Air Embolism 2 3 Anterior Mediastinal Mass 4 Bradycardia 5 Bronchospasm 6 PediCrisis 7-9 Difficult Airway 10 Fire: Airway / OR 11-12 13 Hypertension 14 Hypotension 15 CRITICAL EVENTS 16 CARDS Intracranial Pressure 17 Local Anesthetic Toxicity 18 Call for help! Loss of Evoked Potentials 19 20 Code Team ______Malignant Hyperthermia PICU ______Myocardial Ischemia 21 Fire ______Pulmonary Hypertension 22 Overhead STAT ______Tachycardia 23 ECMO ______Tension 24 Nofy surgeon. Transfusion & Reactions 25-26 Trauma 27 Revision May 31, 2017 Air Embolism ↓ EtCO2 ↓ SaO2 ↓ BP 2

§ Notify Surgeon, stop nitrous oxide and volatile agents. Increase O2 to 100%.

§ Stop air entrainment: Find air entry point, stop source, and limit further entry. • Ask surgeon to: • Flood wound with irrigation/soaked saline dressing • Turn off all pressurized gas sources, e.g. laparoscope, endoscope • Place bone wax or cement on exposed bone edges • Check for open venous lines or air in IV tubing Air Embolism • Lower surgical site below level of (if possible) • Perform Valsalva on patient using hand ventilation

§ Consider: • Compress jugular veins intermittently if head or cranial case • Aspirate from central venous catheter

§ Hemodynamic support if hypotensive: • Give epinephrine 1-10 MICROgrams/kg, followed by infusion of epinephrine 0.02-1 MICROgrams/kg/min or norepinephrine 0.05-2 MICROgrams/kg/min • Chest compressions: 100/min to force air through lock, even if not in cardiac arrest • If available, call for transesophageal

§ If cardiac arrest, see card: /PEA or VF/VT 3 Anaphylaxis

rapidly /kg IV IV /kg Neuromuscular blockers blockers Neuromuscular Latex Chlorhexidine colloids IV Antibiotics level within 2 hours of event event of hours within 2 level

• • • • • Common causative agents: Common MICROunits tryptase 1 mg/kg IV/IO MAX 50 mg mg 50 MAX IV/IO mg/kg 1 IV mg/kg 0.25 IV mg/kg 1 Dosageand Administration IV/IO, mL/kg 10-30 as IV/IO, MICROgrams/kg 1-10 infusion need may needed, MICROgrams/kg/min 0.02-0.2 10 needed as puffs 4-10 mg 100 MAX IV/IO mg/kg 2

Rash,bronchospasm, hypotension

DiphenhydrAMINE or Famotidine Ranitidine Treatments Treatments LR or NS Epinephrine Vasopressin Albuterol (Beta-agonists) MethylPREDNISolone

↓ BP after after BP ↓ to 100% 100% to 2 effects of histamine histamine of effects histamine-mediated histamine-mediated bronchoconstriction bronchoconstriction release mediator ↓ ↓ ↓ ↓

If latex is suspected, thoroughly wash area area wash thoroughly issuspected, latex If

To effects effects To To To For continued continued For given epinephrine mediator release release mediator volume and BP restore To To restore intravascular intravascular restore To Purpose

•

If HYPOtensive, turn off anesthetic agents agents anesthetic off turn HYPOtensive, If Increase O Increase trigger(s) suspected Remove ventilation/oxygenation adequate Ensure

For laboratory confirmation, if needed, send mast cell mast send needed, if confirmation, laboratory For Anaphylaxis

§ § § § § Anterior Mediastinal Mass 4

§ Increase O2 to 100%

Intra-operative Treatments

Airway collapse Cardiovascular collapse Anterior Mediastinal Mass

§ Increase FiO2 § Give fluid bolus § Add CPAP for spontaneous ventilation; § Reposition to lateral or prone add PEEP for controlled ventilation § Ask surgeon for sternotomy and § Reposition to lateral or prone elevation of mass § Ventilate via rigid bronchoscope § Consider ECMO

Preoperative Considerations High Risk Factors Anesthetic Plan § Diagnosis: Hodgkin’s and non- § Perform surgery under local Hodgkin’s lymphoma anesthesia, if possible § Clinical signs: orthopnea, upper body § Pre-treat with irradiation or edema, stridor, wheezing corticosteroids § Imaging findings: tracheal, bronchial, § Maintain spontaneous ventilation carinal, or great vessel compression; and avoid paralysis SVC or RVOT obstruction; ventricular § Ensure availability of fiberoptic and dysfunction; pericardial effusion rigid bronchoscope § or ECMO 5 Bradycardia 100mA) - (mA) of PACER OUTPUT PACER of (mA) capture untilelectrical with aligned spikes (pacer threshold complex; QRS normally 65 level this above electrodes AND pacer pads pads pacer AND electrodes package per chest on instructions mode PACER to set ON, be (Can rate/min. desired based down or up adjusted once clinical response on isestablished) pacing Confirm pulse is present ispresent pulse Confirm Place pacing ECG pacing Place monitor/defibrillator Turn to (ppm) RATE PACER Set milliamperes the Increase 10mA to mA final Set Instructions for PACING InstructionsPACING for

6. 2. 3. 4. 5. 1. /kg IV, IV, /kg

< 100 desufflate HR HR < 80 < 60

MICROgrams 2 Treatment Treatment Check sugar sugar blood Check

Calcium chloride 10-20 mg/kg IV or or IV mg/kg 10-20 chloride Calcium mg/kg 50 gluconate Calcium doses above at Glucagon ineffective, If Atropine 0.01-0.02 mg/kg IV IV mg/kg 0.01-0.02 Atropine stimulation Stop laparoscopy, If 50 Glucagon Give 100% O 100% Give ventilation Good card ‘Hypoxia’ See then then •

§ § § § § § § infusion IV mg/kg/hour 0.07 § § § < 30 days days <30 30 days < 1 yr yr <1 days ≥30 ≥ 1 yr Age

Start pacing, when available available when pacing, Start

Etiology Etiology w Give epinephrine 10 MICROgrams/kg IV IV MICROgrams/kg 10 epinephrine Give inset) (see pacer transcutaneous Callfor

-Channel -Channel

• • If NOT hypotensive or pulseless: or hypotensive NOT If If hypotensive, pulseless, or poor perfusion, start chest chest start perfusion, poor or pulseless, hypotensive, If Definition:

compressions compressions Bradycardia Overdose Overdose Ca Blocker Overdose Overdose Beta-Blocker Beta-Blocker Surgical Surgical Stimulation Vagal Vagal (most common) common) (most Hypoxia Hypoxia

§ §

§ ↓ EtCO2, upslope stage III EtCO2 Bronchospasm airway pressures, SpO ↑ ↓ 2 6 Intubated Patient Non-Intubated Patient § Increase FiO2 to 100% § Administer supplemental § Auscultate the chest § Auscultate the chest, differentiate from • Equal breath sounds? stridor/extrathoracic airway obstruction • Endobronchial ETT? § Give inhaled albuterol, if needed • Wheezing? § Consider chest radiograph § Check the ETT § Consider IV steroids • Kinked? § If severe, consider intravenous epinephrine Bronchospasm • Secretions/blood in the ETT? Need for suctioning? 1-2 mcg/kg § Give inhaled albuterol with spacer, if available § If severe, consider ICU and/or advanced § If BP and HR will tolerate, increase MAC% of airway management. If ETT, go to ‘Intubated sevoflurane Patient’ column on this card (at the left) § For refractory bronchospasm, give ketamine 1-2 mg/kg IV § If severe, consider intravenous epinephrine 1 mcg/kg § Consider IV steroids § Consider chest radiograph and lung ultrasound (see ‘Tension Pneumothorax’ card) Upslope Stage III EtCO

2

Differential Diagnosis § URI/tobacco exposure § Pulmonary edema § Foreign body § Tension pneumothorax § GERD § Aspiration pneumonitis § Mechanical obstruction of ETT § • Kinking § Endobronchial intubation • Solidified secretions or blood § Persistent coughing and straining • Overinflation of tracheal tube cuff § Asthmatic attack § Inadequate depth of anesthesia § Anaphylaxis 7 Cardiac Arrest: Asystole, PEA Non-shockable and/orNon-shockable pulselesscardiac arrest PEA

Tension Pneumothorax Pneumothorax Tension (Cardiac) Tamponade β-blocker) (anesthetic, Toxin area) surgical outside ( Trauma

• • • • • for ROSC. Do NOT stop compressions for pulse check check pulse for compressions stop NOT Do ROSC. for 2 Hsand Ts:Reversible Causes Asystole,

with force/depth of compressions compressions of withforce/depth 2 Arrest: . Turn off all anesthetic gases and infusions infusions and gases allanesthetic off Turn .

2 Hydrogen ion ()ion Hydrogen Hyperkalemia Hypovolemia Hypoxemia

• • • • • •

Allow full recoil between compressions compressions between Allowrecoil full possible if min, 2 every provider withanother Switch EtCOin increase sudden Use Place patient on backboard, maintain good hand position; if prone, see ‘Prone CPR’ card card CPR’ ‘Prone see prone, position;if hand good maintain backboard, on patient Place EtCO Maximize

• • • • • Check for reversible causes (Hs and Ts) early and often (see table below) table (see often and early Ts) (Hsand causes reversible for Check available) (ifECMO activate min, >6 arrest cardiac If Give epinephrine 10 MICROgrams/kg IV q 3-5 min min 3-5 q IV MICROgrams/kg 10 epinephrine Give switch) compressor during min 2 (q rhythm and pulse Check CPR resume PEA), (asystole, rhythm shockable stilla not and pulse no If VF/VT’ Arrest: ‘Cardiac card next see VT): (VF, rhythm shockable a If Give 100% O 100% Give family. Notify scribe/recorder. a Designate roles. Assign leader. team Designate timer. Start pads Attach defibrillator. Obtain If no ETT, 15:2 compression: ventilation ratio (100 chest compressions/min + 8 breaths/min) breaths/min) +8 compressions/min chest (100 ratio ventilation compression: 15:2 ETT, no If compressions: chest For

If ETT, 100-120 chest compressions/min + 10 breaths/min. breaths/min. +10 compressions/min chest 100-120 ETT, If Cardiac

§ § § § § § § § § § § § 8 Cardiac Arrest: VF/VT Shockable,pulseless cardiac arrest Tension Pneumothorax Pneumothorax Tension (Cardiac) Tamponade Thrombosis β-blocker) (anesthetic, Toxin area) surgical outside (bleeding Trauma

5 mg/kg bolus; may repeat (total of 2 doses) doses) 2 of (total repeat may bolus; mg/kg 5 • • • • • ratio (100 chest compressions/min + 8 breaths/min) breaths/min) +8 compressions/min chest (100 ratio for ROSC, Do NOT stop compressions for pulse check check pulse for compressions stop NOT Do ROSC, for Hsand Ts:Reversible Causes 2 VF/VT amiodarone

> 10 mmHg with force/depth of compressions compressions of withforce/depth mmHg 10 > 2 compression:ventilation Arrest:

1 mg/kg bolus ORbolus mg/kg 1 Hypothermia Hypothermia Hypovolemia Hypovolemia Hypoxemia (acidosis)ion Hydrogen Hyperkalemia Hypoglycemia

• • • • • •

Use sudden increase in EtCOin increase sudden Use Maximize EtCO Maximize compressions between Allowrecoil full min 2 every compressor Switch Place patient on backboard, maintain good hand position; if prone, see ‘Prone CPR’ card card CPR’ ‘Prone see prone, position;if hand good maintain backboard, on patient Place

• • • • • Check for reversible causes (Hs and Ts) early and often (see table below) table (see often and early Ts) (Hsand causes reversible for Check circulation spontaneous of untilreturn sequence Repeat Lidocaine available) (ifECMO activate min, >6 arrest cardiac If Resume chest compressions immediately regardless of rhythm rhythm of regardless immediately compressions chest Resume whilearrest in min 3-5 q IV MICROgrams/kg 10 Epinephrine change compressor during min 2 q rhythm & pulse Check Give 100% oxygen. Turn off anesthetics anesthetics off Turn oxygen. 100% Give Family. Notify scribe/recorder. a Designate roles. Assign leader. team Designate timer. Start shocks) subsequent on joules/kg 10 to (up joules/kg 2-4 Shock pads. Attach defibrillator. Obtain If ETT, 100-120 chest compressions/min + 10 breaths/min) breaths/min) +10 compressions/min chest 100-120 ETT, If 15:2 If no ETT, compressions: chest For

Notify surgeon, call for help and code cart/defibrillator cart/defibrillator code and help for call surgeon, Notify Cardiac

§ § § § § § § § § § § § § § Chest compressions for Cardiac Arrest: Prone CPR patient in prone position 9

Children/Adolescents Infants

Compress with

encircling technique: PRONE § If no midline incision: Compress with heel of § If no midline hand on spine and incision: thumbs second hand on top

midline CPR Figure 1 § If midline incision:

thumbs lateral to –

incision § If midline incision: How Compress with heel of each hand under scapula

to

Figure 2

Figure 3

Figure 1: From Dequin P-F et al. Cardiopulmonary in the prone position: Kouwenhoven revisited. Intensive Care Medicine, 1996;22:1272 Figure 2: From Tobias et al, Journal of Pediatric Surgery, 1994:29, 1537-1539 Figure 3: Original artwork by Brooke Albright Trainer, MD 10 10 Difficult Airway, Unexpected

stylet scope scope Intubation Intubation Alternative Alternative Approachesfor Different blade blade Different head Re-position operator Different Video-laryngoscope LMA Intubating Fiberoptic Intubating oral Blind nasal Blind

• • • • • • • • • or

, Pierre-Robin), Pierre-Robin), , tube tube cricothyrotomy sugammadex Wiedemann or orogastric glycopyrrolate (e.g. Beckwith- (e.g. to 100% and maintain continuous oxygen flow during airway management management airway during flow oxygen continuous maintain and 100% to 2

neostigmine/ Consider awakening pt if surgery not started started not surgery if pt awakening Consider Consider reversing neuromuscular blocker with with blocker neuromuscular reversing Consider Emergency invasive/surgical airway airway invasive/surgical Emergency Emergency non-invasive airway rigid bronchoscopy in in rigidbronchoscopy airway non-invasive Emergency macroglossia

Insert oral and/or nasal airway; airway; nasal and/or oral Insert LMA) (e.g., airway supraglottic insert unsuccessful, If with stomach Decompress younger children, jet ventilation in older children children older in ventilation jet children, younger

• tracheostomy • If still unable to ventilate: ventilate: to still unable If • • • • • If Consider alternative approach for for approach alternative Consider If able to re-establish pt spontaneous ventilation: ventilation: spontaneous pt re-establish to able If If unable to mask ventilate, ask for 2-handed assistance and: and: assistance 2-handed for ask ventilate, mask to unable If Increase O Increase kit tracheostomy and rigidbronchoscope cart, and expert airway help, Callfor or mediastinal mass, consider prone or lateral position position lateral or prone consider mass, mediastinal or intubation (see table) table) (see intubation DifficultAirway, Unexpected

§ § § § § § § 11 11 Airway Fire Picture from ECRI: www.ecri.org ECRI: www.ecri.org from Picture Firetrachealintube, circuit, canister O) 2 , N 2

Look for tracheal tube fragments fragments tube tracheal for Look material residual Remove If intubation difficult, don’t hesitate to obtain surgical airway don’tdifficult, intubation If airway surgical obtain to hesitate Stop all gas flow (O flow allgas Stop airway from materials flammable other and sponges Remove airway into saline Pour Disconnect circuit from tracheal tube and remove tracheal tube tube tracheal remove and tube tracheal circuitfrom Disconnect

• • • • • • • Impound all equipment and supplies for later inspection later for supplies and allequipment Impound Consider bronchoscopy to assess for thermal injury thermal for assess to bronchoscopy Consider Re-intubate and re-establish ventilation ventilation re-establish and Re-intubate

Simultaneously: Simultaneously: Fire:Airway

§ § §

§ 12 12 OR Fire Picture from ECRI: www.ecri.org ECRI: www.ecri.org from Picture fumes,flash/fire patient on Fire in OR, equipment smoke, smoke, equipment OR, in Fire fire extinguisher extinguisher fire 2 attempt, use CO use attempt, st gas supply to OR to supply gas 2

Remove patient from OR from patient Remove closingallORdoors by fire Confine Turn off O Activate fire alarm Activate Make one attempt to extinguish fire by pouring saline on fire fire on saline pouring by fire extinguish to attempt one Make Stop flow of medical gases gases medical of flow Stop patient from material flammable and allburning and drapes Remove

• • • • • • • Consider PICU Consider inspection later for supplies and allequipment Impound Maintain ventilation. Assess for inhalation injury injury inhalation for Assess ventilation. Maintain surgery plastic pulmonary, ENT, from input Consider If fire not extinguished on 1 on extinguished not fire If persists: fire If

Simultaneously: Simultaneously: ORFire(non-airway)

§ § § § § § § 13 13 Hyperkalemia /L /L mEq wave Tall peaked T peaked Tall block Heart Sine wave asystole or fib V

• • • • Manifestations: From: Slovis C, Jenkins R. BMJ 2002 2002 BMJ R. Jenkins C, Slovis From: Serum 6 >K+ blood products, cardioplegia, KCl infusion KClinfusion cardioplegia, products, blood ” sample, thrombocytosis, leukocytosis leukocytosis thrombocytosis, sample, /kg /kg old “

2 mEq hemolyzed : 10 MICROgrams/kg load, load, MICROgrams/kg 10 terbutaline

Directly visualize site to avoid infiltration, infiltration, avoid to site visualize Directly flush tubing after calcium administration administration calcium after tubing flush

hyperthermia, acidosis hyperthermia, • Inadequate excretion: renal failure failure renal excretion: Inadequate Pseudohyperkalemia Excessive intake: massive or or massive intake: Excessive malignant succinylcholine, burns, injury, crush plasma: to tissues from K+ of Shift if refractory to treatment treatment to refractory if Dialysis RBC fresh or washed use required, transfusion If IV 1-2 1-2 IV bicarbonate Sodium mg/kg 0.5-1 IV Consider available) ECMO(if activate min, >6 arrest cardiac If Albuterol puffs or nebulized, once cardiac rhythm stable stable rhythm cardiac once nebulized, or puffs Albuterol Stop K+ containing fluids (LR/RBC); switch to NS NS switch to (LR/RBC); fluids containing K+ Stop Unit/kg 0.1 insulinIV and g/kg 0.25-1 IV Dextrose If hemodynamically unstable, initiate CPR/PALS CPR/PALS initiate unstable, hemodynamically If O with100% Hyperventilate mg/kg 20 chloride calcium or mg/kg 60 gluconate calcium IV

§ § § § § § § § § MICROgrams/kg/min 0.1-10 then § § § § § § § Hyperkalemia CausesHyperkalemia: of Treatment: Treatment: 14 14 Hypertension 70 61-75 86-91 Diastolic Diastolic 97-100 97-100 105-120 113-135 Systolic Systolic 1-3 to treating reversible causestreating to 4-12 newborn newborn Age (yr) (yr) Age Hypertensive Blood Pressure HypertensiveRange* Blood Sustainedpressure high blood refractory Drug (IV Dosing) Drug (IV Dosing) effect) 0.2-1 mg/kg q 10 min; 0.4-3 mg/kg/hour mg/kg/hour 0.4-3 min; 10 q mg/kg 0.2-1 effect) α 0.1-0.2 mg/kg (adult dose 5-10 mg) mg) 5-10 dose (adult mg/kg 0.1-0.2 0.5-5 MICROgrams/kg/min MICROgrams/kg/min 0.5-5 0.2-0.5 MICROgrams/kg/min (MAX 2.5 MICROgrams/kg/ 2.5 (MAX MICROgrams/kg/min 0.2-0.5 Fenoldopam min) Labetalol (also Labetalol mg) 1-5 dose bolus (adult slowpush MICROgrams/kg 10-100 Propranolol MICROgrams/kg 0.5-2 Clonidine NICARdipine MICROgrams/kg/min Clevidipine0.5-3.5 Sodium nitroprusside 0.5-10 MICROgrams/kg/min MICROgrams/kg/min 0.5-10 nitroprusside Sodium HydrALAZINE then min, 5 over MICROgrams/kg 100-500 Esmolol 25-300 MICROgrams/kg/min MICROgrams/kg/min 25-300 (infusion)

§ § § § § § § § § medications are almost exclusively used for specialized cardiac, neurosurgical, or or neurosurgical, cardiac, specialized for used exclusively almost are medications use. before expert an Consult cases. (pheochromocytoma) endocrine Anti-hypertensive drugs are almost never needed for routine pediatric cases. These These cases. pediatric routine for needed never almost are drugs Anti-hypertensive - Consider placing arterial line if not already present present already not if line arterial placing Consider - Action Action

Ensure correct BP cuff size: cuff bladder bladder cuff size: cuff BP correct Ensure heart of level isat transducer line arterial Ensure

• • limbcircumference of width~40% -Agonist -Agonist In pediatrics, hypertension is almost always always isalmost hypertension pediatrics, In treated by addressing likely causes such as as such causes likely addressing by treated error: measurement or lightanesthesia 2

-Adrenergic -Adrenergic Acute Hypertension Hypertension Acute

D1-dopamine agonist agonist D1-dopamine blockade blockade Calcium channel channel Calcium α

β blockade relaxation relaxation Direct smooth muscle muscle smooth Direct *CAUTION: *CAUTION: § Sustained low blood pressure with patient at risk for Hypotension end- hypoperfusion, typically > 20% below baseline 15

§ Ensure oxygenation/ ventilation < 5th% Systolic BP Age (mmHg)* § Turn anesthetic agents down or off Preemie 47– 57 § Check cuff size and transducer position 0 – 3 mo 62 – 69 3 mo – 1 yr 65 – 68 § Consider placing arterial line if not already 1 – 3 yr 68 – 74 present 4 – 12 yr 70 – 85

§ Give appropriate treatment (see table below) > 12 yr 85 – 92

* Numbers are only a guide and vary for individual Hypotension patients and situations

↓ Preload ↓ Contractility ↓ Afterload § Hypovolemia § Negative inotropic drugs § Drug-induced vasodilation § Vasodilation (anesthetic agents) § Sepsis § Impaired venous return § § Anaphylaxis Causes § Tamponade § Hypoxemia § Endocrine crisis § Pulmonary embolism § Heart failure (ischemia)

§ Expand circulating blood § Start inotrope infusion § Start vasopressor volume (administer fluids (DOPamine, epinephrine, infusion: phenylephrine, rapidly) milrinone), as needed norepinephrine § Trendelenberg position § Review ECG for rhythm § Go to ‘Anaphylaxis’ card, disturbances or ischemia if appropriate. § Place or replace IV;

Treatment Treatment consider intraosseous line § Send ABG, Hgb, § Administer steroids for electrolytes endocrine crisis ↓ SpO Hypoxia 2 16

§ Turn FiO 2 to 100%

§ Confirm presence of end-tidal CO2, look for any changes in capnogram § Hand-ventilate to assess compliance § Listen to breath sounds § Check: • ETT tube position and patency. Correct if mainstem or supraglottic, suction to r/o mucous plug, secretions, or kink • Circuit integrity: look for disconnection, kinks • Blood pressure, pulse. If low, see appropriate card: hypotension, bradycardia, or cardiac arrest • Pulse oximeter: try new probe or changing placement

§ If machine problem, consider using self inflating bag and oxygen tank Hypoxia § Further assessment: Draw blood gas. Perform bronchoscopy, CXR, TEE, ECG § Is airway cause suspected? (see appropriate table below)

YES, Airway Cause IS Suspected NO, Airway Cause IS NOT Suspected Lungs Drugs/Allergy § Bronchospasm § Recent drugs given

§ Atelectasis § Allergy / anaphylaxis (see card: § Aspiration anaphylaxis)/dose error § Pneumothorax § Methylene blue/dyes or § Pulmonary Edema methemoglobinemia

ETT Circulation § Mainstem intubation § Embolism – air (see card: ‘Air § Mucous Plug Embolus’), fat, CO2, pulmonary, septic, § ETT kinked or dislodged MI, CHF, § Severe sepsis Machine § If associated with hypotension, § Ventilator settings – RR, TV, I:E ratio, see card: hypotension auto-PEEP § Machine malfunction 17 17 Increased Intracranial Pressure

> 60 mmHg mmHg >60 2

C) o /L /L 28-35 mmHg) 28-35 2 mOsm

<360 (temperature 34 (temperature 30-35 mmHg and PaO and mmHg 30-35 2

⁰ osmolarity

Monitor serum sodium sodium serum Monitor Keep Compression of neck vessels vessels neck of Compression Hyperthermia mg/dL) <200 level glucose (maintain solutions containing dextrose & Hyperglycemia Paralysis with non-depolarizing agent agent withnon-depolarizing Paralysis Hyperventilation (PaCO Hyperventilation Hypothermia coma Barbiturate Keep PaCO Keep Secure airway airway Secure transport to prior sedation Provide

• • • • • • • • • • • • Refractory elevated ICP treatment, consider: consider: treatment, ICP elevated Refractory AVOID: AVOID: Give mannitol 0.25-1 g/kg, to decrease ICP decrease to g/kg, 0.25-1 mannitol Give IV mg/kg 10 (levetiracetam) Keppra prophylaxis: seizure Consider Give steroids as indicated indicated as steroids Give then min, 20 over mL/kg catheter)1-3 venous central via saline (3% saline Hypertonic Use vasopressors (phenylephrine or norepinephrine) as needed to maintain BP and CPP and BP maintain to needed as norepinephrine) or (phenylephrine vasopressors Use 30 at HOB maintenance anesthesia for TIVA Consider Maintain cerebral perfusion pressure (CPP) > 50 mmHg mmHg (CPP)>50 pressure perfusion cerebral Maintain If GCS < 9, respiratory distress, hemodynamic instability: instability: hemodynamic distress, respiratory 9,

0.1-1 mL/kg/hour mL/kg/hour 0.1-1 IncreasedIntracranial Pressure

§ § § § § § § § § § § 18 18 Local Anesthetic Toxicity

altered consciousness, altered seizures Hypotension,rhythm disturbance, 3 mL/kg total dose until dose total mL/kg 3 isrestored circulation declines low or remains BP if min isrestored. stability hemodynamic min 30 first over mL/kg over 1 min Repeat bolus every 3-5 min up to to up min 3-5 every bolus Repeat mL/kg/ 0.5 to rate the Increase after min 10 for infusion Continue 10 dose: 20% Intralipid total MAX Bolus Intralipid 20% 1.5 mL/kg mL/kg 1.5 20% Intralipid Bolus mL/kg/min 0.25 infusion Start

§ § § § § § Intralipid Dosing Intralipid 2 kit

0.05-0.1 mg/kg IV IV mg/kg 0.05-0.1 2

Intralipid vasopressin, calcium channel blockers and beta blockers blockers beta and blockers channel calcium vasopressin,

Continue chest compressions (lipid must circulate) (lipidcirculate) must compressions chest Continue

w Start CPR/PALS CPR/PALS Start Be prepared to treat resultant hypoventilation hypoventilation resultant treat to prepared Be Midazolam

• • • Start Intralipid therapy (see inset box) box) inset (see therapy Intralipid Start occurs: instability cardiac If Treat hypotension with small doses of of doses withsmall hypotension Treat Seizure treatment: treatment: Seizure Confirm or establish adequate IV access. access. IV adequate establish or Confirm SaO and ECG,BP, continuous monitor & Confirm Stop local anesthetic anesthetic local Stop Request ventilation and airway Secure O 100% Give Consider alerting nearest cardiopulmonary bypass/ECMO center and ICU if no ROSC after after ROSC no if ICU and center bypass/ECMO cardiopulmonary nearest alerting Consider Avoid hyperkalemia and hypercarbia acidosis, correct and Monitor

6 min Local Anesthetic Toxicity Anesthetic Local Toxicity

§ § § § § epinephrine 1 MICROgram/kg MICROgram/kg 1 epinephrine § § § § § § § § 19 19 Loss of Evoked Potentials PEEP) ↓

Managementsignal of changes during spine surgery I/E ratio, ratio, I/E ↑

normothermia normothermia 30 mg/kg IV over one hour, then 5.4 mg/kg/hour IV for 23 hours hours 23 for IV mg/kg/hour 5.4 then hour, one over IV mg/kg 30 : ensure normocarbia or slight hypercarbia ( slighthypercarbia or normocarbia ensure : 2 EP technologist: rule out technical causes for loss/change loss/change for causes technical out rule technologist: EP if NMB reverse ispresent; blockade neuromuscular no assure Anesthesiologist: Surgeon: rule out mechanical causes for loss/change loss/change for causes mechanical out rule Surgeon: necessary necessary

or phenylephrine 0.3 - 10 MICROgrams/kg IV, with repeated doses as needed needed as doses withrepeated IV, MICROgrams/kg 10 - 0.3 phenylephrine or w w neurologist or neurophysiologist, and experienced nurse nurse experienced and neurophysiologist, or neurologist w MethylPREDNISolone Patient is appropriate candidate if capable of following verbal commands commands following verbal of capable if candidate isappropriate Patient Temperature: ensure ensure Temperature: blocker) neuromuscular (e.g. given drugs “unintended” for Check anesthetic of depth Decrease Mean arterial pressure: maintain MAP > 65 mmHg using ephedrine 0.1 mg/kg IV and/ IV mg/kg 0.1 ephedrine using mmHg >65 MAP maintain pressure: arterial Mean delivery oxygen improve to RBC transfuse anemic, Hemoglobin:if PaCO pHand Assure the presence of attending surgeon, attending anesthesiologist, senior senior anesthesiologist, attending surgeon, attending of presence the Assure taken actions corrective and management on report situation, review service: Each

• • • • • • • • • • Consider high-dose steroid if no improvement: improvement: no if steroid high-dose Consider Discuss feasibility of a useful wake-up test: test: wake-up useful a of feasibility Discuss Review the anesthetic and consider improving spinal cord perfusion by modifying: modifying: by perfusion cord spinal improving consider and anesthetic the Review Check patient positioning (neck, upper and lower extremities) extremities) lower and upper positioning(neck, patient Check Notify all members of health care team. Call a “time out" out" “time Calla team. care health of allmembers Notify perfusion/remove re-establish to steps definitive (EP)requires potentials evoked of Loss mechanical cause; MEP loss for > 40 min may increase possibility of long term injury injury term long of possibility increase may min 40 > for loss MEP cause; mechanical

Loss of Evoked Potentials Evoked Lossof § § § § § § 20 20 Malignant Hyperthermia 9737 9737 -

644 acidosis 2 - CO 800 ↑ - HR ↑ www.mhaus.org Temp Temp ↑ MHhotline 1 , consider other dx: sepsis, NMS, serotonin synd., myopathy, myopathy, synd., serotonin NMS, sepsis, dx: other consider , C o

2 C o dantrolene 39

flow to 10 L/min L/min 10 to flow 2 2 mEq/kg IV; IV; mEq/kg 2 - , and help help and , : Assign dedicated person to mix these formulations of of formulations these mix to person dedicated Assign :

triggering anesthetic anesthetic triggering - 2.5 mg/kg IV, rapidly, through large bore IV if possible, every 5 min until symptoms untilsymptoms min 5 every possible, if IV bore large through rapidly, IV, mg/kg 2.5 (20 mg/vial) with 60 mL non-bacteriostatic sterile water water sterile non-bacteriostatic mL with60 mg/vial) (20 dantrolene Revonto : 250 mg is mixed with 5 mL non-bacteriostatic sterile water water sterile non-bacteriostatic mL with5 ismixed mg 250 :

dantrolene

Ryanodex Dantrium/ Regular 0.1 units/kg IV (MAX 10 units) and dextrose 0.5 g/kg g/kg 0.5 dextrose and units) 10 (MAX IV units/kg insulin0.1 Regular 30 mg/kg IV or 10 mg/kg IV; IV; mg/kg 10 chloride calcium or IV mg/kg 30 gluconate Calcium 1 bicarbonate Sodium NG and open body cavity lavage with cold water withwater cold lavage cavity body open NGand <38 temperature coolingwhen Stop Apply ice externally to axilla, groin and around head head around and groin axilla, to externally ice Apply intravenously saline cold Infuse dantrolene

• • • • • • • • • Malignant Hyperthermia Malignant

Call ICU to arrange disposition. For post-acute management, see: http:// see: management, post-acute disposition.For arrange to CallICU If no response after 10 mg/kg mg/kg 10 after response no If Place urinary catheter, maintain UO > 2 ml/kg/hr. ml/kg/hr. >2 UO maintain catheter, urinary Place ECMO consider CPR& begin occurs, arrest cardiac If VT or afib treatment: Do NOT use ; give amiodarone 5 mg/kg mg/kg 5 amiodarone give blocker; channel calcium use NOT Do treatment: afib or VT coagulation myoglobin, serum/urine CK, serum electrolytes, VBG, or ABG labs: Send Hyperkalemia treatment: treatment: Hyperkalemia Give sodium bicarbonate 1-2 mEq/kg IV for suspected metabolic acidosis metabolic suspected for IV mEq/kg 1-2 bicarbonate sodium Give > temperature if Coolpatient Transition to non to Transition Hyperventilate patient to reduce EtCO reduce to patient Hyperventilate Give Stop volatile anesthetic, succinylcholine. succinylcholine. anesthetic, volatile Stop O Turn filter. charcoal Attach Get MH Cart, Cart, MH Get possible if procedure, stop and surgeon Inform pheochromocytoma resolve. May need up to 30 mg/kg mg/kg 30 to up need May resolve.

§ § § § § § § § § § § § § § § § 21 21 Myocardial Ischemia ) LCx

ST changes ST ECG on V5 for lateral ischemia ( ischemia lateral for V5 (LAD) ischemia anterior V3 V2, II, III, aVF for inferior (RCA)

• • • Compare to previous ECGs previous to Compare Cardiology Pediatric Request ST depression >0.5 mm in any lead lead any in mm >0.5 depression ST in (2mm mm >1 elevation ST waves T inverted or Flattened ventricular VT, VF, : ECG: 12-lead consult and echocardiogram echocardiogram and consult precordial leads) precordial block heart ectopy,

§ § § § § § § Recognition Recognition studiesDiagnostic 2 Demand: Demand: Supply: Supply: 2 2

Nitroglycerin 0.5-5 MICROgrams/kg/min MICROgrams/kg/min 0.5-5 Nitroglycerin bolus, Units/kg 10 infusion heparin Consider Correct hypertension hypertension Correct rhythm sinus Restore Correct anemia anemia Correct hypotension Correct rate heart Reduce Give 100% O 100% Give then 10 Units/kg/hour Units/kg/hour 10 then

• • • • • • • • Local anesthetic toxicity toxicity anesthetic Local Severe anemia Severe embolus air Coronary shock Cardiogenic Severe hypoxemia hypoxemia Severe hypertension or hypo- arterial Systemic tachycardia Marked Drug therapy: therapy: Drug Decrease O Decrease Improve O Improve

§ § § § § § § § §

§ Myocardial Ischemia Myocardial Potential Causes: Potential Treatment: Treatment: 22 22 Pulmonary Hypertensive Crisis Mean PAP > Mean SAP MeanMean>PAPSAP cardiac output output cardiac ↓ ) 20-40 ppm ppm 20-40 ) iNO CVP CVP Cardiac arrest arrest Cardiac ↑

, 2 → reduced LV filling and filling and LV reduced → EtCO ↓ BP, BP, ↓ Hypotension Hypotension 2 → sat, sat, 2 O ↓ Consider Plasmalyte rather than normal saline to reduce acid load load acid reduce to saline normal than rather Plasmalyte Consider perfusion maintain to vasopressin phenylephrine, norepinephrine, Administer needed as vasodilators pulmonary Utilize Hyperventilation to avoid hypercarbia hypercarbia avoid to Hyperventilation administration judiciousfluid Use bicarbonate with acidosissodium Correct Use lowest PEEP necessary to maintain oxygenation, long expiratory phase phase expiratory long oxygenation, maintain to lowestPEEPnecessary Use atelectasis avoid to tidalvolume adequate maintain but pressures, withlow airway Ventilate

Airway pressures from RV failure after abrupt pulmonary vasoconstriction vasoconstriction pulmonary abrupt after failure RV from pressures Airway • • • • • • • • FRC preserve and Temperature: ensure normothermia normothermia ensure Temperature: ECMO consider CPRand begin occurs, arrest cardiac If Maintain coronary perfusion and treat RV ischemia ischemia RV treat and perfusion coronary Maintain synchrony AV and NSR Maintain Fluid management: management: Fluid Deepen anesthetic/sedation, administer narcotic, but avoid decreasing SVR. SVR. decreasing avoid but narcotic, administer anesthetic/sedation, Deepen milrinone IV & prostacyclin inhaled as such vasodilators pulmonary additional using Consider relaxant muscle Administer Ventilation: Give 100% O 100% Give ( oxide nitric inhaled Callfor ASAP: Acute Acute ↓ diastolichypertension RV Bradycardia

§ § § § § § § § § § § § § § § Pulmonary HypertensivePulmonary Crisis

Management Manifestation Manifestation 23 23 Tachycardia, unstable

1 mg/kg mg/kg 1 polymorphic VT VT polymorphic Isoproterenol Isoproterenol Lidocaine Sodium pacing Temporary Magnesium sulfate sulfate Magnesium IV (for bicarbonate quinidine-related SVT) ‘Bradycardia’ (see card)

with prolonged QT QT prolonged with Torsade de Pointes: Torsade § § § § § Wide complex complex Wide Amiodarone 5 mg/ 5 Amiodarone 15 Procainamide mg/kg 1 Lidocaine kg IV bolus over over bolus IV kg 20-60 min or bolus IV mg/kg over 30-60 min or bolus IV

§ § § Tachycardiawithassociatedhypotension

Treatment Treatment : SVT, SVT, tachyarrythmia Synchronized Synchronized cardioversion joule/kg, 0.5-1 for joules/kg 2 then shocks additional

§ stop anesthetic agents, inform surgeon, consider cardiology consult cardiology consider surgeon, inform agents, anesthetic stop 2, Ice to face face to Ice Valsalva massage Carotid

• • • Vagal maneuvers maneuvers Vagal (1st Adenosine MAX) dose 0.1 mg/kg, 6 6 mg/kg, 0.1 dose dose 2nd MAX; mg mg 12 mg/kg, 0.2 pwaves present

Narrow complex: complex: Narrow before every QRS before

§ § If NO pulse present, start CPR/PALS; go to ‘Cardiac Arrest, VF/VT’ card card VF/VT’ Arrest, ‘Cardiac to go CPR/PALS; start present, pulse NO If below) table (see treatment appropriate administer present, pulse If

Call for defibrillator and code cart. Typically infant >220 bpm, child >180 bpm bpm child>180 bpm, >220 infant Typically cart. code and defibrillator Callfor pads defibrillator Attach backboard. on pt Place O 100% Give Tachycardia,unstable

§ § § § § 24 24 Tension Pneumothorax

nd

Chest tube BP tracheal BP ptx ↓ Needle decompression

If see pleural pleural see If pleural no If 2 sliding, 100% PPV PPV sliding,100% no sliding, consider pneumothorax, fibrosis, ARDS, asthma, acute pleurodesis

• • SpO ↓ M.D. HR deviation, mediastinal shiftmediastinal deviation, Downloaded from: hp://www.uwhealth.org/ images/ewebeditpro/uploadimages/ 5384_Figure_1.jpg ↑ Shahul Photo S. longitudinally on chest, 2 chest, longitudinally on probe Slide space. intercostal pleural observe to downwards sliding High frequency probe, place place probe, Highfrequency

§ LungUltrasoundInstructions line clavicular

rib, mid- rib, rd to 100% 100% to 2 for teens/adults teens/adults for infants/children for pneumopericardium angiocath angiocath increase O increase O; 2 intercostal space, mid-axillary line mid-axillary space, intercostal th rib space superior to 3 to superior space rib

14-16g 14-16g 18-20g nd

Needle decompression of contralateral side contralateral of decompression Needle of Presence for evaluate to withultrasound lungs both Scan 5-6 2 alternate side or insufficiently decompressed decompressed insufficiently or side alternate pneumothorax w w

• • • • • If no improvement in hemodynamics after a rush of of rush a after hemodynamics in improvement no If Chest tube insertion insertion tube Chest Needle decompression: decompression: Needle Administer vasopressors for circulatory collapse collapse circulatory for vasopressors Administer decompression, needle immediate Perform Reduce positive ventilation pressure pressure ventilation positive Reduce diagnosis confirm to ultrasound lung Consider Secure airway with endotracheal tube withendotracheal airway Secure Stop N Stop air, consider: consider: air, then chest tube placement placement tube chest then

(see inset) inset) (see

Tension Pneumothorax Pneumothorax Tension

§

§ §

§ §

§ §

§ § 25 25 Transfusion: Massive Hemorrhage

, up to 90 90 to up , VIIa /kg /kg Treatment Treatment (TBV) per hour or TBV < 24 hours hours 24 < TBV or hour per (TBV) Replacement > half total blood volume volume blood Replacementhalf> total mg/dL mg/dL MICROgrams increases platelet count by 30 – – 30 by count platelet increases 50k by factors coagulation increases 20% 30-50 by fibrinogen increases 10 ml/kg apheresed platelets platelets apheresed ml/kg 10 Consider factor factor Consider 10ml/kg thawed plasma plasma thawed 10ml/kg cryoprecipitate pooled ml/kg 10 4 ml/kg PRBC increases Hct by 3 3 Hctby increases PRBC ml/kg 4

• • • • • INR > 1.5 (or > 1.3 brain injury), injury), brain >1.3 (or >1.5 INR rapid or mg/dL <100 Fibrinogen HCT < 21% or Hgb < 7: Hgb7: < or HCT <21% (<100K 50,000 < count Platelet for brain injury), rapid TEG-MA 120 TEG-ACT rapid sec: >120 value k TEG-angle<66°, Refractory hemorrhage hemorrhage Refractory

§ § § § § blood available available blood , lactate lactate , Ca 30-50 mg/kg while directly whiledirectly mg/kg 30-50

gluconate transfusion (NOT for platelets) platelets) for (NOT transfusion (e.g., Cell Saver) CellSaver) (e.g., crossmatched RBC : FFP : Platelets = 2:1:1 or 1:1:1 1:1:1 or =2:1:1 Platelets : FFP : RBC transfusion protocol. Consider Consider protocol. transfusion Activate institutional pediatric massive massive institutionalpediatric Activate Monitor ABG, electrolytes, and temperature temperature and electrolytes, ABG, Monitor Consider use of rapid transfusion pumps pumps transfusion rapid of use Consider Use a blood warmer for RBC and FFP FFP and RBC for warmer blood a Use Use 140 micron filter for all products allproducts for filter micron 140 Use Consider intraoperative blood salvage salvage blood intraoperative Consider Use un-crossmatched O negative blood until until blood negative O un-crossmatched Use

Transfusion:HemorrhageMassive

• • • • • • •

Blood product administration: administration: product Blood Send labs/perform point of care testing q 30 min: min: 30 q testing care of point labs/perform Send Warm the room room the Warm Obtain additional vascular access if needed needed if access vascular additional Obtain chloride calcium give hyperkalemia, for Watch Notify Blood Bank immediately immediately Bank Blood Notify CBC, platelets, PT/PTT/INR, fibrinogen, rapid TEG, TEG, rapid fibrinogen, PT/PTT/INR, platelets, CBC, K, Na, ABG, visualizingsite or When under control: call blood bank to terminate terminate to bank callblood control: under When

§

§ §

§ §

§ § 26 26 Transfusion Reactions

Anaphylactic : Erythema, urticaria, urticaria, Erythema, : Support airway and and airway Support Epinephrine Epinephrine DiphenhydrAMINE mg/kg 2-5 Hydrocortisone intravascular Maintain circulation as necessary. necessary. as circulation IV MICROgrams/kg 10 IV mg/kg 1 volume

§ Signs bronchospasm, angioedema, shock tachycardia, § § § § Important to determine type of reaction. of determine type to Important Reactions may occurproduct.Reactions may of withany type BP, bronchospasm, bronchospasm, BP, ↓ Non-Hemolytic Non-Hemolytic : Treat fever fever Treat edema pulmonary Treat of signs for Observe hemolysis hemolysis

Signs fever, edema, pulmonary rash § § § BP, BP, , ↓

Hemolytic Hemolytic Hemoglobinemia

:

Disconnect donor product and IV tubing IV and product donor Disconnect tubing clean through saline normal Infuse pt correct determine ID; product blood Examine Bank Blood to product Send Stop transfusion transfusion Stop Prepare for cardiovascular cardiovascular for Prepare urine and blood Send DOPamine at output urine Maintain Furosemide 0.1 mg/kg mg/kg 0.1 Furosemide g/kg 0.5 Mannitol sample to laboratory laboratory to sample least 1-2 mL/kg/hour mL/kg/hour 1-2 least instability 2-4 MICROgrams/kg/min MICROgrams/kg/min 2-4

HR, bronchospasm HR,bronchospasm

§ § § § § TransfusionReactions § § § § § § mannitol) 25% of mL/kg (2

hemoglobinuria, DIC, DIC, hemoglobinuria, ↑ Signs For All Reactions: All For Trauma Initial Management of Trauma 27 Set-up prior to patient arrival to OR: § Assemble team and assign roles § Estimate weight and prepare emergency drugs § Gather equipment: • Airway supplies • Line placement and monitoring devices • Fluid warmer/rapid infusion device • Code cart with programmed defibrillator

§ Type and cross blood products. Activate massive transfusion protocol if indicated Trauma

On patient arrival to OR: § Maintain c-spine precautions for transport § Secure/confirm airway (often aspiration risk, unstable c-spine)

§ Ensure adequate ventilation (maintain PIP < 20 cm H20) § Obtain/confirm large-bore IV access (central or intraosseous if peripheral unsuccessful) § Assess hemodynamic stability. Pre-induction fluid bolus recommended if hypovolemic • 20 mL/kg LR or NS (repeat x 2) and/or 10 mL/kg RBCs or 20 mL/kg whole blood § Arterial and central venous line placement if indicated § Maintain normothermia § Monitor and treat associated conditions • Anemia, coagulopathy, acidosis, electrolyte derangements § Continuously assess for undiagnosed secondary and/or developing , blood loss