Managing Surgical Emergencies · •Malignant Hyperthermia •Lidocaine Toxicity •Hemorrhage....
Transcript of Managing Surgical Emergencies · •Malignant Hyperthermia •Lidocaine Toxicity •Hemorrhage....
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MANAGING SURGICAL EMERGENCIES
Ginger Mars, MSN, RN, NP-c, CCRN, CPSN
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• Airway/Breathing:
• Difficult Airway
• Anaphylaxis
• Pulmonary Embolus
• Circulation:
• Malignant Hyperthermia
• Lidocaine Toxicity
• Hemorrhage
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Defined as a clinical situation where a health care
professional experiences or may experience difficulty
with:
●Face mask ventilation of upper airway
●Tracheal intubation
Or Both
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PATIENTS AT RISK FOR DIFFICULT AIRWAY
• Cleft Lip
• Cleft Palate
• Micrognathia
• Macroglossia
• Upper/lower jaw surgery
• Recent URI (increased risk of laryngospasm or bronchospasm)
• Bleeding/Hematoma
• Sleep Apnea History
• Obesity
• Recent intubation/re-intubation
• Issues with joint mobility due to chronic disease (TMJ, RA, Ankylosing spondylitis)
• Airway pathology
• Facial trauma
• Narcotic Overdose
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CLINICAL EXAMINATION AND HISTORY
• No ideal airway assessment tool
• History and assessment should heighten awareness of potential problems
• Tongue size
• Oropharyngeal cavity size (Mallampati Classification)
• Neck Assessment
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CLINICAL FINDINGS
•EARLY• Change in voice quality
• Difficulty breathing
• (increased work of breathing)
• Inspiratory Stridor
• LATE• Cyanosis
• Respiratory Arrest
Restlessness
Agitation
Panic
Somnolence
Unresponsiveness
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ASSESSMENT AND MANAGEMENT
• Early Assessment:• Know Patient History
• Identify those at risk
• Pre-op Planning
• Clinical Examination
• Body Habitus
• Airway assessment
• Management/Treatment:• Continuous pulse oximetry
• Appropriate room assignment/handoff
• Broncholytics/inhalers/nebulizers
• Racemic epinephrine
• Steroids
• Escalation to Surgical Airway
• Tracheostomy
• Crycothyrotomy
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TREATMENT
• Being prepared is the best treatment
• PRACTICE!!!
• Know where emergency carts/equipment are kept
• Have oxygen devices handy (Ambu bag)/suctioning equipment
• Crycothyrotomy/Trach sets available
•ASK QUESTIONS!• What should I be looking for?
• When should I be concerned?
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PEARLS FOR USE OF BAG/MASK
•PEARLS:
• Lift mandible to mask rather than pushing mask onto face
• Easier to make a seal with a mask that is too big than 1 than is too small
• Leave dentures in place to improve seal
• If facial hair makes seal difficult – apply water soluble lubricant over beard to improve contact
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WHAT IS ANAPHYLAXIS?
•Severe systemic allergic reaction
•Results from exposure to allergens
•Rapid in onset
•Can result in a life-threatening emergency
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SYMPTOMS
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TREATMENT
• Initiate BCLS/ACLS protocols as necessary
• EPINEPHRINE: Subcutaneous: 0.1 to 0.5 mg (0.1 to 0.5 mL of 1:1000 solution). May be repeated every 20 minutes to every 4 hours as needed.
• IV Antihistamines (Diphenhydramine)
• Steroids
• If surgery center – transfer to hospital for further management
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PULMONARY EMBOLUS
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PULMONARY EMBOLUS
•3rd leading cause of CV death in the US
•Women more susceptible than men
•Diagnosis often missed because symptoms can be vague and non-specific
• First symptom may be sudden death (25% of people diagnosed)
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POTENTIAL CAUSES
• Previous history of DVT or PE
• Family history
• Recent surgery or pregnancy
• Prolonged immobilization or bed-rest
• Trauma
• Obesity
• Varicose veins
• Oral contraceptives
• Underlying malignancy
• Smoking
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PROPHYLAXIS
•Early mobilization• Pneumatic compression boots
• SQ Heparin or LMW Heparins/ Xa inhibitors
• Hematology clearance for prior history
• Consider home anticoagulation for high-risk patients
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DIAGNOSIS
• Diagnosis by suspicion initially• Shortness of breath• Tachycardia• Hypoxemia
• Venous duplex
• D-dimer
• VQ Scan
•CT Angiogram
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TREATMENT
• LMW Heparin products: • Dalteparin (Fragmin)
• Enoxaparin (Lovenox)
• Tinzaparin (Innohep)
• IV Heparin drip• Use Argatroban in patients with HIT
• Coumadin
• Factor Xa and direct thrombin inhibitors• Pradaxa (dabigatran)
• Xarelto (rivaroxaban)
• Eliquis (apixaban)
• Thrombolysis/Thrombectomy
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WHAT IS MH?
•Malignant Hyperthermia is a LIFE THREATENING severe reaction that occurs to particular medications given during general anesthesia among those people who are susceptible.
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CAUSES OF MH
•Acceleration of skeletal muscle metabolism
•Abnormally increased levels of intracellular calcium
• MH may develop with exercise and/or exposure to hot environments in susceptible individuals
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CAUSATIVE AGENTS
• Muscle Relaxants:
• Succinylcholine
• Volatile Inhaled agents:
• Desflurane
• Enflurane
• Halothane
• Sevoflurane
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RECOGNIZING MH
• Sinus tachycardia
• Tachypnea
• Hypercarbia (increased end-tidal CO2)/ Respiratory Acidosis
• Muscle rigidity/masseter spasm
• Cyanosis or mottled skin
• Hyperthermia
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BEGIN TREATMENT
•Declare MH Emergency • Without prompt and proper treatment mortality is
extremely high• Discontinue Triggering Agents
• 100% Oxygen at High Flow – Hyperventilate
• Summon additional staff/help- Call 911 if a surgery center
• Give Dantrolene
• 2.5 mg/kg IV push
• Titrate to effect
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TREATMENT
• Cool Patient: gastric lavage, cooling blanket/ IV fluids/ Ice packs
• Treat arrhythmias
• Initiate Transfer Plan (If Ambulatory Center)
• Whenever possible, don’t move unless clinician judges patient to be stable
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24-HOUR MH HOTLINE
800-644-9737Outside North America: 001-209-417-3722
FOR EMERGENCIES ONLY
https://www.mhaus.org
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THERAPY IS AIMED AT:
• Prompt administration of Dantrolene
• Treatment of hyperkalemia
• Hyperventilation
• Cooling to target core temp of no more than 38 degrees
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POST ACUTE MANAGEMENT
•Dantrolene for at least 24 hours or longer as clinically indicated• 1mg/kg q4-6 hours IV OR
• 0.25mg/kg/hour by infusion
• Many MH experts recommend intermittent IV rather than continuous infusion to prevent IV drug extravasation & resultant tissue necrosis.
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POST ACUTE MANAGEMENT• Continuous monitoring of:
• EKG,
• ETCO2,
• Minute ventilation
• Core temperature
• Urine output
• Muscle tone
• Every 8 hours:
• pH & lactate
• K+
• CPK (until decreasing steadily)
• Baseline coagulation studies
• Baseline renal function & q24h if myoglobinuria
• Follow urine color for signs of myoglobinuria/rhabdomyolysis
•Watch for S/S of relapse• 25% of MH events relapse
• Relapses can be fatal
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SIGNS OF MH RELAPSE
• Increase muscular rigidity in absence of shivering
• Metabolic acidosis without other cause
• ‘Inappropriate’ hypercarbia with respiratory acidosis
• ‘Inappropriate’ temperature increase
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INDICATORS OF PATIENT STABILITY
• Metabolic stability for 24 hours
• End tidal CO2 stable or decreasing
• No ominous dysrhythmias
• Core temp is less than 38°C
• CPK is decreasing
• No evidence of myoglobinuria
• Muscle is no longer rigid
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POTENTIAL COMPLICATIONS
• Consciousness Level Change/Coma
• Cardiac Dysfunction
• Pulmonary Edema
• Renal Dysfunction
• Disseminated Intravascular Coagulation (DIC)
• Hepatic Dysfunction
• Relapse
• Death
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FACTORS INCREASING M&M
• Increased time 1st sign to 1st dantrolene• For every 30 minute increase in the interval between 1st MH sign
and 1st dantrolene dose, the complication likelihood is increased 1.6 X.
• Increased maximal temperature• For every 2◦C increase in maximal temperature, the complication
likelihood increased 2.9 X.
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STOCKING THE MH CART
• Dantrium/Revonto• 20mg/60ml sterile H20 (without
preservative). Shake until clear
• Each vial also contains 3gm mannitol/ 20mg vial
• 36 vials MUST be available in each institution where MH can occur.
Ryanodex 250mg/5ml sterile H20 (without
preservative). Shake to uniform
orange color
Each vial also contains 0.125
grams of mannitol
3 vials MUST be available in
each institution where MH
can occur.
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STOCKING THE MH CART
• Sodium Bicarb (NaHCO3)• 50ml x 5
• Dextrose 50%• 50ml x 2
• Calcium Chloride (10%)• 10ml x 2
• Regular Insulin• 100units/ml x1 vial (refrigerated)
• Lidocaine for injection• (2%) – 100mg/5ml or 100mg/10ml
(preloaded syringes)
• Cold Saline solution• 3 liters for IV cooling
For additional information: https://www.mhaus.org
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LIDOCAINE• Antiarrhythmic Drug:• To treat ventricular tachycardia
• Class 1b antiarrhythmic medication used in the treatment of ventricular arrhythmias
• Local Anesthetic:• Numb tissue in a specific area
• Nerve blocks
• Liposuction • Typically begins working within minutes and lasts for 30 minutes-3 hours
• Mixing with Epinephrine – makes it last longer and decreases bleeding when given as local anesthetic
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LIPO FACTS
• Tumescent Lipo:• Subcutaneous infusion of solution containing anesthetic
with aspiration of liquified fat through cannulas
• No standard, official, or rigidly prescribed formulation exists for tumescent anesthetic solutions.
• Concentrations of the lidocaine and epinephrine should depend on the areas treated and the clinical situation
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LIPOSUCTION INFUSATE
•Provides prolonged local anesthesia with minimal blood loss.
• Large volume Liposuction (removal of > 1500ml fat) may require infusion of several liters of solution.
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ANESTHETIC BLOCKS
• Indwelling catheters are usually placed by anesthesia • Brachial, Thoracic, Femoral
• Important to assess absorption rate (bupivicainedisk/ball)
• TAP (Transverse Abdominal Plane) blocks used for abdominal surgical procedures
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ANESTHETIC CONCENTRATIONS/DILUTION
• Drug concentration is expressed as percentage
• Bupivicaine 0.25%, Lidocaine 1%
• Percentage is measured in grams/100ml
• 1% = 1gram/100ml=1000mg/100ml or 10mg/ml
• Calculate mg/ml concentration from percentage by moving the decimal point 1 place to the right
• Bupivicaine 0.25% = 2.5mg/ml
• Lidocaine 1% = 10mg/ml
• Lidocaine 2% = 20mg/ml
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TOXICITY
•CNS
•Cardiovascular
•Hematologic
•Allergic
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CNS MANIFESTATIONS
• Circumoral or Tongue numbness
• Metallic Taste
• Lightheadedness
• Dizziness
• Visual/Auditory Disturbances
• Disorientation
• Drowsiness
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HIGHER DOSES MAY RESULT IN:
•Muscle Twitching
• Seizures
• Loss of consciousness
•Coma
•Respiratory/Cardiac depression/arrest
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CARDIOVACULAR MANIFESTATIONS
• Chest pain
• Shortness of breath
• Palpitations/Arrhythmia
• Lightheadedness
• Diaphoresis
• Hypotension
• Syncope
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RESPIRATORY/SYSTEMIC MANIFESTATIONS
• Cyanosis
• Gray color
• Tachypnea
• Dyspnea
• Fatigue
• Exercise Intolerance
• Dizziness
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TREATMENT
• DISCONTINUE THE DRUG
• ABC’s
• Initiation of BCLS/ACLS Protocols
• Airway management
• Oxygen administration
• Arrhythmia management
• Mild symptoms:
• Benzodiazepines
• Seizures:
• Treatment with benzodiazepines or barbituates
Failure to recognize early signs may result in progression to severe CNS effects
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ANTIDOTE
• LIPID RESCUE:
• Rapid administration of IV fat emulsion
• 20% lipid solution – bolus of 1.5mL/kg over 1 minute followed by 0.25mL/kg/min or 15 mL/kg/hour run over 30-60 min
• Usually for treatment of bupivicaine toxicity, but can be used for treatment of severe lidocaine toxicity.
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LIDOCAINE DOSING RECOMMENDATIONS IN LIPOSUCTION
•Maximum Safe Dosage Guidelines:•45mg/kg in ‘relatively’ thin patients
•50mg/kg in obese patients
•Higher plasma lidocaine concentrations may result from adverse drug reactions (CYP450 pathway)
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SAFETY TIPS
• Understand maximum safe dosing
• Use explicit/signed surgeon orders for tumescent solution.
• Designated licensed personnel should prepare solution• Normal saline is preferred tumescent solvent
• Include determination of maximum safe dose in mg/kg
• Specify dose in terms of mg
• Specify EXACT total mg Lidocaine and Epinephrine &
mEq sodium bicarb/liter of solution (mg/L & mEq/L)
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SAFETY TIPS
• Know the dose given (in mg and mg/kg)
• Use ONLY 1% Lidocaine
• Prepare & Label solution at time of surgery
• Save all empty bottles
• Avoid post op sedation
• Review ALL home medications before surgery• Including Rx, OTC & homeopathic/nutriceuticals
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HEMORRHAGE
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DEFINITION
•“Significant” Bleeding that occurs after any surgical procedure.
• Bleeding may occur immediately or delayed.
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POTENTIAL CAUSES
• Surgical/Technical causes:• Blood vessel clamps
/sutures coming undone
• Injury to surrounding structures
• Vomiting/coughing
• Patient Causes:• Pre-existing disease
• Liver, kidney, HTN
• Bleeding disorders
• Strenuous activity
• Medications• Prescription
• OTC
• Herbal
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SIGNS & SYMPTOMS
• Increased bloody drain output
• Bleeding from suture line
• Increase in swelling to surrounding area
• Tachycardia
• Hypotension
• Decreased urine output
• Restlessness/Agitation
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MANAGEMENT
• Prevention• Pre-Op assessment of home medications
• Post op rounding/assessment of drain output and incision site
• Frequent assessment of high risk patients• What defines high risk?
• Rapid intervention once diagnosed
• Supportive Care/Management
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