Post on 27-Dec-2019
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ACID: Anaesthetic Critical Incident Drills
Trainee Package !
Key Basic Plan for Management of Critical Incidents- Look, Listen, Feel:
Adequate Oxygen Delivery
Adequate FGF Check FiO2
Connections Bag / Bellows Moving
Clear Airway
Airway position, Airway noise
Adjuncts, LMA / ETT Clear
Capnograph Trace
Check Breathing
Rate, Symmetry, SpO2
Exp tidal volume, EtCO2 Airway pressure
Check Circulation
Rate, Rhythm Perfusion
BP
Check Depth
Anaesthesia Analgesia
Consider Surgical Problem
Call for HELP if problem not resolving quickly
01A_Unexpected increase in peak airway pressure You are 30 minutes in to anaesthetic maintenance of a 35 year old female undergoing elective gynaecological exploratory laparoscopy under general anaesthetic. Her history includes cigarette smoking and she is otherwise fit and healthy. Since moving to the head down position, the peak airway pressure has gone up to 39cmH2O from 15cmH2O following induction. The uneventful induction was with Propofol 200mg, Rocuronium 30mg and Morphine 5mg. She has a size 8 ETT in situ, being ventilated with Oxygen, Air and Sevoflurane. You have 4 minutes to manage this problem.
Management of increased airway pressure- Look, Listen, Feel:
Adequate Oxygen Delivery
Adequate FGF Check FiO2 Connections
Bag / Bellows Moving
FiO2 1.0 Confirm pPeak
Clear Airway
Airway position, Airway noise
Adjuncts, LMA / ETT Clear
Capnograph Trace
Isolate equipment
Suction catheter
for patency
Attach AmbuBag
direct to ETT
Easy to ventilate = EQUIPMENT PROBLEM
Check Breathing
Rate, Symmetry, SpO2
Exp tidal volume, EtCO2 Airway pressure
Patient problem:
Reconnect Equipment
Check muscle relaxation
Check Endobronchial
ETT
Neutral position
Release abdo gas
Broncho-dilators
Check Circulation
Rate, Rhythm Perfusion
BP
Check Depth
Anaesthesia Analgesia
Consider Surgical Problem
Call for HELP if problem not resolving quickly
02A_Progressive fall in minute volume You are 30 minutes in to anaesthetic maintenance of a 59 year old male undergoing elective repair of umbilical hernia under general anaesthetic. He has acid reflux but is otherwise fit and healthy. The uneventful rapid sequence induction was with Thiopentone 450mg, Fentanyl 100mcg and Suxamethonium 100mg, followed by 5mg Morphine and Vecuronium 6mg. He has a size 8 ETT in situ, being ventilated with Oxygen, Air and Sevoflurane. His expired minute volume on the monitor has reduced from 5L to 2L over the past 5 minutes. You have 2 minutes to manage this problem.
Management of Fall in MV - Look, Listen, Feel:
Adequate Oxygen Delivery
Adequate FGF Check FiO2
Connections Bag / Bellows Moving
Check for leak FGF Connections ETT Cuff Capnograph
and tubing
Clear Airway
Airway position, Airway noise Adjuncts, LMA / ETT Clear
Capnograph Trace
Check Breathing
Rate, Symmetry, SpO2
Exp tidal volume, EtCO2 Airway pressure
Check Circulation
Rate, Rhythm Perfusion
BP
Check Depth
Anaesthesia Analgesia
If spont breathing
Assist ventilation
Consider Surgical Problem
Call for HELP if problem not resolving quickly
03A_Unexpected hypoxia You are 15 minutes in to anaesthetic maintenance of a fit and healthy 35 year old male undergoing elective repair of inguinal hernia under general anaesthetic. The SpO2 has been gradually dropping since moving from the anaesthetic room in to theatre and is now 90%. The uneventful induction was with Propofol 200mg and Fentanyl 200mcg followed by an Ultrasound guided ilioinguinal field block with 10ml 0.25% levobupivacaine. He has a size 4 LMA in situ, breathing Oxygen, Air and Sevoflurane. You have 3 minutes to manage this problem.
Management of Unexpected Hypoxia- Look, Listen, Feel:
Adequate Oxygen Delivery
Adequate FGF Check FiO2
Connections:Leak Bag / Bellows Moving
FiO2 1.0 Ensure SpO2
accurate
Is it a Perfusion Problem?
Clear Airway
Airway position, Airway noise
Adjuncts, LMA / ETT Clear
Capnograph Trace
Clear tongue
obstruction
Reposition airway device
Suction catheter
for patency Clear FB /
Kink
Check Breathing
Rate, Symmetry, SpO2
Exp tidal volume, EtCO2
Airway pressure
No movement: Drugs
Asymmetrical: Endobronchial / Pneumothorax
Resp Depressant
Vent settings
Clear lower • Suction • Bronchodilation • Diuretic/PEEP
Check Circulation
Rate, Rhythm
Perfusion
BP
If unstable is it due to hypoxia?
Check ABG
Check Depth
Anaesthesia
Analgesia
Consider Surgical Problem
Call for HELP if problem not resolving quickly
04A_Fall in EtCO2 You are 10 minutes in to anaesthetic maintenance of a 75 year old male undergoing urgent DHS for fractured hip sustained within the last 24 hours. He has hypertension and peripheral vascular disease and he is on Aspirin, Ramipril and Bendrofluazide. The uneventful induction was with Propofol 150mg, Fentanyl 100mcg and Vecuronium 6mg, followed by 5mg Morphine and fascia iliaca block with 30ml 0.25% Levobupivacaine. He has a size 8 ETT in situ, being ventilated with Oxygen, Air and Sevoflurane. His EtCO2 was 5.8 following intubation and has gradually reduced to 3.1. You have 3 minutes to manage this problem.
Management of Fall in EtCO2 - Look, Listen, Feel:
Adequate Oxygen Delivery
Adequate FGF Check FiO2
Connections Bag / Bellows Moving
Sudden Fall: Disconnection / No lung blood supply
Clear Airway
Airway position, Airway noise Adjuncts, LMA / ETT Clear
Capnograph Trace
Check Breathing
Rate, Symmetry, SpO2
Exp tidal volume, EtCO2 Airway pressure
Check Circulation
Rate, Rhythm Perfusion
BP
Exclude / Manage �Cardiac Output
Check Depth
Anaesthesia Analgesia
Check anaesthesia level
Check analgesia level
Adjust ventilation
Consider Surgical Problem
Call for HELP if problem not resolving quickly
05A_Rise in EtCO2 You are 20 minutes in to anaesthetic maintenance of a 17 year old male undergoing emergency exploration of testicle for presumed torsion. He is otherwise fit and healthy. The uneventful rapid sequence induction was with Thiopentone 500mg and Suxamethonium 100mg, followed by Rocuronium 20mg, He has a size 8 ETT in situ, being ventilated with Oxygen, Air and Sevoflurane. His EtCO2 has gradually risen from 4.1 following induction to 6.9 kPa currently. You have 3 minutes to manage this problem.
Management of Rise in EtCO2 - Look, Listen, Feel:
Adequate Oxygen Delivery
Adequate FGF Check FiO2
Connections Bag / Bellows Moving
High FiCO2 = Use other drill
Clear Airway
Airway position, Airway noise Adjuncts, LMA / ETT Clear
Capnograph Trace
SV with �MV Clear Airway
Assist Ventilation
Consider Depth
Check Breathing
Rate, Symmetry, SpO2
Exp tidal volume, EtCO2 Airway pressure
IPPV with �MV Increase MV
Check Circulation
Rate, Rhythm Perfusion
BP
Check Depth
Anaesthesia Analgesia
SV with �MV or IPPV with NormMV
="↑CO2"Produc-on
Consider Depth
Consider Uncommon
Consider Surgical Problem
Call for HELP if problem not resolving quickly
06A_Rise in FiCO2 You are 10 minutes in to anaesthetic maintenance of an unfasted 25 year old male undergoing emergency reduction of ankle dislocation under general anaesthetic. He is otherwise fit and healthy. The uneventful rapid sequence induction was with Thiopentone 500mg and Suxamethonium 100mg, followed by Fentanyl 50mcg. He has a size 8 ETT in situ, being ventilated with Oxygen, Air and Sevoflurane via a Bain circuit in the anaesthetic room. There is now FiCO2 appearing in the circuit. You have 3 minutes to manage this problem.
Management of Rise in FiCO2 - Look, Listen, Feel:
Adequate Oxygen Delivery
Adequate FGF Check FiO2
Connections Bag / Bellows Moving
Check FGF for circuit
Clear Airway
Airway position, Airway noise Adjuncts, LMA / ETT Clear
Capnograph Trace
Check Breathing
Rate, Symmetry, SpO2
Exp tidal volume, EtCO2
Airway pressure
Remove Dead Space
�RR: Check anaesthesia &
analgesia Check muscle
relaxation
Check Circulation
Rate, Rhythm
Perfusion
BP
Check Depth
Anaesthesia
Analgesia Circle System CO2 Absorber
(consider ↑FGF) One Way Valves +
Connections
Aux Outlet / Ambubag +
TIVA
Communicate problem with surgeon and request to stop surgery
Call for HELP if problem not resolving quickly
07B_Cardiac and / or respiratory arrest You are 30 minutes in to anaesthetic maintenance of an elderly female undergoing emergency DHS for fractured hip under general anaesthetic. The uneventful induction was with Propofol 100mg and Fentanyl 100mcg followed by Vecuronium 4mg and fascia iliaca block with 30ml 0.25% Levobupivacaine. She has a size 8 ETT in situ, being ventilated with Oxygen, Air and Sevoflurane. She has developed ventricular fibrillation. You have 3 minutes to manage this problem.
Management of Cardiac Arrest - Look, Listen, Feel:
Call for HELP: Your theatre, Next door theatre, Your senior, 2222. START CHEST COMPRESSIONS 30:2
Adequate Oxygen Delivery
Adequate FGF Check FiO2
Connections
FiO2 1.0 Consider turning Volatile / TIVA off
Clear Airway
Airway position, Airway noise Adjuncts, LMA / ETT Clear
Capnograph Trace
Breathing
Rate, Symmetry, SpO2
Exp tidal volume, EtCO2 Airway pressure
Ventilate patient
Circulation Follow ALS algorithm 2 min Cycles
Adrenaline 1mg after 3rd
Shock
Reversible Causes
Hypoxia Hypovolaemia
Hypo / Hyperkalaemia Hypothermia
Tamponade Toxins
Tension Pneumothorax Thrombosis
Remember Intralipid
Remember anaesthesia once
ROSC
3 Stacked shocks in Cardiac Catheter Lab and Post Op Cardiac
Surgery
Consider Surgical Problem
08B_Unexpected Hypotension You are 20 minutes in to anaesthetic maintenance of an elderly female undergoing elective umbilical hernia repair. She is usually hypertensive on a beta-blocker and diuretic. She has been fasting all day and is last on your list. The uneventful induction was with Propofol 150mg and Fentanyl 100mcg followed by Vecuronium 4mg and Morphine 5mg. She has a size 8 ETT in situ, being ventilated with Oxygen, Air and Sevoflurane. Her BP was 120/80 following induction but is now 70/30. You have 3 minutes to manage this problem.
Management of Unexpected Hypotension - Look, Listen, Feel:
Adequate Oxygen Delivery
Adequate FGF Check FiO2
Connections Bag / Bellows Moving
HR >100 non-sinus = Use Arrhythmia
Drill
Clear Airway
Airway position, Airway noise Adjuncts, LMA / ETT Clear
Capnograph Trace
Check Breathing
Rate, Symmetry, SpO2
Exp tidal volume, EtCO2 Airway pressure
Exclude High Intrathoracic
Pressure
Check Circulation
Rate, Rhythm Perfusion
↑frequency BP checking
HR <60: Give anticholinergic
HR >100 sinus: Treat as
Hypovolaemia Fluid bolus Head
down Vasopressor /
Intrope
Check Depth
Anaesthesia Analgesia
Consider Surgical Problem: Pressure on vena cava, Blood loss
Call for HELP if problem not resolving quickly
09B_Unexpected Hypertension You are 10 minutes in to anaesthetic maintenance of a 28 year old fit and healthy male undergoing elective nasal septoplasty. The uneventful induction was with Propofol 200mg and Fentanyl 50mcg followed by Vecuronium 4mg. He has a size 8 ETT in situ, being ventilated with Oxygen, Air and Sevoflurane. His BP was 120/80 following induction but is now 160/90. You have 3 minutes to manage this problem.
Management of Unexpected Hypertension - Look, Listen, Feel:
Adequate Oxygen Delivery
Adequate FGF Check FiO2
Connections Bag / Bellows Moving
Recheck BP and begin review
↑Depth Anaesthesia
↓Surgical Stimulus
Clear Airway
Airway position, Airway noise Adjuncts, LMA / ETT Clear
Capnograph Trace
Check Breathing
Rate, Symmetry, SpO2
Exp tidal volume, EtCO2 Airway pressure
Exclude Hypoxia & Hypercarbia
Check Circulation
Rate, Rhythm Perfusion
↑frequency BP checking
Fluids: distended bladder, renal failure,
TURP
Check Depth
Anaesthesia Analgesia
Consider drug error
Consider drug interaction
Consider medical causes (ICP, Thyroid,
Phaeo, MH)
Consider Surgical Problem: administered vasopressor? / surgical tourniquet time?
Call for HELP if problem not resolving quickly
10B_Sinus Tachycardia You are 20 minutes in to anaesthetic maintenance of a 21 year old fit and healthy male undergoing emergency laparoscopy for presumed appendicitis. He is usually fit and healthy. The uneventful rapid sequence induction was with Thiopentone 450mg, Fentanyl 100mcg and Suxamethonium 100mg, followed by Vecuronium 4mg and Morphine 10mg. He has a size 8 ETT in situ, being ventilated with Oxygen, Air and Sevoflurane. His heart rate pre-induction was 90 but it has gradually risen to 115. You have 3 minutes to manage this problem.
Management of Sinus Tachycardia - Look, Listen, Feel:
Adequate Oxygen Delivery
Adequate FGF Check FiO2
Connections Bag / Bellows Moving
Recheck BP & Begin
Review
↑BP = Use ↑BP Drill
Clear Airway
Airway position, Airway noise Adjuncts, LMA / ETT Clear
Capnograph Trace
Check Breathing
Rate, Symmetry, SpO2
Exp tidal volume, EtCO2 Airway pressure
Check Circulation
Rate, Rhythm Perfusion
↑frequency BP checking
Check Depth
Anaesthesia Analgesia
Look for specific cause
Hypovolaemia Sepsis, Drug interaction, Pneumothorax,
Embolism, Cardiac Disease, Unusual conditions (MH, Phaeo, thyroid)
Consider Surgical Problem
Call for HELP if problem not resolving quickly
11B_Arrhythmias You are 20 minutes in to anaesthetic maintenance of a 29 year old female undergoing elective laparoscopy for investigation of pelvic pain. She has a history of SVT twice in the past 8 years but is on no medication. She is otherwise fit and healthy. The uneventful induction was with Propofol 180mg, Fentanyl 100mcg followed by Rocuronium 30mg. She has a size 8 ETT in situ, being ventilated with Oxygen, Air and Sevoflurane. She has a narrow complex tachycardia at a rate of 170 which developed suddenly from an initial heart rate of 60. You have 3 minutes to manage this problem.
Management of Arrhythmias - Look, Listen, Feel:
Adequate Oxygen Delivery
Adequate FGF Check FiO2
Connections Bag / Bellows Moving
Treat the patient, not the
arrhythmia Recheck
Pulse
No Pulse = Start chest compressions and Use
Cardiac Arrest Algorthm
Clear Airway
Airway position, Airway noise Adjuncts, LMA / ETT Clear
Capnograph Trace
Check Breathing
Rate, Symmetry, SpO2
Exp tidal volume, EtCO2 Airway pressure
Exclude Hypoxia &
Hypercarbia
Check Circulation
Rate, Rhythm Perfusion
↑frequency BP checking
Consider Invasive
Monitoring
If Cardiac Output compromised: Use ALS algorithms (consider
intervention criteria)
Check Depth
Anaesthesia Analgesia
Depth of anaesthesia
↓Surgical Stimulus
Consider Surgical Problem
Call for HELP if problem not resolving quickly
12B_Convulsions You are 10 minutes in to anaesthetic maintenance of a 54 year old female undergoing elective hysteroscopy for postmenopausal bleeding. She has a history of epilepsy and is on 300mg Carbamazepine twice daily and has self-terminating seizures about once every two months. She is otherwise fit and healthy. The uneventful induction was with Propofol 180mg and Fentanyl 50mcg. She has a size 4 LMA in situ, spontaneously breathing Oxygen, Air and Sevoflurane. She has just begun to have a generalized seizure. You have 3 minutes to manage this problem.
Management of Convulsions - Look, Listen, Feel:
Adequate Oxygen Delivery
Adequate FGF Check FiO2 Connections
Bag / Bellows Moving
FiO2 1.0 Prevent injury
Notify Surgeon
Clear Airway
Airway position, Airway noise Adjuncts, LMA / ETT Clear
Capnograph Trace
May need to stop seizure to manage
airway
Check Breathing
Rate, Symmetry, SpO2
Exp tidal volume, EtCO2
Airway pressure
Assist Breathing
Check Circulation
Rate, Rhythm Perfusion
BP
Check Depth
Anaesthesia Analgesia
Check BM
Stop Seizure: Induction Agent Benzodiazapine MgSO4 (Eclampsia) Dextrose (Hypo)
Look for treatable cause: Hypoxaemia, LA Toxicity, Drugs (NB
social history), Sepsis, Pyrexia, Intrinsic CNS, Metabolic
Consider Surgical Problem
Call for HELP if problem not resolving quickly