Surgical EmergenciesKeeping Your Ducks In A Row

“By Failing to

Prepare,

You are Preparing

to Fail”Benjamin Franklin

TOPICS-ABC’s Airway/Breathing:

Difficult Airway

Anaphylaxis

Pulmonary Embolus

Circulation:

Malignant Hyperthermia

Lidocaine Toxicity

Hemorrhage

Other:

Fire

Difficult Airway

Defined as a clinical situation where a health care professional experiences or may experience difficulty with:

Face mask ventilation of upper airway

Tracheal intubation

Or Both

Patients at Risk Cleft Lip

Cleft Palate

Micrognathia

Macroglossia

Upper/lower jaw surgery

Recent URI (increased

risk of laryngospasm or

bronchospasm)

Bleeding/Hematoma

Sleep Apnea History

Obesity

Recent intubation/re-

intubation

Issues with joint mobility

due to chronic disease

(TMJ, RA, Ankylosing

spondylitis)

Airway pathology

Facial trauma

Narcotic Overdose

Clinical Examination

No ideal airway assessment tool

History and assessment should

heighten awareness of potential

problemsTongue size

Oropharyngeal cavity size (Mallampati

Classification)

Neck Assessment

Mallampati

Classification

Neck Hematoma

Sublingual

Hematoma

RESPIRATORY GENERAL

Change in voice quality Restlessness

Difficulty Breathing Agitation

Inspiratory Stridor Panic

Cyanosis Somnolence

Respiratory Arrest Unresponsiveness

EARLY

LATE

ASSESSMENT & MANAGEMENT

Early assessment Know patient history

Clinical exam Body Habitus

Airway Assessment

TreatmentContinuous Pulse Oximetry

Appropriate assignment of room/hand-off

Pre-op planning (? Overnight stay for airway assessment)

Bag-Valve-Mask Ventilation

PEARLS:

Lift mandible to mask rather than pushing mask

onto face

Easier to make a seal with a mask that is too big

than 1 than is too small

Leave dentures in place to improve seal

If facial hair makes seal difficult – apply water

soluble lubricant over beard to improve contact

TREATMENT

Being prepared is the best treatment

Know where emergency carts/equipment are

Have oxygen devices handy (Ambu bag)

Crycothyrotomy/Trach sets available

ASK QUESTIONS!

What should I be looking for?

When should I be concerned?

What is Anaphylaxis?

Anaphylaxis is a severe systemic allergic reaction

Results from exposure to allergens

Rapid in onset

Can result in a life-threatening emergency

SYMPTOMS

Typical symptoms:

Itchy rash

Throat or tongue

swelling

Shortness of breath

Vomiting

Lightheadedness

Hypotension

TREATMENT

Initiate BCLS/ACLS protocols as necessary

EPINEPHRINE: Subcutaneous: 0.1 to 0.5 mg (0.1 to 0.5 mL of 1:1000 solution). May be repeated every 20 minutes to once every 4 hours as needed.

IV Antihistamines (Diphenhydramine)

Steroids

Treatment

Saddle Embolus

PE Statistics

3rd most common cause of death in all age groups in the US

Women more susceptible than men

Diagnosis often missed because symptoms can be vague and non-specific

Risk Factors

Previous history of DVT or PE

Recent surgery or pregnancy

Prolonged immobilization or bed-rest

Trauma

Obesity

Varicose veins

Oral contraceptives

Underlying malignancy

Smoking

Prophylaxis

Early mobilization

Pneumatic compression boots

SQ Heparin or LMW Heparins

Hematology clearance for prior history

Consider home Enoxaparin for high-risk

patients

DiagnosisDiagnosis by suspicion initially

Shortness of breath

Tachycardia

Hypoxemia

Venous duplex

D-dimer

VQ Scan

CT Angiogram

Treatment

Enoxaparin (Lovenox)- 1mg/kg q12h or 1.5mg/kg once daily

Prophylactic dose is 30-40mg SQ once daily

Fondaparinux (Arixtra)- 5 mg (< 50 kg), 7.5 mg (50-100 kg), or 10 mg (body weight > 100

kg) subcutaneous daily

Prophylactic dose is: 2.5 mg SQ once daily

IV Heparin drip

Coumadin

Factor Xa and direct thrombin inhibitors Apixaban (Eliquis) , Rivaroxaban (Xaralto) , Dabigatran

(Pradaxa)

Argatroban

What is MH?

Potentially fatal

Inherited disorder (Dominant)

Associated with administration of

certain anesthetic agents.

Causes of MH

Acceleration of skeletal muscle

metabolism

Abnormally increased levels of

intracellular calcium

Mounting evidence:

MH may develop with exercise

and/or exposure to hot environments

in susceptible individuals.

Causative Drugs

Succinylcholine

Volatile inhaled agentsDesflurane

Enflurane

Halothane

Sevoflurane

Recognizing Suspected MH

Sinus tachycardia

Tachypnea

Hypercarbia (increased end-tidal CO2)/

Respiratory Acidosis

Muscle rigidity/masseter spasm

Cyanosis or mottled skin

Hyperthermia

Begin Treatment

Declare MH Emergency

Discontinue Triggering Agents

100% Oxygen at High Flow –

Hyperventilate

Summon additional staff/help

Give Dantrolene

2.5 mg/kg IV push

Titrate to effect

Treatment

Cool Patient: gastric lavage, cooling

blanket/ IV fluids/ Ice packs

Treat arrhythmias

Initiate Transfer Plan (If Ambulatory

Center)

Whenever possible, don’t move

unless clinician judges patient to be

stable

After Crisis Controlled

Dantrolene 1mg/kg every 4-6 hours for 24-

48 hours

CLOSE MONITORING FOR RETURN OF

SYMPTOMS

Follow labs: electrolytes, ABG’s, CPK,

urine output/color, coags

Monitor for S/S of rhabdomyolysis and

myoglobinuria

MH

Therapy aimed at:

Prompt administration of Dantrolene

Treatment of hyperkalemia

Hyperventilation

Cooling to target core temp of no

more than 38 degrees

Indicators of Patient Stability

End Tidal CO2 is declining or normal

HR is stable or decreasing

No ominous dysrhythmias

Temperature is declining

Generalized muscular rigidity is resolving (if

present)

IV dantrolene administration has begun

Morbidity & Mortality

Consciousness Level Change/Coma

Cardiac Dysfunction

Pulmonary Edema

Renal Dysfunction

Disseminated Intravascular Coagulation

(DIC)

Hepatic Dysfunction

Relapse

Death

Factors Contributing to

Complication Risk

Increased time 1st sign to 1st dantrolene

For every 30 minute increase in the interval

between 1st MH sign and 1st dantrolene dose,

the complication likelihood is increased 1.6 X.

Increased maximal temperature

For every 2◦C increase in maximal temperature,

the complication likelihood increased 2.9 X.

Unsafe Drugs in MH Susceptible

Patients

Inhaled General Anesthetics:

Desflurane

Enflurane

Ether

Halothane

Isoflurane

Methoxyflurane

Sevoflurane

Depolorizing

Muscle Relaxants:

Succinylcholine

Safe Medications in MHAll intravenous anesthetic and sedative agents:

propofol, ketamine, etomidate, dexmedetomidine, and barbiturates

All local anesthetics lidocaine, bupivacaine, ropivicaine

Nondepolarizing neuromuscular blockers vecuronium, rocuronium

Pain relievers and anxiolytics opioids and benzodiazepines

Inhalational agents limited to nitrous oxide and xenon

Stocking an MH Cart

Dantrium/Revonto 20mg/60ml

3gm mannitol/ 20mg vial

36 vials available in each

institution where MH can

occur.

Dilute each vial with 60ml

sterile water (without

preservative)

Ryanodex New formulation

250mg/5ml

0.125gm mannitol/250mg vial

3 vials available in each

institution where MH can occur.

Dilute with 5ml sterile water

(without preservative)

Stocking an MH Cart

Sodium Bicarb

(NaHCO3) 50ml x 5

Dextrose 50% 50ml x 2

Calcium Chloride

(10%) 10ml x 2

Regular Insulin 100units/ml x1 vial

(refrigerated)

Lidocaine for injection (2%) – 100mg/5ml or

100mg/10ml (preloaded

syringes)

Cold Saline solution 3 liters for IV cooling

Refer to www.mhaus.org/faqs/stocking-an-mh-cart for more information

Additional Drugs

Amiodarone 150mg/10 minutes (15mg/minute) bolus dose

Can be repeated once in 10-30 minutes

Followed by IV drip: 1mg/min x 6 hours

Requires dilution in Dextrose only and use of in-line filter.

ACLS protocol

For treatment of arrhythmias

LidocaineAntiarrhythmic Drug:

To treat ventricular tachycardia

Class 1b antiarrhythmic medication used in the treatment

of ventricular arrhythmias

Local Anesthetic:

numb tissue in a specific area

nerve blocks

Liposuction

Typically begins working within minutes and lasts

for 30 minutes-3 hours

Mixing with Epinephrine – makes it last longer and

decreases bleeding when given as local anesthetic

Lipo FactsTumescent Lipo:

Subcutaneous infusion of solution containing anesthetic with aspiration of liquified fat through cannulas

No standard, official, or rigidly prescribed formulation exists for tumescent anesthetic solutions. Concentrations of the lidocaine and epinephrine should depend on the areas treated and the clinical situation

Infusate

Provides prolonged local anesthesia with

minimal blood loss.

Large volume Liposuction (removal of >

1500ml fat) may require infusion of several

liters of solution.

Blocks

Usually placed by anesthesia

Brachial, Thoracic, Femoral

TAP (Transverse Abdominal Plane)

blocks used for abdominal surgical procedures

Important to assess absorption rate (bupivicaine

disk/ball)

Anesthetic Concentrations/Dilution

Drug concentration expressed as percentage

Bupivicaine 0.25%, Lidocaine 1%

Percentage measured in grams/100ml

1% = 1gram/100ml=1000mg/100ml or 10mg/ml

Calculate mg/ml concentration from percentage by

moving the decimal point 1 place to the right

Bupivicaine 0.25% = 2.5mg/ml

Lidocaine 1% = 10mg/ml

Lidocaine 2% = 20mg/ml

Toxicity Manifestations

CNS

Cardiovascular

Hematologic

Allergic

Local Tissue

CNS Manifestations

Circumoral or Tongue numbness

Metallic Taste

Lightheadedness

Dizziness

Visual/Auditory Disturbances

Disorientation

Drowsiness

Higher doses lead to:

Muscle Twitching

Seizures

Loss of consciousness

Coma

Respiratory/Cardiac depression/arrest

Cardiovascular Manifestations

Chest pain

Shortness of breath

Palpitations/Arrhythmia

Lightheadedness

Diaphoresis

Hypotension

Syncope

Respiratory/General

Manifestations

Cyanosis

Gray color

Tachypnea

Dyspnea

Fatigue

Exercise Intolerance

Dizziness

Allergic Manifestations

Rash

Uticaria

Anaphylaxis (very rare)

TREATMENT OF TOXICITY

DISCONTINUE THE DRUG

Failure to recognize early signs may result in progression to severe CNS effects

ABC’s

Initiation of BCLS/ACLS Protocols

Airway management

Oxygen administration

Arrhythmia management

Mild symptoms:

Benzodiazepines

Seizures:

Treatment with benzodiazepines/barbituates

ANTIDOTAL TREATMENT

LIPID RESCUE:

Rapid administration of IV fat emulsion 20% lipid solution – bolus of 1.5mL/kg over 1 minute followed by

0.25mL/kg/min or 15 mL/kg/hour run over 30-60 min

Usually for treatment of bupivicaine toxicity, but

can be used for treatment of severe lidocaine

toxicity.

Lidocaine & Liposuction

Dosage Recommendations

Maximum Safe Dosage Guidelines:

45mg/kg in ‘relatively’ thin patients

50mg/kg in obese patients

At doses <55mg/kg:

Higher plasma lidocaine concentrations may

result from adverse drug reactions (CYP450

pathway)

Tips For Safety

Understand maximum safe dosing

Use explicit/signed surgeon orders for tumescent

solution.

Designated licensed personnel should mix

solution

Normal saline is preferred tumescent solvent Include determination of maximum safe dose in mg/kg

Specify dose in terms of mg

Specify EXACT total mg Lidocaine and Epinephrine & mEq

sodium bicarb/liter of solution (mg/L & mEq/L)

Tips For Safety

Know the dose given (in mg and mg/kg)

Use ONLY 1% Lidocaine

Ensure licensed personnel prepare solution

Prepare & Label solution at time of surgery

Save all empty bottles

Avoid post op sedation

Review ALL home medications before surgery

Including Rx, OTC & homeopathic/nutriceuticals

What is Post Op Hemorrhage

“Significant” Bleeding that occurs after

any surgical procedure.

Bleeding may occur immediately or

there may be a delay.

POTENTIAL CAUSES

Surgical/Technical

Causes:

Blood vessel clamps

/sutures coming

undone

Injury to surrounding

structures

Vomiting/coughing

Patient Causes:

Pre-existing disease

Liver, kidney, HTN

Bleeding disorders

Strenuous activity

Medications

Prescription

OTC

Herbal

Signs/Symptoms

Increased drain output

Tachycardia

Hypotension

Decreased urine output

Restlessness

Surgical Fire550-650 surgical fires occur in U.S every

year

FDA and its partners launched the

“Preventing Surgical Fires” initiative to:

Increase awareness of factors that contribute to

surgical fires

Disseminate surgical fire prevention tools

Promote the adoption of risk reduction practices

throughout the healthcare community

FUEL

IGNITION SOURCE

OXIDIZER

Oxygen, NO2, Room Air Lasers, Electrocautery, Drills,

Fiberoptic Light source

Alcohol-Based Skin Prep, ET Tubes, Surgical Drapes, Sponges, Patient

At the start of each surgery:

Be aware of possible O2 under drapes near

surgical site

Do NOT apply drapes until all flammable preps

have fully dried.

Soak up spilled or pooled agent.

Fiberoptic light sources can start fires

Complete all cable connections before activating source.

Place source in standby mode when disconnecting cables

Moisten sponges to make them ignition resistant in

oropharyngeal surgery.

Head,Face,Neck & Upper Chest

Surgery

Use air only to face if patient can maintain adequate O2

saturation without supplemental O2

If safe O2 sat cannot be maintained without O2, secure airway

with laryngeal mask airway or tracheal tube.

Deliver minimum O2 concentration necessary for adequate

oxygenation

For unavoidable open O2 delivery above 30%, deliver 5 to 10

L/min of air under drapes to wash out excess O2.

Stop supplemental O2 at least one minute before and during

use of electrosurgery, electrocautery, or laser, if possible.

Surgical team communication is

essential for this recommendation

Use an adherent incise drape, to help isolate the

incision from possible O2-enriched atmospheres

beneath the drapes.

Keep fenestration towel edges as far from the

incision as possible.

Arrange drapes to minimize O2 buildup

underneath.

Coat head hair and facial hair (e.g., eyebrows,

beard, moustache) within the fenestration with

water-soluble surgical lubricating jelly to make it

nonflammable.

For coagulation, use bipolar electrocautery, not

monopolar electrocautery.

Take - Away

COMMUNICATION IS KEY!!!

Time-Out including planned anesthesia

Knowing equipment to be used.

Pay attention to details

PREVENTION is truly the best medicine.

SOURCE

New Clinical Guide to Surgical Fire

Prevention. Health Devices 2009

Oct;38(10):319.

www.ecri.org/surgical_fires

http://www.jointcommission.org/assets/1/18

/SEA_29.PDF

Watch the News Report: Patients Who Suffered Severe Burns From

Fires During Surgery, March 4, 2016

AANA contributes to article titled "Empowering Providers to Eliminate

Surgical Fires", October 20, 2014

Seared in the OR: Patients claim they catch fire in surgery, ABC7 News

Chicago, February 4, 2014

$30 million awarded to patient in surgical fire case, December 6, 2014

Operating-Room Fire at Hospital Burns Patient, Prompts Changes, The

Pilot, LLC, August 9, 2013

Woman’s Face Set on Fire During Simple Surgery, FOX8 Cleveland,

February 13, 2012

Fires during surgeries a bigger risk than thought, www.boston.com,

November 7, 2007

Recent Articles/News Reports

Condition: signs of fire (smoke,

odor, flash)

Objective: Extinguish fire; protect

patient

OR FIRE

STOP the flow of O2 or

N2O

Remove drapes or other

flammable material

Extinguish fire with saline or

water soaked gauze

DO NOT use alcohol based

solutions

DO NOT use liquid in fires

caused by electrical

equipment (bovie, lasers,

anesthesia machine)

If fire not extinguished on

1st attempt, use CO2 fire

extinguisher (safe in

wounds).

If fire persists:

Rescue/Evacuate patient

Close OR door

Turn off gas supply to room

ONLY YOU CAN PREVENT OR FIRES