Anesthetic Emergencies – Flashcards
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Define: Opisthotonus
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A state of severe hyper-extension and spasticity in which a patients head, neck, and spinal column enter into a complete "arching" position.
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Define: Ataxia
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A woobly or uncoordinated gait
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Define: Azotemia
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Increase in waste product in the blood (Bun and creatine specially)
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Define: Effusion
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Excess fluid in tissue or body cavity
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Define: Hematemesis
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vomiting of blood
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Define: Hematochezia
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bloody stool
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Define: Hemoptysis
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act of coughing up blood
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Define Hyperkalemia
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Increased concentration of potassium in the blood
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Define Hypernatremia
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Increased concentration of sodium in the blood
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Define Sequestration
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net increase in the quantity of blood within a limited vascular area
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Define Agonal
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abnormal pattern of breathing characterized by gasping, labored breathing.
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Define Pleural effusion
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Fluid in the chest cavity
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Define Shock
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life-threatening condition that occurs when the body is not getting enough blood flow
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Define status eliepticus
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epileptic seizure of greater than five minutes
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Define Stenotic
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abnormal narrowing in a blood vessel or other tubular organ or structure
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Define Nystagmus
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Eyes shake (neurologic, older dogs)
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Define Stridor
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abnormal, high-pitched, musical breathing sound caused by a blockage in the throat or voice box (larynx)
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Define Stertor
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respiratory sound characterized by heavy snoring or gasping.
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Define Tetraparesis
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Weakness of all four limbs
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Define Urticaria
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Hives
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Define Apnea
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Not breathing
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What are some things we can do to help prevent common complications?
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Monitor PE Recheck calculation Place IV catheter Administer IV fluids Pre-oxygenate patient Place an e-tube
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What are some anesthetic problems that will arise?
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Human error Equipment failure Adverse effect of anesthetic agents Patient-related (risk) factors
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Name some human errors?
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Failure to obtain adequate history, perform PE Incorrect drug administration and or lack of knowledge of anesthesia Failure to devote sufficient time to anesthetized patient (technician fatigue) Failure to recognize and respond earlier to patient diffculty
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Name some equipment failure examples?
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Carbon dioxide absorbent exhaustion Soda needs to be changed, scavenge not working Empty 02 tank Anesthetic assembly problem ET problem Vaporizer problem Pop-off problem
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Opioids can be safely used in most _____ patients
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Compromised
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Alpha2-agonist can cause?
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Bradycardia Arrhythmia Vomiting Respiratory depression
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Phenothiazines generally not indicated because of ______ and _____ side effects
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Vasodilatory and hypotensive
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Most inhalants decrease ____ and ___
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BP and CO
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What inhalant is best to use in patients with cardiac disease?
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Isoflurane
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____ should not be used in cats with a history of HCM.
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Ketamine
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What is HCM and why cant we use a dissociative agent?
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Stimulates cardiovascular system
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Which class of induction agents show greater potency in animals that have hypotension or are experiencing shock?
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Barbiturate (redistribute to fat)
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You are getting ready to anesthetize a patient with severe cardiac disease, what induction agent could you consider?
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Etomidate (propofol)
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Complications associated with intubation?
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Wrong size Vagus nerve (brachycephalic) Laryngospasm (cats) Overzealous effects resulting in damage to larynx, pharynx, soft palate Tracheal necrosis (over inflated cuff) Patients awakes bites down on tube ET too long
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What are some problems associated with geriatric patients?
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Reduced organ function Higher risk of hypothermia and fluid overload Underlying degenerative disorders
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Strategies to address problems in geriatric?
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Less anesthetic requirements and slower response to drugs Close monitoring of IVF and rate Close monitoring of all vitals
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What are some problems associated with pediatric?
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Hypothermia Fluid overload Difficult intubation IVC placement
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Strategies to address problems in pediatric?
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Monitor temperature closely (avoid heat loss) Avoid prolonged fasting (Decrease BG)-dextrose rich solutions
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What are some drugs that are safe in geriatric or a good choice?
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Butorphanol Buprenex Induction: Ket-val/propofol
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What are some drugs that are safe in pediatric or a good choice?
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Premed: Acepromazine, morphine, opioid Induction: Propofol/ket-val
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What are some problems associated with brachycephalics?
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Tendency towards respiratory difficulties Abnormally high parasympathetic (vagal tone)=bradycardia Difficult to intubate
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What are strategies to address brachycephalic problems?
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Pre-oxygenate Secure airway quickly Use of anticholinergic in anesthetic protocol (less depression) Close monitoring during recovery period (delay extubation)
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What are some problems associated with obese animals?
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Anesthetic drugs not efficiently distributed (stores in fat cells) Tendency toward respiratory difficulties (unable to expand chest fully-ETCO2 is high because they cant breathe off) Exhibit rapid shallow respirations during anesthesia
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What are some strategies to address obese animals?
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Determine anesthetic dose (ideal weight) Pre-oxygenated induce quickly Assist ventilation as need Delay extubation and observe closely
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What are some problems associated with Cesarean section?
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Bitch/Queen Aspiration (tendency to vomit/regurg) Decreased lung capacity (hypoxic/poor regulation of blood pressure) Poor regulation of BP Physiologic anemia Decreased anesthetic requirements Hemmorrhage and subsequent shock (engorged veins) Neonates Reduced cardiovascular and respiratory function Hypothermia
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What are some strategies to address Cesarean?
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Bitch/Queen Pre-oxygenate Intubate quickly and dont extubate until good swallow reflex Use lowest effective dose of anesthetic Prep patient as much as possible prior to anesthetic Place large bore IVC (shock bolus) Neonates Flow-by 02 (after suctioning nares and oral cavity) Stimulation Warm Towels
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For Cesarean section what anesthetic protocol would you use? and what to avoid?
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Glycoppyrrolate/morphine Avoid- Atropine
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For cesarean section what supplies do you think are important?
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Extra towels dopram booger sucker fluids MB scissors Suture
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For Cesarean section what are some other techniques to help with neonate resuscitation?
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Rescue drugs Swinging
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Problems associated with trauma?
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Respiratory (pneumothorax, pulomonary contusions, hemorrhage, diaphragmatic hernia Cardiovascular (arrhythmia common in 1st 12-72 hours, change in blood pressure) Shock (particularly hypovolemia, dealt with prior to anesthesia) CNS Injury
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Strategies to address problems associated with trauma?
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Stabilize patient Monitor ECG and obtain x-rays soon as possible Thoracentesis (prn) chest tap (pull fluid) O2 delivery (prn) Monitor BP Monitor mentation IVF therapy and pain management (monitol, Hypovolemia-crystalloid, Hemorrhaging-auto transfuse) (morphine/fentnyl)
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What are some problems associated with CNS? (epilepsy, head trauma, spinal cord trauma)
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Increased cranial pressure Be aware of seizure threshold
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What are some strategies to address CNS problems?
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Use caution with drugs that lower seizure (acep) and/ or increase cranial pressure (ketamine) Calm inductions- coughing and tachycardia can cause increase CSF Consider hyperventilating patients (decreases C02 concentration (PaC02)) Increase PaC02=vasodilation=more blood to brain
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What are some problems associated with cardiovascular disease?
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Common disorders: Anemia, shock, cardiomyopathy, CHF, Congenital defect, heartworm (Caval Sn) Increase tendency to develop arrhythmias MOST COMMON problem seen is bradycarida Some parameters that lead to cardiac dysfunction: secondary high blood pressure Hypoxic Electrolyte imbalances Avoid alpha2 (opioids are okay)
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What are some strategies to address cardiovascular disease?
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Stabilize Patients often exihibit signs of pulmonary disease Drug to administer for pulmonary edema tx: furosomide Minimize use of preanesthetic agents that depress myocardium or cause arrhythmias (alpha2/ ketamine/ barbiturates) Avoid over-hydration (fluid overload)
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What are some problems associated with respiratory disease?
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Common causes: pleural effusion, diaphragmatic hernia, collapsing trachea. Clinical signs during anesthesia: Poor oxygenation resulting in tachypnea, dyspnea, cyanosis Remember to carefully evaluate rate, rhythm, depth Short/shallow or deep/exaggerated? Response to pain or anesthetic depth? ET tube occluded placed appropriately in trachea? Pay attention to SP02 and ETC02
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What are some strategies to address respiratory disease?
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Stabilize Avoid stress or excitement Pre-oxygenate Keep anesthetic depth as light as possible Use an injectable induction agent for quick intubation (propofol) Be prepare for manual or controlled ventilation Monitor closely during recovery and be conservative with extubation
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What are some problems associated with hepatic disease?
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Hypoproteinemia Dehydration Anemia Icterus Coagulopathies
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What does the liver do again?
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Drug metabolism, synthesis blood clotting factors and other serum proteins, carbohydrates.
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What are some strategies to address hepatic disease?
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Preanesthetics are usually metabolized in liver (may omit it entirely) Avoid medications like barbiturates and acepromazine Inhalation agents preferred over injection agents Induction agents and maintenance drugs preferred include Fentnayl and propofol Expect prolonged recovery
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What are some problems associated with renal disease?
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Delayed excretion or anesthetic agents (delayed recoveries) Dehydration=lead to hypotension Electrolyte imbalances (hyperkalemia/acide-base disturbances)
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What are some strategies to address renal disease?
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Rehydrate before surgery (during) Pre-op bloodwork Reduce anesthetic doses if possible Dont use barbiturates
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What do the kidneys do again?
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Maintain volume and electrolyte. Also eliminates preanesthetic and anesthetic agents
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What are some problems associated with urinary obstruction
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Depressed Dehydrated Uremic Acidotic Hyperkalemic (Sodium potassium in heart at increased risk of cardiac arrest) Bradycarida
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What are some strategies to address urinary obstruction?
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Tx hyperkalemia if possible IVF during procedure (saline fluid with no potassium) Can use propofol and or ket-val cautiously and at low doses (avoid barbituates) If depressed long enough dont use general anesthesia.
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What are some consideration of diabetes?
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Maintain glucose in normal range if possible Better to be hyperglycemic than hypoglycemic (shaking/ weakness, comma, PU,PD) Monitor BG every 30-60min Schedule patient 1st (fasted overnight) Check BG and administer 1/2 insulin if needed
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Example protocol of diabetic would be?
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Choose a premed and induction that allow for rapid recovery Low-dose Acepromazine + Opioid, propofol Feed as soon as possible and resume insulin protocol following procedure.
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What are some things to consider for ocular surgery?
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Goal is to prevent IOP Fast induction, no struggling Other things that increase IOP: Endotracheal intubation Vomiting Ketamine Etomidate (propofol decreases IOP) PREVENT oculocardiac reflex (Bradycarida resulting from direct pressure on globe) (anticholinergic with premed) Sometimes neuromuscular blockers are indicated to paralyze patients
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What are some common emergency situations?
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Problems with anesthetic depth (too light or deep) Pale MM, prolonged CRT Hypotension Hemorrhage Cyanosis and or dyspnea Hypoxemia Hypercapnia Tachypnea Abnormalities in HR or/and arrhythmias Cardiac and or respiratory arrest
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When the emergency situation is the patient is too light what do you look for?
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Leaks proper measure ET/placement Vaporizer is full/off Patient apneic or taking shallow breaths
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What are the clinical signs of excessive depth (too deep)?
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Low RR, shallow pattern, dyspnea Pale or cyanotic MM, CRT>2 sec Bradycardia, hypotension (weak pulses) Cold extremities, cold core body temp Absent reflexes, flaccid tone Mydriatric pupils, no PLR
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How to address a patient who is too deep anesthetically?
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Turn off (down) vaporizer Communicate Bag (assist ventilate) with pure O2 Use IVF (bolus)m ecternal warming, drugs if indicated Type of drugs used: Opioids-naloxone, bradycardic-atropine
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What are some common causes for pale MM?
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Anemia Neoplasia Hypoglycemia CRT>2 secs suggests BP is inadequate to perfuse superficial tissues Hypotension is most common complication to accompany a prolonged CRT
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How do we respond to a pale MM?
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IV fluids Turn down vaporizer Drugs
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What are the parameters for hypotension?
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MAP: 60 indicates hypotension and poor perfusion Absence of dorsal pedal pulse <60mmHg Absence of femoral pulse <40mmHg Other signs include Tachycardia Hypothermia Pale MM
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What some causes of hypotension?
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Anesthetic drugs (vasodilation-acepromazine) Trauma-blood loss Shock
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What is the treatment for hypotension?
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IVF bolus (Crystalloid vs colloid) Administer presssors-inotropic drugs (anticholinergic for reduce HR) Assess anesthetic depth too deep?
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How many mL is lossed if one 4x4 gauze is soaked with blood?
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10mL
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What is the total blood volume of dogs? cats?
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90. 45-50
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What is the treatment for hemorrhage?
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Blood products (auto transfuse, FWB, pRBCS IVF (crystalloid boluses) Fix source of hemorrhage Reduce anesthetic depth, use 100% oxygen when possible Keep patient warm
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What are some common sources of respiratory distress under anesthesia?
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Not receiving enough 02 Animal unable to breath properly Animal is too deeply anesthetized
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What is the treatment for respiratory distress?
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COMMUNICATE Always check if receiving enough 02 Turn off vaporizer and deliver straight 02 Tracheostomy for complete airway obstruction Monitor for respiratory and cardiac arrest
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What are the clinical signs for hypoxemia?
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Typically hypoventilating (with regards to RR and pattern) MM color (subjective) Sp02 (subjective less than 90) ABG (gold standard) (84)
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What is the treatment for hypoxemia?
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Ventilate (bag or mechanical) Check for pleural space problem (pneumothroax and evacuate prn) Administer Bronchodilator (prn)
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What are the causes of hypercapnia?
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Hypoventilating Restriction of respiratory movement (pneumothorax, surgeon leaning on chest) Exhausted sode-sorb, rebreathing Normals for EtCo2 reading- 45-50 (anesthesia)
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What is the treatment for hypercapnia?
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Ventilate Check O2 canister Check for pleural space problem (pneumothorax and evacuate prn) Administer Bronchodilator (prn) Consider waiting a minute0 give time for body to respond to high CO2 levels
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What are some causes for tachypnea?
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Too light/ too deep Hypovelmia Hyperthermia Pain/awareness Drug induced (opioids)
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What is the treatment for Tachypnea?
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Assess anesthetic depth Check C02 granules-check machine Consider due to opioid induced panting Consider- if depth and vitals appear to be within normal limits, wait and monitor b/c could change in few minutes
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What do you do for respiratory arrest?
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Alert DVM Turn off Vaporizer-O2 only intubate if no E-T in place Ventilate with 100% 02 @ 8-12 bpm IVF therapy for shock (cautious in cardiac or euvolemic) Doxapram, reversal agent?
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What are some tachycardia causes?
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Pain, awareness Atropine/ketamine/epi Hypoxia Hypotension Hypovolemia Tachyarrhythmias (heart dz)
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What causes bradycardia?
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Drugs: opioids, alpha2, agonists Excessive vagal tone: eye, viscera Hypothermia Hyperkalemia Sick sinus syndrome, conduction block
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Cardiac arrest! what does CABDEF stand for?
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Circulation Airway Breathing Drugs or defibrillation ECG Fluids
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With airway and Breathing what is the procedure?
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Intubate ensure 100% o2 Ambu bag (bagging) 8-12bpm using pressure manometer 10-20cm h2O appropriate Acupuncture GV-26 Avoid over ventilate- decrease blood flow
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Circulation procedure is?
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Patient postioned in R, Lat Recumbency Thoracic Vs Cardiac compressions 100-120 compression/minute compress chest wall by 30-50% Never discontinue for more than 30secs Switch personnel every 2-3 mins Monitor effectiveness, EtC02 (to see if compresses are sufficient)
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Drugs ECG, Fluids procedure is?
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Drugs: Epinephrine Naloxone vassopressin atropine lidocaine Common arrest ECG: Aysystole Atril fibrillation Fluids: shock doses-20ml/kg need to be cautious in heart patients
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CPCR aftercare includes?
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Monitor RR and depth ECG monitor HR and rhythm Monitor GI signs Monitor Urine output Monitor Body temperatures Looks for CNS signs
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What are some causes of prolonged recovery?
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Hypothermia Impaired renal/hepatic Individual susceptibility to anesthetic Excessive anesthetic depth or prolonged anesthetic
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What are some considerations with prolonged recovery?
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Patient warmth (warm fluids, h20) Keep close observation on vitals and mentations Reversal agents prn
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What is the response to regurgitation and vomiting ?
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Place head lower than body (no e-tube) Suction oral cavity With e-tube, lower head and remove accumlation around tube, consider extubation with slightly cuffed e-tube Vomiting: Follow same protocol.
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What is a seizure and what should you do?
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Spontaneous twitching or uncontrolled movements of the head, neck, and limbs. often triggered by light or touch stimuli Alert DVM Adm. anticonvulsants (Valium, medazolem) Create quiet environment and monitor Monitor 2 parameters? Hyperthermia and cyanosis
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What is excitement and what should you do?
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Appears as paddling and or occasional vocalization Tx is usually unnecessary, sedative if extreme
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What is the most common death in the postanesthetic period?
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Dyspnea (results from upper airway obstruction)
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During the recovery period what is the most common cause of dyspnea in cats?
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Laryngospasm or larygneal edema
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During the recovery period what is the most common cause of dyspnea in dogs?
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Associated with breed and or tracheal collapse
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How do we respond to dyspnea in cats?
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Prevention easier than treatment (gentle intubation, liodcaine, early extubation (before laryngospasm return) Monitor MM and Sp02 Supplement O2
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How do we respond to dyspnea in dogs?
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Delay extubation, extend neck, supplement 02
