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Ruth Novack BSN, RN, CCRN, CPAN

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1 Ruth Novack BSN, RN, CCRN, CPAN
PACU Emergencies Ruth Novack BSN, RN, CCRN, CPAN


3 Feel the Heat Malignant Hyperthermia an anesthetic nightmare

4 Occurrence MH occurs in one of every 3,000 to 50,000 surgical cases
More common in children than adults Reduction from a mortality rate of 80% in the 1970’s to 5% in the 2000’s

5 Family history and/or genetic testing showing a defect in RYR1 gene
Precursors MH Susceptible MH Positive Family history and/or genetic testing showing a defect in RYR1 gene Caffeine Halothane Contracture Testing CHCT

6 Heat Stroke

7 Pathology of Malignant Hyperthermia

8 Action Potential & Calcium

9 Triggers Anesthetic Gases
Photo courtesy of Christy Hatcher APRN, CRNA, mission work Peru

10 Depolarizing muscle relaxant Succinylcholine

11 Signs and Symptoms Masseter Rigidity Elevating CO2 Tachycardia
Hyperthermia Myoglobinuria

12 Recognition Surgery stopped and MH protocol initiated
Designated team members Multiple people to mix and administer Dantrolene Multiple people to do cooling efforts Lab draws Call MH hotline for assistance and guidance as needed Secure Critical Care Bed Make transportation arrangements as neccessary

13 MH Treatment Box

14 MH Box Accessible location immediate access
MH medical management and dosing Dantrolene 60 cc syringes Sterile H2O (Preservative free) Nastogastric Tube

15 Malignant Hyperthermia Association of the United States
Treatment Medical Emergency MHAUS Malignant Hyperthermia Association of the United States

16 Dantrolene/Dantrium Reconstitution

17 Dantrolene/Dantrium

18 Ongoing Medical Management

19 ICE those hot spots!

20 Electrolytes, Fluid balances & preventative measures for myoglobinuria

21 “I... Ca..n’t..” Photo courtesy Adessa Nelson, SPN , Itasca Community College. First day college

22 Inadequate Ventilation
Narcotic/Paralytic Signs Inadequate breath “Guppy Breathing” Medical complications signs “unable to breath” Audible wheezing Obstructive Stressful breathing Crowing or Stridor

23 Obstructive/Upper airway
Airway Support Oral Nasal Chin Lift Reversal Naloxone- Narcotic reversal Dilute Given to rapidly can cause “pulmonary edema” Romazicon- Benzodiazipine reversal Obstructive Sleep Apnea Stop-bang assessment Bring CPAP to hospital Use in PACU

24 Classic Crowing Laryngospasm Causes Extubation Secretions-aspiration
Treatment Positive Pressure Airway Assistance “Ambu” Re-paralyze/intubate CPAP/BIPAP Considerations Negative Pressure Pulmonary Edema Laryngeal Edema/Epiglottitis Prolonged intubation Traumatic extubation Coughing Treatment IV Xylocaine Racemeic Epinephrine Neb Xylocaine neb Dexamethsone Tessolon Pearle Consider sedation

25 Chemical Signs a) Re-paralyzation after reversal given
b) High spinal Block c) Narcosis Signs Guppy breathing use of neck accessory muscles with poor or no air exchange Weak grasp Inability to lift head No cough effort

26 Airway and Respiratory management
Treatment Airway and Respiratory management Intubate & ventilate CPAP/BiPap B) Paralytic Reversal C) Considerations Sedation/amnesic Pain Management

27 Genetic Makeup Treatment Pseudo cholinesterase Deficiency CO2 Narcosis
Ventilator support Blood test for positive identification Follow-up letter and documentation to primary family made aware hereditary gene CO2 Narcosis ETCO2 Monitoring Verbal naloxone vs naloxone CPAP/BiPap SaO2 monitoring

28 Pulmonary Edema Signs Causes Diagnosis Treatment
Difficult to breath, chest heaviness Increased RR and effort Refractory oxygen saturations despite oxygen delivery Audible wheezing Cough or tickle Air hunger Causes Fluid imbalance Rapid administration of Naloxone Laryngospasm CHF Diagnosis Based on signs and symptoms Chest X-ray Treatment Supportive measure Furosemide Bi-pap Intubate/ventilate

29 Pneumothorax Signs Causes Diagnosis Treatment
Tachypnea Hypo/hypertension Tachycardia Anxious Displace trachea Diaphortetic Chest Discomfort Causes Trauma Central line placements Surgical Procedure PEEP/Mechanical Ventilation Tensions Pneumothorax Spontaneous Right mainstem intubation Diagnosis Chest Xray Lung sounds Symptoms Treatment Oxygen Chest tube insertion Adjustment of Endotracheal tube

30 Laryngeal edema can progress to Laryngospasm
Key Points Listen to your patient what they say and how they sound, listen both anteriorly and posteriorly to lung sounds and all fields Laryngeal edema can progress to Laryngospasm Calm the Cough before the Storm Airway = Anxiety Support airway and consider Midazolam for calming and amnesic effects

31 Crash Cart Crash Cart 101


33 Ekg lead placement



36 Symptomatic A-Fib Atrial Kick Emergency Cardioversion
Lose 20% of atrial kick Hypotension Diaphoretic Increase myocardial oxygenation demand Myocardial ischemia/infarct Decreased Cerebral Perfusion Pressure (confusion) Emergency Cardioversion ACLS protocol Synchronized Cardioversion Lead that gives you highest Q wave Charge, Synch, Clear Consider sedation…it can hurt if your awake

37 Treatment Oxygen Correction of the cause Medications Hypovolemia
Electrolyte imbalances Anemia Pulmonary Mechanical Pain managment Medications Amiodorone Adensosine

38 PEA Pulseless Electrical Activity
Rhythm without pulse CPR and ACLS protocol IV boluses Vasopressors Reversible Causes Hypovolemia Hypoxia Hydrogen ion hypothermia Tension pneumothorax Tamponade, cardiac Toxins Thrombosis, pulmonary Thrombosis, coronary

39 Ventricular Tachycardia
Drug therapy Epinephrine every 3-5 min Amiodarone for refractory VR/VT Consider advanced airway Reintubate/ventilate ETCO2 monitoring Investigate cause and Institute treatment Check lead placement Start CPR Call for assistance Crash Cart Watch for Return of Spontaneous Circulation (ROSC) Continuous CPR with evaluation every 2 minutes

40 Myocardial Stress

41 Wave assessment Normal QRS

42 Heart is telling you it is stressed
Ischemia Heart is telling you it is stressed

43 ST Elevation Tombstones

44 Elevated ST segment associated with:
Myocardial Infarct Signs & Symptoms Elevated ST segment associated with: Chest heaviness Sternal pain Throat and jaw pain Indigestion VS instability Treatment & Diagnosis Investigate Causes Oxygen Hemorrhage 12 lead Ekg Electrolyte imbalance Baby aspirin (if indicated) Pain Troponins Primary Cardiac K+ & Mg++ Nitroglycerin (if BP allows) Pain medication Beta-blockers if indicated Follow-up Hospitalist to follow Admission Telemetry

45 Intravascular Bupivacaine
Spinal, Epidural Block, Peripheral Nerve Block Intravascular Bupivacaine Cardiovascular collapse and Neurological toxic To avoid injection into the vascular system: fractional dosing with aspiration Test doses with epinephrine monitoring for HR elevation or ST changes. Onset of symptoms: Upper extremities within minutes Lower extremities up to 30 minutes post injection Treatment Begin ACLS measures as required 20% Lipids given to bind bupivacaine away from cells Seizures treated with midazolam Continuous monitoring

46 *CNS changes precedes Cardiac
Injection into vascular system Early Signs Tinnitus or ringing in ears Metallic taste &/or Circum-oral tingling Late Signs Motor twitch Seizure Coma Respiratory Arrest *CNS changes precedes Cardiac

47 Figure 1 Recommended treatment protocol reprinted with permission from the American Society of Anesthesiologists. Debbie C. Sandlin-Leming Resuscitation of Local Anesthesia–Induced Cardiac Arrest: Lipids to the Rescue Journal of PeriAnesthesia Nursing, Volume 25, Issue 6, 2010,

48 20% Intralipid dosing 1.5 mL/kg 20% lipid emulsion bolus
0.25 mL/kg per minute of infusion, continued for at least 10 minutes after circulatory stability is attained If circulatory stability is not attained, consider rebo- lus and increasing infusion to 0.5 mL/kg per minute Approximately 10 mL/kg lipid emulsion for 30 min- utes is recommended as the upper limit for initial dosing Fig (7) Recommendations from the 2010 ASRA Practice Advisory on Local Anesthetic Systemic Toxicity [1]. [1] Drasner, K.; Hejtmanek, M. R.; Mulroy, M. F.; Rosenquist, R. W.; Weinberg, G. L. ASRA practice advisory on local anesthetic systemic toxicity. Reg. Anesth. Pain Med., 2010, 35(2), Bern, S., Akpa, B., Kuo, I., & Weinberg, G. (2011). Lipid Resuscitation: A Life-Saving Antidote for Local Anesthetic Toxicity. CURRENT PHARMACEUTICAL BIOTECHNOLOGY, 12(2), 313–319. Retrieved from

49 Sympathetic Block Blood Pressure =
Loss of sympathetic control/not motor Blood Pressure = Stroke Volume X Heart Rate X Peripheral Vascular Resistance Cardiac Output = Stroke Volume X Heart Rate Volume support Lactated Ringers/Saline/Hespan Ephedrine constrict vessels improve blood return Neosynephrine bolus or gtt Provide support until block wears off


51 http://www. articlesweb

52 Tell Me Your Name The Neuro Exam The Neurological Exam
Establish a baseline LOC alert/oriented Speech & Swallow aphasic expressive/receptive dysphagia Movement levels normal/equal/unilateral Decorticate Decerebrate Flaccid

53 Pupils Size Equal Shape Round Irregular Reaction Normal/Brisk Sluggish Hippus Optic Nerve Direct Consensual

54 Utilizing the Web NINDS.NIH.GOV &/or


56 National Institute of Health Stroke Scale Utilized to determine
Stroke extent and recovery outcome Developed to remove user bias Requires training Motor function Verbal Visual Speech


58 National Institutes of Health Stroke Scale
Score [3] Stroke Severity No Stroke Symptoms 1-4 Minor Stroke 5-15 Moderate Stroke 16-20 Moderate to Severe Stroke 21-42 Severe Stroke

59 Interventional Radiology 6 hour window
Time and rtPA rtPA 3 Hour window Interventional Radiology 6 hour window Surgery relative exclusion to rtPA

60 Stroke Center/PCI care

61 Time and rtPA 69 y.o female flu during the last week
Up with husband in am watching TV walked with him to kitchen to get Ibuprofen for H/A Witnessed fall 1015 am Unable to get up left hemi-plegia, garbled speech, left facial droop and ignoring left side deviated gaze 911 called 1100 Hospital Emergency Room Stroke team Stat CT Scan non-hemorrhagic 1215 rtPA and Transport to Interventional Radiology 1239 Sheath time in IR 1252 Anterior Communicating Artery Restored 1316 Middle Cerebral Artery Restored Patient transferred to Intensive Care Unit Total time 3 hours from time of witnessed symptoms to clot evacuation & treatment

62 Blocked level of Anterior Communicating Artery

63 Blockage removed, plaque and clot via Pneumbra suction

64 Re-established circulation

65 Train for the emergency
Photo courtesy of Adessa Nelson


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