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Crisis Management

Evidence-based emergency management for operating room crises

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Cardiac/Circulatory

10
Cardiac Arrest (ACLS)
Critical
High-quality CPR with rhythm-specific advanced life support
  1. Start CPR immediately: 100-120 compressions/min, depth 2-2.4 inches (5-6 cm), allow full chest recoil
  2. Call for help - Get code cart, defibrillator, and additional personnel
  3. Attach defibrillator/monitor: Identify rhythm (shockable vs non-shockable)
  4. Secure airway: ETT or LMA with ETCO₂ monitoring (target 35-40 mmHg)
  5. Establish IV/IO access
  6. Epinephrine 1 mg IV/IO every 3-5 minutes
  7. If VF/pulseless VT: Defibrillate at maximum energy, give amiodarone 300 mg IV after 3rd shock
  8. Treat reversible causes (H's and T's): Hypovolemia, Hypoxia, H⁺ (acidosis), Hypo/hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade, Toxins, Thrombosis
Key Medications
Epinephrine: 1 mg IV/IO every 3-5 minutes
Amiodarone: 300 mg IV (first dose), then 150 mg IV (second dose) for VF/pulseless VT
Sodium Bicarbonate: 1 mEq/kg IV for known hyperkalemia or severe acidosis
Evidence-Based References
Panchal AR, et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for CPR and Emergency Cardiovascular Care. Circulation. 2020;142(16_suppl_2):S366-S468. PMID: 33081529
Soar J, et al. European Resuscitation Council Guidelines 2021: Adult advanced life support. Resuscitation. 2021;161:115-151. PMID: 33773825
Venous Air Embolism
Critical
Air entrainment into venous system causing cardiovascular collapse
  1. Alert surgeon immediately - Stop further air entrainment
  2. Flood surgical field with saline
  3. 100% FiO₂
  4. Discontinue N₂O immediately (if in use)
  5. Lower head/raise feet (Trendelenburg position) if possible
  6. Attempt to aspirate air via CVL if present
  7. Support hemodynamics: Fluids, vasopressors, consider CPR if cardiovascular collapse
  8. Durant position (left lateral decubitus) may trap air in right ventricle
High risk in sitting position neurosurgery. Monitor with precordial Doppler and ETCO₂. Sudden decrease in ETCO₂, hypotension, and mill-wheel murmur are classic signs.
Evidence-Based References
Mirski MA, et al. Diagnosis and treatment of vascular air embolism. Anesthesiology. 2007;106(1):164-177. PMID: 17197859
Shaikh N, Ummunisa F. Acute management of vascular air embolism. J Emerg Trauma Shock. 2009;2(3):180-185. PMID: 20009307
Massive Hemorrhage
Critical
Activate massive transfusion protocol, balanced resuscitation
  1. Activate Massive Transfusion Protocol (MTP) immediately
  2. Large bore IV access (2× 16-18G or central line)
  3. Balanced transfusion ratio 1:1:1 - pRBCs : FFP : platelets
  4. Tranexamic acid (TXA) 1 g IV over 10 minutes, then 1 g over 8 hours
  5. Permissive hypotension (SBP 80-90) until hemorrhage control if no TBI
  6. Calcium chloride 1 g IV with each 4 units pRBCs
  7. Monitor labs: ABG, Hgb, platelets, PT/PTT, fibrinogen, ionized calcium
  8. Consider recombinant Factor VIIa if refractory coagulopathy
Critical Medications
Tranexamic Acid (TXA): 1 g IV over 10 min (loading), then 1 g over 8 hours
Calcium Chloride: 1 g IV after every 4 units pRBCs
Fibrinogen: Target >200 mg/dL (cryoprecipitate 10 units or fibrinogen concentrate)
Evidence-Based References
Spahn DR, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care. 2019;23(1):98. PMID: 30917843
CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): Lancet. 2010;376(9734):23-32. PMID: 20554319
Severe Bradycardia
Urgent
HR <40 with hemodynamic instability
  1. Atropine 0.5-1 mg IV (repeat q3-5min, max 3 mg)
  2. Epinephrine infusion 2-10 mcg/min if atropine fails
  3. Transcutaneous pacing if refractory
  4. Glycopyrrolate 0.2-0.4 mg IV alternative to atropine
Medications
Atropine: 0.5-1 mg IV push (max 3 mg total)
Epinephrine drip: 2-10 mcg/min IV
Evidence-Based References
Kusumoto FM, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay. Circulation. 2019;140(8):e382-e482. PMID: 30586772
Ventricular Tachycardia/Fibrillation
Critical
Immediate defibrillation for pulseless VT/VF
  1. Check pulse - If pulseless, start CPR immediately
  2. Defibrillate 200J biphasic (360J monophasic), resume CPR immediately
  3. Epinephrine 1 mg IV every 3-5 minutes during CPR
  4. After 2nd shock: Amiodarone 300 mg IV push
  5. If stable VT with pulse: Synchronized cardioversion 100J, increase as needed
  6. For monomorphic VT: Amiodarone 150 mg IV over 10 min, then 1 mg/min infusion
  7. Treat reversible causes: Electrolytes (K⁺, Mg²⁺), ischemia, drugs
Key Medications
Amiodarone: 300 mg IV (first dose), 150 mg IV (second dose) for VF/VT
Lidocaine (alternative): 1-1.5 mg/kg IV, then 0.5-0.75 mg/kg q5-10min (max 3 mg/kg)
Magnesium: 2 g IV over 10 min for Torsades de Pointes
Evidence-Based References
Panchal AR, et al. Part 3: Adult Basic and Advanced Life Support: 2020 AHA Guidelines. Circulation. 2020;142(16_suppl_2):S366-S468. PMID: 33081529
Hypertensive Emergency
Urgent
Severe hypertension with end-organ damage
  1. Assess for end-organ damage: MI, stroke, aortic dissection, pulmonary edema
  2. Deepen anesthesia if intraoperative
  3. First-line: Nicardipine 5 mg/hr IV infusion, titrate by 2.5 mg/hr q5-15min (max 15 mg/hr)
  4. Alternative: Labetalol 10-20 mg IV bolus, then 20-80 mg q10min or infusion 0.5-2 mg/min
  5. Goal: Reduce MAP by 20-25% over first hour (avoid precipitous drops)
  6. Avoid in aortic dissection: Use beta-blocker first (esmolol), then vasodilator
Antihypertensive Options
Nicardipine: 5-15 mg/hr IV infusion (preferred)
Labetalol: 10-20 mg IV, then 20-80 mg q10min or 0.5-2 mg/min infusion
Esmolol: 500 mcg/kg load, then 50-300 mcg/kg/min (aortic dissection)
Hydralazine: 5-20 mg IV (avoid in CAD/aortic dissection)
Evidence-Based References
Whelton PK, et al. 2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension. 2018;71(6):e13-e115. PMID: 29133356
Myocardial Infarction/Ischemia
Critical
Perioperative MI - Optimize oxygen supply/demand
  1. Call for help, get cardiology consultation
  2. 12-lead ECG, troponin (stat and serial)
  3. Aspirin 325 mg PO/PR (if not contraindicated)
  4. 100% oxygen, maintain SpO₂ >90%
  5. Optimize hemodynamics: HR 60-80, SBP 100-140, avoid tachycardia/hypertension
  6. Nitroglycerin 0.5-10 mcg/kg/min IV for ongoing ischemia (if SBP >100)
  7. Beta-blocker: Metoprolol 2.5-5 mg IV or esmolol infusion (if no contraindications)
  8. If STEMI: Activate cath lab for emergency PCI (suspend surgery if possible)
  9. Consider heparin 60 units/kg IV bolus (max 4000 units) in consultation with cardiology
Perioperative MI has high mortality. STEMI requires emergent intervention. Avoid hypotension, tachycardia, and increased myocardial oxygen demand. Consider aborting/delaying elective surgery.
Evidence-Based References
Devereaux PJ, et al. Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery. JAMA. 2017;317(16):1642-1651. PMID: 28444280
Fleisher LA, et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation. Circulation. 2014;130(24):e278-e333. PMID: 25085961

Airway/Respiratory

9
Can't Intubate Can't Oxygenate (CICO)
Critical
Emergency front-of-neck access (eFONA) - cricothyroidotomy
  1. Declare CICO - Call for help and surgical airway equipment
  2. Continue face mask ventilation/oxygenation attempts during preparation
  3. Position: Extend neck, palpate cricothyroid membrane
  4. Scalpel technique (preferred): Transverse stab incision through cricothyroid membrane
  5. Insert tracheal hook to stabilize larynx
  6. Insert bougie caudally into trachea
  7. Railroad 6.0 cuffed ETT over bougie into trachea
  8. Confirm placement: Capnography, bilateral breath sounds
Time is critical. Do NOT delay surgical airway if unable to ventilate. Scalpel cricothyroidotomy is preferred over needle technique in adults.
Evidence-Based References
Frerk C, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827-848. PMID: 26556848
Apfelbaum JL, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022;136(1):31-81. PMID: 34762729
Laryngospasm
Urgent
Involuntary closure of vocal cords causing airway obstruction
  1. Remove stimulus (suction secretions, stop surgical stimulation)
  2. 100% oxygen via face mask
  3. Jaw thrust with CPAP (positive pressure 15-20 cm H₂O)
  4. Larson maneuver: Apply firm pressure to "laryngospasm notch" (behind angle of mandible)
  5. If persists: Propofol 0.5-1 mg/kg IV
  6. If severe/refractory: Succinylcholine 0.1-0.5 mg/kg IV (or 4 mg/kg IM if no IV)
  7. Prepare for intubation if giving muscle relaxant
Medications
Propofol: 0.5-1 mg/kg IV (deepens anesthesia)
Succinylcholine: 0.1-0.5 mg/kg IV or 4 mg/kg IM (last resort)
Evidence-Based References
Gavel G, Walker RWM. Laryngospasm in anaesthesia. Contin Educ Anaesth Crit Care Pain. 2014;14(2):47-51.
Visvanathan T, et al. Laryngospasm: review of different prevention and treatment modalities. Paediatr Anaesth. 2015;25(3):4-7-12. PMID: 25580984
Bronchospasm
Urgent
Acute airway constriction with wheezing and increased airway pressure
  1. 100% FiO₂
  2. Deepen anesthesia: Increase volatile agent or propofol bolus
  3. Albuterol inhaler or nebulizer (4-8 puffs MDI or 2.5-5 mg nebulized)
  4. Hand ventilation - Allow prolonged expiration, avoid air trapping
  5. If severe: Epinephrine 10-50 mcg IV (or 0.3-0.5 mg IM)
  6. Consider: Ketamine 0.5-1 mg/kg IV, Magnesium 2 g IV over 20 min
  7. Rule out other causes: ETT malposition, pneumothorax, aspiration, anaphylaxis
Key Medications
Albuterol: 4-8 puffs MDI or 2.5-5 mg nebulized
Epinephrine: 10-50 mcg IV bolus or 0.3 mg IM
Ketamine: 0.5-1 mg/kg IV (bronchodilator)
Magnesium sulfate: 2 g IV over 20 minutes
Evidence-Based References
Woods BD, Sladen RN. Perioperative considerations for the patient with asthma and bronchospasm. Br J Anaesth. 2009;103 Suppl 1:i57-65. PMID: 20007991
Pulmonary Aspiration
Urgent
Aspiration of gastric contents - supportive care
  1. Immediate head-down tilt (Trendelenburg) if possible
  2. Suction oropharynx and airway immediately
  3. 100% oxygen, prepare for intubation if not already intubated
  4. If intubated: Suction ETT, consider bronchoscopy to remove particulate matter
  5. Positive pressure ventilation with PEEP as needed for oxygenation
  6. CXR, ABG to assess severity
  7. Supportive care: Maintain oxygenation/ventilation, fluid management
  8. Do NOT give prophylactic antibiotics or steroids routinely (no proven benefit)
  9. Monitor for ARDS, pneumonia (may develop over 24-72 hours)
Aspiration pneumonitis (chemical injury) develops within 2 hours. Aspiration pneumonia (bacterial infection) develops over 24-72 hours. Treatment is primarily supportive. Avoid routine antibiotics/steroids unless infection develops.
Evidence-Based References
Warner MA, et al. Perioperative Pulmonary Aspiration in Infants and Children. Anesthesiology. 1999;90(1):66-71. PMID: 9915314
Nason KS. Acute Intraoperative Pulmonary Aspiration. Thorac Surg Clin. 2015;25(3):301-307. PMID: 26210928
Tension Pneumothorax
Critical
Immediate needle decompression - life-threatening emergency
  1. Clinical diagnosis: Hypoxia, hypotension, tracheal deviation, unilateral absent breath sounds, increased peak pressures
  2. Do NOT wait for CXR confirmation if tension pneumothorax suspected
  3. Immediate needle decompression: 14-16G IV catheter in 2nd intercostal space, midclavicular line
  4. 100% oxygen
  5. Definitive treatment: Chest tube placement (4th-5th intercostal space, anterior axillary line)
  6. If bilateral breath sounds absent: Consider bilateral pneumothoraces, mainstem intubation, or equipment failure
Tension pneumothorax is a clinical diagnosis requiring immediate treatment. Do NOT delay for imaging. Can occur with central line placement, positive pressure ventilation, trauma, or rib fractures.
Evidence-Based References
Roberts DJ, et al. Anesthesia-related Pneumothorax. Anesth Analg. 2003;96(2):516-522. PMID: 12538205
Leigh-Smith S, Harris T. Tension pneumothorax--time for a re-think? Emerg Med J. 2005;22(1):8-16. PMID: 15611534
Severe Hypoxemia
Urgent
Rapid systematic approach to desaturation
  1. Increase FiO₂ to 100% immediately
  2. Check: Airway patency, ETT position, bilateral breath sounds
  3. Hand ventilate to assess compliance and rule out circuit disconnect
  4. Check circuit connections, oxygen source, fresh gas flow
  5. Suction airway if secretions present
  6. Auscultate: Rule out mainstem intubation, bronchospasm, pneumothorax
  7. Consider: Pulmonary embolism, aspiration, atelectasis, pulmonary edema
  8. Recruitment maneuvers (sustained inflation 30-40 cm H₂O for 30 sec) if atelectasis
  9. Add PEEP (5-10 cm H₂O initially)
  10. ABG, CXR to guide further management
Systematic Approach (DOPE)
Displaced ETT (mainstem, esophageal)
Obstruction (secretions, kinked tube, bronchospasm)
Pneumothorax
Equipment failure (circuit, ventilator, O₂ source)
Evidence-Based References
Whiteley JP, et al. The Investigation and Management of Intraoperative Hypoxemia. BJA Educ. 2016;16(5):170-174.

Metabolic/Toxic

7
Malignant Hyperthermia
Critical
Life-threatening hypermetabolic crisis - Dantrolene immediately
  1. STOP all triggering agents immediately: Discontinue volatile anesthetics and succinylcholine
  2. Call for help and MH cart - Call MH Hotline: 1-800-644-9737
  3. Hyperventilate with 100% O₂ (≥10 L/min, 2-3× minute ventilation)
  4. DANTROLENE 2.5 mg/kg IV rapid push - Repeat every 5 min until signs resolve (max 10 mg/kg)
  5. Abort/complete surgery as rapidly as possible
  6. Active cooling: IV cold saline, ice packs to groin/axilla, cool lavage
  7. Treat hyperkalemia: Insulin + glucose, calcium chloride, bicarbonate, avoid calcium channel blockers
  8. Treat acidosis: Sodium bicarbonate for pH <7.2
  9. Monitor: Core temp q5min, ABG, K⁺, CK, myoglobin, urine output >2 mL/kg/hr
  10. Continue dantrolene 1 mg/kg IV q6h × 24-48 hours to prevent recurrence
Dantrolene Dosing (CRITICAL)
Initial: 2.5 mg/kg IV rapid push, repeat q5min until resolution
Maximum: Up to 10 mg/kg total dose
Maintenance: 1 mg/kg IV q6h × 24-48 hours after crisis
Mixing: Each vial (20 mg) requires 60 mL sterile water (many vials needed)
Classic signs: Unexplained tachycardia, hypercarbia (rising ETCO₂ despite increased ventilation), masseter muscle rigidity, hyperthermia (late sign). DO NOT wait for fever - treat on suspicion. Mortality 10-15% if untreated.
Evidence-Based References
Rosenberg H, et al. Malignant hyperthermia: a review. Orphanet J Rare Dis. 2015;10:93. PMID: 26238698
Hopkins PM, et al. Malignant hyperthermia 2020: Guideline from the Association of Anaesthetists. Anaesthesia. 2021;76(5):655-664. PMID: 33280086
Malignant Hyperthermia Association of the United States (MHAUS). Emergency Therapy for Malignant Hyperthermia. www.mhaus.org
Local Anesthetic Systemic Toxicity (LAST)
Critical
CNS/cardiac toxicity from local anesthetic - Give lipid emulsion
  1. STOP local anesthetic injection immediately
  2. Call for help and lipid emulsion (20% Intralipid)
  3. Airway management: Ventilate with 100% O₂, consider intubation early
  4. Seizure treatment: Benzodiazepines (midazolam, lorazepam), small dose propofol ONLY if needed
  5. LIPID EMULSION 20% (Intralipid): 1.5 mL/kg IV bolus over 1 min (~100 mL for 70 kg adult)
  6. Start lipid infusion: 0.25 mL/kg/min (~18 mL/min for 70 kg)
  7. If cardiovascular instability persists: Repeat bolus q3-5min, increase infusion to 0.5 mL/kg/min
  8. Maximum dose: ~10 mL/kg over first 30 minutes
  9. If cardiac arrest: Continue CPR and lipid therapy (may need prolonged resuscitation)
Lipid Emulsion 20% Dosing
Bolus: 1.5 mL/kg IV over 1 minute (100 mL for 70 kg)
Infusion: 0.25 mL/kg/min (increase to 0.5 mL/kg/min if needed)
Repeat bolus: Every 3-5 minutes if persistent instability
Maximum: ~10 mL/kg over 30 minutes (~700 mL for 70 kg)
Early signs: Circumoral numbness, metallic taste, tinnitus, confusion, seizures. Late signs: Cardiovascular collapse, arrhythmias, cardiac arrest. AVOID propofol (lipid-based), vasopressin, and calcium channel blockers. Prolonged CPR may be required.
Evidence-Based References
Neal JM, et al. American Society of Regional Anesthesia and Pain Medicine Checklist for Managing Local Anesthetic Systemic Toxicity: 2017 Version. Reg Anesth Pain Med. 2018;43(2):113-123. PMID: 29239945
American Society of Regional Anesthesia and Pain Medicine. LAST Checklist. www.asra.com/guidelines-articles/guidelines
Anaphylaxis
Critical
Severe systemic allergic reaction - Epinephrine first-line
  1. STOP suspected triggering agent immediately
  2. Call for help
  3. EPINEPHRINE first-line treatment - See dosing below
  4. Airway management: 100% O₂, consider early intubation (airway edema may worsen)
  5. Aggressive fluid resuscitation: 1-2 L crystalloid rapid bolus (may need 4-6 L total)
  6. Elevate legs (Trendelenburg if hypotensive)
  7. H1 blocker: Diphenhydramine 25-50 mg IV
  8. H2 blocker: Ranitidine 50 mg or famotidine 20 mg IV
  9. Steroids: Hydrocortisone 100-200 mg IV or methylprednisolone 125 mg IV
  10. Send tryptase levels: Immediately, at 1-2 hours, and at 24 hours
Epinephrine Dosing (CRITICAL)
Mild (conscious, urticaria, angioedema): 50-100 mcg IV (or 0.3-0.5 mg IM)
Moderate (hypotension, bronchospasm): 100-200 mcg IV bolus, repeat q2-3min
Severe (cardiac arrest, profound shock): 1 mg IV, start epinephrine infusion 0.05-0.5 mcg/kg/min
Infusion: 4-10 mcg/min IV, titrate to effect
Evidence-Based References
Mertes PM, et al. Perioperative anaphylaxis. Immunol Allergy Clin North Am. 2009;29(3):429-451. PMID: 19563990
Harper NJN, et al. Anaesthesia, surgery, and life-threatening allergic reactions: management of perioperative anaphylaxis. Anaesthesia. 2018;73(8):1007-1014. PMID: 29974440
Hyperkalemia
Critical
Life-threatening K⁺ >6.5 - cardiac membrane stabilization first
  1. ECG immediately: Look for peaked T waves, widened QRS, prolonged PR
  2. If ECG changes: Calcium chloride 1 g IV (or calcium gluconate 3 g IV) over 2-3 min - cardiac membrane stabilization (does NOT lower K⁺)
  3. Shift K⁺ intracellularly: Insulin 10 units IV + D50W 25 g IV (onset 15-30 min, lasts 4-6 hours)
  4. Hyperventilate to create respiratory alkalosis (temporary measure)
  5. Sodium bicarbonate 50 mEq IV if metabolic acidosis present
  6. Albuterol 10-20 mg nebulized (shifts K⁺ into cells)
  7. Stop all K⁺ sources (IV fluids, blood products, succinylcholine)
  8. Definitive treatment: Consider dialysis for refractory hyperkalemia or renal failure
Treatment Sequence
1. Calcium Chloride: 1 g IV (10 mL of 10%) over 2-3 min - FIRST for cardiac protection
2. Insulin + Dextrose: 10 units regular insulin IV + 25 g D50W (50 mL) IV
3. Bicarbonate: 50 mEq (1 amp) IV if acidotic
4. Albuterol: 10-20 mg nebulized continuously
Succinylcholine-induced hyperkalemia can occur in burns, crush injuries, denervation, prolonged immobility. Peaked T waves and widened QRS are ominous signs requiring immediate calcium. Recheck K⁺ after treatment.
Evidence-Based References
Alfonzo AV, et al. Potassium Disorders--Clinical Spectrum and Emergency Management. Resuscitation. 2006;70(1):10-25. PMID: 16730126
Parham WA, et al. Hyperkalemia Revisited. Texas Heart Inst J. 2006;33(1):40-47. PMID: 16572868
Acute Transfusion Reaction
Critical
STOP transfusion immediately - identify reaction type
  1. STOP transfusion immediately - Preserve IV access with saline
  2. Check patient ID and blood product labeling for ABO incompatibility
  3. Notify blood bank - Send blood bag and tubing for analysis
  4. Send labs: CBC, coags, LDH, haptoglobin, direct Coombs, urine hemoglobin
  5. If hemolytic reaction suspected: Maintain urine output >1 mL/kg/hr with fluids/diuretics, alkalinize urine
  6. If allergic: Diphenhydramine 25-50 mg IV, steroids, epinephrine if anaphylaxis
  7. If TRALI (pulmonary edema without fluid overload): Supportive care, oxygen, mechanical ventilation as needed
  8. If TACO (fluid overload): Diuretics, upright positioning
Reaction Types & Treatment
Hemolytic (ABO incompatibility): Aggressive fluids, maintain UOP, alkalinize urine
Allergic/Anaphylactic: Diphenhydramine, steroids, epinephrine if severe
TRALI: Supportive care, mechanical ventilation (usually resolves in 48-96 hours)
TACO: Diuretics (furosemide 20-40 mg IV)
Acute hemolytic transfusion reaction is life-threatening. Classic signs: fever, hypotension, tachycardia, hemoglobinuria (pink/red urine), DIC. Under anesthesia, may only see unexplained hypotension, bleeding, or hemoglobinuria.
Evidence-Based References
Tobian AAR, et al. Transfusion-Related Acute Lung Injury. N Engl J Med. 2019;381(19):1849-1859. PMID: 31693808
Sandler SG, et al. Strategies to Prevent Transfusion-Related Acute Lung Injury. Vox Sang. 2005;88(3):137-142. PMID: 15787717

Neuraxial Complications

2
High/Total Spinal
Critical
Excessive neuraxial blockade - Supportive care and intubation
  1. Call for help
  2. Airway management: Prepare for intubation (respiratory muscle paralysis likely)
  3. 100% oxygen - Assist/control ventilation as needed
  4. Cardiovascular support: Aggressive fluid resuscitation
  5. Vasopressors: Ephedrine 5-10 mg IV or phenylephrine 100-200 mcg IV
  6. Atropine 0.4-0.6 mg IV for bradycardia
  7. Position: Supine (avoid Trendelenburg - worsens block)
  8. Reassure patient (may be conscious but unable to breathe/speak)
  9. Sedation if needed: After securing airway, small doses midazolam/propofol
  10. Monitor until block recedes (2-3 hours typical)
Key Medications
Ephedrine: 5-10 mg IV bolus (repeat as needed)
Phenylephrine: 100-200 mcg IV bolus (or infusion 0.5-1 mcg/kg/min)
Atropine: 0.4-0.6 mg IV for bradycardia
Symptoms: Dyspnea, difficulty speaking, upper extremity weakness, nausea, hypotension, bradycardia, loss of consciousness. Patient may be awake but unable to breathe. DO NOT delay intubation.
Evidence-Based References
Reina MA, et al. Clinical implications of epidural fat in the spinal canal. A scanning electron microscopic study. Acta Anaesthesiol Belg. 2009;60(1):7-17. PMID: 19459550
Guay J. The epidural test dose: a review. Anesth Analg. 2006;102(3):921-929. PMID: 16492853

Environmental/Equipment

2
Operating Room Fire
Critical
Fire triad: oxygen + fuel + ignition source
  1. IF AIRWAY FIRE - Remove ETT immediately, stop flow of all airway gases
  2. Stop oxygen/gas flow to fire
  3. Remove burning material from patient
  4. Extinguish fire with saline or CO₂ extinguisher
  5. If airway fire: Re-examine airway, assess for thermal injury, consider bronchoscopy
  6. If fire not controlled: Evacuate patient from OR, activate fire alarm, close OR doors
  7. Turn off medical gas supply to room
  8. Assess patient for burns/smoke inhalation
High-risk scenarios: Head/neck surgery with supplemental O₂, electrocautery near oxygen source, alcohol-based prep solutions not fully dried. Communicate "fire risk" with surgical team before high-risk cases.
Evidence-Based References
Apfelbaum JL, et al. Practice Advisory for the Prevention and Management of Operating Room Fires: 2013. Anesthesiology. 2013;118(2):271-290. PMID: 23287706
ECRI Institute. New clinical guide to surgical fire prevention. Health Devices. 2009;38(10):314-332. PMID: 19927557

Educational Resource Only

These protocols are evidence-based educational resources synthesized from published guidelines. They are NOT medical advice and should not replace clinical judgment or institutional protocols. Always verify doses and follow your institution's emergency management procedures. For life-threatening emergencies, follow ACLS/PALS guidelines and call for immediate help.