1. Chapter 16 Emergency Situations
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.

2. Objective 1 Define terminology related to emergency situations.
Anaphylaxis
An unusual or exaggerated allergic reaction of an organism to foreign protein or other substances
Asystole
Cardiac standstill or arrest; absence of heartbeat

3. Objective 1. Terms Bolus Bradycardia Bronchospasm Capnography
A concentrated amount of medication administered rapidly intravenously
Bradycardia
Slow heart beat, less than 60 bpm
Bronchospasm
Involuntary contraction of the smooth muscle of the bronchi, causing impaired breathing
Capnography
Measurement of inspired and expired carbon dioxide concentrations

4. Objective 1. Terms Cyanosis Desaturation Diaphoresis
A bluish discoloration of the skin and mucous membranes due to inadequate oxygen in the blood
Desaturation
Reduction of oxygen saturation in the blood
Diaphoresis
Perspiration, especially profuse perspiration

5. Objective 1. Terms Hemoglobinuria Hypermetabolic Pyrexia
Presence of free hemoglobin in the urine
Hypermetabolic
Increased metabolism
Pyrexia
A fever, or febrile condition

6. Objective 1. Terms Tachycardia Tachypnea
Abnormally rapid heart rate, greater than 100 beats per minute
Tachypnea
Very rapid respirations, greater than 30 per minute

7. Objective 2 Identify emergency situations associated with anesthesia.
List by header in text:
Respiratory emergencies
Transfusion reaction, etc

8. Objective 3 Identify medications used in emergency situations
Make drug cards
Emergency situation
Medications used for each

9. Objective 3 Anaphylaxis Dopamine Dobutamine Ephedrine or phenylephrine
(Intropin)
Dobutamine
(Dobutrex)
Ephedrine or phenylephrine
(Neo-synephrine)

10. Objective 3 Mild allergic reaction Diphenhydramine
(Benadryl, Allergan 50)

11. Objective 3 Bronchospasm Albuterol Terbutaline (Proventil, Ventolin)
(Breathaire, Bicanyl)

12. Objective 3 Transfusion reaction For hypotension: Dopamine Dobutamine
(Intropin)
Dobutamine
(Dobutrex)
Ephedrine or phenylephrine
(Neo-synephrine)

13. Objective 3
Transfusion reaction (continued)
Mannitol
(Osmitrol)

14. Objective 3 Note: respiratory obstruction Problem: bronchoconstriction
Due to bronchospasm or asthma
Problem: bronchoconstriction
Medications:
Beta agonists
Proventil (Albuterol)

15. Objective 3 Respiratory obstruction Positive pressure ventilation
Due to laryngospasm
A different problem
Positive pressure ventilation
If unsuccessful then:
Reintubate until spasm subsides
Relax muscles for intubation with:
Succinylcholine (Anectine)

16. Objective 3 Cardiac arrest Epinephrine Vasopressin Lidocaine
Procainamide
Amiodarone
Magnesium sulfate
Sodium bicarbonate

17. Objective 3 Malignant hyperthermia Dantrolene Sodium bicarbonate
Dantrium
Sodium bicarbonate
Mannitol or furosemide
Insulin

18. Objective 4 State the purpose of drugs used in emergency situations.
Make drug cards
Agent on one side
Purpose on the other side

19. Objective 4 Example: Dantrolene sodium (Dantrium)
Malignant hyperthermia

20. Objective 4 Example: Dopamine (Intropin) Lidocaine (Xylocaine)
Anaphylaxis
Lidocaine (Xylocaine)
PVCs, ventricular tachycardia, ventricular arrhythmias
Not as a local anesthetic

21. Objective 4 Example: Sodium bicarbonate Epinephrine Metabolic acidosis
Cardiac stimulant
Arrest due to anaphylaxis
Note: vasoconstriction is NOT emergency use

22. Objective 5 Identify the category of specified emergency medications.
Make drug cards
Agent on one side
Category of agent on other side

23. Objective 6
Discuss the role of the surgical technologist during a cardiac emergency in surgery.

24. Objective 6 Varies by scenario
Justify your answers by filling in detail:
When it occurs
Who is present
What they are doing

25. Objective 6 Cover ST duties in all 3 basic roles:
First scrub
Second scrub
Circulator
Other team members and their basic duties

26. Objective 6
Example:
7:30 am: Patient is brought in room and moves to bed, and cardiac arrest occurs.

27. Objective 6 Who is doing what? Anesthesia provider? Surgeon?
Circulator?
First scrub?
Second scrub?

28. Objective 6
What should the ST be doing during the arrest when performing in the following roles?
Circulator?
First scrub?
Second scrub?

29. Objective 6
Cardiac defibrillator

30. Objective 7
List clinical signs of malignant hyperthermia.

31. Malignant hyperthermia
Background on MH:
RARE, inherited muscle condition
When triggered by some drugs:
Causes hypermetabolic state (huge Ca+ release)
Sudden; life-threatening

32. Malignant hyperthermia
Trigger agents:
Succinylcholine
All inhalation agents except nitrous oxide
Some antipsychotics

33. Malignant hyperthermia
Must have defect AND exposure to trigger
50% of offspring have it
Defect in sarcoplasmic reticulum
Stores and releases Ca+

34. Malignant hyperthermia
Ca+ released in massive amounts
Causes very sustained contraction
Cell metabolism continues at even  rate

35. Malignant hyperthermia
Depletes O2,  CO2 which causes acidosis
Muscle cells break down fast from contraction and release myoglobin into blood; clog kidneys

36. Objective 7 List clinical signs of MH Increase in end-tidal CO2
Tachycardia
Tachypnea
Masseter muscle rigidity (MMR)
Unstable blood pressure
Arrhythmias
Cyanosis
Diaphoresis
Pyrexia

37. Objective 7  in end-tidal CO2 Tachycardia Expired levels of CO2
Many reasons, assess
Tachycardia
Rapid heart rate

38. Objective 7 Tachypnea Rapid breathing Even over ventilator setting
Effort to blow off CO2
Classic for MH

39. Objective 7 Masseter muscle rigidity Noted at intubation
Classic for MH but could be normal for patient

40. Objective 7 Unstable blood pressure Arrhythmias Many reasons, assess
Absence of normal rhythm

41. Objective 7 Cyanosis Diaphoresis Abnormal condition; “blue”
Check ventilator
Diaphoresis
Sweating
Due to heat build up

42. Objective 7 Pyrexia Patient can die in 15 minutes High fever Late sign
Temperatures can rise to 109°
Patient can die in 15 minutes

43. Objective 8
Outline basic course of treatment for malignant hyperthermia.

44. Objective 8 Use pneumonic if helpful How Do Surg Techs Do It?
H D S T D

45. Objective 8 Hyperventilate with O2 Dantrolene Why? Blow off CO2
Skeletal muscle relaxant

46. Objective 8 Sodium bicarbonate Temperature management
Counteract metabolic acidosis
Due to  CO2 = acidosis
Temperature management
Ice packs at pulse points on patient
Attempt to cool patient rapidly

47. Objective 8 Diuretics Mannitol is mixed in with Dantrium
Keeps kidneys from getting clogged with myoglobin

48. Objective 8
Insulin
Treat hyperkalemia

49. Objective 9
Discuss the role of the surgical technologist in a malignant hyperthermia crisis.

50. Objective 9
First, if you aren’t paying attention to what is going on with the patient, you are not much help early in the crisis.

51. Objective 9 Be aware of anesthesia signs
Rapid response increases survival rate
When declared, drop what you are doing!

52. Objective 9 Anesthesia/Operation is stopped STAT
First scrub role; stay sterile if procedure going
Help close PRN
Hand iced NaCl irrigation

53. Objective 9 Second scrub role Break scrub Get or send people for ice
May help reconstitute Dantrium
If no other personnel available
e.g., on call

54. Objective 9 Circulating role Treat like code blue Get MH cart
Call for help
Change anesthesia machine when provider is ready

55. Objective 9 Circulating role Set up iced lavage Reconstitute Dantrium
Bladder, rectum, abdomen
Reconstitute Dantrium

56. Objective 9
Remember, all of these things are happening simultaneously.
Knowing the procedure makes you more valuable in the crisis.

57. Objective 9
Keep in mind
If the patient is identified as MH susceptible, there will be no crisis, as trigger agents are NOT administered to patient.

58. In summary Many emergency situations arise in surgery.
Many of these situations require the administration of medications for treatment.

59. In summary
The more you know, the more effective you are in assisting the anesthesia provider in an emergency.