after

303 CHAPTER 12 Regional Anesthesia Complications 304 CHAPTER 12 Regional Anesthesia Complications • SubsequentManagement Fundoscopy,whenocularmediaare sufﬁ DiagnosticStudies • DIFFERENTIALDIAGNOSIS thy and/orretinaldetachmentmayoccurafterinitialinjury. Mechanicalinjurytotheeyestructures.Proliferativevitreoretinopa- Pathophysiology • Presentation thalmic regionalanesthesia. and exit)oftheglobeeyewithaneedleduringattemptedoph- Accidentalpenetration(needleentry)orperforationentry Deﬁ SidiropoulouT,PompeoE,BozzaoA,LunardiP,DauriM.Epiduralhematoma • • • • •

• • • ImmediateManagement

GlobeInjuryG

Anesth PainMed after thoracicepiduralcatheterremovalintheabsenceofriskfactors. Complex, directed byophthalmologist. Preexisting retinal/intraocularhemorrhage hemorrhage. Sudden lossofvision,hypotonia,poorredrefl Optic nerveinjury pain atthetimeofinjection. injected intotheglobe.Awakepatientsmaycomplainofsevere Intraocular hypertensionoccursrarelyiflocalanesthesiais injection. Pain, morefrequentwithintraocularanestheticinadvertent Preexisting painfuleye Retinal detachment from earlyvitrectomy. Patients withsignificant intraocularhemorrhagemaybenefi cases mayonlyrequirecloseobservation. elect toperformlaserphotocoagulation,cryotherapy.Minor If injuryislimitedtoaretinaltear,theophthalmologistmay Emergency ophthalmologicalconsultationforsurgicaltreatment lo nition b e In

j ury . 2003Nov-Dec;28(6):531–534.

ciently clear.

ex, vitreous t Reg

• Presentation dose orintravascularinjection. Centralnervoussystemexcitatoryresponse tolocalanestheticover- Deﬁ GoldbergM.Complicationsofanesthesiaforocularsurgery. AlhassanMB,KyariF,EjereHO.Peribulbarversusretrobulbaranaesthesiafor FurtherReading • • • SpecialConsiderations • • • • Prevention • •

• • • RiskFactors

LocalAnestheticToxicityLo

North Am cataract surgery. Early symptomsinclude tinnitus,metallictaste,andtongue and CNS manifestations generallyprecedecardiovascular symptoms. undergoing cataractextraction. ovoid shapeoftheglobe.Thiscomplicationisrareinpatients Ocular injuryismorefrequentinmyopicpatientsbecauseofthe periconal blocks. The rateofcomplicationsissimilarforbothintraconaland hemorrhage, andbrainstemanesthesia. Other complicationsincludeopticnerveinjury,retrobulbar Use short,sharpneedles. Always aspiratebeforeinjectinglocalanesthesia. Insert theneedlewitheyesinprimarygaze. detachment surgery. Avoid deepsedationinpatientsundergoingrefractiveorretinal vitreoretinopathy and/orretinaldetachment. caused bypenetrationoftenleadstoproliferative Observation andadditionalsurgeryasvitreoushemorrhage anesthesiologists andophthalmologists. There isnodifferenceintherateofperforationbetween Surgery forretinaldetachment Severe myopia. Deep sedation nition c a l Anesthet . 2006Jun;19(2):293–307.

Cochrane DatabaseSystRev

c Tox

i ty

. 2008Jul16;(3):CD004083.

Ophthalmol Clin 305 CHAPTER 12 Regional Anesthesia Complications 306 CHAPTER 12 Regional Anesthesia Complications • • SubsequentManagement Clinicaldiagnosis.Therearenospeciﬁc diagnostic tests. DiagnosticStudies • • DIFFERENTIALDIAGNOSIS depression. tially blockinhibitoryCNSpathwaysandthenproducediffuse to levelsofanestheticinplasmaandCNS.Localanestheticsini- Centralnervoussystemtoxicityisbothbiphasicandproportional Pathophysiology • • • • •

• • • • • • • ImmediateManagement

respiratory depression,orcardiacarrestmayoccur. With increasedplasmalevels,obtundation,seizures,coma, headedness, tremor,visualdisturbances,andmuscletwitching. circumoral numbness.Thesesymptomsmaybefollowedbylight- surgery. If symptomsresolverapidly,consider whethertocontinuewith Altered mentalstatus(e.g.,oversedation) Hypoxia Provide supportivecare. nystagmus) Preexisting neurologicaldisease(e.g.,CNSmasslesion,ambliopia, Seizure ofdifferentetiology Correct metabolic abnormalities. cardiovascular symptoms arepresent. Consider admission totelemetryunitorintensivecare unitif 30–60 minutes. minute, followedbyacontinuousinfusionof0.25mL/kg/minfor protocol isintravenouslipidemulsion20%1.5mL/kgover1 Bupivacaine Cardiotoxicity,page298)Onerecommended imminent, administerintravenouslipidemulsion.(See If bupivacainetoxicityissuspectedandcardiacarrest Treat bradydysrhythmiaswithatropine. Be preparedtobeginACLS. diazepam, propofol). Administer sedativestocontroltheseizure(e.g.,midazolam, the seizure,butmaybenecessaryifpostictaldepressionoccurs. Intubation isoftennotneedediftheairwayadequateduring Airway, breathing,circulation.Administer100%O Discontinue injection.

2 .

• • • SpecialConsiderations • • Prevention • • • •

• • • • RiskFactors

amide-based localanesthetics. problematic withbupivacaineandotherslowlymetabolized chloroprocaine, whichisrapidlymetabolized,andmore Symptoms arecommon,yetrarelyclinicallysignifi cardiac toxicity. may hidetheearlyCNSsignsoftoxicityandincreaserisk Administration ofsedatives(e.g.,benzodiazepines)beforeablock from theadministrationsite. intravascular injection,andlessoftentheresultofabsorption Local anestheticinducedseizuresareusuallytheresultof of intravascularinjection. tachycardia ifinjectedintoabloodvessel,andspeedthediagnosis Adding epinephrinetothelocalanestheticsolutionwillcause nerve block. Aspirate carefullyafterpositioningtheneedlewhenperforminga common withester localanesthetics. Allergy tolocalanesthetics isextremelyrareandmore bupivacaine toxicity maystartslowlybutlastmuchlonger. Lidocaine toxicityhasafasteronset andresolution,while sciatic, brachialplexus,epidural,caudal, intercostal,intrapleural. rapid isasfollows:spinal,intra-articular, subcutaneous,femoral- injection site.Uptakeandriseinplasma levelsfromslowto The rateofabsorptionandrisktoxicity dependuponthe block isbeingplaced. collapse, respiratorydepressionorarrestwhenevera Be preparedtotreatprofoundCNSdepression,cardiovascular the additionofepinephrine,1:200,000,upto7mg/kgmaybegiven. The maximumrecommendeddoseoflidocaineis3–5mg/kg.With risk ofcardiotoxicityropivacaineandbupivacaine. rate oflocalanestheticuptake.Progesteronemayincreasethe epidural veinplacement,andhigherbloodfl Pregnancy Intravenous regionalanesthesia solution Large volumesorhighconcentrationoflocalanesthetic ability toclearthedrugmaybesignifi liver. Usecautioninpatientswithliverdisease,becausetheir Hepaticfailure. . Pregnantpatientsareatincreasedriskofintravascular

Amidelocalanestheticsaremetabolizedinthe

cantly impaired. ow increasesthe cant, with

307 CHAPTER 12 Regional Anesthesia Complications 308 CHAPTER 12 Regional Anesthesia Complications HeavnerJE.Localanesthetics. • • • DIFFERENTIALDIAGNOSIS injury, particularlyifhighconcentrationsareused. take months.Injectionoflocalanestheticsolutionexacerbatesnerve and symptomsoftenpersistuntilthefi bers regenerate,whichmay sia. Quincke-tippedorcuttingneedlescantransectaxonalfi Nerveinjuriesarearecognizedcomplicationofregionalanesthe- Pathophysiology • • • Presentation nal, regionalorepiduralneedles. Injurytospinalcord,nerveroot,orperipheralcausedbyspi- Defi FeliceK,SchumannH.Intravenouslipidemulsionforlocalanesthetictoxicity: FurtherReading •

• • • • ImmediateManagement •

NerveInjury Nerv

extremity extremity Worsening “electricshock”orburningpainradiatingintoan Aug;20(4):336–342. a reviewoftheliterature. Local anesthetictoxicity Spinal injury Nerve rootinjury Nonsedated patientsmayreportseverepainduringinjection. placement. Patient complainsofsudden“electricshock”duringneedle radiculopathy, peripheralneuropathy Underlying neurologicdisease:myleopathicdisease,preexisting paresthesias. Provide analgesics andanxiolyticstopatientswithpainful deﬁ Perform afullneurologicalassessment toruleoutafocal Carefully withdrawtheneedleand catheter (ifonewasplaced). persistent paresthesias. Do notinjectlocalanestheticifthe patientcomplainsof complains ofpainorparesthesia. Immediately stopadvancinganeedleorcatheterifthepatient nition cit. e In

ury

J MedToxicol

Curr OpinAnaesthesiol . 2008Sep;4(3):184–191.

. 2007 bers,

• • • SpecialConsiderations • Prevention • • SubsequentManagement • DiagnosticStudies • • • • • •

• • • • RiskFactors

of over500patients treatedwithcontinuousbrachial plexus or plexuscatheter increasestheriskofnerveinjury. In aseries It isunclearwhether placementofanindwellingperipheral nerve resolve overaperiodofdays. symptoms ofnumbnessormildneuropathic discomfortgenerally damaged. Thisformofinjuryisrepaired fairlyquicklyand transected, buttheSchwanncellsand myelinsheathcanbe results inpermanentinjury.Ingeneral, thenerveisnot Nerve penetrationwithbluntorround tippedneedlesrarely injury. It isunclearwhetherthistechniqueincreasestheriskofnerve anesthetic injectionandincreasethesuccessrateofblock. Many anesthesiologistselicitparesthesiastoconfi Careful needleandcatheterplacement Consider acourseofsteroidstoreduceneuralinfl tricyclic antidepressants). Consider anti-neuropathicanalgesics(gabapentin,pregabalin, Complete neurologicexamination peripheral neuralblockade. Consider nervestimulationorultrasoundneedleguidancefor Avoid directnervepenetration Consider anemergencyMRIscan. the needlesite. Never injectlocalanesthetictopatientscomplainingofpainat Consider EMGtestingtoruleoutnerveinjury. dose. Stopadministrationifthepatientreportspain. Do notadministermorethan3mLoflocalanestheticasatest Placement ofspinalneedlesabovetheL1interspace. nerve block Use ofparesthesiaelicitingtechniquestofacilitateregional Nerve blockinananesthetizedorsedatedpatient patients) Diffi cult techniqueduetopatientanatomy(obeseorelderly

rm local ammation.

309 CHAPTER 12 Regional Anesthesia Complications 310 CHAPTER 12 Regional Anesthesia Complications • DIFFERENTIALDIAGNOSIS results incardiovascularcollapseand cardiacarrest. inhibit orpreventventilation,aswellintrathecalsympatholysisthat Patientsexperiencerapidanddensesensorimotorblockadethatcan Pathophysiology • • Presentation excessive intrathecallocalanestheticblockade. cardiovascular collapseorcardiacarrestrelatedtounintentional Profoundsensorymotorandautonomicblockadeassociated Deﬁ LiguoriGA.Complicationsofregionalanesthesia:nerveinjuryandperipheral HoganQH.Pathophysiologyofperipheralnerveinjuryduringregionalanes- FurtherReading LynchNM,Coﬁ eld RH,SilbertPL,HermannRC.Neurologiccomplica- • • • • •

TotalSpinalAnesthesiaS neural blockade. thesia. Feb;5(1):53–61. tions aftertotalshoulderarthroplasty. Further Reading,Lynchetal.) catheters, only3(0.5%)experiencedlong-lastingparesthesia(see Dense epiduralblockade blockade withassociatedhypotensionandtachycardia. Early symptomsincluderapidandunexpectedsensorymotor employed. concentration, volume,andbaricityofthelocalanesthetic The severityofsymptomsmayvarydependinguponthe cardiovascular collapse, respiratory arrest and death. cardiovascular collapse,respiratoryarrestanddeath. termed “totalspinal”—dysarthriaoraphonia,unconsciousness, Higher levelsofdermatomal(aboveC4-5)andbrainstemblockade, maintenance ofrespirationandventilation) Subdural injection(usuallyasymmetric blockade,with weakness, bradycardia,respiratoryandCNSdepression. dermatomes blocked—symptomsincludeupperextremity Progressive increasesinthedensityandnumberof myasthenia gravis, hypocalcemia Preexisting conditions suchasmyelopathy,neuropathy, Hypermagnesemia nition Reg AnesthPainMed p

i n al J NeurosurgAnesthesiol An est

. 2008Sep-Oct;33(5):435–441.

h es

. 2004Jan;16(1):84–86. J ShoulderElbowSurg

. 1996Jan-

• SubsequentManagement • DiagnosticStudies • • • • •

• • • • RiskFactors

• • • • • • ImmediateManagement

returns (usually90–120minifbupivacainewasinjected). ventilation followedbygradualweaningasmotorstrength Supportive careincludescarefulsedationandcontrolled examination Clinical diagnosisbasedonreportedsymptomsandphysical Correct metabolicabnormalities(seeMetabolicEmergencies). Administer fluids andvasopressorsasrequired. blockade No specific diagnostictestsotherthanassessmentofdermatomal intrathecal orepiduralmorphine. Administer naloxoneinfusionifthepatientwastreatedwith catheter. aspirate cerebrospinalfluid (CSF),thencarefullyremovethe Test epiduralcatheter—toconfirm thediagnosis,attemptto disautonomia) Preexisting disturbances (e.g.,COPD,myasthenia, in Trendelenburg position followingspinalinjection. Patients whocoughorretchexcessively, orarequicklyplaced unintentional intrathecalplacement andinjection. Patients withdifficult epidurallandmarks(greaterchance of effects ofprogesteroneandpossibly magnesiuminfusion. secondary todiminishedintrathecal space,andneuralblockade Pregnancy: increasedchanceofhigh dermatomalblockade why subsequentcardiacarrestmayberefractorytotreatment. loss ofsympathetictonecausedbyspinalblockademayexplain The rapidonsetofbradycardiaorasystolecombinedwiththe If cardiacarrestoccurs,beginACLS. vasopressors (epinephrine),andatropine. Aggressively treathypotensionandbradycardiawithfl taken outofTrendelenburgposition. Patients treatedwithhyperbaricspinalsolutionsshouldbe permits. Attempt toassesstheleveldermatomalblockadeiftime FiO Intubate thetracheaandbeginmechanicalventilation.Increase 2 tomaintainadequateoxygenation.

uids,

311 CHAPTER 12 Regional Anesthesia Complications 312 CHAPTER 12 Regional Anesthesia Complications BernardsCM.Epiduralandspinalanesthesia.In:BarashPG,CullenBF, FurtherReading • SpecialConsiderations • Prevention CamorciaM.Testingtheepiduralcatheter. • • • • • • •

Philadelphia: LippincottWilliams&Wilkins;2009:948. Stoelting RK,CahalanMK,StockMC(Eds.), Dilated pupilsindicateahighlevelofblockade,notCNSinjury. positioning theneedleorcatheter. When placinganepiduralblock,aspirateforCSFfrequentlyafter 1990s wereassociatedwithunintentionalintrathecalblockade. 14% oftheneuraxialcardiacarrestclaimsfrom1980sand have adelayedonsetandmuchlongerdurationofaction. resolution, whilebupivacaineorplusepinephrine Intrathecal blockadewithlidocainehasafasteronsetand Jun;22(3):336–340. dural puncture. diffusion oflocalanestheticintotheintrathecalspacethrough migration oftheepiduralcatheterintointrathecalspace,or combined spinalandepiduralanesthesia,iscausedby High spinalanesthesiahasbeenreportedinthesettingof after injectionofhyperbariclocalanestheticsolutions. Avoid placingthepatientinTrendelenburgpositionsoon intrathecal placementoftheneedleorcatheter. Symptoms mayoccurduringepiduralanesthesiawithaccidental diagnosed andtreatedquickly. Dermatomal levelsaboveC7maybelifethreateningifnot followed carefully. administration. Duringthistime,thelevelofblockadeshouldbe dermatomal levelmaycontinuetoascendfor12–15minutesafter If hyperbaricbupivacaineplusepinephrineisinjected,the

Curr OpinAnaesthesiol Clinical Anesthesia

, 6thed. . 2009

Chapter 13 Respiratory Emergencies Vivek K. Moitra and Tricia E. Brentjens

Acute Lung Injury (ALI) and Acute Respiratory Distress Syndrome (ARDS) 314 Bronchospasm 316

Decreased ETCO2 (Intraoperative) 317 Difﬁ cult Controlled Ventilation 319 Hemoptysis 322 Hypercarbia (Intraoperative) 323 Hypoxemia (Intraoperative) 326 Pneumothorax 328 Pulmonary Edema 330 313 Pulmonary Embolus 332 Respiratory Precautions 334

314 CHAPTER 13 Respiratory Emergencies

• DiagnosticStudies • • • • • • • DIFFERENTIALDIAGNOSIS decreased lungcompliancecandevelop. tant activity.DuringthelatephaseofARDS,pulmonaryfi leak andbyinterstitialalveolaredema.Thereisalossofsurfac- TheearlyphaseofARDSischaracterizedbypulmonarycapillary Pathophysiology show hypercarbiainthesettingofpoorlungcompliance. be seenwithpositivepressureventilation.Arterialbloodgasesmay bly wheezing.Increasedpeakinspiratoryandplateaupressuresmay Their physicalexamisnotableforreducedbreathsoundsandpossi- PatientswithALIorARDSareintubatedandmechanicallyventilated. Presentation left atrialhypertension. with pulmonaryedema,poorsystemicoxygenationandabsenceof Acuteonsetofbilateralpulmonaryinfi ltrates onnotedchestX-ray Defi

• • • • • ImmediateManagement

Respiratory DistressSyndrome(ARDS) AcuteLungInjury(ALI)and Acute periphery) Chest X-ray(shows patchyinﬁltrates thatextendtothe Brochiolitis obliterans-organizingpneumonia (BOOP) Transfusion relatedacutelunginjury (TRALI) Pulmonary embolus Pneumonitis Diffuse alveolarhemorrhage Multilobar pneumonia Pulmonary edema release ventilation[APRV]). Consider alternativeventilatorystrategies(e.g Permissive hypercapniamaybenecessary. Avoid plateaupressures>30cmH body weight). Consider ventilationwithlowtidalvolume(6–8cc/kgpredicted Increase FIO nition L

u n 2 g tomaintainadequateoxygenation.

ury

( ALI

)

andAcute 2 O.

( . ARDS , airwaypressure

brosis and brosis )

JasonD.ChristiePaulN.Lanken.Acute lunginjuryandtheacuterespiratory FurtherReading • • • SpecialConsiderations progression tolunginjury. Earlyandaggressivetreatmentofprecipitatingcausesmayprevent Prevention • • • • • SubsequentManagement •

• • • • • • • RiskFactors

Critical Care distress syndrome “Transportation ofCriticallyIllPatients,”Page288.) Patients oftenrequirespecializedtransportfromanICU.(See positive end-expiratorypressure(PEEP). present withincreasedpeakairwaypressuresandhighlevelsof Patients whocometotheoperatingroomwithARDScan ventilation andoxygenation. Neuromuscular blockademayrarelyberequiredtofacilitate management. Transfer thepatienttointensivecareunitforfurther Consider high-dosesteroidtherapy. Ventilator managementofrespiratoryabnormalities Treat theprecipitatingcauseofALI/ARDS. catheter) Right heartcatheterization(CVPorpulmonaryartery room. samples canguidechangesinventilator strategyintheoperating ventilation inordertoensuresafetransport.Arterialbloodgas The anesthesiologistmustbefamiliarwiththepatient’smodeof Massive Transfusion Inhalational injury Toxic drugreaction Pancreatitis Pneumonitis Pneumonia Sepsis , 3rded.NewYork: McGraw-Hill;2005:515–547.

. In:JBHall,GSchmidt, LDHWood(eds.).

Principles of 315 CHAPTER 13 Respiratory Emergencies 316 CHAPTER 13 Respiratory Emergencies

• SubsequentManagement Clinicalpresentation.Nospeciﬁc diagnosticstudies. DiagnosticStudies • • • • • • • DIFFERENTIALDIAGNOSIS increases airwayresistance. table airwayisoftenedematousandproducesmucus,whichfurther i.e., histamine,toconstrictbronchialsmoothmuscle.Thehyperirri- cytes, epithelialcellsandmacrophagestoreleasevariousmediators, (anaphylatoxin) stimulusactivatesmastcells,eosinophils,lympho- Bronchospasmcanoccurafteramechanical(intubation)orchemical Pathophysiology DecreasedSpO Presentation Spasmodiccontractionofbronchialsmoothmuscle. Deﬁ due to hypoxia or auto-PEEP leading to decreased venous return. due tohypoxiaorauto-PEEPleadingdecreasedvenousreturn. sounds maybeheard.Hypotensionisalatesigninseverebronchospasm the patientismechanicallyventilated.Wheezingordecreasedbreath graph. Anincreaseinpeakairwaypressure(PIP)mayalsobeseenif

• • • • • ImmediateManagement

B Bronchospasm

procedure ifthepatient isunstable. If surgeryhasnot started, considerpostponinganelective Endobronchial intubation Pulmonary edema Pulmonary embolus Aspiration Pneumonitis Tension Pneumothorax Pulmonary Edema Mechanical obstruction(kinkedendotrachealtube) Increase FIO to effect. Consider epinephrine10–30mcgIVinrefractorycases,titrate Consider terbutaline0.25–0.5mgsubcutaneousinjection. Administer Increase depthofanesthesiawithinhalationalagents. ronc nition h

ospasm

β-agonist bronchodilators. 2 2 oranupslopingoftheETCO to100%.

2 tracingonthecapno-

with CO with eitherhypocarbia (hyperventilation)orhypercarbia (problem cardiovascular collapse oranembolicphenomenon. AdecreaseinETCO Presentation EndtidalCO Deﬁ YaoF.Asthmaandchronicobstructivepulmonarydisease.In:F(ed.). FurtherReading measures, bronchospasmmaystilloccurintheoperatingroom. Evenwithadequatepreparationandimplementationofpreventative SpecialConsiderations • • • • Prevention • • • •

• • • RiskFactors

DecreasedETCO

Lippincott Williams&Wilkins;2003:3–31. Anesthesiology:Problem-OrientedPatientManagement decrease airwayresistance. IV agents,includingpropofol,ketamineandlidocaine,may and maybeneﬁt frompreoperativecorticosteroidtreatment. Patients withahistoryofasthmahavebronchialhyperreactivity, a historyofreactiveairwaydisease. Consider useofaregionalanesthesiatechniqueifthepatienthas at-risk patients. If theclinicalsituationpermits,avoidendotrachealintubationin Avoid triggeringagents,i.e.,histamine-releasingdrugs. Avoid unnecessaryairwaymanipulation. bronchospasm. Maintain anadequatedepthofanesthesiatopreventfurther Consider administrationofsteroids. Can occurinhealthypatients Recent upperairwayinfection History ofasthma,COPD,emphysema nition 2 elimination).Asudden decreaseinETCO

2 <30mmHg

2 inamechanicallyventilatedpatient mayoccur

2 2 (Intraoperative) (

Intraoperative

.5thed.NewYork: )

2 mayindicate

317 CHAPTER 13 Respiratory Emergencies 318 CHAPTER 13 Respiratory Emergencies

ETCO Sudden, catastrophicdecreaseincardiacoutputwillthe

to lungs). • • • • • • DIFFERENTIALDIAGNOSIS lation. Itmayalsoreﬂect increaseddeadspacewithanormalPaCO Mostcommonlycausedbyhyperventilationduringmechanicalventi- Etiology

• • • ImmediateManagement

• • Obstruction • Low ETCO • Hyperventilation Low ETCO Gas analyzererror Air leakinsampleline • • • • • • Amniotic ﬂ Mechanical(kinkingoftube) Pulmonary thromboembolus Highminuteventilationinamechanicallyventilatedpatient CO Fat embolus Air embolus Compensationformetabolicacidosis Anxiety Pain • • Gradual: • • • • Sudden: Assess causeofdecreasedETCO Ifanembolic eventissuspected: Decreaseminuteventilation(ifpatientisbeingventilated). Considerproviding cardiovascularsupportusinginotropesor Assessvolume status. Assessperfusion byothermeans(bloodpressure,presence Considercardiovascular collapse. vasopressors. of pulseoximeterwaveform). • • • Flush ﬁ Adjusthead ofbeddown. Providehemodynamic support. 2 becauseofdecreasedperfusion(CO 2

embolus(laparoscopicsurgery)

2 2 eld withsalineifairembolusissuspected. withhypercarbia(PaCO withhypocarbia(PaCO uid embolus

<35mmHg) 2 >45mmHg)

2 isnotbeingcarried

2 . pressures thatmay decreasevenousreturn. for hemodynamic compromisesecondarytoincreased intrathoracic cult controlledventilation.Patients areoftenhypoxemicandatrisk Highpeakairwaypressuresandhypercarbia areobservedwithdifﬁ Presentation mechanically ventilated. Inabilitytoeffectivelyoxygenateand/or ventilateapatientwhois Deﬁ EisenkraftJ,LeibowitzA.Hypoxiaandequipmentfailure.In:FYao(ed.). FurtherReading • • • SubsequentManagement • • • DiagnosticStudies • •

• • • RiskFactors Difﬁ Difﬁ

Lippincott Williams&Wilkins;2003:1116–1136. Anesthesiology:Problem-OrientedPatientManagement • Intubate thetracheaandinitiatemechanicalventilation. Provide hemodynamicsupport. Correct theunderlyingcause. Spiral CTifthromboemboliceventissuspected cardiac function Transthoracic ortransesophagealechocardiogramtoassess Arterial bloodgas(ABG)todeterminePaCO Esophageal intubation Low cardiacoutputstate • Bronchospasm COPD Hemorrhagic orcardiogenicshock:lowcardiacoutputstate Implantation Syndrome,”Page130.) Bone cementimplantation:fatembolus(See“BoneCement operative siteisabovetheheart:airembolus Sitting craniotomyoranysurgicalprocedureinwhichthe nition cult Controlled Ventilation cult Co

ntrolled Ventilation

.5thed.NewYork:

- 319 CHAPTER 13 Respiratory Emergencies 320 CHAPTER 13 Respiratory Emergencies

• • DIFFERENTIALDIAGNOSIS • • • Etiology

• • • • • • • • ImmediateManagement

• lung compliance. airways andthealveoliduringpositivepressure)suggestspoor Elevated plateaupressure(theappliedtothesmall • lung parenchymaandincreasedresistancetoairflow dueto: High peakairwaypressuresresultfrompoorcomplianceofthe • Decreased lungcompliance Increased resistancetofl tree (i.e.,abronchopulmonaryfi may indicateanairleakinthecircuitortracheobronchial Low peakairwaypressuresandlossofmeasuredtidalvolumes • • • • • • • • • Bronchospasm Mucous plug Inadequatemusclerelaxation Pulmonary edema Acutelunginjury/acuterespiratory distresssyndrome Autopeep Tension pneumothorax Bronchospasm Pulmonary edema Pneumothorax Autopeep Obstruction necessary. Increase sedationandconsiderneuromuscularblockadeif Exclude machinefailure. (furosemide 20mgIV). Administer adiureticifpulmonaryedemaispresent (albuterol 2–4puffsintotheETT). Administer abronchodilatorifbronchospasmissuspected. Suction theendotrachealtube. Begin manualventilation. Auscultate breathsounds. Increase FiO • • Mucus plug Kinkedendotrachealtube

2 to100%.

stula).

ating room. ABG samplescan guidechangesinventilatorstrategy intheoper- patient’s modeofventilationinorder toensureasafetransport. to orfromanICU.Theanesthesiologist mustbefamiliarwiththe way pressuresandhighlevelsofPEEP andoftenrequiretransport Patientswhoaredifﬁ cult toventilatemayhaveincreasedpeakair- SpecialConsiderations • • • Prevention • • • • • • SubsequentManagement • • • DiagnosticStudies

• • RiskFactors

• (ECMO). ventilation (APRV),orextracorporealmembraneoxygenation frequency oscillatoryventilation(HFOV),airwaypressurerelease If conventionalmechanicalventilationisinadequate,considerhigh Treat theunderlyingcauseofdecreasedcompliance. Consider CTscanofthechest,ifunderlyingcauseisunknown. evidence of“breathstacking”). Monitor forevidenceofautopeep(suddenhypotension,clinical Increase respiratoryratetoensureadequateminuteventilation. Decrease tidalvolumetolimitvolutrauma. Chest X-ray Measure plateaupressure Measure peakairwaypressures Monitor forsignsofautoPEEP. Consider useofneuromuscularblockingagentsifnecessary. Maintain adequatesedation. • • • • Aspiration High insufﬂ Intra-abdominal hypertension/abdominalcompartment Pulmonary hemorrhage Opioid-induced chestwallrigidity develop ARDSastheirdiseaseprogresses. Patients withdiffusepulmonaryinjury(infection,sepsis)may Patients withCOPDareatriskforautoPEEP syndrome

ation pressuresinlaparoscopicsurgery

321 CHAPTER 13 Respiratory Emergencies 322 CHAPTER 13 Respiratory Emergencies

• • • DIFFERENTIALDIAGNOSIS conditions. cular disordersandtrauma.Coagulopathymayexacerbatethese alveoli. Disruptioncanoccurinthesettingofinfection,tumor,vas- Disruptionofthepulmonaryvesselsliningtrachea,bronchior Pathophysiology tion ormalignancy. Hemoptysis maybethepresentingsymptomforpulmonaryinfec- Coagulopathy cantriggerhemoptysis,andanemiamaybepresent. positive pressureventilationmayoccurwithmassivehemoptysis. X-ray. Hypoxiawithincreasedpeakinspiratorypressures in theendotrachealtube.Diffusepulmonaryinﬁ ltrates onchest Reducedbreathsounds.Inanintubatedpatient,bloodmayappear Presentation the productionof300–600ccbloodina12–24hourperiod. Coughproductiveofbloodorbloodysputum.Massivehemoptysisis Deﬁ SchmidtG.Ventilatorwaveforms:clinicalinterpretation.In:JBHall,G FurtherReading

• • • • • • ImmediateManagement

Hemoptysis Hem

Schmidt, LDHWood(eds.). Gastrointestinal bleeding Pharyngeal trauma Nasal trauma McGraw-Hill; 2005:427–443. bleeding. Consider thepresence ofagastrointestinalsource irradiation, orsurgicalresection. ablation, bronchialarteryembolization, externalbeam For life-threateninghemoptysis,consider endobronchial bronchial blockertoisolatethebleeding site. Consider placementofadoublelumen endotrachealtubeor Consider bronchoscopytoidentify bleedingsite. source ofbleeding. Inspect thenoseandpharynxtoexcludeanupper-airway Increase FiO nition o ptys

2 tomaintainoxygenation. i s

Principles ofCriticalCare

. 3rded.NewYork:

Increasedarterial partialpressureofcarbondioxide (PaCO Deﬁ SakrL,DutauH.MassiveHemoptysis:An UpdateontheRoleofBronchoscopy AlbertR.Massivehemoptysis.In:JBHall,GSchmidt,LDHWood(eds.). FurtherReading hemoptysis. Frequentsuctioningoftheendotrachealtubemaycause SpecialConsiderations • • Prevention • • • • • SubsequentManagement bleeding. ChestCTandbronchoscopymaylocalizethesourceofpulmonary DiagnosticStudies mmHg)

• • • • • • • RiskFactors

Hypercarbia(Intraoperative)

in DiagnosisandManagement. PrinciplesofCriticalCare unsuccessful or multiple bleeding vessels are seen with angiography. unsuccessful ormultiplebleedingvesselsareseenwithangiography. Consider asurgicalconsultationifbronchialembolizationis Correct underlyingcoagulopathy.(See“Coagulopathy”) Avoid unnecessaryinstrumentationoftheairway. Consider plasmapheresisinpatientswithGoodpasturesyndrome. Consider acourseofsteroidsinpatientswithvasculitis. Identify andtreatthecauseofcoagulopathy. Identify andtreatthecauseofhemoptysis. Trauma Cardiac causes(e.g.,mitralstenosis) Pulmonary vascularabnormalities Tumor Infection Pulmonary-renal syndromes(Goodpasturesyndrome) Coagulopathy nition

( Int

. 3rded.NewYork:McGraw-Hill;2005:583–585.

aoperative Respiration

. 2010Jan8. )

2 >45

323 CHAPTER 13 Respiratory Emergencies 324 CHAPTER 13 Respiratory Emergencies production.

Hypermetabolic statesandfevermaycontributetoincreasedCO can leadtoincreaseddeadspace,hypoventilationandhypercarbia. ants cancausepostoperativehypercarbia.Splintingduetopain Residual anestheticeffectsorinadequatereversalofmusclerelax- compliance mayreduceminuteventilationandcausehypercarbia. obstruction insedatedpatientsoftenleadstohypercarbia.Poorlung tion. Hypoventilationduetodecreasedrespiratorydriveorairway

• • • • • • • • • • • DIFFERENTIALDIAGNOSIS HypercarbiaiscausedbyhypoventilationorincreasedCO Etiology Tachycardia,agitation,hypertension,andeventuallyobtundation. Presentation

• • • • ImmediateManagement

Malignant hyperthermia(see“SpecialConsiderations”below) Thyrotoxicosis Bicarbonate administration CO Sepsis Shivering Aspiration Severe pneumonia Acute lunginjury,acuterespiratory distresssyndrome Bronchospasm (COPDorasthmaexacerbation) • • • • Hypoventilation Splinting Inadequatereversalofmusclerelaxant Narcoticsoroversedation Lowminuteventilation increments) reversal ofopioidswithnaloxone.(Naloxone0.04mgIV In aspontaneouslybreathingpatient,considerjudicious laparoscopic surgery. Ask thesurgeontolowerinsufﬂation pressureduring Increase minuteventilationtoreducePaCO necessary. Intubate thetracheaandinitiatemechanicalventilationif 2 insufﬂation duringlaparoscopy

2 .

2 produc-

LaneJ.Postoperative respiratoryinsufﬁ FurtherReading • • SpecialConsiderations • • • Prevention • • SubsequentManagement and acidosis. Arterialbloodgasanalysis(ABG)toquantifydegreeofhypercarbia DiagnosticStudies

• • • • • • • • RiskFactors

and increasedpulmonaryvascularresistance. depression, alteredmentalstatus,increasedintracranialpressure severe hypertension,hyperkalemia,arrhythmias,myocardial compensated forintheacuteperiod.Hypercarbiamaycause Hypercarbia causesrespiratoryacidosisthatcannotbe Adequate minuteventilation,especiallyinlaparoscopicsurgery Adequate reversalofmusclerelaxants Judicious useofnarcoticsandothersedatives ventilation (CPAP,BiPap)ifnecessary Endotracheal intubationornoninvasivepositivepressure Treat theunderlyingcauseofhypercarbia RapidlyrisingETCO immediately. (See“MalignantHyperthermia,” Page114.) MH mustbediagnosedquicklyand treatmentinitiated rising temperaturemaybecaused bymalignanthyperthermia. in Anesthesia Narcotic administration Poor lungcompliance Asthma COPD Chronic CO Obstructive sleepapnea(OSA) Obesity CO Laparoscopic surgery(insufﬂation ofperitonealcavitywith 2 ) . 2nded.Philadelphia: SaundersElsevier;2007:877–880.

2 retainers

inconjunctionwithtachycardiaand

ciency

In:JLAtlee(ed.).

Complications

325 CHAPTER 13 Respiratory Emergencies 326 CHAPTER 13 Respiratory Emergencies

• • • • • • • • DIFFERENTIALDIAGNOSIS • • • • • • • • Etiology DecreasedSpO Presentation Decreasedpartialpressureofoxygenintheblood(PaO Deﬁ often manifestedbyadecreaseinSpO dia, arrhythmias,andneurologicalmyocardialischemia. Left untreated,hypoxemiamayprogresstohypotension,bradycar-

• • • • ImmediateManagement

Hypoxemia(Intraoperative) Hypoxemia

Bronchospasm Presence ofamucus plug Atelectasis Hypoventilation Airway obstruction Right mainstemintubation Mechanical disconnectfromventilator orO Esophageal intubation Anesthesia machinemalfunction Intrapulmonary shuntduetomainstembronchusintubation Ventilation perfusionmismatching inhaled anesthetics) Blunted hypoxicpulmonaryvasoconstriction(maybecausedby Atelectasis andalveolarshunting Position (supinepositiondecreasesFRC) Decrease infunctionalresidualcapacity(FRC) surgery withmonitoredanestheticcare(MAC). hypoventilation andairwayobstructioninpatientsundergoing Oversedation and/ornarcoticoverdosecancause failure isimminent. mechanical ventilationforseverehypoxiaorifrespiratory If thepatientisnotalreadyintubated,considerintubationand Check ETCO Ascultate thelungﬁelds toassessbreathsounds. Increase FIO nition

2 2 to100%whileassessingpatient. 2 ,cyanosis,andpossiblyhypertensionagitation. toensurethattheETTisintrachea. ( Intraoperative

2 . )

2 source

2 <60mmHg)

LaneJ.Postoperative respiratoryinsufﬁciency. In:JLAtlee(ed.). FurtherReading complications, i.e.,hypotension,arrhythmias andendorgandamage. ing. Promptdiagnosisandtreatment areessentialtopreventingfurther an anesthesiologistencounters,andshould beconsideredlifethreaten- Intraoperativehypoxemiaisoneof the mostcommonproblemsthat SpecialConsiderations • • • Prevention • • • SubsequentManagement • • • DiagnosticStudies • • • • • •

• • • • • • • RiskFactors

breathing spontaneously. Use narcoticsandsedativescarefullyinpatientswhoare Conﬁ Prepare forendotrachealintubationandmechanicalventilation. Treat theunderlyingcauseofhypoxemia. Administer supplementalO obstruction). Consider bronchoscopy(assessETTplacement,ﬁnd apossible Chest X-ray Arterial bloodgasanalysis(ABG)toquantifyPaO Low cardiacoutputstate Aspiration Acute lunginjury Pulmonary edema Pulmonary embolus Pneumothorax Ensure thatthepatientisadequatelyventilated. in Anesthesia Shivering Obesity Advanced age Use ofnarcotics Aspiration risk Obstructive sleepapnea(OSA) Underlying pulmonarydisease rm ETTplacementwithcapnographyandauscultation. . 2nded.Philadelphia: SaundersElsevier;2007:877–880.

tomaintainoxygenation.

Complications

327 CHAPTER 13 Respiratory Emergencies 328 CHAPTER 13 Respiratory Emergencies

• SubsequentManagement • • • DiagnosticStudies • • • • DIFFERENTIALDIAGNOSIS resulting indecreasedvenousreturnandhypotension. major veinsatthethoracicinletofneckandinferiorvenacava, ral pressureincreasessigniﬁcantly, mediastinal shiftcauseskinkingof trapped inthepleuralspacecausingcollapseoflung.Ifintrapleu- occurs afterinjurytothepleuralspace.Witheachinspiration,gasis Atensionpneumothoraxoccurswhenaone-wayvalvemechanism Pathophysiology sion pneumothoraxisoftenassociatedwithhypotension. plateau pressuresoccurinmechanicallyventilatedpatients.Aten- be heardontheaffectedside.Increasedpeakairwaypressuresand side withpercussion.Decreasedorabsentbreathsoundsmayalso occur. Itmaybepossibletohearhyperresonanceontheaffected becomes larger,hypoxia,tachypnea,tachycardia,andchestpainmay Asmallpneumothoraxisoftenasymptomatic.Asthe Presentation escape (i.e.,tensionpneumothorax). of thelung.Thisconditionmaybelifethreateningifgascannot Presenceofgas,usuallyair,inthepleuralcavitythatleadstocollapse Deﬁ

• • • ImmediateManagement

P Pneumothorax

Bronchoscopy ifbronchial treeinjuryissuspected Chest X-ray(lungcollapseandmediastinal shift) Percussion (hyperresonance). Auscultation (absentbreathsounds ontheaffectedside) Severe bronchospasm Endobronchial intubation Mucus plug Hemothorax Insert achesttube. mid-clavicular lineinthe2ndintercostalspace(seeFigure13.1). Decompress thepleuralspacewithalargeboreneedlein Increase FIO neu nition m o

t h 2 to100%. orax

AliJ.TorsoTrauma. In:JBHall,GSchmidt,LDHWood(eds.). FurtherReading develop apulselesselectricalactivity (PEA)cardiacarrest. Tensionpneumothoraxshouldbe consideredinpatientswho SpecialConsiderations • • Prevention • • Figure13.1

• • • • RiskFactors

Critical Care Avoid excessivetidalvolumeorpeakairwaypressure. Chest tubemanagement pneumothorax Surveillance chestX-raytoevaluateprogressionof progression ofasmallpneumothorax toatensionpneumothorax. Chest X-rayorimagingaftercentrallineplacementtoprevent Blebs Excessive tidalvolumesorpeakairwaypressures Laparoscopic surgery Central lineplacement

Decompression oftensionpneumothorax. . 3rded.NewYork: McGraw-Hill;2005:1421–1441.

Principles of

329 CHAPTER 13 Respiratory Emergencies 330 CHAPTER 13 Respiratory Emergencies examination. and agitation.Jugularvenousdistensionmaybeseenonphysical cheal tube.Inanawakepatient,respiratorydistress,tachycardia over thelungﬁ elds. Frothysputummaybenotedinthe endotra-

• • • • DIFFERENTIALDIAGNOSIS • • • Pathophysiology often hypoxemiaanddecreasedSpO Thefi rst signsofpulmonaryedemainananesthetizedpatientare Presentation parenchyma. Theabnormalaccumulationofextravascularfl uid inthelung Defi

• • • • • ImmediateManagement

PulmonaryEdemaP

Aspiration pneumonitis Neurogenic pulmonary edema Acute lunginjury/ARDS Aspiration pneumonitis pulmonary vasculaturetotheinterstitium. hydrostatic pressuregradient,causingﬂuid tomovefromthe when negativeintrapleuralpressureincreasesthepulmonary Negative pressureorpostobstructionpulmonaryedemaoccurs left ventriculardysfunctionand/orvalvularabnormalities. often occurswhentheleftatrialpressureishighinsettingof drainage fromthepulmonaryvasculaturetoleftatrium.This Cardiogenic pulmonaryedemaiscausedbyimpairedvenous cardiogenic). (cardiogenic) orincreasedcapillarypermeability(non- Occurs duetohighpulmonaryandvenoushydrostaticpressure Initiate diuresis(startwithfurosemide20mgIV). Increase FIO Treat theunderlyingcause. Congestive HeartFailure,inchapter 2,Page31) kg/min) andsupportbloodpressurewithvasopressors.(See reduction withnitroglycerine(Infusionstartingat0.5mcg/ If cardiogenicpulmonaryedemaissuspected,considerafterload the patientishypoxicorrespiratoryfailureimminent. Intubate thetracheaandbeginpositivepressureventilationif ulmonar nition

2 y to100%.

Ed ema

2 .Ralesorwheezingareheard

when ﬂuids aremobilized. Cardiogenic pulmonary edemamayoccur2–3days postoperatively Negativepressure pulmonaryedemaoftenresolves within 24hours. SpecialConsiderations • • • Prevention • • • SubsequentManagement • • DiagnosticStudies • • •

• • RiskFactors

management, i.e.diuresis. Central venouspressuremonitoringmayaidinmedical Serial arterialbloodgasmeasurements. Ventilatory supportincludingPEEP edema. between cardiogenicandnoncardiogenicpulmonary Pulmonary arterycatheterorechocardiogramcandifferentiate pulmonary arteries) Chext X-ray(bilateralpulmonaryinﬁltrates andedemaaround Transfusion RelatedAcuteLungInjury(TRALI) TACO (transfusionassociatedcirculatoryoverload) Fat embolism Identify patientsatriskforairwayobstruction. patients withcoronaryarterydisease. Ensure adequateperfusionpressure andavoidtachycardiain function. Avoid ﬂuid overloadinapatientwithcompromisedmyocardial • • • • • • • Negative Pressure • • Cardiogenic Tonsillar hypertrophy Upperairwaytumororforeignbody Upperairwayobstruction Valvular abnormalities Myocardial Infarction Volume overload Laryngospasm Diastolic dysfunction Systolic dysfunction

331 CHAPTER 13 Respiratory Emergencies 332 CHAPTER 13 Respiratory Emergencies

• • • • • • DIFFERENTIALDIAGNOSIS increases. alveolar toarterialgradientisoftenseen.Rightventricularafterload Gas exchangebecomesimpairedasdeadspaceincreases.Awidened also becausedbyair,fat,carbondioxideoramnioticfl in thelowerextremitydeepveinsystem.Pulmonaryembolismcan the settingofvenousstasisorinjury,andmostthrombioriginate dislodged andtravelstothelungs.Thisoccursmostcommonlyin Pulmonarythromboembolismoccurswhenavenousthrombusis Pathophysiology ETCO present withsuddenhypoxia,hypercarbia,tachypnea,decreased pnea, hemoptysis,andchestpain.Patientswithlargeembolimay presenting symptoms.Somepatientsmaypresentwithatriadofdys- undected; unexplainedfever,tachycardia,andralesmaybetheonly Thesignsandsymptomsmaybesubtle.Smallemboligo Presentation fat, air,carbondioxideoramnioticfl tually travelstothelungs.Pulmonaryembolusmayalsobecausedby commonly byavenousthrombusthatbecomesdislodgedandeven- Obstructionofapulmonaryarteryoroneitsbranches,most Defi HuntSA,AbrahamWT,ChinMH,FeldmanAM,FrancisGS, AliJ.Specialconsiderationsinthesurgicalpatient.In:JBHall,GSchmidt,LDH FurtherReading

PulmonaryEmbolus Pulmo 2009 Apr14;53(15):e1–e90. International SocietyforHeartandLungTransplantation. Task ForceonPracticeGuidelinesDevelopedinCollaborationWiththe American CollegeofCardiologyFoundation/AmericanHeartAssociation Diagnosis andManagementofHeartFailureinAdultsAReportthe Focused updateincorporatedintotheACC/AHA2005Guidelinesfor 2005:1321–1330. Wood (eds.). Severe bronchospasm Acute myocardial infarction Amniotic ﬂ Fat embolism Air embolism Thromboembolism nition 2 ,andcirculatorycollapse. nar

uid embolism Principles ofCriticalCare

y Embolus

uid emboli. . 3rded.NewYork:McGraw-Hill; J AmCollCardiol. uid emboli. uid et al : 2009

• • • SubsequentManagement • • • • • DiagnosticStudies • •

• • • • • • ImmediateManagement

• RiskFactors

contraindicated. Consider insertinganinferiorvenacavaﬁlter ifanticoagulationis Continue anticoagulationifindicated. Identify thesourceofembolism. strain Echocardiography toevaluateforrightventriculardilationor thrombosis Noninvasive venousdopplerstudiestoassessfordeepvein Ventilation-perfusion scan perioperative setting. D-dimer isoflimitedvalue,aslevelsareoftenelevatedinthe Helical chestcomputerizedtomographyangiography Pneumothorax Anaphylaxis severe. Consider intubationandmechanicalventilationifhypoxiais Increase FIO of hemodynamicinstability. *Consider thrombolytictherapyorembolectomyinthesetting then 18units/kg/hIV,titratedtotherapeuticINR) thromboembolism isdiagnosed.(Heparin80units/kgIVbolus, Begin systemicanticoagulationifnotcontraindicatedanda Consider rightventricularafterloadreductionwithnitricoxide. Support circulationwithﬂuid, vasopressors,andinotropes. • • • • • • • Thromboembolism Pregnancy Indwellingcentrallines Hypercoagulable states Immobility Obesity Surgeryandtrauma Malignancy

to100%maintainoxygenation.

333 CHAPTER 13 Respiratory Emergencies 334 CHAPTER 13 Respiratory Emergencies

0.3 micrometers. rectly, itshouldfi lter outatleast95percent ofparticlesassmall the noseandmouthisdesigned tohaveatightfi t. Ifworncor- than atraditionalfacemask.(Figure 13.2)AnN95respiratorcovers for patientswithsuspectedH1N1. TheN95maskistighter-fi diseases. same timemakingsuretoprotect themselvesfromcommunicable rapid andappropriatecarewhenmanaginganairway,whileatthe and especiallytheanesthesiologist.Anesthesiologistsmustprovide infl Bioterrorism,SARS,multi-drugresistanttuberculosis,andH1N1 PatelK,ChaneyM.Hypercoagulablestates:thrombosisandembolism.In: DeLougheryTG.Venousthromboticemergencies. FurtherReading • • • SpecialConsiderations • • • Prevention

Risk Factors(continued) •

RespiratoryPrecautions Respirator

Elsevier; 2007:361–364. JL Atlee(ed.). 2009;27(3):445–458. Intermittent compressionstockings Pulmonary embolusshouldbeconsideredinpatientswithPEA. dysfunction andmortality. Brain natriureticpeptidelevelspredictrightventricular must takeintoconsiderationtheriskofpostoperativebleeding be complicatedinpatientswhorecentlyunderwentsurgery,and The decisiontoadministeranticoagulantsorthrombolyticsmay Early mobilizationaftersurgery Subcutaneous heparininhigh-riskpatients TheCDCrecommendsuseofN95 respiratormaskswhilecaring uenza havebroughtnewconcernstothehealthcareprovider, • • • Other embolicevents Hipreplacement (fatembolus) Laparoscopic surgery(CO Sittingcraniotomy (airembolus) Complications inAnesthesia y Precautions

2 embolus)

. 2nded.Philadelphia:Saunders

Emerg MedClinNAm. tting

Figure13.2 contained breathingapparatus. precautions, includingpotentiallyasplashprotectivesuitandself- ities andtheCDCforlikelypathogenstakefurtherproper and ﬂ uid shieldsshouldbeworn.Immediatelycontactlocalauthor- gist, aswellotherpatients. Additionally, wearingagownmayfurtherprotecttheanesthesiolo- tric contentsorotherbodilyﬂ is alsorecommendedtoprotectagainstcontactwithsputum,gas-

Theuseofeyeprotectionintheformﬂ uid shieldsorgoggles Ifabioterrorismstrikeissuspected,gown,gloves,N95respirators

Standard ﬂuid shieldmask(top)andN95respirator(bottom). uidswhilesecuringapatient’sairway.

335 CHAPTER 13 Respiratory Emergencies This page intentionally left blank Chapter 14 Surgical Emergencies Linda L. Maerz and Stephen M. Luczycki

Bleeding after Carotid Endarterectomy 338 Bleeding after Thyroid Surgery 340 Facial Trauma 342 Laparotomy in the Critically Ill Patient 344 Massive Hemorrhage 347 Neck Injury 350 Ruptured Abdominal Aortic Aneurysm 352 Ruptured Ectopic Pregnancy 355 Upper GI Bleeding 358 337

338 CHAPTER 14 Surgical Emergencies

• • AnatomyandPathophysiology • • • • Presentation hemorrhage israre(occursinlessthan1%–4%). sels orrawtissueaftercarotidendarterectomy(CEA).Postoperative Bleedingfromthecarotidartery,internaljugularvein,smallerves- Deﬁ

• • • • • ImmediateManagementofAcuteRespiratoryDistress

BleedingafterCarotidEndarterectomya

from disruptionofthesuturelineoccursrarely. saturation isalateoccurrence.Hypotensionduetoexsanguination tachypnea mayoccur,possiblyduetoanxiety.Decreasedoxygen or disruptionoftheinternalcarotidartery.Tachycardiaand Neurologic symptomsmayrarelyoccurasaresultofcompression airway compromise. In theawakepatient,anxietymaybeﬁrst symptomofearly cause life-threateningairwaycompromise. An acuteneckhematomaexertspressureonthelarynxandmay pulsatile. An expandinghematomamaydevelop,whichornotbe compromise. New onsetofdysphoniaandstridorarediagnosticairway occur. Arterial bleeding may result in exsanguinating hemorrhage. occur. Arterialbleedingmayresultinexsanguinatinghemorrhage. in whichvein-patchangioplastyisemployed,veinpatchrupturemay endarterectomy siteisanotherpotentialsource.Inthoseinstances or effectsofanti-plateletagentsalsooccurs.Thesuturelinethe Diffuse microvascularbleedingfromresidualheparineffectand/ and arterialbleedingatsitesremotefromthecarotidarteryitself. Sites ofoperativehemorrhageafterCEAincludebothvenous evacuation. if endotrachealintubation isnotpossibleinspiteofhematoma Rapid establishment ofasurgicalairwaymayrarelynecessary accomplish endotrachealintubation. It maybenecessarytoevacuatethe hematomaﬁrst inorderto clinical situationpermits. the airway.Transportpatientto theoperatingroomif initially appearsbenigncanrapidlyprogress andcompromise Immediate re-explorationismandatory. Evenahematomathat Elevate theheadofbed. Increase FiO nition

2 to100%. f ter

C arotid Endarterectomy

• • • Prevention • • SubsequentManagement • • • DiagnosticStudies • • • • • • DIFFERENTIALDIAGNOSIS

• • • • • • RiskFactors

isolation andrepair. Be preparedforamajorvascularoperation,includingcarotid the ORforexplorationofoperativesite. After adeﬁnitive airwayisestablished,transportthepatientto be usedtoestablishthediagnosis. carotid duplexultrasoundanddiagnosticcervicalmay In moresubtlehemorrhagewithoutacuteairwaycompromise, (i.e., imaging)arenotusuallyfeasible. Because thepatientcandeterioraterapidly,diagnosticstudies high indexofsuspicionarecritical. This isprimarilyaclinicaldiagnosis.Physicalexaminationand Pulmonary embolus Acute coronarysyndrome Tension pneumothorax Acute pulmonaryedema Laryngeal edema Anaphylaxis greater saphenous veinharvestedfromthethigh. The incidenceofvein patchrupturecanbeminimized byusing procedure. Consider reversalofheparinthatwas administeredduringthe Meticulous hemostasisatthetime of theoriginaloperation vein patchprocedure. The useofasmallveinmayincreasetheriskruptureafter Postoperative anticoagulationwithheparinorwarfarin Failure toreverseheparinwithprotaminesulfate perioperative period Perioperative useofaspirinorotheranti-plateletagentsinthe Perioperative hypertension Surgical technique

339 CHAPTER 14 Surgical Emergencies 340 CHAPTER 14 Surgical Emergencies RilesTS,RockmanCB.Cerebrovasculardisease.In:CMTownsend,RD

• • Pathophysiology • • • • Presentation vessels afterthyroidsurgery. Bleedingfromtherawthyroidsurface,dissectedmuscles,orblood Deﬁ RerkasemK,RothwellPM.Localversusgeneralanaesthesiaforcarotidendar- FurtherReading line disruption. airway compromiseor,rarely,exsanguinationfromarterialsuture Thiscomplicationispotentiallylife-threateningbecauseofassociated SpecialConsiderations

BleedingafterThyroidSurgery Beauchamp, BMEversetal.(eds.). Saunders; 2007:1882–1904. terectomy. patients withthyroid malignancies. abnormal bleeding tendency,butcoagulopathymay also occurin Patients whohavehypothyroidism are themostlikelytohavean most commonabnormalityresembles vonWillebrand’sdisease. surgery havevariousacquiredabnormalities ofcoagulation.The Up to3%ofpatientswiththyroiddiseases undergoingthyroid life-threatening airwaycompromise. pressure resultsincompressionof the larynx,whichcanleadto When anacutehematomaoccursin theneck,resulting vessels deeporsuperﬁcial tothecervicalstrapmusculature. bleeding andarterialbleeding.Themayoriginatefrom include therawsurfacesofresidualthyroidtissue,venous Sources ofpostoperativehemorrhageafterthyroidsurgery a hematomauntilprovenotherwise. may notbeassociatedwithbleedingfromtheincision,represents A newneckmassinproximitytotheoperativesite,whichmayor New onsetofdysphoniaandstridorindicateairwaycompromise. airway compromise. In theawakepatient,anxietymaybeﬁrst symptomofearly occurrence. compromise mayoccur.Decreasedoxygensaturationisalate Tachycardia andtachypneaduetoanxietyorairway nition

Cochrane DatabaseSystRev

Sabiston TextbookofSurgery.

. 2008Oct8;(4):CD000126.

Philadelphia:

detection andtreatment ofreversiblecoagulopathy. tion screeningto identify patientsatincreasedriskof bleeding.Early Meticuloushemostasis atthetimeofsurgery.Preoperative coagula- Prevention site isperformedandthesourceofhemorrhagecontrolled. Afteradeﬁ nitive airwayisestablished,explorationoftheoperative SubsequentManagement • • DiagnosticStudies • • • • • • DIFFERENTIALDIAGNOSIS

• • • • • RiskFactors • • • • ImmediateManagementforAcuteRespiratoryDistress

Advanced

diagnostic studies. The urgencyofthesituationprecludesimagingorother Physical examinationandahighindexofsuspicion. Pulmonary embolus Acute coronarysyndrome Tension pneumothorax Acute pulmonaryedema Laryngeal edema Anaphylaxis Male gender heparin, warfarin,clopidogrel) Underlying bleedingdiathesisortheuseofanticoagulants(e.g., Extensive surgery Surgical techniqueismostcommonlyresponsible. intubation isnotpossibleafterhematomaevacuation. A surgicalairwaymayrarelybenecessaryifendotracheal restored, endotrachealintubationisusuallypossible. After thehematomaisevacuatedandlaryngealanatomy immediate management. the operatingroomunlessairwaycompromiserequires hematoma ismandatory.Ifpossible,transportthepatientto Immediate surgicalexplorationandevacuationofthe Administer 100%.FiO age

341 CHAPTER 14 Surgical Emergencies 342 CHAPTER 14 Surgical Emergencies BergenfelzA,JanssonS,Kristofferssonetal.Complicationstothyroidsur- HanksJB,SalomoneLJ.Thyroid.In:CMTownsend,RDBeauchamp,BM involve thebrainor neck. from simplelacerations tohighvelocitymissileinjuries thatmayalso injury andmultipleremotesitesof injury. Penetratingtraumaranges Blunttraumamaycausepanfacial fractures,signiﬁ cant softtissue AnatomyandPathophysiology • • Presentation mised asaresultoftheinjury. life-threatening, unlessairway,breathing,orcirculationarecompro- Maxillofacialinjuriesmaybedramaticinappearancebutarerarely Deﬁ BacuzziA,DionigiG,DelBoscoetal.Anaesthesiaforthyroidsurgery: FurtherReading compromise. of <1%,thesecomplicationsmaybelife-threateningduetoairway Althoughbleedingandwoundhematomashaveanoccurrencerate SpecialConsiderations

FacialTraumaFac 3,660 patients. gery: resultsasreportedinadatabasefrommulticenterauditcomprising 2007;917–952. Evers, etal.(eds.). perioperative management. • • • • • • Compromise ofcirculationresultinginhemorrhage: • Compromise ofairwayandbreathing:

cyanosis, droolingorineffectivegagreﬂ Signs ofimpendingrespiratoryobstructionincludestridor, LeFort fractures Tongue lacerations Scalp lacerations airway obstruction. Aspiration ofteeth,blood,vomitus,orforeignbodiescancause Epistaxis maxillary andmandibularfractures. of multiplemandibularfracturesorthecombinationnasal, Airway obstructionmayresultinearlydeaththesetting nition i al Trauma

Langenbecks ArchSurg.

Sabiston TextbookofSurgery

Int JSurg

. 2008;6Suppl1:S82–S85. 2008;393:667–673.

ex. . Philadelphia:Saunders;

in ordertoprevent lossoflife. Associated injuries, however,areseriousandmustbe managedfi Maxillofacialinjuriesthemselves areseldomlife-threatening. Prevention • • • • SubsequentManagement defi CTscanisthestandardofcare.Panorexfilms areausefuladjunctfor DiagnosticStudies • • • • ASSOCIATEDINJURIES

• • • • ImmediateManagement

• • follows: Early tracheostomyshouldbeconsideredinselectedpatientsas fi Management ofassociatedlife-threateninginjuriesisundertaken Hemorrhage fromothersites Cervical spineinjury Brain injury Airway obstruction fractures, usuallyoccursinadelayed timeframe. Defi physical examinationandradiographic examination. remain inplaceuntildefinitive clearancebyacombination of Assume thatthecervicalspineisunstable.Acollarshould • • • • • • rst.

Establish large-boreperipheralintravenousaccess. Local controlofhemorrhage. Maintain cervicalspinestabilizationduringairwaymanagement. intubation iscontraindicated. airway iforotrachealintubationisnotpossible.Nasotracheal Secure theairway:orotrachealintubationifneeded;surgical ning mandiblefractures. profuse nasalbleeding pan-facial fractures patients withalteredmentalstatus severe softtissueedemaintheproximityofairway severe facialburns need forprolongedintubation difﬁ high spinalcordinjuries nitive managementoffacialinjuries,particularly facial

cult airwaycharacteristics

rst

343 CHAPTER 14 Surgical Emergencies 344 CHAPTER 14 Surgical Emergencies • • Pathophysiology • • • • Presentation syndrome. ing infection,hemorrhage,ischemia,andabdominalcompartment Indicationsforlaparotomyinthecriticallyillincludelife-threaten- Deﬁ CappuccinoGJ,RheeST,GranickMS.Maxillofacialinjuries.In:JAAsensio, FurtherReading

KellmanRM,RontalML.Face.In:DVFeliciano,KLMattox,EEMoore(eds.). PierreEJ,McNeerRR,ShamirMY.Earlymanagementofthetraumatizedair-

LaparotomyintheCriticallyIllPatient DD Trunkey(eds.). • • • • coagulopathy. setting ofmassive transfusionareassociatedwithlife-threatening Persistent hypothermia andprogressivemetabolicacidosis inthe • scheme isasfollows: characterized invariouswaysbasedonetiology.Aclinicallyuseful nutrients totissues,aresultofhypoperfusion.Shockis Shock isdefined as theinadequatedeliveryofoxygenand severe physiologicdecompensation. arterial bloodpressure.Thepresenceofhypotensionimplies Signifi hyperlactacidemia andincreasedbasedefi perfusion, includingalteredmentalstatus,oliguria,tachypnea, Symptoms mayincludesignsofimpairedend-organ Shock (hemorrhagic,septicortraumatic)isusuallypresent. laparotomy. Signs andsymptomsvarywithetiologyindicationfor Trauma Philadelphia: Mosby;2008:175–181. way.

activation ofproinﬂ Traumatic (acombinationofhemorrhage, ischemia,reperfusion, Cardiogenic (myocardialinfarction, tamponade,arrhythmias) Obstructive (pulmonaryembolus,pneumothorax) spinal cordinjury,liverfailure,anaphylaxis) Vasodilatory/distributive (sepsis,adrenalinsufﬁ peritonitis, pancreatitis,bowelobstruction) Hypovolemic/hemorrhagic (acutehemorrhageofanyetiology, nition Anesthesiol Clin cant tissuehypoperfusioncanoccurinspiteofanormal . NewYork:McGraw-Hill;2008:437–466.

. 2007Mar;25(1):1–11. ammatory cascades)

Current TherapyofTraumaandCriticalCare . C ritically IllPatient

cit.

ciency, high

• • SubsequentManagement • • • DiagnosticStudies • • • • DIFFERENTIALDIAGNOSIS

• • • • • • • • ImmediateManagement

abdominal hemorrhage. expeditiously performedinthetraumabaytoconﬁ for trauma(FAST)anddiagnosticperitoneallavagecanbe In theunstabletraumapatient,focusedabdominalsonography and physicalexamination. be indicatedbasedonadiagnosismadefromtheclinicalscenario If thepatientistoounstableforCTscan,emergencysurgerymay intra-abdominal catastrophes. Abdominal andpelvicCTscanisthestandardfordiagnosisof Massive pulmonaryemboluswithcardiovascularcollapse cardiovascular collapse Massive myocardialinfarctionwithacutecardiacfailureand lacerations) bone fractures,thoracicinjuries,openextremitywounds,scalp Hemorrhage fromextra-abdominaltrauma(pelvicfractures,long- Cardiovascular collapsefromextra-abdominalsourceofsepsis hypotension incritically illpatientswhohavehighcirculating Sympathomimetic agents(e.g.,ketamine)maycause profound (0.3 mg/kgIV)ifthe patientishemodynamicallyunstable. volume statusand medicalcondition.Consideretomidate and perfusion.Inductionagentsare chosenbasedonthepatient’s Anesthetic managementshouldfocus onmaintainingoxygenation Communication withthesurgicalteam isessential. and plateletdysfunction Promptly identifyandcorrectcoagulopathy,thrombocytopenia, hemorrhagic shock) with packedredbloodcells(PRBCs)ifindicated(i.e,for Begin aggressiveresuscitationwithIVﬂ access. Establish large-boreperipheralIVaccessorcentralvenous Increase FiO Intubate thetracheaandinitiatemechanicalventilation. therapy (septicshock) Begin broad-spectrumempiricorculture-directedantibiotic Consider epinephrineinfusionstartingat0.03–0.05mcg/kg/min. shock). Support bloodpressurewithvasopressorsifindicated(septic 2 tomaintainadequateoxygenation.

uids. Transfuse

rm intra-

345 CHAPTER 14 Surgical Emergencies 346 CHAPTER 14 Surgical Emergencies

• SpecialConsiderations ated endorgandysfunction,complications,anddeath. development ofshockmaypreventsigniﬁcant hypoperfusion,associ- Earlydiagnosisofimpendingintra-abdominalcatastrophepriorto Prevention • •

• • • RiskFactors

positive pressuremechanicalventilation. exacerbated bythetransitionfromspontaneousventilationto or hemorrhage;myocardialdysfunction;pain).Hypotensionis levels ofendogenouscatecholamines(hypovolemiafromsepsis injuries. mechanical ventilationcircuit),andpreventionofpositioning air blanket,elevatedroomtemperature,humidiﬁcation ofthe volume status,bodytemperature(ﬂuid warmer,forcedhot myocardial dysfunction.Paycloseattentiontothepatient’s for hemodynamicallyunstablepatientsandthosewithunderlying less vasodilationandnegativeinotropymaybeappropriate pathophysiology. Anarcoticbasedtechniqueisassociatedwith due tosurgicalmanipulationandthepatient’sunderlying Instability duringthesurgicalprocedureismostlikely • • • Abdominal compartmentsyndrome: ongoing resuscitationintheICU. many patientswillrequireprolongedmechanicalventilationand extubation. Dependingonthedegreeofphysiologicimpairment, surgery toallowfordelayedemergenceandpossiblesubsequent patients remainintubatedandmechanicallyventilatedafter hemodynamic instabilityinthepostoperativeperiod.Most from anesthesiamoreslowlyandarelikelytohave Patients undergoingemergencylaparotomytypicallyemerge •

Chronic illness;comorbidities Advanced age The lethaltriad:hypothermia,acidosis,coagulopathy Bladder pressureisusedtoassessintra-abdominal pressure. ischemia-reperfusion oftheabdominalviscera. pelvic fractures,severeburns,massive resuscitation,and Etiologies includebluntandpenetrating abdominaltrauma, (most commonlyoliguriaandelevated peakairwaypressures) Abdominal hypertensionwithassociated endorgandysfunction decompressive laparotomy, leavingtheabdomenopen. Treatment isabdominal decompression,typicallyvia

TiwariA,HaqAI,MyintF,etal.Acutecompartmentsyndromes. • • Deﬁ MoayedO,DuttonRP.Anesthesiaandacutecaresurgery.In:LDBritt,DD AsensioJA,McDufﬁ e L,PetroneP,etal.Reliablevariablesintheexsan- FurtherReading •

MassiveHemorrhageHemorrha 2002;89:397–412. New York:Springer;2007:30–42. Trunkey, DVFeliciano(eds.). J Surg guinated patientwhichindicatedamagecontrolandpredictoutcome. • • gastrointestinal andobstetric. Major categoriesofmassivehemorrhageincludetraumatic, • Damage controlsurgery: • Classes ofhemorrhagicshock: • • • •

and cardiovascularcollapse,isessential. Early decompression,priortoirreversibleendorganischemia underlying pathophysiology. Mortality ratesof60%–70%reﬂect delayeddiagnosisand be usedforcriticallyillnontraumapatients. hypothermia, coagulopathyandacidosis.Thisstrategycanalso trauma patientswithabdominalinjuriescomplicatedby Damage controlisthepreferredmanagementstrategyfor Class I:bloodlossupto750cc(up to15%ofbloodvolume) derangements occursintheICU. Ongoing resuscitationandcorrectionofphysiologic a temporaryabdominalclosureinplace. hemorrhage andcontamination;theabdomenisleftopenwith Limited initialoperationfortheimmediatecontrolof occurs inthestabilizedpatient. Subsequent operationforcorrectionofanatomicabnormalities Class II:bloodloss750–1500cc(15–30% ofbloodvolume) nition • • • • • •

Heart rate<100 Blood pressurenormal Pulse pressurenormalorincreased Heart rate>100 Blood pressurenormal Pulse pressuredecreased . 2001;182:743–751.

Acute CareSurgery:PrinciplesandPractice. e

Br JSurg . Am 347 CHAPTER 14 Surgical Emergencies 348 CHAPTER 14 Surgical Emergencies

Hemorrhagicshockisacomplexspectrumofevents: Pathophysiology • • • • Presentation

• • • • • • ImmediateManagement

• • • • metabolic demands. Oliguria is caused by renal hypoperfusion. metabolic demands.Oliguriaiscausedbyrenalhypoperfusion. spontaneous minuteventilationincreasesinordertomeetincreased degree ofshockprogresses.Tachypneaprogressesasthepatient’s status changesprogressfromanxietytoconfusionlethargyasthe Severe shockisnotableforcool,moist,pallidorcyanoticskin.Mental injury. loss associatedwithtraumaispainduetothe Gastrointestinal bloodlossistypicallypainless,while Symptoms dependontheetiologyofhemorrhage. • examination. The sourceofhemorrhagemayornotbevisibleonexternal Perturbation ofvitalsignsdependsonthedegreebloodloss. •

PT, PTT,INR,fibrinogen andplatelet count. If timepermits,identify andcorrectspecifi continued microvascular bleeding. and plateletsina1:1:1ratio.Administer cryoprecipitatefor minimal useofcrystalloidsolutions anduseofplasma,PRBCs for massivetransfusiontherapyintraumatic injuryinclude If laboratorystudiesarenotfeasible, currentrecommendations Ringer’s solutionornormalsalinesolution) Interstitial resuscitationwithcrystalloid solutions(e.g.,lactated Consider activatingthemassivetransfusion protocol. Transfuse withpackedredbloodandfactorscellsasindicated. Establish large-boreperipheralandcentralIVaccess. Intubate thetracheaandinitiatemechanicalventilation. Multiple organdysfunction Infl Ischemia-reperfusion injury Acute massivebloodlossresultingincirculatorycollapse Class III:bloodloss1500–2000cc(30–40%ofvolume) Class IV:bloodloss>2000cc(>40%ofvolume) • • • • • •

Heart rate>120 Blood pressuredecreased Pulse pressuredecreased Heart rate>140 Blood pressuredecreased Pulse pressuredecreased ammatory andanti-inﬂ

ammatory responses

c deﬁ

cits withserial

resuscitation, regardlessof theetiologyof hemorrhage. tion isdependent onearlycontrolofthebleedingand appropriate Preventionofshock andresultanthypoperfusion organdysfunc- Prevention • • • SubsequentManagement • • • DiagnosticStudies • • • • DIFFERENTIALDIAGNOSIS

• • • RiskFactors

Includesothercausesofacutecirculatorycollapse: intervention inhemodynamicallyunstablepatients. trauma (FAST),diagnosticperitoneallavage,immediateoperative • • patient. Therefore,multipleendpointsshouldbeoptimized: perfusion. Nosingleparameterisuniversallyapplicabletoevery performance, bloodpressure,oxygendeliveryandend-organ The goalsofresuscitationareoptimizationpreload,cardiac Continue resuscitationpostoperativelyorpost-procedure. importance. Prompt surgicalcontrolofthebleedingisparamount ultrasound examination. Obstetricsource Traumaticsource nuclear medicine. Gastrointestinalsource Cardiogenic shock Obstructive shock Vasodilatory/distributive shock obstruction, pancreatitis) Hypovolemic shockofnonhemorrhagicetiology(bowel • •

uterine atony. Obstetricsource: and lifestyleissues. death forpersonsyoungerthan44 yearsofageintheUS) Traumaticsource: GIsource: Cardiac outputmeasurement urine output,levelofconsciousness,pulsepressure) Clinical endpoints(heartrate,respiratorybloodpressure, near-infrared spectroscopy) Regional perfusion(gastrictonometry,sublingualcapnography, Metabolic parameters(lactate,basedeﬁ Advancedage,comorbidities.

: usuallyapparentonphysicalexaminationor : CTscan,focusedabdominalsonographyin Postpartumhemorrhageislargelydue to

Youngage(injuryistheleadingcause of

: endoscopy,interventionalradiology,

cit)

349 CHAPTER 14 Surgical Emergencies 350 CHAPTER 14 Surgical Emergencies SpinellaPC,HolcombJB.Resuscitationandtransfusionprinciplesfortrau-

• • Presentation sequence ofasingletraumaticevent. and unprotectedarea.Thismayresultinmultisysteminjuryasacon- Theneckcontainsahighdensityofvitalstructureslocatedinsmall Deﬁ PuyanaJC,TishermanSA,PeitzmanAB.Currentconceptsinthediagno- HardyJF,DeMoerlooseP,SamamaM.Grouped’intérêtenhémostasepério- EnglehartM,TieuB,SchreiberM.Endpointsofresuscitation.In:Asensio FurtherReading SpecialConsiderations

NeckInjuryIn 2008:437–445. matic hemorrhagicshock.

(eds.) sis andmanagementofhemorrhagicshock.In:AsensioJA,TrunkeyDD cations forclinicalmanagement. pératoire. Massivetransfusionandcoagulopathy:pathophysiologyimpli- Philadelphia: Mosby;2008:143–146. JA, TrunkeyDD(eds.). • • • • • “Soft signs”warrant amoreselectiveorexpectantapproach: • “Hard signs”warranturgentsurgical intervention: •

Role ofrecombinant-activatedfactorVII(rFVIIa): PRBC—in a24-hourperiod. replacement ofthepatient’sentirebloodvolume—10units Massive transfusionisusuallydeﬁned asthecomplete Subcutaneous emphysemaorairbubbling fromwound Expanding orpulsatilehematoma Dysphagia Active bleeding Voice change nition • • • • •

Hypothermia haslittleeffectoneffi correction ofacidosispriortoadministration). May notbeefficient inacidosis(considerbiochemical of afi Generates athrombinpeak,whichinturnleadstoformation reversal ofthecoagulopathytrauma. Signifi hemophilia. Approved intheUSonlyforbleedingassociatedwith Current TherapyofTraumaandCriticalCare. brin plug. cant off-labelusehasbeennoted,includingforthe

j ury

Blood Rev Current TherapyofTraumaandCriticalCare.

Can JAnaesth

. 2009Nov;23(6):231–240.

cacy. . 2004Apr;51(4):293–310.

Philadelphia:Mosby;

• • DiagnosticStudies • • • ASSOCIATEDINJURIES • • • AnatomyandPathophysiology

• • • • • ImmediateManagement

• • • • Facial trauma Brain injury Spinal cordinjury • Zones oftheneck: sternocleidomastoid muscles Anterior trianglesoftheneck:areabetween • • • Structures locatedintheneck: • Immediate surgery inthesettingofactivehemorrhage. Selected radiographic andendoscopicstudies(seebelow). • • • •

preferred, surgical airway if orotracheal intubation is not possible. preferred, surgicalairwayiforotrachealintubationisnotpossible. Secure theairwayifitiscompromised.Orotrachealintubation on thewaytooperatingroom. Control activehemorrhagewithlocal applicationofpressure Resuscitation withcrystalloidandPRBC ifindicated. required, considerfemoralvenous cannulation. Establish large-boreIVaccess.Ifcentral venousaccessis Maintain cervicalspinestabilizationduringairwaymanagement. Hemoptysis Cervical vertebraandspinalcord Thyroid andparathyroidglands laterally the thoracicinletinferiorlyandsternocleidomastoid Zone I:theareaboundedbycricoidcartilagesuperiorly, Thoracic duct—entersthejugulosubclaviansysteminleftneck Larynx andproximaltrachea Pharyngeo-esophageal junction Sternocleidomastoid muscles Carotid arteryandinternaljugularvein Wide mediastinum Long cervicalmusculature(posterior) inferiorly andthebaseofskullsuperiorly Zone III:theareaboundedbyangleofmandible the mandible Zone II:theareabetweencricoidcartilageandangleof

351 CHAPTER 14 Surgical Emergencies 352 CHAPTER 14 Surgical Emergencies WeireterLJ,BrittLD.Penetratingneckinjuries:diagnosisandselectiveman-

• Presentation rysm (AAA). Ruptureisapotentiallylethalcomplication ofabdominalaorticaneu- Deﬁ PierreEJ,McNeerRR,ShamirMY.Earlymanagementofthetraumatizedair- FurtherReading hemorrhage preventlossoflife. Immediateprotectionoftheairwayandcontrolexsanguinating SpecialConsiderations • • • • • SubsequentManagement

RupturedAbdominalAorticAneurysm Ru Surgical CriticalCare. agement. In:AsensioJA,TrunkeyDD(eds.). way. • • • • • • and aerodigestivetractinjuries: examination andspeciﬁc diagnosticstudiestoidentifyvascular management canbeundertaken.Thisincludesthoroughphysical In theabsenceof“hardsigns,”aselectiveapproachfor formal neckexploration. should onlybeperformedintheoperatingroomaspartofa Penetrating woundsshouldnotbeexploredlocally.Exploration injury. of “hardsigns”thatindicatemajorvascularoraerodigestivetract Formal neckexplorationiscurrentlyperformedinthepresence contained leak,or freerupture. a symptomaticaneurysm (painwithoutevidenceofrupture), a that theyhaveaneurysmaldisease. Patients maypresentwith Most patientswhopresentwitharuptured AAAareunaware Endovascular managementapproachesareinevolution. Deﬁ

CT scan Doppler ultrasonography Arteriography (conventionalandCTA) Laryngoscopy/tracheoscopy Esophagography Esophagoscopy nition p nitive operativemanagementofidentiﬁ Anesthesiol Clin. tured AbdominalAorticAneur

Philadelphia:Mosby;2008:197–206. 2007Mar;25(1):1–11.

Current TherapyofTraumaand

ed injuries

y sm

• • • DIFFERENTIALDIAGNOSIS than smallones. the radius.Largeaneurysmsarethereforemorelikelytorupture disrupts thewallofasphere),Pistransmuralpressure,andR is governedbytheLawofLaplace,T=PR.Ttangentialstress(which Onceananeurysmdevelops,regardlessoftheetiology,enlargement Pathophysiology • • • •

• • • • ImmediateManagement

ureter, pain may be referred to the ipsilateral testicle or groin. ureter, painmaybereferredtotheipsilateraltesticleorgroin. the back.Ifruptureisinretroperitoneumadjacentto The abdominalpainisusuallyacute,unremitting,andradiatesto pain, hemodynamicinstabilityandapulsatileabdominalmass. The classicclinicalpresentationofAAAruptureincludesabdominal congestive heartfailureresults. If ruptureoccursdirectlyintotheinferiorvenacava,high-output gastrointestinal hemorrhagemayoccur. If theaneurysmperforatesintoduodenumorcolon,massive of acutehypovolemia. The patientmayexperiencelight-headednessorcollapsebecause Massive gastrointestinal hemorrhage spleen, kidney),hepatobiliary tumorrupture ruptured visceralarteryaneurysm, solid organrupture(liver, Hemorrhage fromanotherintra-abdominal source,including infl acute pancreatitis)causingsepticshock orexaggeratedsystemic viscus rupture,ischemic/infarctedbowel, acutecholecystitis, Acute infectiousorinflammatory abdominalprocess (hollow unable toprotecttheairway. Intubate thetracheaifpatientisinsevereshockand Any delayincontrolofthehemorrhagemaybelife-threatening. immediately totheoperatingroomwhilebeingresuscitated. instability andapulsatileabdominalmass—mustbetransferred Patients whopresentwiththeclassictriad—pain,hemodynamic Initiate aggressiveresuscitationwithIVfluids andPRBC. access. hypotension. Establishlarge-boreperipheralandcentralvenous prepped anddraped,becauseofthepossibilitysevere operating roomandinduceanesthesiaafterthepatientis If theclinicalsituationpermits,transportpatientto ammatory response

353 CHAPTER 14 Surgical Emergencies 354 CHAPTER 14 Surgical Emergencies

• • • • SubsequentManagement • • DiagnosticStudies • • •

• • • • • • • RiskFactors

indicated bylaboratoryparameters. Coagulopathy istreatedwithfreshfrozenplasmaandplatelets,as PTT, comprehensivechemistrypanelandcardiacenzymes. dysfunction. BaselinelaboratorystudiesincludeCBC,PT, Assess andtreatcoagulopathy,thrombocytopeniaplatelet condition isoptimized. be postponedforupto24hourswhilethepatient’smedical who donotdemonstrateCTevidenceofrupture,repaircan for acontainedperitonealrupture.Insymptomaticpatients CT scanresults.Emergencysurgicalmanagementisnecessary In hemodynamicallystablepatients,timingofrepairdependson cardiogenic shock and hemodynamic collapse cardiogenic shockandhemodynamiccollapse Massive myocardialinfarctionwithresultantacutecardiacfailure, distinguish betweenarupturedandnonrupturedAAA. can rapidlydeterminethepresenceofanAAAbutmaynot Duplex ultrasound(whichmaybeperformedatthebedside) abdomen andpelviswithintravenouscontrast. Hemodynamically stablepatientsshouldundergoCTofthe hemodynamic collapse Massive pulmonaryemboluswithresultantobstructiveshockand Aortic dissectionoraorticocclusion intervention cannotbedelayed. surgery. Resuscitationoccursduringsurgerybecauseoperative Hemodynamically unstablepatientsmustundergoimmediate All patientswithrupturedAAArequireurgentsurgery. been implicatedbut notproven. Rate ofexpansion oftheAAAasanindependentrisk factorhas Eccentric saccularaneurysms Female gender Smoking COPD Hypertension have a6.6%riskofruptureperyear. have ayearlyriskofrupture0.5–1%.Aneurysms6–7cm diameter oftheaneurysm.Aneurysms4.0–5.4cmin The mostimportantriskfactorforruptureisthemaximum

• Deﬁ NorrisEJ.Anesthesiaforvascularsurgery.In:MillerRD(ed.). GloviczkiP,RicottaJJ.Aneurysmalvasculardisease.In:TownsendCM, FurtherReading • • SpecialConsiderations • • • • Prevention

RupturedEctopicPregnancyR Philadelphia: Saunders;2007:1907–1938. Beauchamp RD,EversBM,etal.(eds.). infection associatedwithumbilicalarterycatheters. Behcet’s disease,Marfansyndrome,Ehlers-Danlosand adults andchildrenoccurinthesettingoftuberoussclerosis, tissue disordersandpseudoaneurysmformation.AAAsinyoung arteritis, cysticmedialnecrosis,trauma,inheritedconnective Less frequentetiologiesofAAAformationincludeinfection, implicated. wall, proteolyticenzymesandinﬂammatory changeshavebeen formation. Alterationsintheconnectivetissueofaortic destruction ofthemediaaorticwall,leadingtoaneurysm occlusive vasculardisease.Multiplefactorscontributetothe but 75%ofpatientswithaneurysmaldiseasedonothave More than90%ofaneurysmsareassociatedwithatherosclerosis, greater thanaveragerupturerisk. greater inmalesand4.5–5.0cmfemalespatientswith Elective operativerepairisrecommendedforAAAs5.5cmor patients diepriortoreachingtheoperatingroom. The overallmortalityrateforrupturedAAAis90%,since60%of of rupturedAAA. mortality ofelectiverepairis6%comparedwith>48%for The goalofelectiverepairAAAsistoavoidrupture. been secured. Avoid abruptepisodesofhypertensionuntiltheaneurysmhas occurrence ofintrauterine andextrauterinegestation. the remaining2%. Heterotopicpregnancyisthesimultaneous Abdominal, ovarian andcervicalectopicpregnancies comprise fallopian tube(approximately98%of allectopicgestations). cavity. Themostcommonsiteofectopic pregnancyisthe Implantation ofafertilizedovumoutside oftheendometrial Anesthesia u nition ptured EctopicPregnancy , 7thed.Philadelphia:ChurchillLivingstone;2010:1995–2006.

Sabiston TextbookofSurgery .

Miller’s

355 CHAPTER 14 Surgical Emergencies 356 CHAPTER 14 Surgical Emergencies

• • DIFFERENTIALDIAGNOSIS tion, significant and life-threateningbleedingcanresult. pregnancies areclinicallysilentandresultinspontaneoustubalabor- rhage thatdistortsthetubeandcausespain.Althoughsomeofthese into thelargebloodvesselsinbroadligamentresultshemor- the muscularisandlaminapropria,fi nally theserosa.Invasion the proliferatingtrophoblastfi rst invadestheluminalmucosa,then Intubalimplantations(themostcommontypeofectopicgestation), Pathophysiology • • • Presentation •

• • • ImmediateManagement

patients. secondary torupturedectopicpregnancyandoccurin20%of shoulder, syncope,andshockarecausedbyhemoperitoneum with anassociatedpositivepregnancytest.Painradiatingtothe Classic symptoms:abdominalorpelvicpainandvaginalbleeding ligament. pregnancy extendsintothelargebloodvesselsinbroad extends throughthetube.Hemorrhageoccurswhen In rupturedtubalectopicpregnancy,trophoblasticproliferation involve thegastrointestinal tract(perforatedviscus,peptic ulcer Infectious orinflammatory intra-abdominal andpelvicdiagnoses cause painandshock. Any pathologicconditionoftheabdomen andpelvisthatcan mass isevidentinupto50%. present inapproximately30%ofpatients,whileatenderadnexal (typically reboundtenderness).Cervicalmotiontendernessis Abdominal tendernessin90%ofpatients.Peritonitis70% Massive Hemorrhage,Page347) Hemorrhagic shockdependentonthedegreeofbloodloss(See tachycardia maybethefirst signofsignifi cant bloodloss. occur until30%ofthecirculatingbloodvolumeislost.Mild Early diagnosisofhemorrhageiscritical.Hypotensiondoesnot shock. (See“MassiveHemorrhage,” Page347.) infusions. TransfusePRBCsinpatientwithClassIIIandIV hemorrhagic shockcanusuallybetreatedwithcrystalloid Begin aggressivefluid resuscitation.ClassIandII access. Establish large-boreperipheralIVsand/orcentralvenous

hemorrhage develop. pregnancy canusually bediagnosedandtreatedbefore ruptureand Basedonriskstratiﬁ cation anda high indexofsuspicion,ectopic Prevention • • • SubsequentManagement • • DiagnosticStudies •

• • • RiskFactors

infl nephroureterolithiasis) andthereproductivetract(pelvic any etiology,includingpyelonephritis,cystitis,obstructive diverticulitis, pancreatitis),theurinarytract(urosepsisof disease, intestinalischemia,appendicitis,colitis,cholecystitis, emergency laparotomyisusuallythebestchoice. entry intotheperitonealcavityforsourcecontrolisneeded, When significant hemorrhagicshockispresentandrapid performed forrupturedectopicpregnancy. Either laparotomyorlaparoscopywithsalpingectomyis and surgicalbleeding. cryoprecipitate, andplateletsisguidedbylaboratoryparameters obtain periodicfibrinogen level.Infusionoffreshfrozenplasma, of massivehemorrhage,checkbaselinefibrinogen leveland Resuscitation isguidedbyCBC,PT,PTT,andINR.Incases and ultrasoundwillguidedefi diagnosis ofectopicpregnancy,asinglebeta-hCGmeasurement In patientspresentinginhemorrhagicshockwithoutaprevious uterine sampling,andoccasionallyprogesteronelevels. include serialmeasurementsofbeta-hCG,ultrasonography, Routine non-emergentteststoestablishectopicpregnancy rupture (mayoccurwithtraumaticinjury). visceral aneurysm,rupturedhemorrhagicovariancystanduterine ruptured solidorgan(liver,spleen,kidney),aorticor Hemorrhagic intra-abdominalandpelvicdiagnosesinclude douching, youngageatfi Low risk:previouspelvicinfection, cigarette smoking,vaginal sexual partners. Moderate risk:infertility,previousgenital infections,multiple reproduction. tube development),useofIUD,tubalpathology,assisted pregnancy, inuteroexposuretoDES(alteredfallopian High risk:tubalsurgery,ligation,previousectopic ammatory disease,salpingitis,endometritis).

rst intercourse.

nitive management.

357 CHAPTER 14 Surgical Emergencies 358 CHAPTER 14 Surgical Emergencies

• • • AnatomyandPathophysiology • • Presentation pancreas andaortoentericﬁ agus, stomach,duodenum,and,morerarely,thehepatobiliarytree, ligament ofTreitz.Thisincludesetiologiesattributabletotheesoph- Uppergastrointestinal(UGI)hemorrhageoriginatesproximaltothe Deﬁ SeeberBE,BarnhartKT.Ectopicpregnancy.In:GibbsRS,KarlanBY,Haney FurtherReading • • SpecialConsiderations

UpperGIBleedingBleedin AF, etal.(eds.). always thetreatmentofchoiceforrupturedectopicpregnancy. medical treatmentofectopicpregnancy,operativemanagementis Although multiple-dosesystemicmethotrexateistheﬁ no establishedcutofftousedistinguishbetweenthetwo. ectopic pregnanciesthaninintrauterinegestations,butthereis used indiagnosticalgorithms.Progesteronelevelsarelower Serial beta-humanchorionicgonadotropin(beta-hCG)levelsare hemorrhage, these patientsmayhaveabdominalpain. pancreaticus; unlike mostpatientspresentingwithUGI Unusual etiologiesincludehemobilia andhemosuccus Mallory-Weiss tear,Dieulafoy’slesion, AVMsandtumors. Less commonetiologiesincludestress ulceration,esophagitis, formation ofvarices. Cirrhosis causesportalhypertension, whichinturnresults etiology andaccountfor15%ofcases ofUGIhemorrhage. Gastric andesophagealvaricesare the secondmostcommon Helicobacter pyloriandNSAIDsareimplicatedinmostcases. hemorrhage andaccountsforgreaterthan50%ofcases. Peptic ulcerdiseaseisthemostcommonetiologyofUGI portal hypertensionandjaundicemaybenoted. present. Inpatientspresentingwithvaricealhemorrhage,signsof such astachypnea,oliguria,andmentalstatuschangesmaybe blood loss(see“MassiveHemorrhage”).Manifestationsofshock, Hemorrhagic shock.Classiﬁcation isdependentonthedegreeof Hematemesis and/ormelena.Abdominalpainrarelyoccurs. Williams &Wilkins;2008:71–86. nition

Danforth’s ObstetricsandGynecology

stulae.

.NewYork:Lippincott

rst-line

• • • • DiagnosticStudies nasal ororopharyngealhemorrhageresultinginswallowedblood. hemorrhage haveanuppergastrointestinalsource,includingmassive from therectum.20%ofallcasesapparentlowergastrointestinal all patientswithgastrointestinalhemorrhagepassbloodinsomeform is lesslikelyandtransfusionrequirementsaretypicallylower.80%of Treitz andisgenerallylesslifethreateningthanUGIhemorrhage;shock Lowergastrointestinalhemorrhageoriginatesbelowtheligamentof DIFFERENTIALDIAGNOSIS

• • • • • • ImmediateManagement

hemorrhage. Aortoenteric ﬁstula isanotherinfrequentetiologyofUGI choice. Findingsareusefulinpredictingtheriskofrebleeding: determined. Esophagogastroduodenoscopyisthemodalityof After initialstabilization,thesourceofbleedingmustbe • • • • Adherent clotinulcer base • Visible nonbleedingvessel • Active arterialbleeding

Class IVshock. with crystalloidinfusions.PRBCarenecessaryinClassIIIand Class IandIIhemorrhagicshockcanusuallybetreated Resuscitate aggressivelywithcrystalloidIVﬂuids andPRBC. Establish large-boreperipheraland/orcentralvenousaccess. Be preparedtosuctioncopiousbloodfromtheairway. mental status,orifshockisimminent. Intubate thetracheaifpatienthashematemesisoraltered ddAVP. (medication inducedorpathologic)withbloodproductsand Correct coagulopathy,thrombocytopenia,plateletdysfunction the resuscitation. check ﬁbrinogen level atbaselineandperiodicallythroughout In casesofmassivehemorrhageorknownhepaticdysfunction, comprehensive metabolicpanel,includingliverfunctiontests. Draw baselinelaboratories:CBC,PT,PTT,INRand 5% riskofrebleeding withendoscopicintervention 15–30% riskofrebleedingwithendoscopic intervention 15–30% riskofrebleedingwithendoscopic intervention 20–30% riskofrebleeding withoutendoscopicintervention 40–50% riskofrebleedingwithout endoscopic intervention 90–100% riskofrebleedingwithout endoscopicintervention

359 CHAPTER 14 Surgical Emergencies 360 CHAPTER 14 Surgical Emergencies

respiratory failureandcoagulopathy. indications forstressulcerprophylaxis inthecriticallyillinclude use mayhelptopreventcomplications ofpepticulceration.Major Treatmentofhelicobacterpyloriinfection andlimitationofNSAID Prevention • • • • • • • SubsequentManagement • •

• • • • RiskFactorsforMortality(6–10%)

documented malignantulcers. large visiblevesselsnotamenabletoendoscopiccoagulation,and hemostasis, rapiddeteriorationattributabletoexsanguination, to pepticulcerdiseaseincludetwofailedattemptsofendoscopic Surgical indicationsinpatientswithUGIhemorrhageattributable vasopressin orembolizethelesioninpoorsurgicalcandidates. Interventional radiologymaybeusedtodeliverintra-arterial 90% hemostasisratesareachievedwithendoscopictherapy. In general,80%ofcasesUGIhemorrhagestopspontaneously. be atleast0.1mL/minutetodetected. Nuclear medicinescans(taggedRBCscan):bleedingratesmust adequate visualization. Angiography: bleedingratesmustbeatleast0.5mL/minutefor encephalopathy. transplantation. Thereisanassociatedriskofworseninghepatic endoscopic therapyfailorarenotfeasible,asabridgetohepatic intrahepatic portosystemicshunt(TIPS)whenmedicaland Esophageal varicealbleedingmaybetreatedwithtransjugular sclerotherapy andvaricealbandligation. Endoscopic managementofvaricealhemorrhageincludes infusion for5days). (10–50 mcg/minute)oroctreotide(50mcgboluswith50mcg/h (bolus 0.4Uwith0.4–1U/minuteinfusion)plusnitroglycerin Medical managementofvaricealhemorrhageincludesvasopressin Renal insufﬁ Advanced age Disseminated malignancy Hepatic failure ciency

SassDA,ChopraKB.Portalhypertensionandvaricealhemorrhage. DonahuePE.Foregut.In:BrittLD,TrunkeyDD,FelicianoDV(eds.). CheungFK,LauJY.Managementofmassivepepticulcerbleeding. FurtherReading North Am 2007:450–470. AcuteCareSurgery:PrinciplesandPractice Clin NorthAm . 2009Jul;93(4):837–853. . 2009Jun;38(2):231–243.

.NewYork:Springer; Gastroenterol Med Clin 361 CHAPTER 14 Surgical Emergencies This page intentionally left blank Chapter 15 Thoracic Emergencies Marc S. Azran and Michael Nurok

Bleeding During Mediastinoscopy 364 Bronchopleural Fistula (BPF) 365 Cardiac Herniation after Pneumonectomy 368 Inhaled Foreign Body (Adult) 371 Intrathoracic and Mediastinal Lesions Causing Tracheal, Bronchial, Cardiac, and/or Vascular Obstruction 374 One-Lung Ventilation: Hypoxemia 378 One-Lung Ventilation: Increased Airway Pressure 380 Tension Pneumothorax 381 Tracheal Injury 384 363

364 CHAPTER 15 Thoracic Emergencies

• • • • SubsequentManagement • • • • • • Etiology • • • • Presentation median sternotomyorthoracotomy.Theincidenceis0.4%. Bleedinggreaterthan500ccorrequiringexplorationthrougha Deﬁ

• • • • • • ImmediateManagement

BleedingDuringMediastinoscopy Bleedin

injured vessel. refractory bleeding.Thesurgicalapproach willdependonthe Surgical explorationandrepairisthe deﬁ Tachycardia Hypotension Arterial orvenoussurgicalbleeding Lung isolationmay enhancesurgicalexposure. artery orbonchial artery Right posterolateralthoracotomy: Azygous vein,rightpulmonary Midline sternotomy:Innominatevein, pulmonaryartery Patient movement Injury totheaorticarch Pulmonary arteryinjury Innominate veinorarteryinjury Azygous veininjury Accidental biopsyofavascularstructure. Cardiovascular collapse pressure monitoring. Secure arterialaccessandequipmentforinvasiveblood Begin volumeresuscitation. Obtain crossmatchedbloodandsetuprapidinfusers. innominate veininjuryissuspected. Establish large-boreIVaccessinthe mediastinoscope, orgauzesoakedinepinephrine. Surgical compressionandwoundpacking—applypressurewith phenylephrine infusion(0.5–1mcg/kg/min). phenylephrine (100µgIV)boluses.Ifrefractory,consider Support bloodpressurewithephedrine(5mgIV)or nition

g Durin

Mediastinoscopy

lower extremities nitive treatmentfor

mortality ratemay reach50%. is differentfromthe remotesmall,parenchymalBPF, forwhichthe stump willresultintheinabilitytoventilate effectively.Thissituation causing apneumothorax.Immediate postoperativeblow-outofthe Acommunicationbetweenthebronchial treeandpleuralspace Deﬁ ParkBJ,FloresR,DowneyRJ,BainsMS,RuschVW.Managementofmajor FurtherReading • SpecialConsiderations • • Prevention • • • RiskFactors • • LungIsolationforRightThoracotomy

BronchopleuralFistulaB (BPF)

Sep;126(3):726–731. hemorrhage duringmediastinoscopy. • • physiology. be performedtoruleoutpericardialeffusionandtamponade result ofbiopsy.Transesophagealechocardiographyshould bronchial arteryintothepericardialsachasoccurredasa loss maybecausedbycardiactamponade.Bleedingfromthe Persistent hemodynamicinstabilitywithonlyminorblood to preventmovementduringthiscriticalperiod. Adequate musclerelaxationshouldbeconfirmed beforebiopsy biopsy toidentifyavascularstructure. Surgical palpationofthelesionorneedleaspirationpriorto radiation therapy,ormediastinalprocedure Mediastinal inflammation asaresultofpriorchemotherapy, Superior venacava(SVC)syndromecausingengorgedvasculature Aberrant vessels Previouslydiffi cult intubationoruncontrolledbleeding: • Previouslyeasyintubation&controlofbleeding: •

ronc over aﬁ Left mainstemintubationusingtheexistingendotrachealtube Alternatively, aright-sidedbronchialblockermaybeused. Conﬁ without anairwayexchangecatheter). Change theETTtoaleft-sideddouble-lumentube(withor nition rm adequatemusclerelaxation. h beroptic bronchoscope. opleura

Fistula

( BPF J ThoracCardiovascSurg.

)

2003

365 CHAPTER 15 Thoracic Emergencies 366 CHAPTER 15 Thoracic Emergencies

• • • • Etiology • • • • • • • Presentation

• • ImmediateManagement

Tachycardia Hypotension Cyanosis Increased inspiratorypressures Oxygen desaturation Dyspnea Inability toventilate(completestumpblow-out) ﬁ Penetrating chesttraumamaycauseabronchopleuralcutaneous • Iatrogenic • Infectious • Surgical • • • • stula.

• • • Immediate postoperativestumpblow-out Remote BPF

Central lineplacement Pneumonia, empyema,orlungabscess Any pulmonaryresection Tuberculosis setting ofacutelunginjury) Baro- orvolutraumaduringmechanicalventilation(ofteninthe Pneumonectomy orlobectomy Lung volumereductionsurgery Surgical re-exploration Thoracostomy tubeplacementasdescribedbelow bronchial blocker. Isolate thelungswithadouble-lumenendotrachealtubeor •

• •

degree ofﬂow andavoidtensionpneumothorax. diameter ofatleast6mmisrequired toevacuatethis across thedefect.Athoracostomy tube withaninternal A BPFmaypermitairﬂow upto16litersperminute (LPM) Immediate thoracostomytubeinsertion of -20cmH capable ofevacuating upto35LPMwithasuctionpressure High volumethoracostomytubedrainage systemideally

2 O.

• • • • • InvasiveManagement • • • SubsequentManagement

• • • • cautery. proximal BPFmaybesealedwithfibrin, autologousbloodor Bronchoscopy maybeusedtolocalizeandmanageBPFs.A • pressures. Alternative modesofventilationmaydecreasemeanairway • Conventional mechanicalventilation ventilation, minimizingthevolumeofleakpromoteshealing. space, allowingairtopassthroughthefistula. Duringmechanical ventilation createsagradientbetweentheairwaysandpleural pathology andweaningmechanicalventilation.Positivepressure Can bemanagedconservativelybytreatingunderlyinglung because electrocautery maycauseafi If 100%oxygenis required, thesurgicalteamshould be alerted refractory cases. Surgical pleurodesisorbronchialstapling remainsanoptionfor response, therebysealingaBPF. Chest tubeorthorascopicsclerosis mayinciteaninfl not visualized. Occlusion balloonsmaybeleftinplace fordistalBPFsthatare • • • • •

Minimize positiveend-expiratorypressure(PEEP). Utilize weaningmodestoencouragespontaneousventilation. increasing inspiratoryfl Decrease inspiratorytimebyalteringtheI:Eratioor Decrease minuteventilation(bothrateandtidalvolume). Tension pneumothoraxisarisk. tube PEEPmayminimizetheegressofairduringventilation. Chest tubeocclusionduringtheinspiratoryphaseandchest Minimize alveolardistensionandairwaypressure. Aggressively treatbronchospasmandotherairfl Decrease chesttubesuctionastolerated. position theoreticallydecreasesBPFairfl Lateral decubitusventilationwiththeBPFindependent CO oxygenation, althoughrespiratoryacidosismayoccurbecause High-frequency jetventilationmaybeusedtomaintain are required. any oftheabovetechniques.Twosynchronizedventilators conventionally, whiletheinjuredlungmaybemanagedwith endotracheal tube.Thenormallungmaybeventilated Differential lungventilationwithadouble-lumen 2 eliminationiscompromised.

ow rates.

re.

ow.

ow obstruction.

ammatory

367 CHAPTER 15 Thoracic Emergencies 368 CHAPTER 15 Thoracic Emergencies

a pericardialdefect createdduringpneumonectomy. Both Herniationofthe myocardiumintoanemptyhemithorax through Deﬁ BaumannMH,SahnSA.Medicalmanagement andtherapyofbron- FurtherReading • • • • • • • • Prevention Chestradiographfollowingchesttubeinsertionoftheaffectedlung DiagnosticStudies • • • • • DIFFERENTIALDIAGNOSIS

• • • • • RiskFactors

CardiacHerniationafterC Pneumonectomy

Mar;97(3):721–728. chopleural fi stulas inthemechanicallyventilatedpatient. Cardiac tamponade Hemothorax Extrinsic lungcompressionfrommassesorfl Bronchospasm Endotracheal tubemalposition omental tissue,etc.) Surgical reinforcementofstumpswithflaps (intercostalmuscle, internal jugularorsubclavianveins. Suspend mechanicalventilationwhileinsertinganeedleintothe Institute measurestoavoidnosocomialpneumonia Wean mechanicalventilationearly falls. during incrementalPEEPincreases.Decreaseifcompliance Use judiciousPEEPbymonitoringstaticrespiratorycompliance Reduce inspiratorypressures Permissive hypercapnia Decrease tidalvolumesto6mL/kg ardiac Obstructive lungdiseasewithautoPEEP lung injury Excessive tidalvolumes(morethan10mL/kg)inthesettingof Central lineplacement Pulmonary infection High-risk pulmonarysurgeryorlungvolumereduction nition

erniation a

ter Pneumonectomy

uid

Chest . 1990

• • Pathophysiology • • • Etiology • • • • • • • Presentation left untreated. hemodyamic instability.Mortalityis50%ifrecognized,and100% left- andright-sidedcardiacherniationmayoccur,causingsevere

• • • Right-sided cardiacherniationresultsinmalposition. mediastinum toshift. the rightsidemaypredisposetoherniationbyallowing after excisionofthelung.Alooselyconstructedpatchon mesothelioma involvingtheconstructionofapericardialpatch Extrapleural pneumonectomyisperformedforresectionof pericardial defectplacesthepatientatriskforherniation. Pneumonectomy withanemptyhemithoraxandunclosed the ﬁrst 24hoursaftersurgery. Usually occursduringtransferofthepatient.Mayoccurwithin • Right-sided herniation ECG changes(STsegmentoraxischanges) Dysrhythmias Cardiovascular collapse Tachycardia Hypotension • • through thedefect. Left-sided cardiacherniationinvolves prolapseoftheventricles defect. and massesinvadingthepericardiumcreatesapericardial Intrapericardial pneumonectomyperformedforhilartumors • • •

collapse. The endresultismyocardialischemia andcardiovascular obstruction tobloodfl Torsion ofthegreatvesselsorventricularoutflow tract,causing return. Torsion oftheatriocavaljunctionseverelyimpedesvenous Jugular venousdistension in myocardialischemia. Strangulation ofthe myocardiumandepicardialvessels results Cardiac orientationandvenousreturn ispreserved. Absence ofaleft-sidedcardiacimpulse Cyanosis oftheface Ventricular outflow tractobstruction mayalsooccur.

ow.

369 CHAPTER 15 Thoracic Emergencies 370 CHAPTER 15 Thoracic Emergencies

• • • DiagnosticStudies • • • • • DIFFERENTIALDIAGNOSIS

• • • • • • • • ManagementofPresumedCardiacHerniation • ImmediateManagement

• Cardiac tamponade Pulmonary embolus Contralateral pneumothorax Hypovolemic shock Myocardial infarction myocardium ora malpositioned heart. Echocardiography (TTEorTEE)mayrevealprolapsed • Chest radiograph delayed. The diagnosisshouldbeclinicalandmanagementnot

pericardial patchconstruction. Surgical correctionwithreductionofmyocardialprolapseand CPR maymakeherniationworse. intervene immediately. If completecardiacarrestoccurs,repositionandhavesurgeon mcg/kg/min). of phenylephrine(0.5–1mcg/kg/min)orepinephrine(0.03–0.05 hypotension mayrequireaggressivetreatmentwithaninfusion Support bloodpressureasnecessarywithvasopressors.Severe preload deﬁ Begin aggressivevolumeresuscitationtocorrectrelative Reposition thepatientwithoperativesideup Alert thesurgeonimmediately. respond tovolumeadministrationand/orvasopressors). hypotension duetohypovolemiaordeepanesthesia(whichwill herniation (whichrequiresimmediatesurgicalintervention)and Clinical scenariocanhelptodifferentiatebetweencardiac Decrease tidal volumes and positive end-expiratory pressure (PEEP). Decrease tidalvolumesandpositiveend-expiratorypressure(PEEP). left hemithoraxduetoventricularstrangulation. Left-sided herniationmayshowarounded opacityinthelower Right-sided herniation • •

catheter Abnormal (clockwise)conﬁguration ofapulmonary artery Opaciﬁ cation oftherighthemithoraxfrommediastinal shift ciency.

• • Etiology • • • • Presentation tree. Aspirationoforganicorinorganicmaterialintothetracheobronchial Deﬁ ChambersN,WaltonS,PearceA.Cardiacherniationfollowingpneumo- FurtherReading suture line. smaller defects,althoughherniationcanoccurfromaruptured dial defects.Primaryclosureofthepericardiumhasbeenusedfor Apericardialslingorpatchshouldbeusedtocloselargepericar- Prevention

• • • • • RiskFactors

InhaledForeignBody(Adult)

Jun;33(3):403–409. nectomy—an oldcomplicationrevisited. cyanosis. At thelaryngealinlet:coughing,choking,hoarsenessor In abronchus:unilateralwheezingandcoughing. Below thecords:inspiratorystridorandcoughing. symptoms. Inorganic material maybetoleratedforyearswithminimal • Organic material pneumonia, empyema,hemoptysisorbronchopleuralﬁ In casesofdelayeddiagnosis,maypresentwithrecurrent •

the operatingroom(especiallyoperativesidedown) Position changesinoperatingroomorduringtransportfrom Coughing secondarytosuctioningorextubation Positive pressureventilationandPEEP Chest tubesplacedtosuctionorevenwaterseal Pericardial defectofanysizeandanemptyhemithorax complete airwayobstruction. Beans orotherorganicmaterialmay becomeengorgedcausing Inspissated oralsecretionsmaycause respiratoryarrest. nition

Body

( Adult

Anaesth IntensiveCare )

stula.

. 2005

371 CHAPTER 15 Thoracic Emergencies 372 CHAPTER 15 Thoracic Emergencies • • SubsequentManagement

• • ImmediateManagement

• Flexiblebronchoscopy • and usuallyrequiresgeneralanesthesia. Rigidbronchoscopy • when thepatientisintubatedandmechanicallyventilated. in adistalsegment,patientswithcervicalspinepathology,or • • • •

• • supraglottic larynxorsubglottictrachea. Emergency FBasphyxiationusuallyinvolvesmaterialatthe • • In adults,FBaspirationisrarelyatrueemergency.

sparingly. full stomachsandalsoaidsinFBexpulsion. Uselocalanesthetics Preservation ofthecoughreflex isimperativeinpatients with a ball-valveobstruction. Positive pressureventilationcanwedgetheFBdistally,creating ventilation. Avoids generalanesthesiaandpreservesspontaneous extraction ofthe FB. degree ofairwaycontrol andislargeenoughtoallow for conduit fortheflexible bronchoscope. Thisprovidessome after topicalanesthesiaoftheoropharynx, andcanusedasa A laryngealmaskairwaymaybeinserted inanawakepatient Sedatives shouldbeadministeredjudiciously. when thebronchoscopist’socularwindowisopen. anesthetic technique.Spontaneousbreathingenablesventilation Spontaneous ventilationispreferableusinganinhaled volatile agents. anesthetic techniquetoreduceoperatingroompollutionwith pressure ventilationisnecessary,consideranintravenous ventilation ispossiblethroughthebronchoscope.Ifpositive laryngoscopy. Short-actingagentsarepreferable.Intermittent Neuromuscular blockademaybenecessarytofacilitate patient ispreparedforbronchoscopy. a distalbronchus,enablinglife-savingventilationwhilethe Intubation withanETTmaybeusedtopushtheobjectinto awake andtheoffendingobjectisgraspedwithMagillforceps. Direct laryngoscopycanbeperformedwhilethepatientis thoracotomy shouldbeimmediatelyavailable. The abilitytoconvertfromflexible torigidbronchoscopy operating roomisprepared. Monitor closelyandgivesupplementaloxygenwhilethe

isthemosteffectivetherapeuticintervention isthetoolofchoicewhenFBwedged

RafananAL,Mehta HC. Adultforeignbodyremoval.What’s new? FurtherReading • • • SpecialConsiderations mediastinal shift. Findings mayincludeair-trapping,atelectasis,pumonaryinﬁ Chestradiographsareusefulonlyinpatientswithradio-opaqueFBs. DiagnosticStudies • • • • DIFFERENTIALDIAGNOSIS

• • • • • • RiskFactors

Med. • • laryngeal edema.Treatmentoptionsinclude: Prolonged rigidbronchoscopymayleadtopostoperative thoracotomy orbronchialarteryembolization. bleeding cannotbecontrolled.Preparationsshouldmadefor lung isolationwithadouble-lumenETTorbronchialblockerif Massive hemoptysismayoccurwithFBremoval.Consider Airway compressionfromtheintrathoracicmass Tracheal injury Bronchospasm Pneumothorax bronchotomy toremovetheimpacted object. Failed bronchoscopymayultimately requirethoracotomyand • • •

Seizures General anesthesia Trauma withlossofconsciousness Alcohol andsedativeuse Neurologic disorderswithimpairmentofswallowing Advanced age utilize the Trendelenberg position and ask the patient to cough. utilize theTrendelenbergpositionandaskpatienttocough. all removedasaunit.IftheFBdislodgesinproximaltrachea, the bronchoscope.Thebronchoscope,graspingdevice,andFBare Special forcepsandsnaresarepassedthroughtheworkingportof Nebulized racemicepinephrine extraction. necessitating extubationalongwithFBandbronchoscope If anETTisinplace,theFBmaynotpassthroughETT— Dexamethasone 10mgIVbolus Helium/oxygen mixtures 2001Jun;22(2):319–330.

ltrates, or Clin Chest

373 CHAPTER 15 Thoracic Emergencies 374 CHAPTER 15 Thoracic Emergencies

• • • DIFFERENTIALDIAGNOSIS • • • Causesofobstructioninclude: Etiology • • • • • • • Presentation oxygenate andventilate. to leadcardiovascularcollapseand/orthecompleteinability by tumor,trachealdisease,orvascularcompression,withpotential Extrinsicorintrinsicobstructionofintrathoracicstructurescaused Deﬁ

cause worseningorcompleteobstruction. capacity. Asaresult,airwaysthathad beenpatentcancollapseand increased intrapleuralpressure,and decreasedfunctionalresidual Generalanesthesiacancausecessationofspontaneousventilation,

and/or VascularObstructiona Causing Tracheal,Bronchial,Cardiac,C IntrathoracicandMediastinalLesions Intrath (instrinsic) Tracheal diseaserelatedtostenosisortracheolmalacia • • Pneumothorax Bronchospasm Foreign bodyaspiration Vascular compressionorring(extrinsic) • Malignancy Obstructive pneumonia Hemoptysis Hoarseness Inspiratory stridororexpiratorywheeze Orthopnea Cough Dyspnea

nd/ ausing Tracheal,Bronchial, sarcoma Metastatic cancer(extrinsic):renal,breast,colonor carcinoma middle mediastinaltumors,lungcarcinoma,oresophageal Primary adjacenttumor(usuallyintrinsic):anterioror carcinoma, adenoidcysticcarcinomaorcarcinoidtumor Primary airwaytumors(usuallyintrinsic):squamouscell nition o r Vascular

rac i c and Med O

bstructi

ast o i nal Les n

C ardiac, io ns

Procedure:

• • • • • • • • • • • • • • • • Pre-procedure: ImmediateManagement

Induction:

general anesthesia. conservative approach). compression bytracheallesionsonimagingwarrantsa bronchi, andcardiovascularstructures(greaterthan50% Anticipate thepotentialforcompressionoftrachea, Identify relationshipoflesiontoadjacentstructures. Identify locationoflesiononimaging. The airwayismost safelymanaged • Stepwise airwayapproach: Maintain patientinthesittingpositionifpossible. Avoid sedatives,oradministerjudiciously. severe obstruction. breathing patientissafestinpatientswithsevereorpotentially A localanesthetictechniqueintheawake,spontaneously extracorporeal supportdeviceinextremecases. Femoral arterialandvenousaccessisestablished,withstandby Surgical teammustbepresentintheroom. Rigid bronchoscopyshouldbeimmediatelyavailable. Ensure thatvasopressorsareimmediatelyavailable. Ensure amechanismforadministeringintravenousﬂ lower extremity. If SVCinvolvementorsyndrome,placealarge-boreIVin Obtain large-boreIVaccess. compromise. Insert anintraarterialcatheterifthereisariskofcardiovascular • •

patient awakethroughout—followingtopicallocalanesthesia) facilitated bytheuseofalaryngealmaskairway—maintaining plan anapproachtodefinitive airwaymanagement(maybe by anesthesiaandsurgicalteamtocharacterizethelesion Awake fiberoptic examinationofairway,trachea,andbronchi lesion ifpossible Awake fiberoptic intubationwithpassageoftubedistalto Securing theairway immediately available. with greatcaution,andappropriately skilledindividuals •

considered, includingtheuseofextracorporeal support. airway whilemaintainingspontaneous ventilationshouldbe If notpossible,alternativestrategiesforsecuringthe

after

inductionshouldbeattemptedonly

prior

totheinductionof

uids rapidly.

375 CHAPTER 15 Thoracic Emergencies 376 CHAPTER 15 Thoracic Emergencies

• • • • • • TherapeuticApproaches

• • • • • Immediate Management(continued)

• • • Photodynamic therapy and hemorrhage,airwayﬁre, areriskswiththis procedure. can vaporizelesionsandachievehemostasis. Trachealperforation Nd:YAG lasertherapyinconjunction withrigidbronchoscopy Endobronchial brachytherapyorexternal beamradiotherapy control oftheairwaydistaltolesion. Awake tracheostomywithalong-lengthprosthesisallowsfor Tracheal (orbronchial)stentplacementforsymptomaticrelief. Surgical airwayresectionandreconstruction

surgical manipulationoftheairway. inhalational agentswillcontaminatetheoperatingroomwith An intravenousanestheticispreferableformaintenance,as distal tothelesion. An alternativerescuestrategyistopassajetventilatorcannula used inanattempttosecuretheairwaydistalcollapse. a rigidbronchoscopeorarmoredendotrachealtubemaybe to patientrepositioning(lateraldecubitusorproneposition), In theeventoftotalairwayobstructionthatisnotresponsive succinylcholine If musclerelaxationisrequired,useasmalldoseof • Attempt toassistwithbag-ventilation intravenous agentswhilemaintainingspontaneousventilation. Gradually administeraninhalationalagentorsmalldosesof agents canbesafelyadministered. marginal patient. Neuromuscularblockademaycauseairwaycollapseina provide positivepressureventilationhasbeenconﬁ •

cytotoxic oxygen radicals. Preoperative radiationcansigniﬁcantly reducetumor burden. Speciﬁ IV photosensitizer isadministeredandretainedintumor cells. If successful If notsuccessful • • • •

Gradually increasethedepthofanesthesia. Overtake spontaneousventilationwithpositivepressure. and/or usingextracorporealsupport. Awaken thepatientandreconsiderairwayapproach decubitus orpronepositionmayimproveventilation. Shifting thelesionbyplacingpatientinlateral c wavelengthlightactivates theagentandgenerates after Ifsuccinylcholineistolerated,longer-acting

theairwayissecureandabilityto

rmed.

WoodDE.Management ofmalignanttracheobronchialobstruction. FurtherReading • • • • SpecialConsiderations the incidenceofcomplicationsfromprolongedintubation. Dailyspontaneousbreathingtrialsandsedationholidaysmayreduce Prevention • • • • • DiagnosticStudies

Prolongedintubationortracheostomymayleadtostenosis RiskFactors North Am • • Postoperative airwayobstruction • Superior venacava(SVC)syndrome ventilation. should becannulatedtopermitextracorporealoxygenationand procedure, priortoproceedingthefemoralarteryandvein a patentairwayduringinstrumentationorotherstagesofthe If theclinicalscenarioisconcerningforaninabilitytomaintain characterizing obstruction. Flow-volume loopsareneithersensitivenorspeciﬁ effusion ortumor. TTE maybeusefulinevaluatingthepericardiumformalignant malformations. Both MRIandCTangiographyareusefulincharacterizingvascular length, andnatureoftheobstruction. CT oftheneckandchestcandetermineexactlocation, endoluminal narrowing,andobstructivepneumonia. Neck andchestradiographsmaydetecttrachealdeviation, patient developspositionaldyspnea whilesupine. There isariskofacuteintraoperative airwayobstructionifthe • •

tracheomalacia. increased risk. Tracheal narrowingtolessthan50% ofnormalconfersa7-fold May occurfromtumorswellingaftermanipulation Obstruction bytumorburdenoftheSVC Requires lowerextremityIVaccess May havesigniﬁcant upperairwayedemaandfriabletissue . 2002Jun;82(3):621–642.

c in

Surg Clin

377 CHAPTER 15 Thoracic Emergencies 378 CHAPTER 15 Thoracic Emergencies

• • DIFFERENTIALDIAGNOSIS tube orlungisolationdevicemalposition. ventilated lungandincreasingshunt),secretions,doublelumen monary vasoconstriction(causingredistributionofbloodtothenon- causes ofhypoxemiafromtheventilatedlungincludehypoxicpul- nonventilated lung,mediastinalstructures,andthediaphragm.Other of atalectasisandWestzoneIIIconditionsfromcompressionbythe lung, regionsoflowventilationtoperfusionratiosdevelopasaresult lated lungfollowingresorptionofresidualoxygen.Intheventilated Pathophysiologyismultifactorial.Shuntdevelopsinthenonventi- Pathophysiology • • • • Presentation LowPaO Deﬁ

• • ImmediateManagement

One-LungVentilation:HypoxemiaO

Cardiac dysrhythmias Cyanotic patient Dark arterialblood Low oxygensaturationbypulseoximetry Decreased oxygendelivery(lowcardiacoutputstates) Increased oxygenutilization • Mild hypoxemia(SpO ventilator disconnectorfailure. Eliminate causesproximaltothedoublelumentubeincluding • • • • • ne-Lung

nition Increase FiO narrow portonﬁ passage ofsuctioncatheterismoreefﬁcient thanusingthe Check theventilatedlungforobstructionorsecretions— double lumentubeorlungisolationdevice Fiberoptic bronchoscopytoensurecorrectpositionof Ensure adequatecardiacoutputand oxygencarryingcapacity. pressure volumecurve). ventilated inanoncompliantregion onthelowendofits low tidalvolumeventilation(willonly workiflungisbeing Recruit ventilatedlung.Followwith additionofPEEPifusing (start with5cmH Continuous positive airwaypressuretononventilated lung 2 ,LowSvO

Vent 2 to100%.

beroptic bronchoscope. 2 i

Otoavoiddistention ofoperativelung) lat 2 >90%)

on: Hypoxem

i a

• • • • • Prevention • • DiagnosticStudies

• • • • RiskFactors Immediate Management(continued)

•

Fiberoptic bronchoscopy Arterial andmixedvenousbloodgasmeasurement which blunthypoxic pulmonaryvasoconstriction. Avoid highconcentration ofpotentvolatileanesthetic agents, Adapt ventilatory strategytolungpathology. ventilation, 4–6cc/kgidealbodyweight with5–10cmH ventilation (inpatientswithnormal lungs,pressurecontrol Ensure appropriateventilatorsettings whenbeginningone-lung position followingsignificant changesinpatientpositioning. Ensure properdoublelumentubeor lungisolationdevice Maintain two-lungventilationaslongpossible. respiratory rate10–15/min,FiO Normal orhighFEV1/FVCratio Low PaO blood fl Right-sided operations(rightlungnormallyreceives60%of ventilation. to theoperativelungwillhavealargershuntduringone-lung Patients withincreasedornormalventilationandperfusion • • No improvementorsignificant hypoxemia(SpO • • • • •

Consider increasingtidalvolumeto6–10cc/kg. nonventilated lung(impairedbypotentvolatileanesthetics). to promotehypoxicpulmonaryvasoconstrictioninthe Consider administrationoftotalintravenousanesthetic oxygenation (ECMO). If noimprovement,considerextracorporealmembrane available intheUS). If noimprovement,considernitricoxideoralmitrine(not operative lung. If noimprovement,considerhigh-frequencyjetventilationto pneumonectomy ofnonventilatedlung. surgeon toclamppulmonaryarteryintheeventofaplanned If noimprovement,ortheabovestepsarenotpossible,ask Inform surgeonandventilatebothlungs. ow) 2 duringtwo-lungventilation

2 0.5–0.8).

<90%)

2 OPEEP,

379 CHAPTER 15 Thoracic Emergencies 380 CHAPTER 15 Thoracic Emergencies chospasm, andtensionpneumothorax. include excessivetidalvolumedeliverytoonelung,secretions,bron- smaller portionoflung,leadingtoelevatedpressures.Othercauses lation device,suchthatalargervolumeofgasisdisplacedinto lung ventilationismalpositionofthedoublelumentubeoriso- Themostcommoncauseofelevatedairwaypressureduringone- Pathophysiology • • • Presentation Increaseinpeakorplateauinspiratoryairwaypressure Deﬁ LohserJ.Evidence-basedmanagementofone-lungventilation. FurtherReading •

• • • • • • ImmediateManagement

Pressure One-LungVentilation:IncreasedAirway One-Lun

blood tothenonventilatedlung. which increasespulmonaryvascularresistanceandmayshunt Avoid largetidalvolumeorhighPEEPtotheventilatedlung, Low bloodpressure ventilation Low tidalvolumeduringapressure-controlledmodeof ventilation Elevated airwaypressuresduringvolume-controlledmodeof Clin. ventilated portion ofthelungtoeliminateobstruction. Pass asuctioncatheterthroughthe lumenleadingtothe of doublelumentubeorlungisolation device. Perform ﬁberoptic bronchoscopytoensureproper positioning two-lung ventilation. If highairwaypressureisaccompanied byhypoxemia,resume Manually ventilatethepatienttoevaluate compliance. fully toexcludeairtrapping/autoPEEP. Disconnect thepatientfromventilatorandallowtoexhale Inspect theventilatortubingandendotrachealtubeforkinks. nition 2008;26:241–272.

g Ventilation: IncreasedAirwa

Anesthesiology

• • Presentation escape, causingpressureonintrathoracic structures. Abnormalpresenceofgasinthe pleuralcavitywithinabilityto Defi manipulation. lung isolationdeviceafterpositionchangesorsignifi Confi Prevention • • • • • • DIFFERENTIALDIAGNOSIS

Immediate Management(continued)

• •

• • • • RiskFactors

TensionPneumothoraxTens

Air trapping/AutoPEEP(allowpatienttoexhalefully) Tension pneumothorax Bronchospasm Excessive tidalvolumetoonelung body) Obstruction todoublelumentube(blood,secretions,foreign Double lumentubeorlungisolationdevicemalposition Decreased tidalvolume High peakairway pressure ventilation, 4–6cc/kgidealbodyweight.with5–10cmH ventilation (inpatientswithnormallungs,pressurecontrol Ensure appropriatetidalvolumeandPEEPsettingsforone-lung Address othercausesindividually. PEEP, respiratoryrate10–15/min,FiO long expiratorytimes). Obstructive lungdiseaseisariskfactorforairtrapping(use the rightlowerandmiddlelobes) right upperloadandentiretidalvolumebeingdeliveredtoonly upper lobemaybecomemisaligned,leadingtoexclusionof Right-sided doublelumentubeplacement(oriﬁce toright Change inpatientposition Surgical manipulationoftheairway nition rmation ofcorrectplacementdoublelumentubeor io n

neum o

t h

rax

2 0.5–0.8).

cn surgical cant

2 O 381 CHAPTER 15 Thoracic Emergencies 382 CHAPTER 15 Thoracic Emergencies

• • • • • • DIFFERENTIALDIAGNOSIS vessels. intrathoracic structuresincludingthemediastinum,lung,andblood from accumulationofgasresultsinclinicalsymptomsbycompressing escaping thepleuralspace.Increasingpressureincavity or throughthechestwall.Aone-wayvalveeffectpreventsgasfrom tilated lungasaresultofhighairwaypressure,rupturingbleb, Gasaccumulatesinthepleuralspacethroughpassagefromven- Pathophysiology • • • • • • • • • • •

• • • • ImmediateManagement

Compression ofbronchionfiberoptic inspectionofaffectedside Reduced breathsoundsintheaffectedchest Hyperexpansion oftheaffectedchest Hyperresonance oftheaffectedchest Contralateral trachealdeviation Subcutaneous emphysema Distension ofneckveins Tachycardia Hypotension Decreased SpO Cardiac tamponade Hemothorax Extrinsic lungcompression Bronchospasm Double lumentubeorlungisolationdevicemalposition (disconnect patientfromventilatorcircuitandallowexhalation) Hyperinfl Elevation ofthemediastinuminsurgicalfi • surgical fi Consult surgeonabouttheabilityto accessthelungfrom Increase FiO Resume two-lungventilation. Inform surgicalteam. •

posteriorly, andthepericardiumanteriorly. the affectedpleuralspacebetween theaortaandesophagus Enquire aboutthepossibilitytosurgically dissectaplaneto pneumothorax. Accessing thisspace willimmediatelydecompressthe ation oftheventilatedlungwithintrinsicPEEP eld: 2 to1.0. 2 ,SvO

eld

MalikS,ShapiroWA, JablonsD,KatzJA.Contralateraltension pneumotho- FurtherReading in theabsenceofclassicsigns hypoxemiaandhypotension. Tensionpneumothoraxhasbeenreported duringone-lungventilation SpecialConsiderations • • Prevention Tubethoracostomy SubsequentManagement ChestX-rayfollowingdecompressionofaffectedlung DiagnosticStudies

• • • • • • • RiskFactors Immediate Management(continued)

• •

bronchoscopy. rax duringone-lung ventilation forlobectomy:diagnosisaided byfi placement Appropriate doublelumentubeorlungisolationdevice pressures Appropriate ventilatorymanagementtoavoidelevatedairway Recent centralvenouscatheterinsertion Penetrating chestwallinjury Pleural blebs Acute lunginjury Obstructive lungdisease pressure Malposition ofthedoublelumentubeleadingtohighairway Elevated peakairwaypressures provide adefi compression ofmajorbronchi,andachestradiographwill hemodynamically stable,fiberoptic bronchoscopymayshow If thereisuncertaintyaboutthediagnosis,andpatient thoracostomy. at themidclavicularline.Proceedimmediatelytoformaltube 14 gaugeintravenouscatheterinthesecondintercostalspace decompress theaffectedsidewithalarge-boreneedleorlong If theabovestepsarenotpossible,rollpatientsupineand

Anesth Analg nitive diagnosis.

. 2002Sep;95(3):570–572.

beroptic 383 CHAPTER 15 Thoracic Emergencies 384 CHAPTER 15 Thoracic Emergencies

• • • • Etiology • • • • • • • Presentation estimates varywidelydependingupontheetiology. May involvecompleteorpartialdisruptionofthetrachea.Mortality Injurytoanyportionoftheextrathoracicorintrathoracictrachea. Deﬁ

• • • upper thirdofthetracheamaybemanaged conservatively. Iatrogenictraumathatresultsin small tearstothemiddleand ManagementofIatrogenicInjury

TrachealInjury Tr

• Hoarseness/stridor Dyspnea require specialistcare. Mucosaltears third mayaffectthelarynx. Penetratingtrauma • • Blunttrauma crichothyroidotomy. exchange catheter,percutaneousdilationaltracheostomy,and Iatrogenic Hemoptysis Cyanosis andoxygendesaturation Pneumothorax, pneumomediastinumorpneumopericardium Subcutaneous emphysema Signs ofexternaltrauma • •

Long-term ventilation mayberequiredtoallowhealing. tear. Inﬂ lesion usingaﬁ Advance thetracheostomyorendotracheal tubebeyondthe Often resultsintearingoftheposteriormembranoustrachea membranous trachealtear. Chest traumamayresultincompletetransectionorposterior Frequently injuresthetracheawithin2cmofcarina separation. Flexion-extension injurymayprecipitatefulllaryngotracheal Upper airwaytraumamayresultinfracturedlaryngealcartilages. nition ac ate thecufftoeliminate airwaypressureontheproximal h e al causesincludeendotrachealintubation,useoftube

In areoftenself-limited—through-and-throughtears beroptic bronchoscope. j ury mostlyoccurstothecervicaltrachea,butone-

• • • threatening onebyprecipitatingcompleteobstruction. Airwaymanipulationmayquicklyturnastablesituationintolife- AirwayManagementofBluntorPenetratingTrauma

• • • Cervicaltrachealandupperairwaylesions • • Generalguidelines • • Lowertracheallesions • • • • •

may causeafi team shouldbealerted,asconcomitantuseofelectrocautery of theinjuryaswellsecuringairway. interventional procedureofchoicefordeterminingthenature Awake fiberoptic bronchoscopyisthediagnosticand or airdissectionaroundtheairways. injury canworsenexistingpneumothorax,pneumomediastinum, Positive pressureventilationbeforeacuffhasexcludedthe ventilator cannulamayalsobeusedforoxygenation. facemask andcannulatedwiththeaidofabronchoscope.Ajet Patients withopentrachealdisruptionsmaybeoxygenatedvia and neuromuscularblockersuntiltheairwayissecure. Maintain spontaneousventilation.Avoidintravenoussedatives bronchoscope. safely crossingthelesion.Intubation isbestachievedoverthe Flexible fiberoptic bronchoscopyisessentialindiagnosing and Tracheostomy equipmentandaskilledsurgeonshouldbepresent. ventilation inthissituation. centimeters ofthecarina.Tracheostomy willnotpermit Blunt chesttraumadisruptsthetracheawithinseveral tracheal disruptiontopermitpositivepressureventilation. The goalistoinflate acuffedairwaydeviceorcannuladistalto the lesion are safe airway management options. the lesionaresafeairwaymanagementoptions. Awake oralfi beroptic intubationorawaketracheostomydistalto cartilage orprovokecompletetransection.Avoidcricoidpressure. laryngoscopy andendotrachealintubationmayfracturethecricoid With bluntlaryngealinjuries,attemptedconventional anesthetic approach. gastric contents.Theclinicalscenarioshoulddictatethebest facilitate thisapproach,butthereisapossibilityofaspiration technique withspontaneousventilationcanbeusedto airway precludesflexible bronchoscopy.Aninhaledanesthetic Rigid bronchoscopymaybediagnosticwhenbloodinthe the lesion. intubation orjetventilation throughacatheterlocated distalto to thecarinaifpossible. Alternatively,considerendobronchial The ETTcuffshouldbeplaceddistal tothelesionandproximal If 100%O 2

isrequiredtomaintainoxygenation,thesurgical re.

385 CHAPTER 15 Thoracic Emergencies 386 CHAPTER 15 Thoracic Emergencies

• • • • AssociatedPathology • • • • DiagnosticStudies • • • • DIFFERENTIALDIAGNOSIS • • • • SurgicalConsiderations

injury Neurologic traumaincludingcervicalspineandclosedhead Airway managementshouldnotbedelayedbystudies. • exposure viaathoracotomyapproach. One-lung ventilationmayberequiredtofacilitatesurgical consulted. left approachissometimesused,sothesurgeonshouldbe trachea isrepairedviaarightposterolateralthoracotomy.The The approachforhighlesionsisacollarincision.mediastinal • • Vascular injurywith associatedhemodynamicinstability Esophageal injury • Related airwaypathology tracheal injurytoruleoutesophagealperforation. Esophagoscopy shouldeventuallybepursuedinallpatientswith should beusedwithgreatcautionbeforetheairwayissecure. CT issensitive,butlyingflat mayprovediffi cult andsedatives pneumothorax, pneumomediastinumoraircolumndisruption. Radiographic findings mayincludecervicalemphysema, Bronchospasm Pulmonary hemorrhage Foreign bodyaspiration Pneumothorax position thecuffofETTdistaltoanastomosis. At theconclusionofsurgery,bronchoscopyshouldbeusedto should beusedtoprovideventilationacrossthesurgicalfi of thesurgicalanastomosis.AnarmoredETTandsterilecircuit The ETTmayneedtobepulledbackfacilitatevisualization •

An airwayisolationdeviceorblockermaybeused. Subcutanous emphysemaofupper airway andepiglottis Laryngotracheal hematomaandedema Maxillofacial trauma airway exchangecatheterofadequatelength. may safelybeachievedoveraﬁberoptic bronchoscopeor Alternatively, bronchialintubationwithadoublelumenETT

eld.

HurfordWE,PeraltaR.Managementoftrachealtrauma. FurtherReading • • SpecialConsiderations an ETT. by ensuringthatthetipofastyletdoesnotprotrudepast Iatrogenicinjuryduringendotrachealintubationcanbeminimized Prevention

cause completetrachealdisruption. if uppertrachealorlaryngealinjuryissuspected,becauseitcan Cricothyroid pressure(Sellick’smaneuver)iscontraindicated oxygenation andventilationpriortoproceeding. artery andveinshouldbecannulatedtopermitextracorporeal instrumentation orotherstagesoftheprocedure,femoral If itisimpossibletomaintainapatentairwayduring Jun;50:R4–R7.

Can JAnesth . 2003 387 CHAPTER 15 Thoracic Emergencies This page intentionally left blank

Index

Note: Page references followed by “ f ” and “ t ” denote ﬁ gures and tables, respectively.

Alkalosis , 90–91 for myocardial A Altered mental status , ischemia , 48 Abdominal aortic 240–42 for preeclampsia/ aneurysm, ruptured , Amantadine, for dystonic eclampsia , 192 352 reactions , 149 Asthma , 206–9 Abscess, epidural , American Academy of Asynchronous 300–301 Neurology , 82 pacemaker , 268 Accidental dural American Society of Asystole , 26–27 puncture , 166–68 Anesthesiologists , Atrial fi brillation, 33–35 Acidosis , 86–88 194 Atropine Acute intermittent Aminophylline, for for asthma/status porphyria , 119 asthma/status asthmaticus , 207 Acute lung injury (ALI) , asthmaticus , 207 for asystole , 26 314–15 Amiodarone for bradycardia , 36 Acute renal failure , for atrial fi brillation, for major trauma , 220 389 249–51 34 for pediatric advanced Acute respiratory for narrow complex life support , 232 disease, management tachycardia , 38 for total spinal of , 356 for pediatric advanced anesthesia , 311 Acute respiratory life support , 231 Automated external distress syndrome for ventricular defi brillator (AED), (ARDS) , 314–15 fi brillation, 61 228 Acute transfusion for wide complex Autonomic reaction , 128–29 tachycardia , 40 hyperrefl exia, 144–45 Adenosine, for narrow Anaphylaxis , 91–93 , complex tachycardia , 204–6 38 Anesthesia information Adrenocortical management systems B insuffi ciency (AI), (AIMS) , 69 Bellows ventilators , 72 88–90 Antepartum Benzodiazepine Advanced cardiac life hemorrhage , 184 for local anesthetic support (ACLS) , 214 Antiemetics, and toxicity , 180 for bupivacaine dystonic reactions , for porphyria , 121 cardiotoxicity , 298 148 Benztropine, for Airway Antihistamines, for dystonic reactions , blood in , 9–13 anaphylaxis , 205 149 obstruction in the Antiplatelet therapy, for Bleeding. See also spontaneously stroke , 264 Coagulopathy; breathing patient , Aortic regurgitation , Hemorrhage 3–4 51–52 after carotid Airway fi re, 2–3 Aortic stenosis , 53–54 endarterectomy , Albuterol Apgar score , 226 t 338–40 for airway obstruction , Artifi cial pacing, 268 after thyroid surgery , 4 Aspiration , 4–8 340–42 for anaphylaxis , 92 Aspirin during for asthma/status for bleeding mediastinoscopy , asthmaticus , 207 after carotid 364–65 for diffi cult controlled endarterectomy , following ventilation , 320 339 tonsillectomy , 8–9 390 INDEX Burns , 131–33 , 209–12 . Bupivacaine Bupivacaine, fortotal Bronchospasm , 316–17 Butyrophenones, and Bronchopleural fi Bronchial intubation , Bronchial blocker Bronchial blocker(BB) Breech presentation , Breathing circuit Brain death,declaration Cardiac herniationafter Cardiac arrest C Bradycardia , 35–37 Botulinum toxin(Botox) Bone cement Blood transfusion. Blind nasalintubation , vs. doublelumen pitfalls in , 82 donation aftercardiac determination of , 82 fetal , 177–79 maternal , 181–83 defi for dystonicreactions , treatment modalities refusal of , 78 , 80–81 room fi Seealso Operating 298–300 cardiotoxicity , spinal anesthesia , 311 (BPF) , 365–68 148 dystonic reactions , 13–14 placement , 271–73 168–70 64–66 pressure condition , malfunction, low of , 81–83 368–71 pneumonectomy , 130–31 syndrome (BCIS) , implantation transfusion reaction Seealso Acute 270–71 nition of nition 12 endotrachealtube , death (DCD) , 83 149 for , 80–81 t re , 177 stula Dexamethasone Demand pacemaker , 268 Deep veinthrombosis D Continuous positive Congestive heartfailure , Compazine, for Cocaine, forblindnasal Coagulopathy , 93–96 Closed headinjury , 145 Clopidogrel, for Clevidipine, for Chest pain , 242–44 Carotid endarterectomy, Cardiopulmonary Cardiac trauma , 29–31 Cardiac tamponade , Cyclooxygenase-2 Critically illpatient Cricothyroidotomy , Corticosteroids, for for thyroidstorm , 124 for stridor , 235 for inhaledforeign for anaphylaxis , 205 for airwayobstruction , laparotomy in , 344–47 intrahospital transport for respiratory 156 (DVT) prophylaxis , (CPAP) , 213 airway pressure 31–33 and vomiting , 257 postoperative nausea 270 intubation , 48 myocardial ischemia , hypertension , 252 postoperative 338–40 bleeding after , 227 , 228 resuscitation (CPR) , 27–29 262 postoperative pain , for severe inhibitors (COX-2), 273–75 anaphylaxis , 205 body , 373 4 of , 288–90 failure , 260 depression or Dystonic reactions , Dysrhythmias Drug extravasation , Drowning , 212–14 Droperidol Double lumen Dopamine, for Donation aftercardiac Dobutamine, for Disseminated Diphenhydramine Diltiazem, fornarrow Digoxin Ectopic pregnancy, Eclampsia , 189–92 E Diffi Diffi Diabetic ketoacidosis wide complex narrow complex bradycardia , 35–37 atrial fi for postoperative anddystonicreactions vs. bronchialblocker , for dystonicreactions , for anaphylaxis , 92 , for congestiveheart for atrialfi 148–50 133–35 (DLET) , 276–78 endotracheal tube bradycardia , 36 death (DCD) , 83 failure , 250 oliguria/acute renal 128 coagulation (DIC) , intravascular 38 complex tachycardia , ventilation , 17–18 ruptured , 355–58 ventilation , 319–21 (DKA) , 96–99 cult mask cult cult controlled cult tachycardia , 39–41 tachycardia , 37–39 33–35 vomiting , 257 nausea and 148 12 149 205 failure , 32 34 t brillation brillation , , , Erythropoietic Epinephrine Epiglottitis , 215–17 Epidural hematoma Epidural abscess , Ephedrine Endobronchial Enalapril, forcongestive Embolism , 170–74 Electric powerfailure , for ventricular for total spinal for stridor , 235 for postoperative for pediatric advanced for neonatal for localanesthetic for laparotomyinthe for hypotension , 44 for foreignbody for cardiac for bupivacaine for bronchospasm , for bradycardia , 36 for asystole , 26 for anaphylaxis , 92 , for airwayobstruction , for hypotension , 44 for fetalbradycardia , for bonecement for bleedingduring 301–4 (EDH) , 152 , 153 300–301 Bronchial intubation intubation. heart failure , 32 66–69 fi anesthesia , 311 hypotension , 254 life support , 231 224 resuscitation , 188 , toxicity , 307 345 critically illpatient , inhalation , 219 370 pneumonectomy , herniation after cardiotoxicity , 298 316 204 4 179 syndrome , 130 implantation 364 mediastinoscopy , brillation See , 61 f , ETCO Esmolol Foreign body,inhalation Focused abdominal Fiberoptic intubation , Fetal heartrate(FHR) , Fetal bradycardia , Fentanyl Fenoldopam, for Femoral veincatheter , Famotidine, for Failed intubation , 174–77 Facial trauma , 342–44 F Furosemide Etomidate forpheochromo- for myocardial for congestiveheart for thyroidstorm , 123 for postoperative for atrialfi for subarachnoid for rapid-sequence and porphyria , 121 for burns , 211 for diffi for congestiveheart pediatric , 217–19 adult , 371–73 for rapid-sequence for majortrauma , 220 for laparotomyinthe porphyria , 119 of trauma (FAST) , 345 sonography for 279–82 177 177–79 117 pheochromocytoma , 278–79 anaphylaxis , 92 317–19 (intraoperative) , cytoma , 117 ischemia , 48 failure , 32 34 hypertension , 252 ventilation , 320 hemorrhage , 158 intubation , 23 failure , 32 intubation , 23 345 critically illpatient , 2 , decreased cult controlled cult brillation

, Heparin Hemorrhage Hemoptysis , 322–23 Heart failure. Head injury Haloperidol, foraltered Haldol, anddystonic Haemophilusinfl uenzae , H Glycopyrrolate Glucagon, for Globe injury , 304–5 Glasgow ComaScale , Gas embolism , 45–47 G Hemodialysis , 250 Hemin, forporphyria , Hematoma. for TURPsyndrome , for pulmonaryedema , for oliguria/acuterenal for hypoxia , 246 for hyponatremia , 111 for hyperkalemia , 101 for hypercalcemia , 100 for pulmonary for myocardial subarachnoid , 157–60 postoperative , 49–50 maternal , 184–87 massive , 347–50 penetrating , 152–55 closed , 145 agents of , 152 for fi for asthma/status for oliguria/acuterenal mental status , 241 reactions , 148 and epiglottitis , 215 bradycardia , 37 147 120 hematoma hematoma; Subdural failure Congestive heart intubation , 280 125 330 failure , 250 embolus , 333 ischemia , 48 asthmaticus , 207 failure , 250 beroptic t See Epidural See 391 INDEX 392 INDEX Intravenous Intrathoracic Intrahospital transport Intracranial Intra-arterial injection , Insulin, fordiabetic Informed consent , 78–80 Increased airway I Hyperbaric oxygen Hydrocortisone Hydralazine, for High spinalanesthesia. HHH therapy,for Hypoxia , 244–47 Hypoxemia , 378–80 Hypothermia , 112–14 Hypotension , 43–45 Hyponatremia , 110–12 Hypomagnesemia , Hypokalemia , 107–9 Hypocalcemia , 105–7 Hypertension , 41–43 Hypernatremia , 104–5 Hypermagnesemia , Hyperkalemia , 101–2 Hypercarbia, Hypercalcemia , 99–101 for thyroidstorm , 124 for anaphylaxis , 92 for asthma/status for venousair for burns , 133 intraoperative , 326–27 postoperative , 253–55 postoperative , 251–53 intracranial , 150–52 corticosteroids obstruction , 374–77 288–90 of criticallyillpatient , hypertension , 150–52 135–37 ketoacidosis , 97 pressure , 380–81 therapy hypertension , 252 postoperative anesthesia See Totalspinal hemorrhage , 160 subarachnoid 109–10 102–4 323–25 intraoperative , asthmaticus , 207 embolism , 162 Local anesthetics,for Ketamine K Laryngeal maskairway Laparotomy incritically Labetalol L Lidocaine Lidocaine, epinephrine, Law ofLaplace , 353 Laryngospasm , 19–20 Intubation inability , Ischemia, myocardial , for wide complex for rapid-sequence for porphyria , 121 for burns , 210 for asthma/status for thyroidstorm , 123 for postoperative forpheochromo- for myocardial for hypertension , 42 for chestpain , 244 for ventricular for rapid-sequence for pediatric advanced for majortrauma , 220 for localanesthetic after intra-arterial for blindnasal intubation , 282–84 with ventilation with ventilationability , severe postoperative (LMA) , 18 ill patient , 344–47 234 naloxone (“LEAN”) , atropine, and 174–77 47–49 , 247–49 tachycardia , 40 intubation , 23 asthmaticus , 207 hypertension , 252 cytoma , 117 ischemia , 248 fi intubation , 23 life support , 231 toxicity , 307 injection , 136 intubation , 270 inability , 16–17 14–15 brillation , 61

Ludwig’s angina , 20–22 Low pressurecondition , Local anesthetictoxicity , Midazolam Metoprolol Methyxanthines, for Methylprednisolone, Metaclopramide, and Mental status,altered , Mediastinoscopy, Mediastinal obstruction , Maternal hemorrhage , Maternal cardiacarrest , Massive hemorrhage , Massive hemoptysis , 9 Malignant hyperthermia Major trauma , 219–23 Magnesium sulfate M for subarachnoid for rapid-sequence for postoperative for fi for burns , 211 for thyroid storm , for narrowcomplex for myocardial for chestpain , 244 emergency cardiac 64–66 179–81 , 305–8 pain , 262 asthmaticus , 207 asthma/status asthmaticus , 207 for asthma/status 148 dystonic reactions , 240–42 364–65 bleeding during , 374–77 184–87 181–83 347–50 (MH) , 114–16 eclampsia , 190 preeclampsia/ (MgSO hemorrhage , 158 intubation , 23 hypertension , 251 intubation , 280 123 tachycardia , 38 248 ischemia , 48 , 247 , care , 182 beroptic 4 ), for Octreotide, forupperGI Occupational exposure , O Nonsteroidal anti- Nifedipine, for Nicardipine Nerve injury , 308–10 Neonatal resuscitation , Neck injury , 350–52 Nebulized ipratropium, Near drowning , 212–14 Nausea andvomiting, Narrow complex Naloxone, for N Myocardial ischemia , Multimodal therapy,for Morphine Mitral stenosis , 56–58 Mitral regurgitation , for postoperative for pheochromo- for hypertension , 42 for sicklecellcrisis , for postoperative for porphyria , 121 for myocardial for severe endotracheal tube bleeding , 360 137–39 (NSAIDS) , 222 infl hyperrefl autonomic 187–89 , 223–27 asthmaticus , 207 for asthma/status 255–57 postoperative , tachycardia , 37–39 hypercarbia , 324 47–49 , 247–49 and vomiting , 257 postoperative nausea 55–56 252 hypertension , cytoma , 117 122 hypertension , 251 ischemia , 47 262 postoperative pain , lengths , 226 diameters and ammatory drugs ammatory exia , 144 t Phenylephrine , 130 Phenothiazines Phenergan, for Penetrating headinjury , Pediatric basiclife Pediatric advancedlife Patient-controlled Papaverine, forintra- Panorex fi Packed redblood Pacemakers, anesthetic P Oxytocin, foruterine Oxymetazoline, forblind Oxygen pipelinefailure , Organ harvesting, Oral corticosteroids, Opioids, forsevere Operating roomfi One-lung ventilation Ondansetron, for Oliguria , 249–51 Ocular injury , 305 for postoperative anddystonicreactions increased airway hypoxemia , 378–80 and vomiting , 257 postoperative nausea 152–55 support , 227–30 support , 230–34 analgesia (PCA) , 222 136 arterial injection , 345 critically illpatient , laparotomy inthe cells (PRBCs),for 268–70 , 268 implications of , rupture , 201 nasal intubation , 270 69–72 declaration , 81–83 and braindeath asthmaticus , 207 for asthma/status 262 postoperative pain , Burns 139–41 . and vomiting , 256 postoperative nausea vomiting , 257 nausea and 148 pressure , 380–81 lms See also , 343 t re , , Primary braininjury Preeclampsia , 189–92 Prednisone, forasthma/ Postpartum hemorrhage , Postoperative pain , Postoperative nausea Postoperative Postoperative Postoperative Positive end-expiratory Porphyria , 119–21 Pneumothorax , 328–29 Pneumonectomy, Placenta previa , 184 Placental abruption , Piston ventilators , 72 Physostigmine, for Pheochromocytoma , Phenytoin, for types of , 119 tension , 381–83 for postoperative for hypotension , 44 for fetalbradycardia , for cardiac for bonecement for blindnasal for bleedingduring (PBI) , 220 208 status asthmaticus , 184 261–63 (PONV) , 255–57 and vomiting 253–55 hypotension , hypertension , 251–53 hemorrhage , 49–50 162 venous airembolism , pressure (PEEP),for after , 368–71 cardiac herniation 184 241 altered mentalstatus , 116–18 147 intracranial pressure , hypotension , 254 179 370 pneumonectomy , herniation after syndrome , 130 implantation intubation , 270 364 mediastinoscopy , 393 INDEX 394 INDEX Rule ofNines , 132 Rocuronium Retrograde intubation , Respiratory precautions , Respiratory failure , Respiratory depression , Regurgitant fraction , 52 Regional anesthesia, Rapid-sequence Rapid sequence R Pulseless electrical Pulmonary embolus , Pulmonary edema , Propofol Promethazine, and Prolonged neurologic Prolixin, anddystonic Prochlorperazine, and Procainamide for rapid-sequence for majortrauma , 221 for rapid-sequence for postoperative for porphyria , 121 for laryngospasm , 20 for fi for burns , 210 for widecomplex for narrowcomplex 284–85 334–35 259–61 259–61 257–59 impairment after , prolonged neurologic 22–24 intubation (RSI) , induction , 22–24 activity (PEA) , 233 332–34 330–32 148 dystonic reactions , 257–59 regional anesthesia , impairment after reactions , 148 148 dystonic reactions , intubation , 23 intubation , 23 vomiting , 257 nausea and intubation , 282 tachycardia , 40 tachycardia , 38 beroptic Sudden infantdeath Succinylcholine Sublingual nitroglycerin, Subdural hematoma Subarachnoid Stroke , 263–65 Stridor , 234–37 Stevens-Johnson Stenosis, aortic , 53–54 Status asthmaticus , Spinal cordinjury , Sodium nitroprusside Sickle cellcrisis , 121–23 Shoulder dystocia , S Theophylline, for Terbutaline Tension pneumothorax , Tardive dystonia , 150 Tachycardia T Ruptured ectopic Ruptured abdominal Sufentanil, forporphyria , for rapid-sequence for malignant for majortrauma , 221 for burns , 133 for pheochromo- for hypertension , 42 for bronchospasm , for asthma/status wide complex , 39–41 narrow complex , syndrome (SIDS) , for chestpain , 243 (SDH) , 152 , 153 157–60 hemorrhage (SAH) , syndrome , 210 206–9 155–57 192–94 asthmaticus , 207 asthma/status 381–83 pregnancy , 355–58 352–55 aortic aneurysm , 121 intubation , 23 hyperthermia , 116 cytoma , 117 316 asthmaticus , 208 37–39 f 229 Valvular disease V Uterine rupture , 199 Uterine dehiscence , Upper gastrointestinal Umbilical cordprolapse , Ultrasound-guided U Transesophageal Transesophageal Transcutaneous pacing , Tracheal injury , 384–87 Total spinalanesthesia , Tonsillectomy, bleeding Tissue plasmogen Thyroid surgery, Thyroid storm , 123–25 Thorazine, anddystonic Thoracotomy, right Thoracic aortic Thioridazine, and Thiopental TURP syndrome , 125–26 Trihexyphenidyl, for Traumatic braininjury Transvenous pacing , Transjugular intrahepatic aortic regurgitation , lung isolationfor , 365 for rapid-sequence for burns , 210 217 bleeding , 358–61 197–99 access , 292–95 , 294 central venous echocardiography 286–88 195–97 , 310–12 following , 8–9 stroke , 264 activator (t-PA),for 340–42 bleeding after , reactions , 148 dissection , 58–60 148 dystonic reactions , 149 dystonic reactions , (TBI) , 222 290–92 bleeding , 360 (TIPS), forupperGI portosystemic shunt 51–52 intubation , 23 , 172 172 f

Vasopressin Vasodilators, forupper mitral stenosis , mitral regurgitation , aortic stenosis , 53–54 for ventricular for upperGIbleeding , for asystole , 26 GI bleeding , 360 56–58 55–56 fi 360 brillation , 61 Vitamin K,for Ventilation Venous airembolism Ventricular fi Ventilator failure , 72–75 diffi diffi coagulopathy , 94 (VF) , 60–62 , 230 (VAE) , 161–63 cult mask cult cult controlled cult 18–19 endotracheal tube , 319–21 through an brillation , 17–18 , Zavenelli Maneuver,for Z Wide complex Warfarin, for W 193 shoulder dystocia , 39–41 tachycardia , coagulopathy , 94 395 INDEX