MANAGING SURGICAL EMERGENCIES

Ginger Mars, MSN, RN, NP-c, CCRN, CPSN

• Airway/Breathing:

• Difficult Airway

• Anaphylaxis

• Pulmonary Embolus

• Circulation:

• Malignant Hyperthermia

• Lidocaine Toxicity

• Hemorrhage

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 FOR DIFFICULT AIRWAY

• 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 AND HISTORY

• No ideal airway assessment tool

• History and assessment should heighten awareness of potential problems

• Tongue size

• Oropharyngeal cavity size (Mallampati Classification)

• Neck Assessment

CLINICAL FINDINGS

•EARLY• Change in voice quality

• Difficulty breathing

• (increased work of breathing)

• Inspiratory Stridor

• LATE• Cyanosis

• Respiratory Arrest

Restlessness

Agitation

Panic

Somnolence

Unresponsiveness

ASSESSMENT AND MANAGEMENT

• Early Assessment:• Know Patient History

• Identify those at risk

• Pre-op Planning

• Clinical Examination

• Body Habitus

• Airway assessment

• Management/Treatment:• Continuous pulse oximetry

• Appropriate room assignment/handoff

• Broncholytics/inhalers/nebulizers

• Racemic epinephrine

• Steroids

• Escalation to Surgical Airway

• Tracheostomy

• Crycothyrotomy

TREATMENT

• Being prepared is the best treatment

• PRACTICE!!!

• Know where emergency carts/equipment are kept

• Have oxygen devices handy (Ambu bag)/suctioning equipment

• Crycothyrotomy/Trach sets available

•ASK QUESTIONS!• What should I be looking for?

• When should I be concerned?

PEARLS FOR USE OF BAG/MASK

•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

WHAT IS ANAPHYLAXIS?

•Severe systemic allergic reaction

•Results from exposure to allergens

•Rapid in onset

•Can result in a life-threatening emergency

SYMPTOMS

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 every 4 hours as needed.

• IV Antihistamines (Diphenhydramine)

• Steroids

• If surgery center – transfer to hospital for further management

PULMONARY EMBOLUS

PULMONARY EMBOLUS

•3rd leading cause of CV death in the US

•Women more susceptible than men

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

• First symptom may be sudden death (25% of people diagnosed)

POTENTIAL CAUSES

• Previous history of DVT or PE

• Family history

• 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/ Xa inhibitors

• Hematology clearance for prior history

• Consider home anticoagulation for high-risk patients

DIAGNOSIS

• Diagnosis by suspicion initially• Shortness of breath• Tachycardia• Hypoxemia

• Venous duplex

• D-dimer

• VQ Scan

•CT Angiogram

TREATMENT

• LMW Heparin products: • Dalteparin (Fragmin)

• Enoxaparin (Lovenox)

• Tinzaparin (Innohep)

• IV Heparin drip• Use Argatroban in patients with HIT

• Coumadin

• Factor Xa and direct thrombin inhibitors• Pradaxa (dabigatran)

• Xarelto (rivaroxaban)

• Eliquis (apixaban)

• Thrombolysis/Thrombectomy

WHAT IS MH?

•Malignant Hyperthermia is a LIFE THREATENING severe reaction that occurs to particular medications given during general anesthesia among those people who are susceptible.

CAUSES OF MH

•Acceleration of skeletal muscle metabolism

•Abnormally increased levels of intracellular calcium

• MH may develop with exercise and/or exposure to hot environments in susceptible individuals

CAUSATIVE AGENTS

• Muscle Relaxants:

• Succinylcholine

• Volatile Inhaled agents:

• Desflurane

• Enflurane

• Halothane

• Sevoflurane

RECOGNIZING 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 • Without prompt and proper treatment mortality is

extremely high• Discontinue Triggering Agents

• 100% Oxygen at High Flow – Hyperventilate

• Summon additional staff/help- Call 911 if a surgery center

• 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

24-HOUR MH HOTLINE

800-644-9737Outside North America: 001-209-417-3722

FOR EMERGENCIES ONLY

https://www.mhaus.org

THERAPY IS AIMED AT:

• Prompt administration of Dantrolene

• Treatment of hyperkalemia

• Hyperventilation

• Cooling to target core temp of no more than 38 degrees

POST ACUTE MANAGEMENT

•Dantrolene for at least 24 hours or longer as clinically indicated• 1mg/kg q4-6 hours IV OR

• 0.25mg/kg/hour by infusion

• Many MH experts recommend intermittent IV rather than continuous infusion to prevent IV drug extravasation & resultant tissue necrosis.

POST ACUTE MANAGEMENT• Continuous monitoring of:

• EKG,

• ETCO2,

• Minute ventilation

• Core temperature

• Urine output

• Muscle tone

• Every 8 hours:

• pH & lactate

• K+

• CPK (until decreasing steadily)

• Baseline coagulation studies

• Baseline renal function & q24h if myoglobinuria

• Follow urine color for signs of myoglobinuria/rhabdomyolysis

•Watch for S/S of relapse• 25% of MH events relapse

• Relapses can be fatal

SIGNS OF MH RELAPSE

• Increase muscular rigidity in absence of shivering

• Metabolic acidosis without other cause

• ‘Inappropriate’ hypercarbia with respiratory acidosis

• ‘Inappropriate’ temperature increase

INDICATORS OF PATIENT STABILITY

• Metabolic stability for 24 hours

• End tidal CO2 stable or decreasing

• No ominous dysrhythmias

• Core temp is less than 38°C

• CPK is decreasing

• No evidence of myoglobinuria

• Muscle is no longer rigid

POTENTIAL COMPLICATIONS

• Consciousness Level Change/Coma

• Cardiac Dysfunction

• Pulmonary Edema

• Renal Dysfunction

• Disseminated Intravascular Coagulation (DIC)

• Hepatic Dysfunction

• Relapse

• Death

FACTORS INCREASING M&M

• 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.

STOCKING THE MH CART

• Dantrium/Revonto• 20mg/60ml sterile H20 (without

preservative). Shake until clear

• Each vial also contains 3gm mannitol/ 20mg vial

• 36 vials MUST be available in each institution where MH can occur.

Ryanodex 250mg/5ml sterile H20 (without

preservative). Shake to uniform

orange color

Each vial also contains 0.125

grams of mannitol

3 vials MUST be available in

each institution where MH

can occur.

STOCKING THE 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

For additional information: https://www.mhaus.org

LIDOCAINE• Antiarrhythmic 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 FACTS

• Tumescent 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

LIPOSUCTION INFUSATE

•Provides prolonged local anesthesia with minimal blood loss.

• Large volume Liposuction (removal of > 1500ml fat) may require infusion of several liters of solution.

ANESTHETIC BLOCKS

• Indwelling catheters are usually placed by anesthesia • Brachial, Thoracic, Femoral

• Important to assess absorption rate (bupivicainedisk/ball)

• TAP (Transverse Abdominal Plane) blocks used for abdominal surgical procedures

ANESTHETIC CONCENTRATIONS/DILUTION

• Drug concentration is expressed as percentage

• Bupivicaine 0.25%, Lidocaine 1%

• Percentage is 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

•CNS

•Cardiovascular

•Hematologic

•Allergic

CNS MANIFESTATIONS

• Circumoral or Tongue numbness

• Metallic Taste

• Lightheadedness

• Dizziness

• Visual/Auditory Disturbances

• Disorientation

• Drowsiness

HIGHER DOSES MAY RESULT IN:

•Muscle Twitching

• Seizures

• Loss of consciousness

•Coma

•Respiratory/Cardiac depression/arrest

CARDIOVACULAR MANIFESTATIONS

• Chest pain

• Shortness of breath

• Palpitations/Arrhythmia

• Lightheadedness

• Diaphoresis

• Hypotension

• Syncope

RESPIRATORY/SYSTEMIC MANIFESTATIONS

• Cyanosis

• Gray color

• Tachypnea

• Dyspnea

• Fatigue

• Exercise Intolerance

• Dizziness

TREATMENT

• DISCONTINUE THE DRUG

• ABC’s

• Initiation of BCLS/ACLS Protocols

• Airway management

• Oxygen administration

• Arrhythmia management

• Mild symptoms:

• Benzodiazepines

• Seizures:

• Treatment with benzodiazepines or barbituates

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

ANTIDOTE

• 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 DOSING RECOMMENDATIONS IN LIPOSUCTION

•Maximum Safe Dosage Guidelines:•45mg/kg in ‘relatively’ thin patients

•50mg/kg in obese patients

•Higher plasma lidocaine concentrations may result from adverse drug reactions (CYP450 pathway)

SAFETY TIPS

• Understand maximum safe dosing

• Use explicit/signed surgeon orders for tumescent solution.

• Designated licensed personnel should prepare 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)

SAFETY TIPS

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

• Use ONLY 1% Lidocaine

• 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

HEMORRHAGE

DEFINITION

•“Significant” Bleeding that occurs after any surgical procedure.

• Bleeding may occur immediately or delayed.

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 bloody drain output

• Bleeding from suture line

• Increase in swelling to surrounding area

• Tachycardia

• Hypotension

• Decreased urine output

• Restlessness/Agitation

MANAGEMENT

• Prevention• Pre-Op assessment of home medications

• Post op rounding/assessment of drain output and incision site

• Frequent assessment of high risk patients• What defines high risk?

• Rapid intervention once diagnosed

• Supportive Care/Management