February, 1962

Anesthesia for the Emergency Patient

Mary A. Costello, C.R.N.A.*

Cincinnati, Ohio

In singling out the topic of "Anes-thesia for the Emergency Patient,"we imply that there are inherent fac-tors associated with emergency sur-gery which particularize it and differ-entiate it from elective surgery. Thatthese factors are numerous in no waylessens their individual or collectiveimportance. Cardiac and respiratoryadequacy are so completely essentialas to make each indispensable to ade-quate function of the other. (Geo-graphically methods of controllingthese systems may vary but basicphysiologic rules tell us that failureof the intervening mechanism at anypoint in these systems spells disas-ter.) As with other units in the hu-man body, pulmonary and cardiacreserves offer protection for all ordi-nary demands; but in emergency sur-gery physiological reserves may bereduced.

Marked reduction in tidal volumeis a common finding in patients ar-riving in operating rooms and emer-gency rooms. Regardless of the cause,i.e., chronic lung disease, depressionof the central nervous system or tho-racic trauma, the supply of oxygenfrom without must be adequate. Dili-gent guarding of the airway must bepracticed by the anesthetist.

* From the Department of Surgery, Divisionof Anesthesia of the University of CincinnatiCollege of Medicine and the Cincinnati GeneralHospital, Cincinnati 29, Ohio.

Presented at the annual meeting, Florida As-sociation of Nurse Anesthetists, Jacksonville,November 17. 1961.

The transport of oxygen dependson an adequate hemoglobin, theheart serving as an efficient pump,and peripheral vascular tone beingintact to distribute blood to the vitalareas. Carbon dioxide elimination isof the utmost importance and ade-quate means of discharge must beknown, available and applied.

Rapport between surgeon andanesthetist is imperative, the loss oflife due to lack of cooperativenessand consideration is inexcusable. Inemergency surgery, the margin ofsafety is too narrow to allow forspeculative decisions.

Fatigue or a particular attitudeamong individuals on the team whichmay stem from interpersonal or ex-tracurricular activities has beenknown to make the patient the re-cipient of unjustified treatment. In-terdependence on the part of surgeonand anesthetist is always to be foundbut in emergency surgery this isespecially true. Between them theycan make the task relatively easy, orimpossible.

Diagnostic thoroughness is some-times an impossible accomplishmentin emergency surgery, but certain im-mediate preparations and precautionscan and should be observed. Theanesthetist's own interview with thepatient and assay of vital signs shouldnot be underestimated if conscious-ness is present.

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J Am Assoc Nurs Anesth. 1962;30(1): 31-34,64.

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There is always time, while pre-paring the patient, to ask a few perti-nent questions that will have a bear-ing on the individual's requirement.To use the most simple terminologyat this time is important. To ask thepatient if he is on digitalis may notelicit the same response as inquiringabout "heart pills." Medications inthe ataractic group (specifically drugsthat are derivatives of phenothiazineand rauwolfia) may be referred to as"nerve pills." Diuretics, leading togreat loss of potassium which in turnmay precipitate a cardiac arrhythmia,are sometimes called "water pills."Steroid therapy may be suspected inthe arthritic patient. Disaster may beavoided, however, by asking the help-ful question, "Are you taking anymedication at this time and for whatreason ?"

A patient with an empty stomachbefore anesthesia is the desire of allanesthetists but often the desire isnot a fact. To allow sufficient timeto elapse after ingestion of a recentmeal and before induction of anes-thesia is a precaution making theanesthetist's task infinitely less diffi-cult. When possible a lapse of timeshould be allowed, in order to mini-mize the dangers of vomiting andaspirating, but when the surgeon'stask must be accomplished withoutdelay, techniques must be used tocircumvent aspiration.

Patients come to emergency sur-gery after prolonged, debilitating, ex-haustive illness with bodies depletedof vitality, intoxicated by their dis-ease, and usually with a disturbancewhich by its very nature imposesmechanical as well as physiologichazards for surgery. Such are patientswith asthma, tuberculosis and em-physema; or patients in the advanc-

J. Am. A. Nurse Anesthetists

ing years with reduction in cardiacreserve, arteriosclerosis and limita-tion of vasomotor response. Here thenare some of the problems faced bysurgeon and anesthetist in choosingproper management for a successfulprocedure.

Contemplation of the great strainto be thrust on the patient's physi-ological reserve by anesthesia andsurgery should mobilize every effortto bring the patient to as normal astate as his disease will permit. Ifcardiac pathology exists, it must becorrected if possible.

Minimal requirements of labora-tory work for hospital admission areprescribed by the Joint Committeeon Hospital Accreditation. These arehemoglobin, hematocrit, white bloodcount and urinalysis. In an acuteemergency, assumptions often mustbe allowed. If a complete battery ofelectrolyte studies can be made asbasic laboratory studies, they shouldbe a part of the work-up and appreci-ated by the anesthetist. The knowl-edge that electrolyte alterations andacid base balance disturbances mayplay a role in cardiovascular collapsecannot be emphasized too strongly.Particular attention should be focusedon sodium, potassium and calciumdeterminations and their relationshipsto the chloride and carbon dioxidecombining power determinations. Aci-dosis, whether metabolic or respira-tory, can be lethal and should beavoided.

Pre-anesthetic medication in pro-portion to the patient's age andweight very often must be discardedbecause of the condition of the pa-tient. It should be used to suit thepatient's requirement, i.e.: 1. The un-conscious patient obviously does notneed a drug to allay apprehension;

February, 1962

2. If shock is an existing factor, thenintravenous medication, given slowly,will benefit the course of anesthesiaand the patient's needs in a fashionsuperior to subcutaneous depotinjection.

Although the tasks of an anesthe-tist are many, all others are over-shadowed by the constant necessityfor maintaining a clear airway. What-ever the method may be -GuardAgainst Hypoxial One method is theuse of the intratracheal tube; over-whelming authority supports endo-tracheal intubation. To have controlof respirations, to decrease deadspace and to provide a route for tra-cheal aspiration makes it imperativethat every anesthetist be skilled inintratracheal intubation. Controversydoes exist concerning the manner ofanesthetizing the patient p r i o r toplacing the intratracheal tube. One

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method used at our clinic since 1953for a universally good topical anes-thesia has been transtracheal block.Indications for transtracheal block:1. To facilitate intratracheal intuba-tion without central nervous systemdepression or further depression ofmuscles of respiration. 2. For endo-scopic examination or intubation ofthe conscious patient. 3. To alleviatecoughing or spasm precipitated byrapid administration of irritatingagents. 4. To allow suctioning with-out associated bucking and coughing.Technique

Drug: 5% Cyclaine, because of lowtoxicity.

1. Onset of anesthesia - two minutes.2. Duration: approximately - thirty

minutes.3. It has been reported that Cyclaine

has some bronchodilating effects.Equipment:

A 5 cc. syringe is necessary to containthe drug and allow for a test aspira-

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J. Am. A. Nurse Anesthetists

tion of air from the trachea. A one-inch #21 needle (some authorities ad-vocate a larger bore needle but we feelthis size gives better spraying effect).

Procedure:1. If patient is to have the block

awake he is indoctrinated to theprocedure. He is asked not to coughor swallow while the needle is inplace, although this may be difficultfor him.

2. With the patient in supine positionthe head is placed in maximum ex-tension. A folded sheet is placedunder his shoulders.

3. By palpation the thyroid cartilageis identified. Locate cricothyroidmembrane.

4. Advance needle perpendicular toskin through membrane into trachea.

5. Draw back plunger to withdraw airbefore injection is made.

6. Inject drug (3 cc.) rapidly into tra-chea and withdraw needle.

7. Allow patient to cough to spreaddrug.

8. If the patient is to be asleep beforetranstracheal block the same pro-cedure is exercised.

The patient undergoing emergencysurgery frequently has a full stomach.

Vomiting or regurgitation may occuron induction or emergence but arenot unheard of during maintenance.Assured topical anesthesia, with asmooth induction and correct place-ment of the intratracheal tube, allowsthe surgeon to continue his task withminimal fear of induction or intra-operative complications.

Most anesthetists are so accus-tomed to certain techniques andagents that they have become special-ized in their use; they may be securein this position or perhaps they canmodify their armamentarium. Thereasons for the advantage of one an-esthetic over another may vary fromclinic to clinic and anesthetist toanesthetist, but it is the anesthetist'sduty to remember that all agents maydepress myocardium and circulationas well as respiration. The weakestanesthetic agents should be used to

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