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Chapter 16 Emergency Situations Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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 Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 1. Terms Bolus 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 Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 1. Terms Cyanosis 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 Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 1. Terms Hemoglobinuria Presence of free hemoglobin in the urine Hypermetabolic Increased metabolism Pyrexia A fever, or febrile condition Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 1. Terms Tachycardia Abnormally rapid heart rate, greater than 100 beats per minute Tachypnea Very rapid respirations, greater than 30 per minute Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2 Identify emergency situations associated with anesthesia. List by header in text: Respiratory emergencies Transfusion reaction, etc Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3 Identify medications used in emergency situations Make drug cards Emergency situation Medications used for each Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3 Anaphylaxis Dopamine • (Intropin) Dobutamine • (Dobutrex) Ephedrine or phenylephrine • (Neo-synephrine) Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3 Mild allergic reaction Diphenhydramine • (Benadryl, Allergan 50) Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3 Bronchospasm Albuterol • (Proventil, Ventolin) Terbutaline • (Breathaire, Bicanyl) Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3 Transfusion reaction For hypotension: Dopamine • (Intropin) Dobutamine • (Dobutrex) Ephedrine or phenylephrine • (Neo-synephrine) Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3 Transfusion reaction (continued) Mannitol • (Osmitrol) Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3 Note: respiratory obstruction Due to bronchospasm or asthma Problem: bronchoconstriction Medications: Beta agonists • Proventil (Albuterol) Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3 Respiratory obstruction Positive pressure ventilation Due to laryngospasm A different problem If unsuccessful then: Reintubate until spasm subsides Relax muscles for intubation with: Succinylcholine (Anectine) Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3 Cardiac arrest Epinephrine Vasopressin Lidocaine Procainamide Amiodarone Magnesium sulfate Sodium bicarbonate Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3 Malignant hyperthermia Dantrolene • Dantrium Sodium bicarbonate Mannitol or furosemide Insulin Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 4 State the purpose of drugs used in emergency situations. Make drug cards Agent on one side Purpose on the other side Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 4 Example: Dantrolene sodium (Dantrium) Malignant hyperthermia Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 4 Example: Dopamine (Intropin) Anaphylaxis Lidocaine (Xylocaine) PVCs, ventricular tachycardia, ventricular arrhythmias Not as a local anesthetic Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 4 Example: Sodium bicarbonate Metabolic acidosis Epinephrine Cardiac stimulant Arrest due to anaphylaxis Note: vasoconstriction is NOT emergency use Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 5 Identify the category of specified emergency medications. Make drug cards Agent on one side Category of agent on other side Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 6 Discuss the role of the surgical technologist during a cardiac emergency in surgery. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 6 Varies by scenario Justify your answers by filling in detail: When it occurs Who is present What they are doing Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 6 Cover ST duties in all 3 basic roles: First scrub Second scrub Circulator Other team members and their basic duties Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 6 Example: 7:30 am: Patient is brought in room and moves to bed, and cardiac arrest occurs. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 6 Who is doing what? Anesthesia provider? Surgeon? Circulator? First scrub? Second scrub? Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 6 What should the ST be doing during the arrest when performing in the following roles? Circulator? First scrub? Second scrub? Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 6 Cardiac defibrillator Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7 List clinical signs of malignant hyperthermia. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Malignant hyperthermia Background on MH: RARE, inherited muscle condition When triggered by some drugs: Causes hypermetabolic state (huge Ca+ release) Sudden; life-threatening Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Malignant hyperthermia Trigger agents: Succinylcholine All inhalation agents except nitrous oxide Some antipsychotics Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Malignant hyperthermia Must have defect AND exposure to trigger 50% of offspring have it Defect in sarcoplasmic reticulum Stores and releases Ca+ Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Malignant hyperthermia Ca+ released in massive amounts Causes very sustained contraction Cell metabolism continues at even rate Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Malignant hyperthermia Depletes O2, CO2 which causes acidosis Muscle cells break down fast from contraction and release myoglobin into blood; clog kidneys Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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 Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7 in end-tidal CO2 Expired levels of CO2 Many reasons, assess Tachycardia Rapid heart rate Many reasons, assess Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7 Tachypnea Rapid breathing Even over ventilator setting Effort to blow off CO2 Classic for MH Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7 Masseter muscle rigidity Noted at intubation Classic for MH but could be normal for patient Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7 Unstable blood pressure Many reasons, assess Arrhythmias Absence of normal rhythm Many reasons, assess Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7 Cyanosis Abnormal condition; “blue” Check ventilator Diaphoresis Sweating Due to heat build up Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7 Pyrexia High fever Late sign Temperatures can rise to 109° Patient can die in 15 minutes Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 8 Outline basic course of treatment for malignant hyperthermia. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 8 Use pneumonic if helpful How Do Surg Techs Do It? H D S T D Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 8 Hyperventilate with O2 Why? Blow off CO2 Dantrolene Why? Skeletal muscle relaxant Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 8 Sodium bicarbonate Counteract metabolic acidosis Due to CO2 = acidosis Temperature management Ice packs at pulse points on patient Attempt to cool patient rapidly Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 8 Diuretics Mannitol is mixed in with Dantrium Keeps kidneys from getting clogged with myoglobin Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 8 Insulin Treat hyperkalemia Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 9 Discuss the role of the surgical technologist in a malignant hyperthermia crisis. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 9 Be aware of anesthesia signs Rapid response increases survival rate When declared, drop what you are doing! Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 9 Anesthesia/Operation is stopped STAT First scrub role; stay sterile if procedure going Help close PRN Hand iced NaCl irrigation Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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 Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 9 Circulating role Treat like code blue Get MH cart Call for help Change anesthesia machine when provider is ready Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 9 Circulating role Set up iced lavage • Bladder, rectum, abdomen Reconstitute Dantrium Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 9 Remember, all of these things are happening simultaneously. Knowing the procedure makes you more valuable in the crisis. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. In summary Many emergency situations arise in surgery. Many of these situations require the administration of medications for treatment. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. In summary The more you know, the more effective you are in assisting the anesthesia provider in an emergency. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.