anesthesia checklists
TRANSCRIPT
Thea
tre
Che
cklis
ts -
Rou
tine
& E
mer
genc
yTi
m L
eeuw
enbu
rg F
AC
RR
MK
anga
roo
Isla
nd, S
outh
Aus
tral
ia
Thea
tre
Che
cklis
ts -
Rou
tine
& E
mer
genc
yTi
m L
eeuw
enbu
rg F
AC
RR
MK
anga
roo
Isla
nd, S
outh
Aus
tral
ia
Alth
ough
not
a fa
n of
‘coo
kook
med
icin
e’, t
here
is n
o do
ubt t
hat c
heck
lists
can
hel
p el
imin
ate
sim
ple
erro
rs o
r ove
rsig
ht in
eve
n th
e m
ost e
xper
ienc
ed d
octo
r - p
artic
ular
ly w
hen
task
-lo
aded
in a
n em
erge
ncy.
Thes
e ch
eckl
ists
and
aid
e m
emoi
res
have
bee
n co
mpi
led
from
a v
arie
ty o
f sou
rces
and
sho
uld
be u
sed
in th
eatre
bot
h ro
utin
ely
and
in a
n ev
olvi
ng c
risis
.
Sour
ces
Aust
ralia
n R
esus
cita
tion
Cou
ncil
- ww
w.re
sus.
org.
auD
ifficu
lt Ai
rway
Soc
iety
UK
- ww
w.da
s.uk
.com
Nat
iona
l Pat
ient
Saf
ety
Foun
datio
n - w
ww.
apsf
.net
.au
Tim
Lee
uwen
burg
FAC
RRM
Kang
aroo
Isla
nd, S
outh
Aus
tralia
CONT
ENTS
Plea
se n
otify
any
erro
rs, o
mis
sion
sor
sug
gest
ions
for i
mpr
ovem
ent.
Res
pons
ibilit
y fo
r dru
g do
ses
rem
ains
with
th
e pr
escr
iber
. If i
n do
ubt,
chec
k.
No
liabi
lity
is a
ccep
ted
for e
rrors
in th
is
com
pila
tion
of c
heck
lists
& a
lgor
ithm
s
INTR
ODU
CTIO
N
PRI
NCIP
LES
OF
CRIS
IS M
ANAG
EMEN
TCO
VER
ABCD
A S
WIF
T CH
ECK
SAFE
SUR
GER
Y CH
ECKL
IST
APPE
NDIC
ES
FORM
ULAR
YPS
YCHI
ATRI
C SE
DATI
ON
RETR
IEVA
L HA
NDO
VER
ANAE
STHE
SIA
& AV
IATI
ON
ANAP
HYLA
XIS
LOCA
L AN
AEST
HETI
C TO
XICI
TY
TURP
SYN
DRO
ME
MAL
IGNA
NT H
YPER
THER
MIA
PAED
IATR
IC C
ARDI
AC A
RRES
T
NEO
NATA
L RE
SUSC
ITAT
ION
PAED
IATR
IC C
HEAT
SHE
ET
NEUR
AXIA
L BL
OCK
ADE
CAES
AREA
N SE
CTIO
N
GA
& Sp
inal
em
LSCS
HYPO
TENS
ION
MAS
SIVE
BLO
OD
LOSS
MYO
CARD
IAL
ISCH
AEM
IA
ARRH
YTHM
IAS
& AR
REST
EMER
GEN
CY IN
DUCT
ION
HYPO
XIA
AIRW
AY P
RESS
URES
HYPO
/HYP
ERCA
PNIA
DIFF
ICUL
T AI
RWAY
PRIN
CIPL
ES O
F CR
ISIS
MAN
AGEM
ENT
KNO
W, M
ODI
FY a
nd O
PTIM
ISE
THE
ENVI
RONM
ENT
ANTI
CIPA
TE a
ndPL
AN F
OR
A CR
ISIS
ENSU
RE L
EADE
RSHI
P an
dRO
LE C
LARI
TY
COM
MUN
ICAT
EEF
FECT
IVEL
Y
CALL
FO
R HE
LP o
rSE
COND
OPI
NIO
N EA
RLY
ALLO
CATE
ATT
ENTI
ON
and
USE
AVAI
LABL
E IN
FORM
ATIO
N
DIST
RIBU
TE W
ORK
LOAD
and
USE
AVAI
LABL
E RE
SOUR
CES
esta
blis
h pr
otoc
ols
and
proc
edur
esen
sure
room
set
up
is c
ondu
cive
to c
risis
- la
yout
, equ
ipm
ent e
tcho
w c
an th
ings
be
impr
oved
(thi
s in
clud
es e
quip
men
t)
patie
nt -
proc
edur
e - e
quip
men
t - d
rugs
- pe
rson
nel -
retri
eval
- glo
bal p
lans
- spe
cific
pla
ns
assi
gn le
ader
pref
erab
ly n
ot re
spon
sibl
e fo
r tas
ks ie
: has
an
over
view
of t
he s
ituat
ion
lead
er d
ecid
es, p
riorit
ises
and
ass
igns
task
s to
team
lead
ersh
ip a
nd fo
llow
rshi
p ai
ded
by c
lear
com
mun
icat
ion
eye
cont
act,
use
nam
es, c
lear
inst
ruct
ions
, ens
ure
unde
rsta
ndin
g an
d re
port
back
clos
e th
e lo
op -
upst
ream
/dow
nstre
am c
omm
unic
atio
n
call
for h
elp
early
- ev
en if
not
in a
cris
isse
cond
opi
nion
may
be
reas
sura
nce
enou
gh o
r sug
gest
alte
rnat
ives
avoi
d th
erap
eutic
iner
tia
fixat
ion
erro
rs c
omm
onbe
war
e at
tent
iona
l tun
nellin
g / s
ituat
iona
l ove
rload
if yo
u ar
e st
ress
ed y
ou a
re li
kely
to b
e m
issi
ng s
omet
hing
mai
ntai
n si
tuat
iona
l aw
aren
ess
dele
gate
task
s, u
se e
xter
nal r
esou
rces
(tel
emed
icin
e/re
triev
al)
if al
l els
e fa
ils, t
hink
late
rally
- im
prov
ise/
adap
t/ove
rcom
e
COVE
R AB
CD -
A Sw
ift C
heck
SCAN
BP, H
R, R
hyth
m, E
TCO
2Sp
O2,
Col
our
FiO
2, R
otam
eter
,O
2 an
alys
er m
atch
es F
iO2
Vent
ilatio
n - R
R, T
VVa
poris
er &
Mix
ETT
posit
ion
& se
curit
yAb
le to
Elim
inat
e (b
ag)?
Revie
w m
onito
rs, u
pdat
e re
cord
s, re
view
equi
pmen
t
Airw
ay p
ositio
n, p
aten
t?Di
stan
ce in
cm
Brea
thin
g pa
ttern
OK?
Circ
ulat
ion
- tre
nds,
flui
ds
and
bloo
d lo
ss
Drug
s gi
ven
& ap
prop
riate
resp
onse
?
Awar
enes
s - P
atie
nt
Asle
ep, S
elf O
K?
C O V E R A B C D ASW
IFT
CHEC
KPr
ogre
ss o
f Sur
geon
and
of O
pera
tion
CHEC
K
Radi
al p
ulse
, cor
rela
te,
SPO
2 di
slodg
ed?
Incr
ease
FiO
2, w
atch
MAC
Chec
k cir
cuit
& va
poris
er,
vent
ilate
by
hand
Dist
ance
in c
m?
Kink
ed?
Bag
and
O2
avai
labl
e?
Revie
w m
onito
rs, r
evie
w eq
uipm
ent -
any
cha
nges
?
Obs
erve
& p
alpa
te n
eck,
ET
T po
sitio
n, c
uff
Obs
erve
, pal
pate
&
ausc
ulta
te c
hest
. ETC
O2?
Cros
s ch
eck
BP, I
V, lo
sses
&
resp
onse
to R
x/su
rger
y
Chec
k dr
ugs
(erro
r?) a
nd
pate
ncy
IV lin
e. F
lush
ed?
Awar
enes
s, A
ir Em
bolis
m,
Anap
hyla
xis, A
ir in
Ple
ura?
Que
stio
n su
rgeo
n,re
view
old
Note
s
Allo
cate
role
s - I
V ac
cess
Arre
st tr
olle
y
FiO
2 10
0%M
aint
ain
anae
sthe
sia?
Self-
infla
ting
bag,
turn
off
vapo
riser
(use
pro
pofo
l?)
Switc
h ET
T or
use
LM
AEl
imin
ate
circu
it/m
achi
ne
Emer
genc
y Eq
uipm
ent
RETR
IEVA
L?
Bron
chos
pasm
, Oed
ema,
Hypo
xia, H
ypov
entila
tiion
Drug
erro
r? A
ntid
ote?
ANAP
HYLA
XIS?
Awar
enes
s, A
ir Em
bolis
m,
Anap
hyla
xis, A
ir in
Ple
ura?
Notif
y Su
rgeo
n
& M
obilis
e St
aff
EMER
GEN
CY
LARG
E BO
RE IV
s,
FLUI
DS, D
EFIB
, DRU
GS
HIG
H FL
OW
OXY
GEN
AVO
ID A
WAR
ENES
S
VENT
ILAT
E BY
BAG
ENSU
RE E
TT P
LACE
DO
R AL
TERN
ATIV
E
DELE
GAT
E O
PERA
TIO
N O
F EQ
UIPM
ENT
ADDR
ESS
HYPO
XIA,
HY
POVE
NTIL
ATIO
N
ATRO
PINE
10m
cg/k
gAD
RENA
LINE
10m
cg/k
g
MAI
NTAI
N SI
TUAT
IONA
LAW
AREN
ESS
DEFI
NITI
VE S
URG
ERY
OTH
ER C
RISI
S?
ALER
T/RE
ADY
Hypo
/Hyp
erte
nsio
nAr
rhyt
hmia
, Arre
st A
lgor
ithm
Aspi
ratio
n, L
aryn
gosp
asm
Obs
truct
ion,
ETT
/LM
AAI
RWAY
PAT
ENT
& PR
OTE
CTED
CRYS
TALL
OID
, BLO
OD
VASO
PRES
SORS
, CPR
Colo
ur, C
ircul
atio
n, C
apno
grap
hy
Oxy
gen
Supp
ly &
O2
Anal
yser
Vent
ilatio
n &
Vapo
riser
s
ETT
tube
& E
limin
ate
Mac
hine
Revie
w - M
onito
rs &
Equ
ipm
ent
Airw
ay (f
ace
or la
ryng
eal m
ask)
, m
eticu
lous
atte
ntio
n to
ETT
Brea
thin
g (S
V/IP
PV)
Circ
ulat
ion,
IV, B
lood
loss
, ECG
Drug
s - c
onsid
er a
ll give
n &
not
give
n, c
heck
em
erge
ncy
drug
s
Be A
ware
of A
ir an
d Al
lerg
y
Chec
k Pa
tient
, Sur
geon
,Pr
oces
ses
& Re
spon
ses
SCAR
E
Nur
se &
Ana
esth
etis
t!!
!!
N
urse
, Sur
geon
& A
naes
thet
ist!
!!
N
urse
, Sur
geon
& A
naes
thet
ist
SAFE
SUR
GER
Y CH
ECKL
IST
BEFO
RE IN
DUCT
ION
BEFO
RE IN
CISI
ON
BEFO
RE L
EAVE
OT
Has
patie
nt c
onfir
med
iden
tity,
site
, su
rger
y an
d co
nsen
t?
Yes
Is th
e su
rgic
al s
ite m
arke
d?
Yes
Not
app
licab
le
Is th
e an
aest
hetic
mac
hine
& m
edic
atio
n ch
eck
com
plet
e?
Yes
Are
puls
e ox
imet
er, B
P &
ECG
on
the
patie
nt, f
unct
ioni
ng &
acc
epta
ble?
Yes
Snap
shot
take
n?
Does
the
patie
nt h
ave
a kn
own
alle
rgy?
No
Y
es
Diffi
cult
airw
ay o
r asp
iratio
n ris
k?
No
Y
es &
equ
ipm
ent/h
elp
avai
labl
e
Risk
> 5
00m
l blo
od lo
ss (7
ml/k
g ch
ildre
n)?
No
Y
es &
2 IV
s si
ted,
blo
od a
vaila
ble
Confi
rm a
ll te
am m
embe
rs n
ame
& ro
le
Yes
Confi
rm p
atie
nt n
ame
& na
ture
of s
urge
ry
Yes
Not
app
licab
le
Confi
rm a
ntib
iotic
pro
phyl
axis
giv
en
Yes
ANTI
CIPA
TED
CRIT
ICAL
EVE
NTS
To S
urge
on
Wha
t are
crit
ical
or n
on-ro
utin
e st
eps?
H
ow lo
ng w
ill ca
se ta
ke?
Antic
ipat
ed b
lood
loss
?
To A
naes
thet
ist?
Any
patie
nt-s
peci
fic c
once
rns?
Eyes
tape
d, p
ress
ure
poin
ts p
rote
cted
?
To N
ursi
ng T
eam
Has
ste
rility
bee
n co
nfirm
ed?
Any
equi
pmen
t iss
ues
or a
ny c
once
rns?
Is a
ppro
pria
te im
agin
g di
spla
yed?
Nurs
e ve
rbal
ly c
onfir
ms
:
Nam
e of
the
proc
edur
e
Equi
pmen
t, sp
onge
& s
harp
cou
nts
corre
ct
Spec
imen
s la
belle
d?
Any
equi
pmen
t iss
ues
aris
ing?
To s
urge
on, a
naes
thet
ist &
nur
se
Wha
t are
the
key
conc
erns
for t
his
patie
nt in
re
cove
ry a
nd o
ngoi
ng m
anag
emen
t?
Reco
very
sta
ff
Patie
nt a
wak
e &
adeq
uate
ven
tilat
ion?
Dru
g ch
art c
ompl
eted
?
Antib
iotic
s an
d an
alge
sia
addr
esse
d?
DVT
thro
mbo
prop
hyla
xis?
Res
pons
ible
Doc
tor i
dent
ified
& a
vaila
ble?
EMER
GEN
CY IN
DUCT
ION
Prep
are
Patie
ntPr
epar
eEq
uipm
ent
Prep
are
Team
Antic
ipat
ePr
oble
ms
Is p
ositi
on o
ptim
al?
-ear
to s
tern
um-r
amp
if ob
ese
-MIL
S fo
r tra
uma
Is p
reox
ygen
atio
n ad
equa
te?
Can
this
pat
ient
’s c
ondi
tion
be o
ptim
ised
any
furth
er
prio
r to
intu
batio
n?
-O2,
Hae
mog
lobi
n-C
ardi
ac c
ontra
ctilit
y, ra
te-A
fterlo
ad, P
relo
ad-P
EEP
-IV
acce
ss a
dequ
ate
& se
cure
How
will
ana
esth
esia
be
mai
ntai
ned
post
indu
ctio
n?
-vap
orise
rs fu
ll & c
heck
ed-a
dequ
ate
IV m
edica
tions
-pum
p se
ts a
vaila
ble
Is p
atie
nt m
onito
ring
appl
ied,
fu
nctio
ning
and
val
ues
acce
ptab
le?
-SpO
2-E
CG-B
P-E
TCO
2-B
IS
Is e
quip
men
t che
cked
and
im
med
iate
ly a
vaila
ble?
-sel
f-infl
atin
g ba
g-a
ppro
pria
te s
ized
Gue
del/N
PO-l
aryn
gosc
ope
work
ing
& sp
are
-ET
tube
and
alte
rnat
ives
-Suc
tion
-Bou
gie
Do y
ou h
ave
all t
he n
eces
sary
dr
ugs,
incl
udin
g va
sopr
esso
rs?
- Am
nesic
and
/or A
nalg
esic
- Ind
uctio
n ag
ent
- Neu
rom
uscu
lar b
lock
ade
Dele
gate
and
brie
f tea
m :
-tea
m le
ader
-int
ubat
or-a
ssist
ant
-cric
oid
pres
sure
-MIL
S-d
rug
adm
inist
ratio
n-e
xtra
ass
istan
ce re
quire
d
How
do
we
get f
urth
er h
elp
if re
quire
d?
-oth
er th
eatre
sta
ff av
aila
ble?
-oth
er d
octo
rs a
vaila
ble?
-ret
rieva
l ser
vice
notifi
ed?
LEM
ON
Asse
ssm
ent
Look
- be
ard,
no
neck
, den
titio
nEv
alua
te -
thyr
omen
tal >
6cm
Mal
lam
pati
scor
e : I
- IV
Obs
truct
ion
- stri
dor/b
urns
Neck
Mov
emen
t - c
olla
r/arth
ritis
If ai
rway
is d
ifficu
lt, c
an w
e w
ake
this
pat
ient
?
Yes
No
If in
tuba
tion
is d
ifficu
lt, h
ow
to m
aint
ain
oxyg
enat
ion?
Plan
A -
Intu
bate
& V
entila
tePl
an B
- iL
MA/
VL/F
ibre
optic
Plan
C -
Oxy
gena
tion
with
BM
VPl
an D
- CI
CO, S
urgi
cal A
irway
Is th
e ne
cess
ary
equi
pmen
t im
med
iate
ly a
vaila
ble?
Are
ther
e an
y sp
ecifi
c pr
oble
ms
antic
ipat
ed?
-awa
rene
ss, a
spira
tion
-pro
foun
d de
satu
ratio
n-h
ypot
ensio
n, a
rrhyt
hmia
s-p
atie
nt p
ositio
ning
/tran
sfer
-oth
er?
HYPO
XIA!!!!!!!!!
SpO
2 <
90%
or S
pO2
fallin
g by
> 5
%
Oxy
gen
supp
lyAn
aest
hetic
mac
hine
Anae
sthe
ticci
rcui
tPa
tient
Airw
ay
Chec
k :
- Pre
ssur
e ga
uges
- Flo
w m
eter
s
- FiO
2
- Vap
orize
r hou
sing
Chec
k Ve
ntila
tor :
-VT
-Rat
e
-Airw
ay P
ress
ures
-Mod
e
Chec
k Ci
rcui
t :
-con
nect
ions
-one
-way
val
ves
-filte
r
- sod
a lim
e
Vent
ilatio
nof
pat
ient
Chec
k Ai
rway
:
Exclu
de o
bstru
ctio
n
-in
nativ
e ai
rway
-in
filter
-in
airw
ay d
evice
s
Exclu
de s
ecre
tions
/plu
ggin
g - p
ass
suct
ion
cath
eter
bey
ond
end
of E
TT
Patie
ntLu
ngs
Patie
ntCi
rcul
atio
nPa
tient
Tiss
ues
Ensu
re a
dequ
ate
vent
ilatio
n:
-exc
lude
bro
nchi
al in
tuba
tion
-loo
k/lis
ten
for b
ilate
ral A
E-a
sses
s ad
equa
cy o
f MV
-exc
lude
bro
ncho
spas
m-r
eche
ck a
irway
pre
ssur
es-e
xclu
de p
neum
otho
rax
Cons
ider
Gas
Exc
hang
e :
-asp
iratio
n-p
ulm
onar
y oe
dem
a-c
onso
lidat
ion
-ate
lect
asis
Cons
ider
Em
bolis
m
- of t
hrom
bus,
air
or fa
t
Circ
ulat
ion
-low
car
diac
out
put
Anae
mia
-red
uced
O2
carri
age
-hig
h O
2 ex
tract
ion
-dec
reas
ed m
ixed
veno
us P
O2
Tiss
ue U
ptak
e of
O2
Incr
ease
d m
etab
olism
-fev
er-t
hyro
id c
risis
-etc
END
TIDA
L CO
2!!!
Apno
ea c
ause
s ris
e of
PaC
o2 8
-15m
mH
g in
firs
t min
ute,
then
3m
mH
g/m
in
INCR
EASE
D ET
CO2
DECR
EASE
D ET
CO2
Inha
led
/ Exo
gene
ous
CO2
Inha
led
Chec
k ca
pnog
raph
for r
etur
n to
bas
elin
e
Exog
eneo
usLa
paro
scop
ic CO
2 in
suffl
atio
nNa
HCO
3 ad
min
istra
tion
Insp
ired
CO2
(sod
a lim
e ex
haus
ted)
Inco
mpe
tent
val
ves
Re-b
reat
hing
Hypo
vent
ilatio
n
Resp
irato
ry d
epre
ssio
nIn
crea
sed
mec
hani
cal lo
ad o
n lu
ngs
(dec
reas
ed c
ompl
ianc
e, in
crea
sed
resis
tanc
e in
sys
tem
)In
adeq
uate
IPPV
- ch
eck
TV/R
R/PE
EPIn
crea
sed
dead
spa
ce -
anat
omica
l/phy
siolo
gica
l
Incr
ease
d Pr
oduc
tion
of C
O2
Feve
rPa
rent
eral
nut
ritio
nM
alig
nant
hyp
erth
erm
ia
Airw
ay
Cons
ider
oes
opha
geal
intu
batio
n, a
ccid
enta
l ext
ubat
ion
Circ
uit
Air e
ntra
inm
ent (
leak
),Di
lutio
n wi
th c
ircui
t gas
es (s
ampl
ing
prob
lem
)
Vent
ilato
r
Vent
ilato
r set
tings
,O
vere
nthu
siast
ic ba
ggin
g
Gas
Exc
hang
e Pr
oble
m
Pulm
onar
y em
bolis
m,
Card
iac
failu
re/a
rrest
, Se
vere
hyp
oten
sion
Decr
ease
d Pr
oduc
tion
Hypo
ther
mia
Hypo
thyr
oidi
smDe
crea
sed
met
abol
ism
HIG
H AI
RWAY
PRE
SSUR
ES
Gas
supp
lyAn
aest
hetic
circ
uit
Patie
ntai
rway
Patie
ntlu
ngs
Chec
k G
as S
uppl
y:
-che
ck O
2 by
pass
-ens
ure
O2
flush
not
jam
med
-elim
inat
e ot
her h
igh
pres
sure
so
urce
Chec
k Ci
rcui
t :
-bag
/ ve
ntila
tor s
witc
h?-o
bstru
ctio
n to
exp
iratio
n in
cir
cuit/
vent
ilato
r/sca
veng
er
syst
em?
-PEE
P va
lve &
set
tings
?-e
xclu
de c
ircui
t & m
achi
ne b
y ve
ntila
ting
with
bag
Excl
ude
Obs
truct
ion
:
-filte
r
-airw
ay
-ETT
- sec
retio
ns /
fore
ign
body
Bila
tera
l che
st e
xpan
sion
?
Endo
bron
chia
l intu
batio
n, P
TX
Brea
th s
ound
s?
Bron
chos
pasm
, ate
lect
asis,
as
pira
tion,
pul
mon
ary
oede
ma,
en
dobr
onch
ial in
tuba
tion
Patie
ntpl
eura
l spa
cePa
tient
ches
t wal
lSu
rgic
alpr
oced
ure
Cons
ider
and
exc
lude
:
-pne
umot
hora
x-h
aem
otho
rax
14G
nee
dle
(2nd
ICS
MCL
)
Fing
er o
r tub
e th
orac
osto
my
(ant
axil
lary
line
5th
ICS)
Excl
ude
inad
equa
te c
hest
wal
l re
laxa
tion
-ina
dequ
ate
mus
cle re
laxa
tion
-opi
oid-
indu
ced
rigid
ity
-mal
igna
nt h
yper
ther
mia
- obe
sity
Rais
ed in
trath
orac
ic p
ress
ure
-sur
gica
l inte
rven
tion
-ins
uffla
tion
-pat
ient
pos
ition
- ass
istan
t lea
ning
on
ches
t !
HIG
H AI
RWAY
PRE
SSUR
ES
Diffi
culty
ven
tilat
ing
patie
ntde
crea
sed
com
plia
nce
in b
agpo
or c
hest
exp
ansio
nre
duce
d tid
al v
olum
ehi
gh a
irway
pre
ssur
e al
arm
Hypo
xia
(due
to h
ypov
entil
atio
n)
Circ
ulat
ory
colla
pse
(hig
h in
trath
orac
ic p
ress
ure)
Tach
ycar
dia
DIFF
ICUL
T AI
RWAY
- O
VERV
IEW
MAX
IMUM
THR
EE A
TTEM
PTS
CHAN
GE
POSI
TIO
N - B
LADE
- O
PERA
TOR
USE
BOUG
IE -
CONS
IDER
STY
LET
- VL
SECO
NDAR
Y IN
TUBA
TIO
N PL
AN
Fast
Trac
h iL
MA
King
Visio
n Vi
deol
aryn
gosc
ope
Ambu
Asc
ope
thro
ugh
dedi
cate
d iL
MA
BAG
MAS
K VE
NTIL
ATIO
NW
AKE
THE
PATI
ENT
RESC
UE T
ECHN
IQUE
S
Decla
re a
CIC
O E
mer
genc
y
Cont
inue
to u
se L
MA
to a
ttem
pt o
xyge
natio
n
Iden
tify
crico
thyr
oid
mem
bran
eNe
edle
or S
calp
el-B
ougi
e-ET
T Te
chni
que
Cons
ider
Fro
va (o
xyge
natin
g bo
ugie
)
DIFF
ICUL
T AI
RWAY
- RO
UTIN
E IN
DUCT
ION
DIF
FIC
ULT
AIR
WAY
- FA
ILED
RSI
DIFF
ICUL
T AI
RWAY
- CI
CV /
CICO
DIFF
ICUL
T AI
RWAY
- KI
T
INTU
BATE
THE
TRA
CHEA
Re-P
ositio
n - U
se a
Bou
gie
- Vid
eola
ryng
osco
pe
MAX
4 E
LECT
IVE
MAX
3 R
SI
LMA
as a
CO
NDUI
T TO
ETT
LMA,
Pro
Seal
/Sup
rem
e iL
MA
Fast
Trac
h or
Am
buAs
cope
via
iLM
A
AWAK
EN &
PO
STPO
NE o
r RE-
GRO
UPBM
V - N
PO &
Gue
dels
- LM
A - C
onsid
er S
ugga
mad
ex
CICV
RES
CUE
TECH
NIQ
UES
Cann
ula
- Jet
Insu
fflat
ion
- Mel
ker D
ilata
tion
Scal
pel -
Bou
gie
- ETT
DIFF
ICUL
T AI
RWAY
- KI
T CH
ECKL
IST
Re-P
ositio
n - U
se a
Bou
gie
- Vid
eola
ryng
osco
pe
PLAN
ATR
ACHE
AL IN
TUBA
TIO
N PL
AN
max
3 a
ttem
pts
RSI
max
4 a
ttem
pts
ELEC
TIVE
Ram
p - E
ar to
Ste
rnum
Bo
ugie
- Ai
ntre
e Ca
thet
er -
Frov
a O
xyge
natin
g Bo
ugie
Chan
ge B
lade
Size
Cons
ider
Stra
ight
Bla
de /
McC
oy /
Kess
elAi
rTra
q - K
ingV
ision
VL
PLAN
BSE
COND
ARY
INTU
BATI
ON
PLAN
not i
n RS
Im
aint
ain
oxyg
enat
ion
& ve
ntila
tion
Use
LMA
- Pro
Seal
or S
upre
me
Fast
Trac
h iL
MA
Ambu
Asc
ope2
via
iLM
A
Bag
Mas
k Ve
ntila
teG
uede
ls - N
asop
hary
ngea
l Airw
ayLM
A in
c iG
el
Sugg
amad
ex a
t 4-8
mg/
kg
PLAN
CAW
AKEN
re-g
roup
post
pone
sur
gery
PLAN
DCI
CO/C
ICV
need
le o
rsu
rgica
l airw
ay
ETT
via iL
MA
blin
d or
fibr
eopt
ic
two
hand
ed B
MV
- Adj
unct
s - L
MA
Cons
ider
USS
to lo
cate
and
mar
k cr
icoth
yroi
d m
embr
ane
14 G
jelco
and
O2
conn
ectio
n wi
th 3
-way
tap
Man
u-Je
tSi
ze 2
2 sc
alpe
l - B
ougi
e - s
ize 6
.0 E
TT
OBE
SE IN
TUBA
TIO
N - B
IG R
AMP
PPP
Buy
time!
!!
Sit u
p, u
se n
on-re
brea
ther
, inc
reas
e Fi
O2,
NIV
, PEE
P (B
MV
or v
ent)
Indi
catio
n !!
!Do
we
real
ly ne
ed to
intu
bate
? Ca
n it
wait?
!!
!!
Opt
ions
: wa
it fo
r hel
p - v
ideo
lary
ngos
copy
- iL
MA
or P
rose
al -
awak
e in
tuba
tion
Get
hel
p!!
!Ex
tra h
ands
. Tal
k to
retri
eval
.
Ram
p!!
!Us
e pi
llows
, ear
to s
tern
um, fl
at o
n to
p - R
AMP
RAM
P RA
MP!
Apno
eic
O2!
!O
xyge
natio
n via
nas
al s
pecs
at 1
0-15
l/m
in d
urin
g RS
I
Min
imal
dru
gs!
!Ne
bulis
e lig
noca
ine
& sp
ray
the
cord
s!!
!!
!Ke
tam
ine/
Prop
ofol
(100
mg
each
in 2
0ml s
yrin
ge)
Preo
xyge
nate
!!
With
NIV
for 3
-5 m
ins
max
Para
lysis!
!!
Onl
y if
need
ed. S
ux 1
mg/
kg o
r Roc
1.2
mg/
kg
Plan
for f
ailu
re!
!Pl
an B
- Pl
an C
- Pl
an D
(CIC
V)
Post
intu
batio
n!!
NGT,
IDC,
IV, s
edat
ion/
para
lysis
!!
!!
pape
rwor
k fo
r tra
nsfe
r
B I G R A M P P P P
SICK
CO
MBA
TIVE
RSI
- RS
A - D
SI
VENT
ILAT
OR
ASSI
STED
BM
VSI
MV
MO
DE -
PEEP
10
- PS
5-10
abo
ve P
EEP
TV 5
-7m
l/kg
idea
l bod
y we
ight
- RR
12 -
FIO
2 10
0% -
Flow
15-
30 l/
min
- ET
CO2
in lin
e
RSI
IV in
duct
ion
agen
t & p
aral
ysis
posit
ion
once
obt
unde
d
conn
ect v
ent t
o m
ask
(set
tings
as
abov
e)
crico
id, t
wo h
ande
d m
ask
seal
ETT
once
OXY
GEN
ATIO
N O
PTIM
AL
RSA
IV in
duct
ion
agen
t & p
aral
ysis
posit
ion
once
obt
unde
d
conn
ect v
ent t
o m
ask
(set
tings
as
abov
e)
crico
id, t
wo h
ande
d m
ask
seal
SGA
once
PAR
ALYS
ED
deco
mpr
ess
stom
ach
via S
GA
optim
ise o
xyge
natio
n
cons
ider
iLM
A as
con
duit
for E
TT
else
rem
ove
LMA
and
plac
e ET
T
DSI
keta
min
e in
duct
ion
1.5
- 2.0
mg/
kg
posit
ion
once
obt
unde
d
patie
nt s
houl
d re
mai
n sp
ont v
ent
conn
ect v
ent t
o m
ask
(set
tings
as
abov
e)
two
hand
ed s
eal,
crico
id
allo
w ve
nt to
del
iver a
ssist
ed b
reat
hs
ETT
once
OXY
GEN
ATIO
N O
PTIM
ALRE
MEM
BER
CLIF
F RE
ID’S
PRO
POFO
L AS
SASS
INS
!
The
pret
ty w
hite
stu
ff dr
ops
SV a
nd
SVR
with
out i
ncr.
in h
eart
rate
Dro
p in
BP
can
add
to c
ereb
ral
hypo
perfu
sion
- BA
D B
AD B
AD
Cons
ider
KET
AMIN
E 1.
5 - 2
mg/
kgor
FEN
TANY
L 10
0-20
0 m
cgCR
ICO
ID
ETT
- size
abo
ve/b
elow
King
Visio
n Vi
deol
aryn
gosc
ope
iLM
A - F
astT
rach
AirQ
and
sco
pe(A
mbu
Asco
pe o
r Lev
itan)
LIFE
THR
EATE
NING
AST
HMA
STEP
ONE
Cont
inuo
us n
ebul
ised
salb
utam
olNe
bulis
ed ip
ratro
pium
bro
mid
eM
ethy
lpre
dniso
lone
125
mg
(1.5
mg/
kg) I
VM
gSO
4 2g
(50m
g/kg
max
2g)
IV
STEP
TW
O
Adre
nalin
e 0.
5mg
IM (0
.01m
g/kg
) = 0
.5m
l 1:1
000
Flui
d bo
lus
20 m
l/kg
CXR,
ECG
, VBG
, Ele
ctro
lytes
, FBC
AGIT
ATED
PAT
IENT
keta
min
e 1.
5 m
g/kg
IV o
ver 3
0 se
csth
en 1
mg/
kg/h
r titr
ate
to e
ffect
if no
IV, 5
mg/
kg IM
IF W
ORS
ENIN
G
NIPP
ViP
AP P
S 8c
m H
2OeP
AP P
EEP
3 cm
H2O
cont
inue
neb
ulise
r thr
ough
NIP
PV
DOSE
S
Use
O2
for n
ebs,
not
room
air
500m
cg 2
0min
x 3
then
hou
rlyAl
tern
ative
DXM
20m
g IM
or I
VG
ive M
gSO
4 ov
er 2
0 m
ins
Cons
ider
the
diffe
rent
ial
hear
t fai
lure
, AC
S, a
rrhyt
hmia
pulm
onar
y em
bolis
mPT
X, p
eric
arid
al ta
mpo
nade
, ob
stru
ctio
n, fo
reig
n bo
dyan
aphl
yaxi
s
COO
PERA
TIVE
PAT
IENT
NIPP
ViP
AP P
S 8c
m H
2OeP
AP P
EEP
3 cm
H2O
cont
inue
neb
ulise
r thr
ough
NIP
PV
IF W
ORS
ENIN
G
keta
min
e 1.
5 m
g/kg
IV o
ver 3
0 se
csth
en 1
mg/
kg/h
r titr
ate
to e
ffect
if no
IV, 5
mg/
kg IM
IF N
O IM
PRO
VEM
ENT
- ABL
E TO
TO
LERA
TE N
IV?
NOYE
S
IF N
O IM
PRO
VEM
ENT
AVO
ID IN
TUBA
TIO
N IF
PO
SSIB
LE
IF Y
OU
HAVE
TO
INTU
BATE
Indi
catio
ns -
fatig
ue, r
esp
dist
ress
, de
terio
ratio
n, a
rrest
Max
imise
pre
oxyg
enat
ion
Opt
imise
firs
t pas
s su
cces
sLa
rges
t ETT
pos
sible
Bewa
re b
reat
h st
ackin
g
Keta
min
e 2m
g/kg
IVRo
curo
nium
1.2
mg/
kg o
r Sux
2m
g/kg
IV
Assis
t con
trol /
Vol
ume
cont
rol
RR 8
TV
5-7
ml/k
g IB
WPE
EP 2
cm H
2O IE
1:5
FiO
2 10
0%
perm
issive
hyp
erca
rbia
Ext c
hest
com
pres
sion
Ppla
t < 3
0cm
H2O
Aggr
essiv
e su
ctio
ning
, che
ck K
Pre-
exis
ting
hype
rtens
ion
-tre
ated
or u
ntre
ated
?-m
edica
tion
take
n?
Sym
path
etic
refle
x re
spon
se
-lig
ht a
naes
thes
ia?
Exclu
de v
apor
izer l
eak,
IV d
iscon
nect
ed-h
ypox
ia-h
yper
carb
ia-c
heck
SpO
2, E
TCO
2-c
ereb
ral e
vent
?-r
aise
d IC
P?-i
scha
emia
?-v
asos
pasm
?
Sym
path
omim
etic
effe
ct?
Exog
eneo
us ie
: ad
min
istra
tion
of v
asop
ress
orEn
doge
neou
s eg
: pha
eoch
rom
ocyt
oma
Surg
ical
- aor
tic c
lam
p- t
ourn
ique
t-p
ositio
n eg
: Tre
ndel
enbu
rg-s
timul
us
Hype
rtens
ion
Hypo
tens
ion
Hypo
vola
emia
-blo
od lo
ss-fl
uid
defic
it
Card
ioge
nic
-con
tract
ility,
rate
, dys
rhyt
hmia
-ana
esth
etic
agen
t-v
asod
ilato
rs
Dist
ribut
ive
(vas
odila
tion)
- dru
gs-s
ympa
thet
ic bl
ock
-sep
sis-a
naph
ylaxis
Obs
truct
ive
-hig
h in
trath
orac
ic pr
essu
res
-tam
pona
de (c
ardi
ac, b
ilate
ral t
PTX)
-pul
mon
ary
embo
lus
-AO
RTO
CAVA
L CO
MPR
ESSI
ON
@ 1
8/40
wee
ks o
nwar
ds
CIRC
ULAT
ION
- BP!
W
hils
t vas
opre
ssor
s el
evat
e BP
, tre
atm
ent s
houl
d be
dire
cted
to c
ause
MAS
SIVE
BLO
OD
LOSS
Cont
rol B
leed
ing
Min
imis
e tim
e to
Sur
gery
Use
tour
niqu
ets
to c
ontro
l per
iphe
ral
Tam
pona
de b
leed
ing
eg: p
elvi
c bi
nder
, dire
ct p
ress
ure,
sut
ures
Ute
rine
mas
sage
, oxy
toci
n, m
isop
rost
ol, h
aem
abat
e
Cons
ider
Mas
sive
Tra
nsfu
sion
Pro
toco
l (M
TP)
ABC
Sco
reAn
ticip
ate
need
s, if
> 4
uni
ts/2
hrs
Mob
ilise
Res
ourc
es
Lab
staf
f, Po
rters
, Nur
sing
, The
atre
Sta
ffR
etrie
val S
ervi
ce &
Blo
od B
ank
Empi
rical
Tre
atm
ent
Tran
sfus
e at
a 1
:1 ra
tio o
f PR
Cs
: FFP
Perm
issi
ve h
ypot
ensi
on M
AP 6
5-70
mm
Hg
(unl
ess
TBI/s
pina
l inj
ury/
exsa
ngui
natio
n)Se
nd F
BE, X
-Mat
ch, V
enou
s G
as, C
alci
um, C
oags
Arte
rial l
ine,
con
side
r Cal
cium
(citr
ate
toxi
city
)W
ARM
FLU
IDS/
WAR
M T
HEA
TRE
IV A
CCES
S - L
ARG
E BO
RE IV
x 2
(14G
)CO
NSID
ER U
SE O
F RA
PID
INFU
SER
KIT
(7Fr
)
CONS
IDER
USE
OF
INTE
ROSS
EOUS
DEV
ICE
CONS
IDER
VEN
OUS
CUT
DOW
N
ABC
SCO
RE
pene
tratin
g in
jury
posi
tive
FAST
exa
mH
R >
120
/min
syst
olic
BP
< 90
mm
Hg
[no
lab
resu
lts -
pure
ly c
linic
al]
0/4
= 1%
risk
of M
TP1/
4 =
10%
risk
of M
TP2/
4 =
41%
risk
of M
TP3/
4 =
48%
risk
of M
TP4/
4 =
100%
risk
of M
TP[A
ctiv
ate
MTP
if 3
+ c
riter
ia m
et]
TRAN
EXAM
IC A
CID
- giv
e 1g
sta
t in
first
3 h
rs fo
r TR
AUM
A
WAR
M F
LUID
S - l
evel
I in
fuse
r/wat
er b
ath
CRYS
TALL
OID
- 25
0ml b
olus
es ti
trate
to M
AP/ra
dial
pul
se
AIM
FO
R
t > 3
5, p
H >
7.2
, Lac
tate
< 4
, BE
< -6
Ca
> 1.
1, P
lt >
50, I
NR
< 1
.5 F
ibrin
ogen
> 1
MYO
CARD
IAL
ISCH
AEM
IA
OH
CRAP
!O
xyge
n, H
aem
oglo
bin
Cont
ract
ility,
Rate
Afte
rload
, Pre
load
MAN
AGEM
ENT
Are
SpO
2, B
P, H
R, H
b, P
EEP
optim
ised?
Chan
ges
verifi
ed w
ith E
CG?
Surg
eon
awar
e of
pro
blem
?
Defib
rilla
tor &
Pac
ing
avai
labl
e ?
RATE
CO
NTRO
L (b
ox) a
ddre
ssed
?
BLO
OD
PRES
SURE
(box
) add
ress
ed?
CARD
IOLO
GIS
T CO
NSUL
TED?
Spec
ific th
erap
y ag
reed
- AS
PIRI
N,HE
PARI
N,
NITR
ATES
etc
Plan
for E
xtub
atio
n &
Reco
very
?
AT R
ISK
Isch
aem
ic he
art d
iseas
eHy
perte
nsio
nFl
uid
loss
esDi
abet
esSm
oker
, Lip
ids,
FHx
etc
.
RATE
CO
NTRO
L
Exclu
de h
ypov
olae
mia
, awa
rene
ss, C
O2
as
caus
e of
tach
ycar
dia
NEXT
BETA
-BLO
CKAD
E (a
im fo
r HR
< 60
)
Esm
olol
0.
25-0
.5 m
g.kg
bol
us25
-300
mg/
kg/m
in in
fusio
n
Met
opro
lol
1-1
5 m
g tit
rate
d ov
er 1
5 m
ins
If be
ta-b
lock
ade
cont
ra-in
dica
ted
use
vera
pam
il 2
.5 m
g - r
epea
t if
need
ed
MIT
IGAT
ION
Perio
pera
tive
Beta
-blo
ckad
eHb
> 1
0g/d
LO
xyge
natio
nBP
in 3
dig
its, H
R 2
digi
ts, B
GL
digi
tRe
gion
al A
naes
thes
ia
SHO
ULD
THIS
ANA
ESTH
ETIC
BE G
IVEN
IN T
HIS
LOCA
TIO
N?
SYM
PTO
MS
& SI
GNS
May
be
none
in a
naes
thet
ised
patie
nt
HIG
H IN
DEX
OF
SUSP
ICIO
NW
ATCH
FO
R EC
G C
HANG
ES (l
ead
II)
Caut
ion
in P
re- &
Pos
t-ope
rativ
e pe
riods
FILL
ING
Opt
imise
fillin
g, c
onsid
er n
eed
for P
EEP
CAUT
ION
USE
OF
VASO
PRES
SORS
For h
yper
tens
ion,
con
sider
G
TN -
subl
ingu
al (0
.3-0
.9 m
g)IV
I(0.2
5 - 4
mgm
/kg/
min
tit
rate
to e
ffect
)
Clon
idin
e(3
0 m
g ev
ery
5 m
inut
es u
p to
300
mg)
RECO
VERY
Plan
Pla
n fo
r Ext
ubat
ion
& Re
cove
ry?
CARD
IOLO
GY
ADVI
CE?
13ST
AR
Lead
II is
bes
t for
det
ectin
g ar
rhyt
hmia
s.C
M5
dete
cts
89%
of S
T-se
gmen
t is
chae
mic
ch
ange
s (r
ight
arm
ele
ctro
de o
n m
anub
rium
, le
ft ar
m e
lect
rode
on
V5 a
nd in
diffe
rent
lead
on
left
shou
lder
).
TAKE
A S
NAPS
HOT
BEFO
RE S
TART
Lead
pos
ition
“w
hite
is ri
ght;
smok
e (b
lack
) abo
ve fi
re (r
ed)”
on
the
L si
de
Adre
nalin
e Bo
lus
(1m
g/m
l 1/1
000
- 1m
g/10
ml 1
/10,
000)
50-1
00m
cg b
olus
IV ti
trate
d to
effe
ctIn
fusi
on 3
mg
in 5
0ml (
60m
cg/m
l) ru
n 5m
l/hr t
o ef
fect
Isop
rena
line
(1m
g in
50m
l 5%
Dex
or 1
mg/
500m
l G
ive
20m
cg (1
ml)
then
infu
se a
t 1-4
mcg
/min
(3-1
2 m
l/hr)
or 3
0-12
0ml/h
r if u
sing
500
ml b
ag
Tran
scut
aneo
us P
acin
gPa
ds A
P ov
er L
ste
rnum
& L
spi
neSt
art a
t 60m
A, in
crea
se to
10%
ove
r cap
ture
, rat
e 80
bpm
Don
’t fo
rget
sed
atio
n!
Atro
pine
10-
20 m
cg/k
g ki
ds (3
00-6
00 m
cg b
olus
adu
lts) I
V!!
!!
Amio
daro
ne 3
00m
g lo
ad th
en 0
.5m
g/kg
/hr I
VM
etar
amin
ol 0
.5m
g bo
lus
IV (1
0mg
in 2
0ml,
1ml =
0.5
mg)!!
!!
Aden
osin
e 6m
g/12
mg/
18m
g bo
lus
IV, f
ast r
unni
ng d
ripEp
hedr
ine
3-6m
g bo
lus
IV!!
!!
!!
!!
!Di
ltiaz
em 0
.25m
g/kg
IVEs
mol
ol 5
00m
icro
gram
s/kg
IV!
!!
!!
!!
!Di
goxi
n 25
0 to
500
mcg
IV
100m
g/m
l dilu
te in
10m
l = 1
0mg/
ml!
!!
!!
!!
Met
opro
lol 2
.5-5
mg
bolu
s IV
70kg
=35m
g=3.
5ml,
100k
g=50
mg=
5ml!
!!
!!
!!
DC s
hock
- SY
NC M
ODE
- 10
0J
CARD
IAC
ARRH
YTHM
IAS
BRAD
YCAR
DIA
Med
icat
ions
Elec
troly
te d
istu
rban
ceH
ypox
iaIs
chae
mia
Giv
e O
XYG
EN -
excl
ude
HYPO
XIA
Firs
t lin
e is
Atro
pine
(1.2
mg
vial
) - 3
00-5
00m
cg b
olus
to to
tal 3
mg
TACH
YCAR
DIA
Wid
e-co
mpl
ex ta
chyc
ardi
as
Nar
row
-com
plex
tach
ycar
dias
Atria
l fibr
illatio
n
Wid
eNa
rrow
A/Fi
b
1st
Amio
daro
neAd
enos
ine
Esm
olol
Amio
daro
ne
2nd
Lign
ocai
neAm
ioda
rone
Esm
olol
Dig
oxin
Dilt
iaze
mAm
ioda
rone
Dig
oxin
CIRC
ULAT
ION
- BRA
DYCA
RDIA
CIRC
ULAT
ION
- TAC
HYCA
RDIA
CIRC
ULAT
ION
- ADU
LT A
RRES
T
ANAP
HYLA
XIS
PRES
ENTA
TIO
N
Wid
e ra
nge
of p
ossi
ble
pres
enta
tions
Mos
t com
mon
incl
ude
:
card
iova
scul
ar c
olla
pse
/ hyp
oten
sion
(88%
)er
ythe
ma
(48%
)br
onch
ospa
sm (4
0%)
angi
oede
ma
(24%
)cu
tane
ous
rash
(13%
)ur
ticar
ia (8
%)
EXCL
USIO
NS
Anae
sthe
tic c
ircui
t obs
truct
ion
filte
r, ki
nked
ETT
, cuf
f her
niat
ion,
tube
mig
ratio
n
Dis
conn
ect c
ircui
t and
ven
tilat
e di
rect
ly w
ith s
elf-i
nflat
ing
bag
if pr
essu
re s
till h
igh,
pro
blem
is in
airw
ay/E
TT
Fore
ign
body
in th
e ai
rway
?Ai
r em
bolis
m?
Tens
ion
PTX?
Seve
re b
ronc
hosp
asm
?
RISK
FAC
TORS
His
tory
of p
revi
ous
expo
sure
not
relia
ble
to e
xclu
de.
Wor
se in
ast
hma,
bet
a-bl
ocka
de, h
ypov
olae
mia
, neu
raxi
al
bloc
kade
(red
uced
end
ogen
eous
cat
echo
lam
ine)
INVE
STIG
ATIO
NS
Dra
w b
lood
for m
ast-c
ell r
elea
sed
trypt
ase
at 0
, 1hr
, 24h
rsSt
ore
at -
20 d
egre
es C
Ref
er to
regi
onal
alle
rgy
cent
re
REM
EMBE
R - A
DREN
ALIN
E CO
NCEN
TRAT
IONS
1ml o
f 1/1
000
= 1m
g10
ml o
f 1/1
0,00
0 =
1mg
IMM
EDIA
TE M
ANAG
EMEN
T
STO
P TR
IGG
ERS
collo
ids/
late
x/an
tibio
tic/b
lood
/NM
B
MAI
NTAI
N AN
AEST
HESI
Aw
ith IN
HALA
TIO
NAL
AGEN
T if
poss
ible
Cal
l for
HEL
P, n
ote
TIM
E, g
ive
100%
OXY
GEN
, giv
e FL
UIDS
ADRE
NALI
NE 5
0-10
0mcg
IV(0
.5m
l-1m
l of 1
/10,
000)
titra
te to
resp
onse
or 0
.5m
g IM
(thi
gh) i
f no
IV a
cces
s
ANTI
HIST
AMIN
E, H
YDRO
CORT
ISO
NE 2
00m
g 6/
24
SALB
UTAM
OL
250
mcg
IV o
r 2.5
-5m
g ne
bulis
er in
to c
ircui
t
TURP
SYN
DRO
ME
PRES
ENTA
TIO
N
Exce
ss a
bsor
ptio
n of
flui
d du
ring
TUR
P
EARL
Y M
ANIF
ESTA
TIO
NS
CVS
brad
ycar
dia,
hyp
erte
nsio
n
GI
naus
ea &
vom
iting
, abd
omin
al d
iste
nsio
n
CN
San
xiet
y/co
nfus
ion,
hea
dach
e,di
zzin
ess,
slo
w w
akin
g G
A
LATE
MAN
IFES
TATI
ONS
CVS
hypo
tens
ion,
ang
ina,
car
diac
failu
re
RES
Pdy
spno
ea, t
achy
pnoe
a, c
yano
sis
CN
Stw
itchi
ng, v
isua
l cha
nges
, sei
zure
s, c
oma
GU
rena
l tub
ular
aci
dosi
s, re
duce
d ur
ine
outp
ut
EXCL
USIO
NS
Con
gest
ive
card
iac
failu
re
All o
ther
cau
ses
of c
onfu
sion
RISK
FAC
TORS
Abso
rptio
n 1-
2 lit
res
fluid
per
40
min
s op
erat
ing
Larg
e pr
osta
tePr
olon
ged
oper
atio
n >
60 m
ins
Hyp
oton
ic fl
uids
giv
en IV
Volu
me
of ir
rigat
ion
> 30
litre
sIn
expe
rienc
ed s
urge
onH
eigh
t of i
rriga
tion
> 60
cm a
bove
pat
ient
Com
orbi
ditie
s - l
iver
dis
ease
, ren
al s
tone
s, U
TI
Imm
edia
te M
anag
emen
t
Hig
h in
dex
of s
uspi
cion
ABC
- 100
% O
xyge
n
Stop
irrig
atio
n flu
id in
fusi
on, c
athe
teris
e
Che
ck N
a an
d Hb
regu
larly
& c
orre
ct th
em
Frus
emid
e 40
mg
IV
LOCA
L AN
AEST
HETI
C TO
XICI
TY
LA C
ONC
ENTR
ATIO
NS
0.5%
= 5
mg/
ml
1% =
10m
g/m
l2%
= 2
0mg/
ml
DRUG
ONS
ET (m
inut
es)
DURA
TIO
N (h
rs)
TOXI
C DO
SE m
g/kg
Amet
hoca
ine
2 m
ins
1 hr
1.5
Prilo
cain
e5-
10 m
ins
1-2
hrs
6
Bupi
vaca
ine
plai
n10
-15
min
s3-
12 h
rs2
Bupi
vaca
ine
with
Adr
enal
ine
10-1
5 m
ins
4-12
hrs
2
Rop
ivac
aine
10-1
5 m
ins
3-12
hrs
3.5
Lign
ocai
ne p
lain
5-10
min
s1-
2 hr
s3
Lign
ocai
ne w
ith A
dren
alin
e5-
10 m
ins
3-4
hrs
7
TOXI
CITY
Initi
ally
CN
S ag
itatio
n, p
eri-o
ral t
ingl
ing,
sei
zure
sth
en C
NS
depr
essi
on, c
oma,
myo
card
ial d
epre
ssio
n
IMM
EDIA
TE M
ANAG
EMEN
T
DISC
ONT
INUE
INJE
CTIO
N - H
IGH
FLO
W O
XYG
EN -
INTU
BATE
AND
VEN
TILA
TE IF
NO
T AL
READ
Y DO
NEM
IDAZ
OLA
M 3
-10m
g fo
r SEI
ZURE
S CA
RDIO
PULM
ONA
RY R
ESUS
CITA
TIO
NIN
TRAL
IPID
20%
1.5
ml/k
g ov
er o
ne m
inut
e (1
00m
l for
70k
g) th
en in
fuse
at 0
.25m
l/kg/
min
MAL
IGNA
NT H
YPER
THER
MIA
PRES
ENTA
TIO
N
mas
sete
r spa
smta
chyp
noea
in s
pont
aneo
us b
reat
hing
pat
ient
rise
in E
TCO
2 in
ven
tilate
d pa
tient
unex
plai
ned
tach
ycar
dia,
pro
gres
sing
to h
ypox
aem
iara
ised
tem
pera
ture
arrh
ythm
ias
EXCL
USIO
NS
Inad
equa
te a
naes
thes
ia /
anal
gesia
Infe
ctio
n / S
epsis
Tour
niqu
et Is
chae
mia
Anap
hyla
xis (e
xclu
de h
ypot
ensio
n)
Phae
ochr
omoc
ytom
a or
Thy
roid
Sto
rm
RISK
FAC
TORS
Fam
ily h
istor
y
Deat
h un
der a
naes
thes
ia in
fam
ily
Vola
tiles
and
Suxa
met
honi
um
INVE
STIG
ATIO
NS
ABG
, U&E
s, C
K, F
BC, C
lotti
ngM
uscle
bio
psy
MO
BILI
SE R
ESO
URCE
S
Surg
eon
- The
atre
Sta
ff - W
ard
Staf
f - IC
U wi
ll be
need
ed
Imm
edia
te M
anag
emen
t
DISC
ONT
INUE
VO
LATI
LES
and
give
100%
OXY
GEN
VIA
HIG
H FL
OW
CALL
FO
R HE
LP -
MH
BOX
HYPE
RVEN
TILA
TE W
ITH
NEW
CIR
CUIT
MAI
NTAI
N AN
AEST
HESI
A wi
th P
ROPO
FOL
and
OPI
OID
EXPE
DITE
SUR
GER
Y
DANT
ROLE
NE 1
mg/
kg IV
up
to 1
0mg/
kg
COO
LING
- AX
ILLA
/ G
ROIN
/ NE
CK
COLD
FLU
SH N
GT
and
IDC
NEUR
AXIA
L BL
OCK
ADE
COM
PLIC
ATIO
NS
Hypo
tens
ion
- Itc
hing
- Ba
ckac
he 1
/10
Failu
re 1
/25
Head
ache
1/1
00Tr
ansie
nt n
erve
dam
age
1/20
00Ca
rdia
c ar
rest
1/3
000
Unex
pect
ed h
igh
spin
al 1
/500
0Pe
rman
ent n
erve
dam
age
1/60
,000
Spin
al a
bsce
ss 1
/100
,000
ANTI
COAG
ULAN
TS
Aspi
rin/N
SAID
S no
con
train
dica
tion
Clop
idog
rel c
ease
7 d
ays
befo
re
Hepa
rin >
6hr
s be
twee
n in
serti
on/re
mov
alCl
exan
e >
12 h
rs b
etwe
en in
serti
on/re
mov
al
War
farin
INR
< 1.
5
BRO
MAG
E SC
ORE
Gra
deCr
iteria
Bloc
k
IFr
ee m
ovem
ent l
egs/
feet
0%
IIFl
ex k
nees
, mov
e fe
et33
%
IIICa
n’t fl
ex k
nees
, mov
e fe
et66
%
IVCa
n’t m
ove
legs
or f
eet
100%
EPID
URAL
ANA
ESTH
ETIC
Expl
anat
ion
and
cons
ent
Prep
/Dra
pe/G
own/
Glo
ves/
Hat/M
ask
2% x
yloca
ine
with
1/2
00,0
00 a
dren
alin
e fo
r bo
th lo
cal in
filtra
te to
skin
& in
itial t
est d
ose
Note
dep
th o
f LO
RTS
or L
ORT
ATh
read
cat
hete
r 3-5
cm fu
rther
Aspi
rate
(CSF
or b
lood
?)
Test
dos
e 3m
l 2%
xylo
1/2
00,0
00 a
dren
alin
e
If no
blo
ck, p
roce
ed w
ith p
rem
ix20
ml 0
.125
% b
upiva
cain
e/20
0mcg
fent
anyl
If in
adve
rtent
spi
nal e
ither
rein
sert
or th
read
ca
thet
er &
top
up w
ith s
pina
l dos
e 3m
l of 2
%
xylo
1/2
00,0
00 a
dren
alin
e O
NLY
by S
ELF
SPIN
AL A
NAES
THET
IC
Tuffi
er’s
line
inte
rsec
ts s
pino
us p
roce
ss L
4-5
Cord
end
s L2
Prep
/Dra
pe/G
own/
Glo
ves/
Hat/M
ask
LA in
filtra
te
Mid
line
until
CSF
Inje
ct L
A wi
th O
piat
e, B
arbo
tage
LSCS
T4-
6~2
.5m
l 0.5
% b
upiva
cain
e +
25m
cg fe
ntan
yl
TURP
T8-
10~3
.2m
l 0.5
% b
upiva
cain
e wi
th o
piat
e10
0-20
0mcg
mor
phin
e or
15-
25m
cg fe
ntan
yl
FLUI
D BO
LUS
MET
ARAM
INO
L or
EPH
EDRI
NE B
OLU
SES
LSCS
to T
4-6
T
URP
to T
8-10
CAES
AREA
N SE
CTIO
N
GA
SECT
ION
Preo
xyge
nate
- 10
0% o
xyge
nAn
ticip
ate
diffi
cult
airw
ay a
nd ra
pid
desa
tura
tion
Crico
id p
ress
ure
RSI :
Pro
pofo
l - S
uxam
etho
nium
- ET
Tub
e
Onc
e su
x we
ars
off p
aral
yse
with
non
depo
laris
ing
NMB
NEUR
AXIA
L SE
CTIO
N
Spin
al 2
.5m
l 0.5
% b
upiva
cain
e wi
th 2
5mcg
fent
anyl
or to
p up
exis
ting
epid
ural
(T10
) to
T4 fo
r LSC
Ssu
pple
men
tal n
itrou
s if
need
ed 5
0:50
N20
/O2
DO I
NEED
BLO
OD?
Posit
ion
of p
lace
nta
Prev
ious
LSC
S/sc
arrin
gM
ultig
ravid
Mul
tipar
ous
Ges
tatio
nal D
MSe
psis
Trau
mat
ic de
liver
yPr
olon
ged
labo
ur
RECO
RD K
EEPI
NG
Posit
ioni
ng
Tim
e ca
lled
Tim
e ar
rived
Tim
e an
aest
hesia
initia
ted
Tim
e of
KTS
Tim
e of
del
ivery
Tim
e of
dru
gs
Spec
ify ri
sks/
cons
ent
GG
HM P
rep/
Drap
eLA
/Stri
ct a
seps
is
Docu
men
t if o
ffere
d co
nver
sion
to G
A an
d if
this
was
decli
ned
Any
com
plica
tions
?Ep
idur
al c
athe
ter t
ip
MAN
AGEM
ENT
OF
PPH
Tone
- Tr
aum
a - T
issue
s - T
hrom
bin
Oxy
tocin
for a
ll - 5
U IV
onc
e ut
erus
em
pty
Oxy
tocin
infu
sion
40U
@ 1
0U/h
r for
4 h
rs
Fund
al ru
b to
ute
rus
Miso
pros
tol 1
000m
cg P
R
Haem
abat
e 0.
25m
g IM
Up to
five
dos
es, m
in 1
5 m
in g
ap b
etwe
en
LARG
E BO
RE IV
- W
ARM
FLU
IDS
- BLO
OD
CONS
IDER
SUR
GIC
AL O
PTIO
NS
PREP
ARE
PATI
ENT
AND
PART
NER
IV a
cces
s 16
G, I
V flu
ids
on p
ump
set
Cons
ider
nee
d fo
r Pae
diat
ricia
n
Sodi
um c
itrat
e dr
ink
Left
late
ral t
ilt to
avo
id a
orto
cava
l syn
drom
e
Give
ant
ibio
tics
unle
ss c
ontra
indi
catio
nO
xyto
cin 5
U IV
onc
e ba
by o
ut (c
heck
not
twin
s!)
Oxy
tocin
infu
sion
- 40U
/100
0ml @
250
ml/h
r
Post
oper
ative
Ana
lges
ia &
DVT
Pro
phyla
xis
NEO
NATA
L RE
SUS
HR 6
0-10
0 as
siste
d ve
ntila
tion
HR <
60
star
t CPR
3:1
Adre
nalin
e 10
mcg
/kg
IV (u
se th
e 1V
, not
2A)
Pre-
Ecla
mps
ia
4g M
gSO
4 ov
er 1
5 m
ins,
then
1g/
hr IV
I
Labe
talo
l 50m
g IV
Hydr
alaz
ine
5mg
IV
CAES
AREA
N SE
CTIO
N
Emer
genc
y G
A LS
CS C
HECK
LIST
CITR
ATE
GIV
EN?!
!!
!!
!
LARG
E BO
RE IV
ACC
ESS
AND
SECU
RED?
!!
FLUI
DS P
RELO
ADED
?!!
!!
!!
TABL
E IN
LEF
T LA
TERA
L TI
LT?!
!!
!
PREO
XYG
ENAT
ED 1
00%
O2
> 4
MIN
UTES
?!!
ETT
- STY
LET
- BO
UGIE
- TA
PE!
!!
!
SUCT
ION
- ETC
O2
- MO
NITO
RING
!!
!!
FAIL
ED R
SI P
LAN
DISC
USSE
D?
RSI!
!!
!!
!!
!
CRIC
OID!!
!!
!!
!!
PR
OPO
FOL
2mg/
kg!
!!
!!
!
SUXA
MET
HONI
UM 1
mg/
kg!
!!
!!
ETT
PLAC
EMEN
T CO
NFIR
MED
WIT
H ET
CO2!
!
VOLA
TILE!!
!!
!!
!!
NE
URO
MUS
CULA
R BL
OCK
ADE!
!!
!
OXY
TOCI
N av
aila
ble
post
-del
ivery!
!!
!
40 U
NITS
/ 10
00m
l @ 2
50m
l/hr i
f nee
ded!
!!
NEO
NATA
L RE
SUS
ANTI
CIPA
TED?
!!
!!
Emer
genc
y SP
INAL
LSC
S CH
ECKL
IST
CITR
ATE
GIV
EN?!
!!
!!
!
LARG
E BO
RE IV
ACC
ESS
AND
SECU
RED?
!!
FLUI
DS P
RELO
ADED
?!!
!!
!!
TABL
E IN
LEF
T LA
TERA
L TI
LT?!
!!
!
L4-5
INTE
RSPA
CE ID
ENTI
FIED
?!!
!!
PREP
- DR
APE
- GO
WN
- GLO
VES
- MAS
K - H
AT!!
ANTI
SEPT
IC R
EMO
VED
FORM
SPI
NAL
TRAY
!!
LOCA
L AN
AEST
HETI
C 2%
XYL
OCA
INE/
ADRE
NALI
NE!
2.5M
L BU
PIVA
CAIN
E 0.
5% w
ith F
ENTA
NYL
20-2
5MCG
!
SKIN
INFI
LTRA
TIO
N!
!!
!!
!
INTE
RSPI
NOUS
LIG
AMEN
T ID
ENTI
FIED
!!
!
CLEA
R CS
F!!
!!
!!
!
SWIF
T IN
JECT
ION
WIT
H BA
RBO
TAG
E!!
!
OXY
TOCI
N av
aila
ble
post
-del
ivery!
!!
!
40 U
NITS
/ 10
00m
l @ 2
50m
l/hr i
f nee
ded!
!!
NEO
NATA
L RE
SUS
ANTI
CIPA
TED?
!!
!!
PAED
IATR
IC C
AR
DIA
C A
RR
EST
NEO
NATA
L RE
SUSC
ITAT
ION!
Um
bilic
al v
enou
s ac
cess
(one
vei
n, tw
o ar
terie
s)
ADEN
OSI
NEfir
st d
ose
0.05
mg/
kgse
cond
dos
e 0.
10m
g/kg
then
0.2
0mg/
kgG
IVE
VIA
FAST
FLU
SH
ADRE
NALI
NEIV
: 0.0
1 m
g/kg
(10m
cg/k
g)1/
10,0
00 -
0.1
ml/k
g IV
ie. 1
0kg
- 1m
lET
T - 1
/100
0 - 0
.1m
l/kg
ADRE
NALI
NE IN
FUSI
ON
0.3m
g/kg
in 1
00m
l N-s
alin
eSt
art a
t 1m
l/hr
= 0.
05m
cg/k
g/m
inR
ange
1-2
0ml/h
r
AMIO
DARO
NE5
mg/
kg lo
adin
fuse
0.5
mg/
kg/h
r
ATRA
CURI
UM0.
5mg/
kg
ATRO
PINE
20m
cg/k
g IV
(max
600
mcg
)di
lute
0.6
mg
to 6
mls
= 10
0 m
cg/5
mls
So g
ive
1 m
l per
5kg
IV
CODE
INE
1mg/
kg
DEFI
BRIL
LATI
ON
2-4
J/kg
– B
ipha
sic
DEXT
ROSE
0.5
gm/k
g10
% -
5 m
l/kg
IV50
% -
1 m
l/kg
IV
ETT
Leng
thAg
e/2
+ 12
cm to
teet
h
ETT
Diam
eter
>1yr
- Ag
e/4
+ 4
FENT
ANYL
1 m
cg/k
g IV
(0.5
mcg
/kg
IN)
KETA
MIN
E SE
DATI
ON
2-4
mg/
kg IM
0.25
- 0.
5 m
g/kg
IVre
peat
as
need
ed
KETA
MIN
E - A
NAES
5-10
mg/
kg IM
1-2
mg/
kg IV
repe
at a
s ne
eded
MET
ARAM
INO
L0.
01 m
g/kg
IV10
mg
in 2
0 m
ls=0
.5 m
g/m
l
MID
AZO
LAM
0.1
- 0.2
mg/
kg IV
MO
RPHI
NE0.
1 m
g/kg
IV
NEO
STIG
MIN
E0.
05 m
g/kg
IV
PARA
CETA
MO
L15
mg/
kg
PRO
POFO
L1-
3.5
mg/
kg IV
REM
IFEN
TANI
L1m
g/20
ml =
50
mcg
per
ml
Run
at 1
0mcg
/kg/
min
ROCU
RONI
UM0.
6-1.
2 m
g/kg
IV S
TAT
0.1
mg/
kg b
olus
es
SALB
UTAM
OL
Und
ilute
d 5m
g/5m
l5m
cg/k
g ov
er 1
min
SUXA
MET
HONI
UM2
mg/
kg IV
, 3m
g’kg
neo
nate
4 m
g/kg
IM
THIO
PENT
ONE
4 m
g/kg
IV
VECU
RONI
UM0.
1 m
g/kg
IV
VOLU
ME
EXPA
NSIO
N20
mls
/kg
N/s
alin
e
WEI
GHT
(kg)
Infa
nts
< 12
mon
ths
(age
in m
onth
s +
9) /
2
Chi
ldre
n 1-
5 ye
ars
2 x
(age
in y
ears
+ 5
)
Chi
ldre
n 5-
12 y
ears
4 x
age
in y
ears
PAED
IATR
IC C
HEAT
SHE
ET
EMER
GEN
CY
Adre
nalin
e 10
mcg
/kg
Atro
pine
20m
cg/k
g
Met
aram
inol
10m
cg/k
g
Prop
ofol
2m
g/kg
Sux
2mg/
kg
Thio
4m
g/kg
Flui
ds 2
0ml/k
g
4J/k
g Bi
phas
ic
Adre
nalin
e IM
1/1
000
0.01
ml/k
g to
max
0.5
ml
IM la
tera
l thi
gh, r
epea
t 5 m
inut
ely
Adre
nalin
e IV
1,1
0,00
01m
g/10
ml 1
/10,
000
IV10
mcg
(0.1
ml)
per k
g of
1/1
0,00
0
Adre
nalin
e In
fusi
on1/
1,00
0 =
1mg/
ml
3mg
in 5
0ml N
sal
ine
0.3m
g/kg
- 60
mcg
/ml
2mcg
/min
= 2
ml/h
r to
20m
cg/m
in =
20m
l/hr
Amio
daro
ne5m
g/kg
ove
r 20
min
can
push
ove
r 2 m
ins
cent
ral a
cces
s IV
Amio
daro
ne In
fusi
on60
0mg
in 5
0mls
5% d
extro
se0.
5mg/
kg/h
r cen
tral a
cces
s
Atra
curiu
m0.
5 m
g/kg
(0.3
-0.6
mg/
kg) I
V in
duce
,th
en 1
/3rd
dos
e su
bseq
uent
ly
Atro
pine
600m
cg in
6m
l NS
10-2
0mcg
/kg
kids
300-
600m
cg a
dults
Cis-
atra
curiu
m0.
15m
g/kg
IV
Dext
rose
0.5
gm/k
g10
% -
5 m
l/kg
IV50
% -
1 m
l/kg
IV
Ephe
drin
e3-
6mg
bolu
s IV
Esm
olol
0.5m
g/kg
100m
g/m
l dilu
te in
10m
l = 1
0mg/
ml
100k
g=50
mg=
5ml
ETT
Leng
thAg
e/2
+ 12
cm to
teet
h
ETT
Diam
eter
>1yr
- Ag
e/4
+ 4
Fent
anyl
100m
cg/2
ml
2-3
mcg
/kg
IV0.
5-1
mcg
/kg
intra
nasa
l
GTN
Infu
sion
50m
g in
50m
l 5%
dex
trose
1m
g/m
l at 3
-12m
l/hr
Hepa
rin In
fusi
on25
,000
uni
ts in
500
ml (
50U/
ml)
1000
U/hr
= 2
0ml/h
r
Insu
lin IV
I 50
uni
ts in
50m
l5-
10 U
/hr =
5-1
0ml/h
r
Isop
rena
line
1mg
in 5
0ml 5
% d
extro
seG
ive 2
0mcg
(1m
l)th
en in
fuse
at 1
-4m
cg/m
in(3
-12
ml/h
r)
Keta
min
e In
duct
ion
1-2
mg/
kg IV
5-
10m
g/kg
IM
Keta
min
e Se
datio
n0.
2-0.
5 m
g/kg
IV s
edat
ion
2-4m
g/kg
IM s
edat
ion
Keta
min
e In
fusi
on0.
25m
g/kg
/hou
r
Keta
min
e/M
idaz
olam
Infu
sion
200m
g Ke
tam
ine
: 50m
cg fe
ntan
ylin
50m
l run
@ 2
-5m
l/hr
Mag
nesi
um S
ulph
ate
Infu
sion
4 am
poul
es (2
.47g
x 4
= 9
.88g
) to
100m
l N s
alin
e =
120m
l
Load
4g
(50m
) ove
r 20
min
s(1
50m
l/hr o
ver 2
0 m
ins)
then
1g/
hr (1
2ml/h
r)
Met
aram
inol
0.5m
g bo
lus
Mid
azol
am01
.-0.2
mg/
kg IV
Mor
phin
e0.
1 m
g/kg
IV
Mor
phin
e/M
idaz
olam
Infu
sion
50m
g ea
ch in
50m
l NS
1mg/
ml (
1mg/
10m
l)at
10m
cg/k
g/hr
= 2.
5 - 1
5ml/h
r
Nalo
xone
0.1
to 0
.2 m
g IV
2-3
min
utel
y to
de
sired
deg
ree
of re
vers
al
Neos
tigm
ine
005m
g/kg
IV
Para
ceta
mol
20m
g/kg
firs
t dos
eth
en15
mg/
kg P
O
Prop
ofol
2mg/
kg ti
trate
Rem
ifent
anil
1mg/
20m
l = 5
0 m
cg p
er m
lRu
n at
0.1
mcg
/kg/
min
Rocu
roni
um0.
6-1.
2 m
g/kg
IV S
TAT
(get
sam
e in
tuba
ting
cond
itions
as
sux
if us
e ro
c 1.
2mg/
kg)
0.1
mg/
kg b
olus
es th
erea
fter
Salb
utam
ol IV
10m
cg/k
g IV
bol
us o
ver 1
0 m
ins
Sodi
um B
icar
bona
te 8
.4%
1-2
ml/k
g
Suxa
met
honi
um1
mg/
kg a
dult
2 m
g/kg
pae
d
Thio
pent
one
3-5
mg/
kg
Vecu
roni
um0.
1 m
g/kg
load
bolu
s ev
ery
30m
with
5-1
0mg
vec
Vecu
roni
um In
fusi
on0.
1 m
g/kg
/hr
Volu
me
Expa
nsio
n20
mls/
kg N
/sal
ine
FORM
ULAR
Y
ADRE
NALI
NE!
!3m
g in
50m
l N/s
alin
e =
60m
cg/m
l!!!
!ru
n at
2 -
20 m
l/hr
1mg/
1ml a
mp!
!!
!!
!!
!!
!in
cr. t
o ke
ep M
AP >
70
AMIO
DARO
NE!
!di
lute
600
mg
(12m
l) up
to 5
0ml 5
% D
EX!!
!ru
n at
0.5
mg/
kg/h
r15
0mg/
3ml a
mp!
!=
12m
g/m
l!!
!!
!!
!ce
ntra
l acc
ess
ESM
OLO
L!!
!lo
ad 5
00 m
cg/k
g ov
er 6
0sec
s!!
!!
100k
g =
5ml (
100m
g/10
ml)
100m
g/10
ml!!
!m
aint
ain
50m
cg/k
g/m
in!
!!
!!
100k
g =
30m
l/hr
FENT
ANYL!!
!10
0 m
cg/2
ml o
r 500
mcg
/50m
l pre
mix!!
!ru
n at
0 -
100
mcg
/hr
GTN!!
!!
dilu
te 5
0mg
up to
50m
l 5%
DEX
!!
!!
run
at 3
- 12
ml/h
r50
mg/
10m
l am
p!!
= 1m
g/m
l!!
!!
!!
!tit
rate
to B
P/pa
in
HEPA
RIN!
!!
25,0
00 U
in 5
0ml!
!!
!!
!lo
ad 5
000
U IV
!!
!!
500
U/m
l!!
!!
!!
!th
en 2
ml/h
r, tit
rate
APT
T
INSU
LIN
IVI!!
!50
U in
50m
l = 1
U/m
l!!
!!
!lo
ad 1
0U IV
(not
kid
s)!
!!
!!
!!
!!
!!
!th
en ru
n @
5-1
0 m
l/hr!
!
(see
Slid
ing
Scal
e ab
ove)
ISO
PREN
ALIN
E!!
1mg
in 5
0ml 5
% D
EX =
20m
cg/m
l!!!
!1
ml b
olus
to re
spon
se!
!!
!!
!!
!!
!!
!th
en 3
-12
ml/h
r
KET/
MID
AZ!!
!20
0mg
keta
min
e /5
0 m
cg fe
nt in
50m
l!!
!ru
n at
2-5
ml /
hr
MgS
O4
(ecl
amps
ia)!
Add
4 am
ps (2
.47g
) to
100m
l N/s
alin
e!!
!bo
lus
50m
l (4g
) ove
r 20m
ins
ie :
150m
l/hr f
or 2
0 m
ins
!!
!!
= 12
0 m
l tot
al v
olum
e (1
g/12
ml)!
!!
!th
en 1
g/hr
(12
ml/h
r)
MO
RPH/
MID
AZ!
!50
mg
each
to 5
0ml w
ith N
/sal
ine
(1m
g/m
l)!!
run
100
mcg
/kg/
hr (2
.5-1
5 m
l/hr)
PRO
POFO
L!!
!1-
4 m
g/kg
500
mg/
50m
l (10
mg/
ml)!
!!
dose
rang
e 0.
5 m
g/kg
/hr (
use
body
wt =
ml/h
r eg
70kg
= 7
0ml/h
r)
REM
IFEN
TANI
L!!
1mg
in 2
0ml =
50m
cg/m
l!!
!!
!ru
n at
0.1
mcg
/kg/
min
(100
kg =
12m
l/hr)
VECU
RONI
UM!
!1m
g/m
l rec
onst
itute
in w
ater
for i
njec
tion!!
!0.
1 m
g/kg
/hr e
g: 8
mg/
hr in
80k
g pa
tient
INFU
SIO
NS!!
!Id
eally
use
ded
icat
ed s
yrin
ge d
river
(10
- 50m
l cap
acity
) eg
Niki
T34
INSU
LIN
SLID
ING
SCA
LE50
U/50
ml =
1U/
ml
B
GL!!
!
RAT
E
mm
ol!!
!U/
hr =
ml/h
r
<
4!!
!0
- STO
P IV
I
4.1
- 9!
!
2
9.1
- 13!
!
3 1
3.1
- 17!
!
4 1
7.1
- 28!
!
6
> 2
8!!
!
8!
!!
chec
k ru
nnin
g
INTR
A-NA
SAL
MED
ICAT
IONS
GEN
ERAL
PRI
NCIP
LES
Use
the
MIN
IMUM
VO
LUM
E, a
nd S
TRO
NGES
T ST
RENG
TH o
f dru
g
Use
an A
TOM
ISER
whe
re p
ossib
le
Adm
inist
er H
ALF
to E
ACH
NOST
RIL
to m
axim
ise m
ucos
al a
rea
STAN
DARD
MO
NITO
RING
inc.
SpO
2 an
d su
pple
men
tal O
2
War
n th
at m
ay S
TING
INIT
IALL
Y.
Be a
ware
will
wear
off
so c
onsid
er O
NGO
ING
NEE
DSan
d m
etho
d of
DEL
IVER
Y (re
peat
IN, I
V, o
ral e
tc)
ANAL
GES
IA
Fent
anyl
2 m
icrog
ram
s/kg
Keta
min
e 0.
5 - 1
mg/
kg
Lign
ocai
ne 2
% (t
opica
l) 5m
l
SEDA
TIO
N
Fent
anyl
1.5
- 3
micr
ogra
ms/
kg
Keta
min
e 10
mg/
kg
Mid
azol
am 0
.5 m
g/kg
SEIZ
URES
Mid
azol
am 0
.2 -
0.3
mg/
kg (u
se 1
0mg
in a
dults
) U
se c
once
ntra
ted
5mg/
ml p
repa
ratio
n
OPI
ATE
WIT
HDRA
WAL
Nalo
xone
2m
g (2
ml)
Exam
ples
of M
AD (M
ucos
al A
tom
isatio
n De
vices
)fro
m P
ACM
ED
TOPI
CALI
SING
THE
AIR
WAY
Ther
e ar
e m
any
diffe
rent
met
hods
. Her
e is
my
pref
erre
d m
etho
d fo
r AFO
I:
Use
an a
nti-s
ialo
gogu
e (g
lycop
yrro
late
0.2
– 0
.4 m
g IV
or I
M (4
– 5
mcg
/kg,
4 –
8
mcg
/kg
in ch
ildre
n). I
f req
uire
sed
atio
n th
en c
onsid
er t
hat y
our t
opica
lisat
ion
has
faile
d an
d ris
k in
chin
g to
ward
s a
true
GA!
3-5m
g/kg
of l
igno
cain
e (2
% =
20m
g/m
l) ad
min
ister
ed u
sing
cann
ula
jet o
ppos
ite
USE
10 m
l syr
inge
3 wa
y ta
p
20 G
can
nula
Oxy
gen
flow
to d
rive
SAFE
PSY
CH S
EDAT
ION
MAT
RIX
LIAI
SE W
ITH
RETR
IEVA
L TE
AM
RAPI
D AS
SESS
MEN
T AC
UTE
AGIT
ATIO
N
AIRW
AY?
BREA
THIN
G?
CIRC
ULAT
ION
DISA
BILI
TY,
DRUG
S?EN
VIRO
NMEN
T, E
CGFU
LL B
LADD
ER?
GLU
COSE
?HE
AD IN
JURY
?
SUG
GES
TED
ALG
ORI
THM
NO IV
ACC
ESS
oral
ola
nzap
ine
10-2
0mg
stat
and/
orIM
I mid
azol
am 5
-10m
gan
d/or
IMI k
etam
ine
4mg/
kg
IV A
CCES
S O
BTAI
NED
IV m
idaz
olam
2-5
mg
and/
orIV
hal
oper
idol
5-1
0mg
and/
orIV
ket
amin
e 1-
1.5m
g/kg
repe
at e
very
5-1
0 m
ins,
targ
et R
ASS
0 to
-3
CONS
IDER
ANAE
STHE
TIC
RISK
ANAE
STHE
TIC
RISK
ANAE
STHE
TIC
RISK
MEN
TAL
HEAL
THSA
FETY
/RIS
K
LOW
thin
, fit,
fast
edM
EDIU
MAS
A II
- III
HIG
Hol
d, s
ick, d
ifficu
lt ai
rway
OSA
etc
LOW
flat,
depr
esse
d, n
o Hx
vio
lenc
e,lo
w ris
k su
icida
l pat
ient
“hap
py” d
runk
thou
ght d
isord
ered
but
com
plia
nt
low
risk
reas
sura
nce
mild
anx
iolyt
ic
rest
rain
tm
onot
hera
pylo
nger
act
ing
agen
ts1:
1 nu
rsin
g
avoi
d dr
ugs
if po
ssib
leor
ient
atio
nre
assu
ranc
e1:
1 nu
rsin
g
MED
IUM
into
xicat
ed /
disin
hibi
ted
unpr
edict
able
delu
siona
l with
poo
r ins
ight
anxio
us +
++
seda
tion
need
edsin
gle
agen
tan
tipsy
chot
ic (+
/- be
nzo)
as a
bove
heav
ier s
edat
ion
airw
ay a
djun
cts
to
hand
airw
ay ri
skno
n-ph
arm
acy
pref
erre
dsh
ort a
ctin
g BD
Ztin
ctur
e of
tim
e
HIG
Hvio
lenc
e /w
eapo
nsph
ysica
l thr
eats
pers
ecut
ory
delu
sions
aro
und
care
“big
guy
” you
who
m c
anno
t res
train
as a
bove
then
keta
min
ese
datio
nor
RSI
/ETT
as o
rang
ebu
t del
ayun
til fa
sted
awai
t ret
rieva
l?
bala
nce
of m
inim
al
seda
tion
& ow
n ai
rway
vsG
A/ET
T
Ola
nzap
ine
- firs
t lin
e or
al a
ntip
sych
otic;
waf
er 1
0-20
mg
oral
, rap
id o
nset
Que
tiapi
ne -
seco
nd lin
e or
al a
ntip
sych
otic;
man
ia, b
ehav
iour
al-b
ased
agi
tatio
n or
pre
vious
use
Halo
perid
ol -
5mg
ORA
L or
10m
g IM
to m
ax 5
0mg;
5-1
0mg
IV u
p to
max
20m
gbe
nztro
pine
1-2
mg
IV s
houl
d be
ava
ilabl
e to
trea
t acu
te d
ysto
nia
Mid
azol
am -
IM 5
-20m
g, IV
0.1
-0.2
mg/
kg in
aliq
uots
, IN
0.2m
g/kg
, ORA
L 0.
5mg/
kgflu
maz
enil 0
.2-0
.5m
g IV
sho
uld
be a
vaila
ble
if ac
ute
reve
rsal
requ
ired
Keta
min
e - P
RE-K
ETAM
INE
SEDA
TIO
N ES
SENT
IAL
to M
INIM
ISE
DELI
RIUM
ie :
BDZ
IM 5
mg/
kg, I
V 0.
5-1.
5mg/
kg s
edat
ion.
Ket
amin
e in
fusio
n ha
s be
en u
sed
for t
rans
port.
Cons
ider
ant
isial
ogog
ue a
djun
ct (a
tropi
ne o
r glyc
opyr
rola
te)
See
also
: M
inh
le C
ong
et a
l. “K
etam
ine
seda
tion
for p
atie
nts
with
acu
te a
gita
tion
and
psyc
hiat
ric il
lnes
s re
quiri
ng a
erom
edic
al
retri
eval
” EM
J M
ay 2
011
- ket
amin
e se
datio
n us
ed to
avo
id R
SI/E
TT o
f red
/bla
ck p
atie
nts
in ri
sk m
atrix
abo
ve
MIN
IMUM
SED
ATIO
N M
ONI
TORI
NG -
SpO
2, E
CG, N
IBP.
Con
sider
ETC
O2
via H
M. S
UPPL
EMEN
TAL
OXY
GEN
AT
ALL
TIM
ESRF
DS re
stra
ints
or n
et, 4
5 de
gree
hea
d up
to m
axim
ise S
V an
d m
inim
ise a
spira
tion
risk.
CHE
CK B
GL!
Proc
edur
e
(i)ob
serv
e pa
tient
- pa
tient
is a
lert,
rest
less
, agi
tate
d or
com
bativ
e (0
to +
4)
(ii)
if no
t ale
rt, s
tate
pat
ient
’s na
me
and
say
to o
pen
eyes
and
look
at s
peak
er-1
if a
wak
ens
with
sus
tain
ed e
ye c
onta
ct to
voi
ce >
10s
to v
oice
-2 if
aw
aken
s w
ith e
ye c
onta
ct to
voi
ce <
10s
-3 if
mov
es o
r ope
ns e
yes
to v
oice
but
no
eye
cont
act
(iii)
if no
resp
onse
to v
oice
, use
phy
sica
l stim
ulus
(sho
ulde
r sha
ke, t
rape
zius
squ
eeze
, jaw
thru
st)
-4 if
any
mov
emen
t to
phys
ical
stim
ulat
ion
-5 if
no
resp
onse
to p
hysi
cal s
timul
atio
n
RICH
MO
ND A
GIT
ATIO
N SE
DATI
ON
SCAL
E
RICH
MO
ND A
GIT
ATIO
N SE
DATI
ON
SCAL
ERI
CHM
OND
AG
ITAT
ION
SEDA
TIO
N SC
ALE
RICH
MO
ND A
GIT
ATIO
N SE
DATI
ON
SCAL
ETe
rmDe
scrip
tion
Scor
e
COM
BATI
VEov
ertly
com
bativ
e, v
iole
nt, i
mm
edia
te d
ange
r to
self/
othe
rs+4
VERY
AG
ITAT
EDpu
lls o
r rem
oves
tube
(s),
cath
eter
(s),
aggr
essi
ve+3
AGIT
ATED
frequ
ent n
on-p
urpo
sefu
l mov
emen
t, fig
hts
vent
ilato
r+2
REST
LESS
anxi
ous
but m
ovem
ents
not
agg
ress
ive
or v
igor
ous
+1
ALER
T &
CALM
Doc
tor o
r Nur
se0
DRO
WSY
Not
fully
ale
rt, b
ut s
usta
ined
aw
aken
ing
to v
oice
(eye
s op
en >
10s
)-1
LIG
HT S
EDAT
ION
brie
fly a
wak
ens
with
eye
con
tact
to v
oice
< 1
0s-2
MO
DERA
TE S
EDAT
ION
mov
emen
t or e
ye o
peni
ng to
voi
ce b
ut n
o ey
e co
ntac
t-3
DEEP
SED
ATIO
Nno
resp
onse
to v
oice
, but
mov
emen
t or e
ye o
peni
ng to
phy
sica
l stim
ulat
ion
-4
UNRO
USAB
LEno
resp
onse
to v
oice
or p
hysi
cal s
timul
atio
n-5
TARG
ET R
ASS
is 0
to -3
AIRW
AY E
QUI
PMEN
T an
d M
ONI
TORI
NG m
ust b
e av
aila
ble
1:1
NURS
ING
, 10
min
utel
y ob
s
LIAI
SE W
ITH
RETR
IEVA
L SE
RVIC
E
TRANSFER INFORMATIONSometimes important details can get forgotten. I use the ABC approach to handover to retrieval team, as follows: “Thank God you’re here! OK, this is John Doe age 21 involved in a motor vehicle accident with prolonged extrication and transferred via ambulance to us. He needs transfer to a trauma centre for a laparotomy for internal bleeding. In terms of summary, here’s his ABC...”
The above would take 90 seconds and is an ordered summary of the patient for handover.
A - Airway Intubated on arrival for GCS M3V1E1 - grade I view.Airway now patent, protected with size 8.5 ETT tube 22cm teeth and tied.Cervical collar in situ.
B - Breathing Paralysed with vecuronium and on volume control TV 600 RR 12R sided HTX and a 34Fr intercostal catheter in place, drained 400ml blood.SpO2 96%
C - Circulation Haemodynamically stable after 750ml crystalloid titrated to radial pulse in 250ml aliquots (permissive hypotension). HR 90 BP 74/50Bleeding likely from HTX, abdomen and pelvis.
D - Disability/Drugs
M3V1E1 PEARLA initially, now M1V1E1 on propofol/vecuronium infusion.
E - Exposure R HTX drained as above.Abdomen tense and tender in LUQ, suspect splenic injury.No other injuries on log roll, pelvic binder applied.Warm blankets and Bair hugger
F - Fluids 3 x 250ml crystalloid aliquots titrated to radial pulse (SBP 70)IDC in situ and drained 300ml clear urine
G - Gut Last ate 7pm. NG passed and on free drainage.
H - Haematology Hb 114 on iStat, INR 1.1 No ACoTS.
I - Infusions Not needed vasopressorsOn propofol and vecuronium infusions for transport
J - JVP Not elevated - no signs tPTX/tamponade.
K - Kelvin Temp is 36 degrees with active warming
L - Lines 14G IV R wrist8Fr rapid infuser L ACF
M - Micro Has been given ADT
N - Notes/NOK His notes are in this envelope, including copies of plain X-raysNOK are aware and here are their contact details.
Para
llels
are
ofte
n dr
awn
betw
een
anae
sthe
sia a
nd a
viatio
n. T
his
is no
t alw
ays
in a
goo
d lig
ht, w
ith th
e of
t-rep
eate
d co
mm
ent t
hat “
givi
ng a
n an
aest
hetic
is li
ke
flyin
g an
airp
lane
- 99
% b
ored
om a
nd 1
% s
heer
terro
r” al
ludi
ng to
the
rela
tive
safe
ty o
f ana
esth
esia
and
the
infre
quen
cy o
f cris
es -
but t
he s
ever
ity o
f tho
se
crise
s if
they
occ
ur d
eman
ds s
wift
actio
n el
se d
isast
er a
waits
. Mor
e re
cent
ly, a
naes
thes
ia h
as b
orro
wed
conc
epts
of c
rew
reso
urce
man
agem
ent f
rom
the
avia
tion
indu
stry
, app
licab
le in
a c
risis.
Che
cklis
ts a
re m
anda
tory
in a
viatio
n an
d ar
e be
ginn
ing
to b
e us
ed in
the
Ope
ratin
g Th
eatre
to a
id s
afet
y.
Inte
rest
ing
Para
llels
Inte
rest
ing
Para
llels
Pre-
oper
ative
Eva
luat
ion
Prefl
ight
Anae
sthe
tic m
achi
ne &
Equ
ipm
ent c
heck
Airc
raft
and
Prefl
ight
che
cklis
t
Indu
ctio
nTa
ke o
ff
Deep
enin
g an
aest
hesia
Asce
nt
Intra
oper
ative
per
iod
Crui
sing
altit
ude
Ligh
teni
ng a
naes
thet
icDe
scen
t
Emer
genc
e &
Reco
very
Land
ing
and
Taxii
ng
ANES
THES
IA &
AVI
ATIO
N
"Anaesthetics - isn't it just like flying an aeroplane, cruising along on autopilot with the real skill only needed if something
goes wrong?"
If one more person tells me that giving an anaesthetic is like flying a plane, I will swing for them, I really will. Look - the whole point of a plane is that it is designed to fly, and if it's not working properly then you don't take it off the ground. And you certainly don’t try to fly the damn thing whilst an Engineer (surgeon) is taking bits off it and doing on-the-spot repairs. Human beings, in contrast, are not designed to be anaesthetised, and are often not working properly when the occasion arises. They are also rather poorly provided with back-up systems and spares, and frequently have long histories of inadequate servicing.
So if giving an anaesthetic is like flying a plane, then this must be what flying a plane is like :
Captain James Bigglesworth stepped out into the thin sunlight and took a deep breath of the damp air. It was good to be alive. He was taking up a new crate today, and he relished the little knot of mixed tension and anticipation that always formed at the pit of his stomach under such circumstances. He strode briskly towards the hangar.
The Junior Engineer was waiting next to the aeroplane. He handed Biggles a single sheet of paper, on which he had scrawled a haphazard note of his work on the craft. "Is this all?" asked Biggles, "Where is the service record?"
"It seems to be lost. The filing department say it may still be at the previous airfield."
"And the manual?"
The Junior Engineer looked startled. "I don't think there is one. We thought you knew how to fly a plane."
A cloud drifted slowly across the sunny sky of Biggles' mind. He began his walk-round. "Where's this oil coming from?"
The Junior Engineer frowned seriously. "I don't know."
Biggles sighed. But he too, long ago, had once been a Junior Engineer. "Where do you think it might be coming from?"
"The engine?" hazarded the youth.
"Of course. So what's the oil level in the engine?"
"I don't know."
"Have you checked the oil level?"
"No."
Biggles could feel his voice becoming a little tight, a little cold. "So could you check it now, please?"
"But you're just going to take off. The Chief Engineer wants you to take off right away."
"Not without an oil level. And this undercarriage strut is broken. And the port aileron is jamming intermittently."
At that moment, the Chief Engineer arrived. "Biggles, old chap! Ready to take her up? Good man."
"She's not remotely airworthy. I need an oil level and some basic repairs."
The Chief Engineer sighed. "What do you want an oil level for? You know it's going to be low. We've got to get her into the air before we can control the leak. And that undercarriage and aileron aren't going to get any better while we stand here. She needs to be in flight before I can properly assess them. Come on, old chap - the tower's given us a slot in ten minutes' time. If we don't take off then, we'll be waiting all day." He eyed the plane despondently, and tapped a tyre with the toe of his boot. "And, frankly, I don't think she'll last much longer."
Biggles rippled the muscles of his square jaw. The Bigglesworths had never balked at a challenge, but this... well, there seemed to be no way out of it. He was going to have to take the old crate into the air, just as she stood. Deuced bad luck, of course, but no point in whining.
Twenty minutes later, they were aloft. The plane kept trying to fly in circles, and the engine temperature gauge was sitting firmly in the red. The Engineer was out on the cowling with a spanner. "Just turn her off for a bit," he bawled over the clattering roar of the sick engine.
Biggles was astonished. "What?"
"Turn off the engine. There's nothing I can do about this leak until the engine's stopped."
Reluctantly, Biggles turned off the engine, and trimmed the aircraft for a shallow glide. The weight of the Engineer, out there on the nose, was not helping matters at all.
Four minutes passed in eerie silence, as the treetops swam up to meet them. "I'm going to need power again soon." There was no response from the Engineer. Another thirty seconds passed. "I need power." No answer. "I'm turning on now." The engine roared, and the Engineer recoiled, cursing, in a cloud of black smoke.
"What's your game, Biggles, old man? I almost had the bally thing fixed, and now we'll need to start all over again!"
Biggles bit back an angry retort, and concentrated on guiding the crippled plane upwards. This time, now that he knew what was going on, they would start their glide from a lot higher.
After another protracted glide, the Engineer clambered back into the cockpit, beaming. "All fixed!"
Biggles tapped the oil pressure gauge. "Pressure's not coming up," he said. "It will, it will," said the Engineer breezily. "Don't be such a fusspot. Now let's get the aileron sorted." He crawled out onto the wing, and began to strike the recalcitrant aileron with a hammer.
A minute later, the plane rolled violently to the right. Biggles struggled momentarily for control, his lips dry. By crikey, they'd almost lost it completely, there. "Don't do that!" he called hoarsely to the Engineer.
"Do what?"
"Whatever you did, just then."
"I wasn't doing anything, old man."
Almost at that moment the plane lurched again, more fiercely, and rolled through forty-five degrees. "That!" screamed Biggles, fighting the controls for his very life. "Don't do that!"
"Fair enough," said the Engineer, cheerily. A minute later he did it again, and the plane was inverted for ten long seconds before a sweating Biggles regained any vestige of control.
"Fixed! Undercarriage next!" called the Engineer, and clambered out of sight below the fuselage.
Ten minutes later, Biggles caught brief sight of a set of wheels dropping away earthwards. "Couldn't save 'em," said the Engineer matter-of-factly when he regained the cockpit. "Better off without them, frankly."
"I still have very little oil pressure," said Biggles, worriedly.
The Engineer pursed his lips and tapped the pressure gauge reflectively. "Well, the leak's fixed, old man. Must be something about the way you're flying her." He reached under his seat and pulled out a parachute. "Look, I'm most frightfully sorry about this, but the nice men from Sopwith are taking me out to dinner tonight, so I've got to dash. Be a brick, Biggles old fellow, and just put her down anywhere you like. I'll cast an eye over her in the hangar tomorrow morning."
And with that, he was gone.
Biggles thought longingly of his own parachute. But he couldn't abandon the old girl now. It wasn't her fault, after all. Black, oily smoke was already billowing out of the engine cowling, however - he needed to put her down soon. He began to peer around for a flat place to land and, almost immediately, he spotted a distant grassy field.
He moved the controls a little so that he could take a closer look - it certainly looked flat enough. Oddly, someone had painted huge white letters across the level green grass - ICU, it 0.75read. He had no idea what that meant, but it seemed vaguely comforting, for some reason. The engine coughed once, and then stopped. He could see a fitful orange glow beneath the cowling. This rummy ICU field would just have to do, it seemed.
As he swung the ailing aircraft around to make his final approach, he realised that the landing field was just a little too short for comfort. He licked his lips, and prayed that there would be enough room…,
THIS IS FROM A TEXT SENT TO ME AND ATTRIBUTED TO AN ARTICLEIN ‘TODAY’S ANAESTHETIST’ BY DR GRANT HUTCHISON (UK)
DIFF
ICUL
T AI
RWAY
- KI
T PH
OTO
S
DIY
Kit f
or to
pica
lisin
g th
e ai
rway
Size
20
cann
ula
(troc
ar re
mov
ed) a
ttach
ed to
a th
ree
way
tap
and
also
con
nect
ed to
O2
at 1
0l/m
in.
Inje
ct lo
cal a
naes
thet
ic (2
or 4
% x
yloca
ine)
to to
pica
lise
the
nasa
l pas
sage
s/or
opha
rynx
as
a ne
bulis
er.
Surg
ical
Airw
ay K
it
Size
20
scal
pel
Trac
heal
hoo
k (o
ptio
nal)
Trac
heal
dila
tors
or a
rtery
forc
eps
to d
ilate
trac
hea
I also
use
a b
ougi
e th
en ra
ilroa
d a
size
6 ET
T
Nove
l suc
tion
appa
ratu
s
I still
nee
d to
wet
test
this,
but
the
idea
is s
impl
e
In c
ase
of to
rrent
ial b
leed
ing/
vom
it, c
an u
se a
swi
vel a
dapt
or
(bro
ncho
scop
e ad
pato
r) to
the
end
of a
n ET
T, a
nd a
ttach
a
mec
oniu
m a
spira
tor t
o th
e su
ctio
n tu
bing
and
out
let.
Then
can
us
e th
e ET
T as
a s
ucke
r - o
nce
plac
ed, i
f the
trac
hea
is so
iled
then
exc
hang
e wi
th A
intre
e fo
r a fr
esh
ETT
DIFF
ICUL
T AI
RWAY
- KI
T PH
OTO
S
Intu
batin
g st
ylet
eg:
Bon
fils,
Lev
itan
AirT
raq
Opt
ical
Lar
yngo
scop
e - c
heap
at $
90
each
, but
lose
situ
atio
nal a
war
enes
s as
opt
ical
onl
y an
d ne
eds
prac
tice
to p
lace
ETT
Pent
ax A
WS
Vide
olar
yngo
scop
e
McG
rath
Vid
eola
ryng
osco
pe
Goo
d im
age
qual
ity, b
ut p
oor i
n gl
are,
flim
sy a
nd n
o vi
deo
out.
The
blad
e is
she
athe
d in
a d
ispo
sabl
e pr
otec
tive
slee
ve. M
id ra
nge
pric
e
King
Visi
onVi
deol
aryn
gosc
ope
The
dogs
nut
s as
far a
s I a
m c
once
rned
- ch
eap,
vid
eo o
ut to
PC
/mon
itor a
nd e
asy
lary
ngos
copy
(bit
of a
lear
ning
cur
ve -
com
mon
mis
take
is to
adv
ance
ETT
too
soon
)
$800
for s
cree
n/ha
ndle
and
blad
es $
30 e
ach
C-M
ACVi
deol
aryn
gosc
ope
Like
oth
er V
Ls, i
t acc
eler
ates
the
lear
ning
cur
ve o
f lar
yngo
scop
y as
th
e m
onito
r allo
ws
othe
rs to
see
w
hat t
he in
tuba
tor s
ees.
Play
back
is g
ood
for t
each
ing
EXPE
NSI
VE a
t $15
K cf
Kin
gVis
ion
DIFF
ICUL
T AI
RWAY
- KI
T PH
OTO
S
Rang
e of
ETT
tips
The
Park
er (t
hird
form
left)
and
Fas
tTra
ch iL
MA
tippe
d ET
Tsar
e pa
rticu
larly
sui
ted
to d
ifficu
lt in
tuba
tion
and
use
with
VL
as le
ss li
kely
to g
et ‘h
ooke
d’ o
n th
e rig
ht a
ryte
noid
car
tilag
e
Wor
th g
ettin
g a
few
Par
ker t
ip E
TTs
for d
ifficu
lt ai
rway
s
The
Com
biTu
be
Easy
obt
urat
ion
of o
esop
hagu
s an
d tra
chea
l ven
tilat
ion
Prob
ably
the
mos
t und
er u
sed
piec
e of
kit
- man
y ho
spita
ls d
on’t
even
car
ry th
em, b
ut e
asy
to u
se
Fast
Trac
h iL
MA
Allo
ws
vent
ilatio
n vi
a iL
MA
then
blin
d pl
acem
ent o
f an
ETT
May
nee
d C
hand
y m
aneo
uvre
Not
alw
ays
succ
essf
ul.
A ne
wer
VL
vers
ion
allo
ws
confi
rmat
ion
of E
TT p
lace
men
t
DIFF
ICUL
T AI
RWAY
- KI
T PH
OTO
S
Ambu
Asc
ope
2
An a
fford
able
alte
rnat
ive to
exp
ensiv
e fib
reop
tic s
yste
ms.
At $
2500
for fi
ve, t
his
is a
disp
osab
le s
yste
m.
Wou
ld a
llow
awak
e fib
reop
tic in
tuba
tion
(see
exc
elle
nt v
ideo
on
yout
ube
at h
ttp://
www.
yout
ube.
com
/wat
ch?v
=c9p
AQ3D
UKVM
&fea
ture
=rel
ated
)
Perh
aps
for t
he ru
ral G
P it
is be
tter a
s a
bail o
ut to
ol u
nder
Pla
n B
in D
AS
algo
rithm
s - c
an d
rop
in th
e ch
eap
Aura
-i iL
MAs
($5
each
) and
then
in
tuba
te th
roug
h th
is wi
th th
e As
cope
- he
nce
vent
ilatin
g an
d th
en
intu
batin
g. In
the
abse
nce
of th
is, th
ere
is NO
REA
L al
tern
ative
opt
ion
at
PLAN
B fo
r the
rura
l doc
tor (
the
Fast
Trac
h iL
MA
is a
bit h
it an
d m
iss)
It do
esn’
t hav
e a
suct
ion
port
- but
eve
n th
e to
p ra
nge
fibre
optic
dev
ices
have
piss
wea
k su
ctio
n. It
doe
s ha
ve a
‘par
k’ fo
r the
ETT
whi
ch is
a n
eat
conc
ept a
nd n
ot a
vaila
ble
on th
e m
ore
expe
nsive
fibr
eopt
ic de
vices
that
I ha
ve p
laye
d wi
th. I
t also
has
a p
ort t
o al
low
oxyg
en a
t 2l/m
in a
nd/o
r to
squi
rt lo
cal a
naes
thet
ic do
wn to
topi
calis
e th
e ai
rway
.
I thi
n th
is is
a ‘m
ust h
ave’
alo
ng w
ith th
e Ki
ngVi
sion
VL
Wou
ld n
eed
to u
se o
ccas
iona
lly o
n el
ectiv
e lis
t or s
acrifi
ce o
ne fo
r tra
inin
g pu
rpos
es. I
f eno
ugh
rura
l hos
pita
ls ha
ve th
em, c
an re
-cyc
le s
tock
bet
ween
he
alth
uni
ts (i
nclu
ding
Med
STAR
) if n
ot u
sed.
EQU
IPM
ENT
FAIL
UR
E C
HEC
KLI
ST