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Surgical EmergenciesKeeping Your Ducks In A Row
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“By Failing to
Prepare,
You are Preparing
to Fail”Benjamin Franklin
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TOPICS-ABC’s Airway/Breathing:
Difficult Airway
Anaphylaxis
Pulmonary Embolus
Circulation:
Malignant Hyperthermia
Lidocaine Toxicity
Hemorrhage
Other:
Fire
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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
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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
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Clinical Examination
No ideal airway assessment tool
History and assessment should
heighten awareness of potential
problemsTongue size
Oropharyngeal cavity size (Mallampati
Classification)
Neck Assessment
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Mallampati
Classification
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Neck Hematoma
Sublingual
Hematoma
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RESPIRATORY GENERAL
Change in voice quality Restlessness
Difficulty Breathing Agitation
Inspiratory Stridor Panic
Cyanosis Somnolence
Respiratory Arrest Unresponsiveness
EARLY
LATE
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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)
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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
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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?
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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
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SYMPTOMS
Typical symptoms:
Itchy rash
Throat or tongue
swelling
Shortness of breath
Vomiting
Lightheadedness
Hypotension
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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
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Treatment
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Saddle Embolus
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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
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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
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Prophylaxis
Early mobilization
Pneumatic compression boots
SQ Heparin or LMW Heparins
Hematology clearance for prior history
Consider home Enoxaparin for high-risk
patients
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DiagnosisDiagnosis by suspicion initially
Shortness of breath
Tachycardia
Hypoxemia
Venous duplex
D-dimer
VQ Scan
CT Angiogram
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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
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What is MH?
Potentially fatal
Inherited disorder (Dominant)
Associated with administration of
certain anesthetic agents.
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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.
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Causative Drugs
Succinylcholine
Volatile inhaled agentsDesflurane
Enflurane
Halothane
Sevoflurane
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Recognizing Suspected MH
Sinus tachycardia
Tachypnea
Hypercarbia (increased end-tidal CO2)/
Respiratory Acidosis
Muscle rigidity/masseter spasm
Cyanosis or mottled skin
Hyperthermia
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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
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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
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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
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MH
Therapy aimed at:
Prompt administration of Dantrolene
Treatment of hyperkalemia
Hyperventilation
Cooling to target core temp of no
more than 38 degrees
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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
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Morbidity & Mortality
Consciousness Level Change/Coma
Cardiac Dysfunction
Pulmonary Edema
Renal Dysfunction
Disseminated Intravascular Coagulation
(DIC)
Hepatic Dysfunction
Relapse
Death
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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.
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Unsafe Drugs in MH Susceptible
Patients
Inhaled General Anesthetics:
Desflurane
Enflurane
Ether
Halothane
Isoflurane
Methoxyflurane
Sevoflurane
Depolorizing
Muscle Relaxants:
Succinylcholine
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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
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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)
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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
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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
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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
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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
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Infusate
Provides prolonged local anesthesia with
minimal blood loss.
Large volume Liposuction (removal of >
1500ml fat) may require infusion of several
liters of solution.
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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)
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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
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Toxicity Manifestations
CNS
Cardiovascular
Hematologic
Allergic
Local Tissue
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CNS Manifestations
Circumoral or Tongue numbness
Metallic Taste
Lightheadedness
Dizziness
Visual/Auditory Disturbances
Disorientation
Drowsiness
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Higher doses lead to:
Muscle Twitching
Seizures
Loss of consciousness
Coma
Respiratory/Cardiac depression/arrest
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Cardiovascular Manifestations
Chest pain
Shortness of breath
Palpitations/Arrhythmia
Lightheadedness
Diaphoresis
Hypotension
Syncope
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Respiratory/General
Manifestations
Cyanosis
Gray color
Tachypnea
Dyspnea
Fatigue
Exercise Intolerance
Dizziness
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Allergic Manifestations
Rash
Uticaria
Anaphylaxis (very rare)
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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
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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.
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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)
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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)
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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
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What is Post Op Hemorrhage
“Significant” Bleeding that occurs after
any surgical procedure.
Bleeding may occur immediately or
there may be a delay.
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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
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Signs/Symptoms
Increased drain output
Tachycardia
Hypotension
Decreased urine output
Restlessness
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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
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FUEL
IGNITION SOURCE
OXIDIZER
Oxygen, NO2, Room Air Lasers, Electrocautery, Drills,
Fiberoptic Light source
Alcohol-Based Skin Prep, ET Tubes, Surgical Drapes, Sponges, Patient
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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.
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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
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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.
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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.
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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
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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
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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
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ONLY YOU CAN PREVENT OR FIRES
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