IAC Module 6v2

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@@.whitetext; !Virtual Anaesthetics_6 Welcome to the one in a series of interactive scenarios to support learning during the IAC. You can find out more on using this scenario ''[[here|howtoguide]]''. ''Disclaimer: Virtual Anaesthetics is not responsible for your use of the information contained in or linked from this site. All users should act within their own competence and according to local and national guidelines and policies. All treatment information contained herein is provided as a general example only and you should always check drug doses in an appropriate formulary. Any descriptions of procedures or techniques is intended as an example only and as a supplement formal training. Individuals should only perform procedures or techniques they have been formally trained in and are competent to perform.'' @@ ''[[Next|Introduction]]'' [[I'm a clinical supervisor or trainer|trainers_area]] @@.whitetext; If you are ''not'' a health care professional please read our brief message first [[here|message]]@@

/* <<countdownTimer>> Widget - Start */ <<widget "countdownTimer">> <<set _seconds = $args[0]>> <<set _minutes = Math.floor(_seconds / 60)>> <<set _replacementPassage = $args[1]>> <div id="timer" class="timergreen">Time remaining _minutes:<<= (_seconds - (_minutes * 60)).toString().padStart(2, '0')>></div><<script>> if (!recall("countdown", undefined)) { setup.countdown = { startTime: new Date(), lastStr: "", passage: passage() }; memorize("countdown", setup.countdown); } else { setup.countdown = recall("countdown"); if (setup.countdown.passage !== passage()) { setup.countdown = { startTime: new Date(), lastStr: "", passage: passage() }; memorize("countdown", setup.countdown); } } setup.countdown.intervalID = setInterval(function () { if (setup.countdown.passage !== passage()) { clearInterval(setup.countdown.intervalID); forget("countdown"); setup.countdown.passage = ""; } else { var curtime = new Date(), str, seconds = State.temporary.seconds; var diff = Math.floor(seconds - ((curtime - setup.countdown.startTime) / 1000)), min = Math.floor(diff / 60); if ((diff >= 0) && (diff < seconds)) { if ($("#timer").length) { str = "Time remaining " + min + ":" + (diff - (min * 60)).toString().padStart(2, '0'); if (str != setup.countdown.lastStr) { $("#timer").empty().wiki(str); setup.countdown.lastStr = str; } if (diff <= 10) { if (!$("#timer").hasClass("timerred")) { $("#timer").removeClass("timeramber").addClass("timerred"); } } else if (diff <= 20) { if (!$("#timer").hasClass("timeramber")) { $("#timer").removeClass("timergreen").addClass("timeramber"); } } } } if (diff < 0) { clearInterval(setup.countdown.intervalID); forget("countdown"); $("#passages div.passage").empty().wiki('<<include "' + State.temporary.replacementPassage + '">>'); delete setup.countdown.passage; } } }, 200); <</script>> <</widget>> /* <<countdownTimer>> Widget - End */ /* Icons widget */ <<widget "scicon">><span @class="'sc-icon sc-' + $args.raw" alt="' + $args.raw + '"></span><</widget>>

@@.whitetext; !Virtual Anaestheics_6: Anaesthetic emergencies Enter your first name: <<textbox "$firstname" "">> Enter your surname: <<textbox "$surname" "">> <<set $role = ["-", "Stage 1 Anaesthetist in Training", "Stage 2 Anaesthetist in Training", "Stage 3 Anaesthetist in Training", "Consultant Anaesthetist", "Associate Specialist Anaesthetist", "Speciality Doctor Anaesthetist", "Foundation Doctor", "Doctor (Other)", "Medical Student", "Other health care professional", "Role outside healthcare"]>>''Select your professional role:'' <<listbox "$role">> <<optionsfrom $role>> <</listbox>> <<set $randomid to random(10000000,99999999)>> <<nobr>><span id="ReplaceMe"> <<link "''Next''">> <<script>> Dialog.setup("Analytics"); Dialog.wiki("Users' privacy and data protection are our priorities. Virtual Anaesthetics uses analytics and collects anonymised data to improve your service and provide academic governance including passage function, anonymised scores, playtime, and any feedback comments you provide. This anonymised data may also be used in part or in its entirety for research and publication. For more information on our privacy policy please see ''[[here|https://www.virtualanaesthetics.com/privacy-policy/]]''. Please also be aware that this information is temporarily stored in your local internet browser cache. If using a public or shared computer you can avoid this by clearing your internet history and website data on competition of the scenario."); Dialog.open(); <</script>> <<replace "#ReplaceMe">> ''[[Next|Core clinical learning objectives]]''<br> <</replace>> <</link>></span><</nobr>>

<<cacheaudio "monitorfast" "audio/monitorfast.mp3">> <<cacheaudio "monitor" "audio/monitor.mp3">> <<cacheaudio "monitor120" "audio/monitor120.mp3">> <<cacheaudio "monitor150" "audio/monitor150.mp3">> <<cacheaudio "monitorlow" "audio/monitorlow.mp3">> <<cacheaudio "monitorlow1" "audio/monitorlow1.mp3">> <<cacheaudio "monitorlow2" "audio/monitorlow2.mp3">> <<cacheaudio "monitorlow3" "audio/monitorlow3.mp3">> <<cacheaudio "stridor" "audio/stridor.mp3">> <<cacheaudio "stridor2" "audio/stridor2.mp3">> <<cacheaudio "emergency" "audio/emergency.mp3">> <<set $history to []>> <<set $started to 0>>

!!!@@.greentext; Scenario learning objectives:@@ * Decision making under pressure * Management of anaesthetic emergencies @@.greentext; ''For optimal interaction this module is better on a larger screen device <u>with an unmuted speaker</u>. [[Next|emerg1]] [[Show me the mapped curriculum|curriculum]] [[Show me the EPA|epa]] <<set $das to "false">> <<set $lary to "false">> <<set $fit to "false">> <<set $hypo to "false">> <<set $sepsis to "false">> <<set $hot to "false">>

<center> @@.whitetext; ''With thanks to everyone who helped make this scenario happen!'' !!!Well done for completing Virtual Anaesthetics_6 <<nobr>><span id="ReplaceMe"> <<link "''certificate''">> <<script>> Dialog.setup("Tell us"); Dialog.wiki("<center> <h3>@@.greentext;You can make Virtual Anaesthetics better. <br><br>Tell us what you think of this scenario [[here|https://forms.gle/QjzbkPQPd5vttkBS7]]. It should take less than a minute. <br><br>Thanks!@@</h3> </center>"); Dialog.open(); <</script>> <<replace "#ReplaceMe">> ''[[certificate]]''<br> <</replace>> <</link>></span><</nobr>> @@ </center>

!!!@@.greentext; Scenario learning objectives:@@ * Decision making under pressure * Management of anaesthetic emergencies [[Next|credits]] <<set $historyOutput to "">> <<nobr>> <<set _last to $started>> <<for _event range $history>> <<set $historyOutput to $historyOutput + "<br>Passage: " + _event.passage + ", Seconds: " + setup.toSeconds(_last, _event.time)>> <<set _last to _event.time>> <</for>> <</nobr>> <<nobr>> <<set $passagetimes to $historyOutput>> <<set $id to "VA6IAC">> <<set $result1 to "-">> <<set $result2 to "-">> <<set $playtimehr to playTime('hours')>> <<set $playtimemin to playTime('minutes')>> <<set _data = {randomid: $randomid, role: $role, id: $id, playtimehr: $playtimehr, playtimemin: $playtimemin, result1: $result1, result2: $result2, passagetimes: $passagetimes }>> <<run sendData4(_data)>> <</nobr>>

<p style="text-align:justify">We are absolutely thrilled that you have found us and shown an interest in our learning platform. We wanted to give you the heads up before you get any deeper into the scenario, that like the best medical dramas, bad things may happen. This is to support learning and clinical decision making. It is ''REALLY RARE'' for things like this to happen to otherwise well people undergoing anaesthetics. The Royal Collage of Anaesthetists has some really helpful information explaining the risks of having an anaesthetic if you want further information, available [[here|https://rcoa.ac.uk/patient-information/patient-information-resources/anaesthesia-risk]]. When you are ready, welcome to our virtual world...</p> [[Start|Introduction]]

!!!@@.greentext;EPA 1: Performing an anaesthetic preoperative Assessment@@ EPA for this scenario in ''bold'' * Take a focused history, perform appropriate physical examination and interpret relevant investigations * Understand how a patient’s past medical, surgical and anaesthetic history influences the safe conduct of anaesthesia * Identify patients with an increased ‘perioperative risk’ and raise concerns appropriately * Communicate the anaesthetic plan to patients in an understandable way, including counselling on commonly occurring risks and addressing patient concerns * Understand limitations and scope of practice of a novice anaesthetist !!!@@.greentext;EPA 2: General anaesthesia for an ASA I/II patient having uncomplicated surgery@@ * ''Understand your scope of practice as an inexperienced practitioner and seek help appropriately'' * Plan and deliver general anaesthesia to appropriate patients including the following techniques: airway management with supraglottic devices and endotracheal intubation; spontaneous and controlled ventilation; rapid sequence induction * Prepare and check emergency drugs and equipment commonly used in anaesthetic practice * Independently check and use a standard anaesthetic machine * Manage tracheal extubation, including common complications occurring during emergence from anaesthesia; eg, laryngeal spasm * Manage acute postoperative pain including the use of rescue opiods in recovery and patient controlled analgesia * ''Demonstrate understanding and capability in Anaesthetic Non-technical Skills'' * ''Initiate management of common anaesthetic emergencies, including unanticipated difficult airway management, and call for senior help'' [[Back|Core clinical learning objectives]]

!!@@.greentext; 2021 Curriculum learning syllabus stage 1@@ !!!@@.greentext;Perioperative medicine and health promotion learning outcomes:@@ @@.greentext;''//Identifies clinical and social challenges that increase risk for patients undergoing surgery Appreciates the principles of sustainability in clinical practice//''@@ !!!@@.greentext; ''Key capabilities''@@ * Explains the patient, anaesthetic and surgical factors influencing patient outcomes * Applies a structured approach to preoperative anaesthetic assessment of ASA 1-3 patients prior to surgery and recognises when further assessment and optimisation is required * Explains the effect that co-existing disease, subsequent treatment and surgical procedure may have on the conduct of anaesthesia and plans perioperative management accordingly * Explains individualised options and risks of anaesthesia and pain management to patients * Considers patient informed preference when obtaining consent for anaesthetic procedures !!!@@.greentext;General anaesthesia learning outcome:@@ @@.greentext;''//Provides safe and effective general anaesthesia with distant supervision for patients undergoing non-complex elective and emergency surgery within a general hospital setting//''@@ !!!@@.greentext;Key capabilities@@ * Conducts comprehensive pre-anaesthetic and pre-operative checks * Safely manages induction and maintenance of anaesthesia by inhalational and intravenous techniques, extubation and emergence from anaesthesia * Plans recovery care, and manages recovery from anaesthesia utilising safe discharge criteria * Diagnoses and manages common peri-operative complications These scenarios are ''not'' designed for exam revision. They are to support your leaning during the IAC and ultimately help you make good decisions at 2am. [[Back|Core clinical learning objectives]]

!!!!What's your emergency? <<run forget("countdown")>> <div class="leftcolumn"><<if $das is "true">><span class = "moreinfo2used">[[Emergency 1|das1][$das = "true"]]  <<scicon checkbox-on>></span> <<else>>[[Emergency 1|das1][$das = "true"]]  <<scicon checkbox-off>> <</if>> <<if $lary is "true">><span class = "moreinfo2used">[[Emergency 2|lary_intro][$lary = "true"]]  <<scicon checkbox-on>></span> <<else>>[[Emergency 2|lary_intro][$lary = "true"]]  <<scicon checkbox-off>> <</if>> <<if $hot is "true">><span class = "moreinfo2used">[[Emergency 3|hot_intro][$hot = "true"]]  <<scicon checkbox-on>></span> <<else>>[[Emergency 3|hot_intro][$hot = "true"]]  <<scicon checkbox-off>> <</if>> </div><div class="rightcolumn"><<if $hypo is "true">><span class = "moreinfo2used">[[Emergency 4|hypo_intro][$hypo = "true"]]  <<scicon checkbox-on>></span> <<else>>[[Emergency 4|hypo_intro][$hypo = "true"]]  <<scicon checkbox-off>> <</if>> <<if $fit is "true">><span class = "moreinfo2used">[[Emergency 5|fit_intro][$fit = "true"]]  <<scicon checkbox-on>></span> <<else>>[[Emergency 5|fit_intro][$fit = "true"]]  <<scicon checkbox-off>> <</if>> <<if $sepsis is "true">><span class = "moreinfo2used">[[Emergency 6|sepsis_intro][$sepsis = "true"]]  <<scicon checkbox-on>></span> <<else>>[[Emergency 6|sepsis_intro][$sepsis = "true"]]  <<scicon checkbox-off>> <</if>> </div> <center> [img[images/exit.jpg][exit2]] </center> <<set $sats1 = 100>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" pause>> <<set $q1 to "No answer given">> <<set $q2 to "No answer given">> <<set $q3 to "No answer given">> <<set $q4 to "No answer given">> <<set $q5 to "No answer given">> <<set $q6 to "No answer given">> <<set $q7 to "No answer given">> <<set $q8 to "No answer given">> <<set $q9 to "No answer given">> <<set $q10 to "No answer given">> <<set $q11 to "No answer given">> <<set $q12 to "No answer given">> <<set $q13 to "No answer given">> <<set $q14 to "No answer given">>

!!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% RSI, preoxygenated, drugs are in, 60 seconds is up. Your laryngoscope view: <center> <img src="images/cormacklehane4.jpg" style="max-width: 400px;"/> </center> What next? [[Change something and try again|das2a][$q1 = "Yes"]] [[Put down an SAD|das2b][$q1 = "No"]] [[I don't know|das2c][$q1 = "Got help"]] SAD = supraglotic airway device <<timed 59s>> <<goto das2c>> <</timed>> <<countdownTimer 60 "das2c">> <<audio "monitor" volume 0.3 loop play>>

<p style="text-align:justify">The lights are dimmed in theatre for a laparoscopic case. "Hi $firstname." The anaesthetic SpR has their head round the anaesthetic room door. "I’ve just been bleeped to obs, they need to open a second theatre down there. I’ve just put Mrs Last in recovery. She’s completely fine, she will be going to the ward any minute. The supraclavicular block is working nicely so she’s comfortable. She didn’t need any sedation while they put the plate on her humeral fracture. Are you happy if I dash off to obs?" "No problem. We’re almost done here."</p> [[Next|fit1]]

<div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink">''78''</span>@@ ^^NIBP^^ @@.delayed;''108/68''@@</div></p></div> "$firstname can you give some antibiotics please? It's pretty grotty here, pus and non-viable tissue. This is why you shouldn't put your hand into a cat's mouth and ignore it for a week." The plastics SpR is grimacing into a small puncture wound. "I wasn't planning too. What do you want?" You adjust the catheter mount a bit, it's dragging on the LMA, and double check the chart. "Penicillin allergy." "They had metronidazole from the GP so let's go teicoplanin and I'll send some samples to micro." [[Next|hypo1]] <<audio "monitor" volume 0.3 loop play>>

Transfer from the anaesthetic room has gone smoothly. You've even remembered to turn the volatile on in theatre. Now the ECG stickers that refuse to stay stuck need some attention. This ORIF radius/ulnar shouldn't take long. [[Next|hot1]]

"Right let's get this tube out. Cuff down." You pull the tube. A long tendril of mucus hangs on the end of the tube for a second before falling back into the patient's mouth. You pick up the facemask. [[OK, lets call recovery|lary1]] <<audio "stridor" pause>>

<<set $sats1 to $sats1 - 2>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% You optimise head and neck position and the ODP provides external larygeal manipulation. When you look down you still see this: <center> <img src="images/cormacklehane4.jpg" style="max-width: 400px;"/> </center> What next? [[Change something and try again|das3a][$q2 = "Yes"]] [[Put down an SAD|das3b][$q2 = "No"]] [[I don't know|das3c][$q2 = "Got help"]] SAD = supraglottic airway device <<timed 59s>> <<goto das3c>> <</timed>> <<countdownTimer 60 "das3c">>

<<set $sats1 to $sats1 - 5>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% "I need an iGel." The ODP looks at your expression. "Why don't we optimise head and neck position and I'll give you some external larygeal manipulation. So you get a better view?" When you look down you still see this: <center> <img src="images/cormacklehane4.jpg" style="max-width: 400px;"/> </center> What next? [[Change something and try again|das3a][$q2 = "Yes"]] [[Put down an SAD|das3b][$q2 = "No"]] [[I don't know|das3c][$q2 = "Got help"]] SAD = supraglottic airway device <<timed 59s>> <<goto das3c>> <</timed>> <<countdownTimer 60 "das3c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 - 2>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% You try again with the video scope. When you look down you still see this: <center> <img src="images/cormacklehane4.jpg" style="max-width: 400px;"/> </center> What next? [[Change something and try again|das4b][$q3 = "No"]] [[Put down an SAD|das4a][$q3 = "Yes"]] [[I don't know|das4c][$q3 = "Got help"]] <<timed 59s>> <<goto das4c>> <</timed>> <<countdownTimer 60 "das4c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 - 5>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% "OK, lets try an LMA." "How about you try again with the video scope?" The ODP is holding the divice out to you. When you look down you still see this: <center> <img src="images/cormacklehane4.jpg" style="max-width: 400px;"/> </center> What next? [[Change something and try again|das4b][$q3 = "No"]] [[Put down an SAD|das4a][$q3 = "Yes"]] [[I don't know|das4c][$q3 = "Got help"]] <<timed 59s>> <<goto das4c>> <</timed>> <<countdownTimer 60 "das4c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 - 5>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% "$firstname, this is a failed intubation, we need to try something else." The ODP is holding out a size 5 i-gel. They hit the emergency buzzer. You screw down the APL valve and squeeze the bag. Nothing. What next? [[Try again with a different SAD or size i-gel|das5a][$q4 = "Yes"]] [[Try facemask ventilation|das5b][$q4 = "No"]] [[I don't know|das5c][$q4 = "Got help"]] <<timed 59s>> <<goto das5c>> <</timed>> <<countdownTimer 60 "das5c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 - 2>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% You steady your breathing. "OK, this is a failed intubation. Hit the emergency buzzer." The ODP hands you a size 5 i-gel. Which you place. You screw down the APL valve and squeeze the bag. Nothing. What next? [[Try again with a different SAD or size i-gel|das5a][$q4 = "Yes"]] [[Try facemask ventilation|das5b][$q4 = "No"]] [[I don't know|das5c][$q4 = "Got help"]] <<timed 59s>> <<goto das5c>> <</timed>> <<countdownTimer 60 "das5c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 - 2>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% You try a size 4 i-gel. Again nothing. What next? [[Try again with a different SAD or size i-gel|das6a][$q5 = "Yes"]] [[Try facemask ventilation|das6b][$q5 = "No"]] [[I don't know|das6c][$q5 = "Got help"]] <<timed 59s>> <<goto das6c>> <</timed>> <<countdownTimer 60 "das6c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 - 5>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% "Give me the mask so I can try face mask ventilate." "OK, but I've got a size 4 i-gel open, let's try that first." iGel in. Again nothing. What next? [[Try again with a different SAD or size i-gel|das6a][$q5 = "Yes"]] [[Try facemask ventilation|das6b][$q5 = "No"]] [[I don't know|das6c][$q5 = "Got help"]] <<timed 59s>> <<goto das6c>> <</timed>> <<countdownTimer 60 "das6c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 - 2>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% You try a size 4 second generation LMA. Again nothing. What next? [[Try again with a different SAD or size i-gel|das7b][$q6 = "No"]] [[Try facemask ventilation|das7a][$q6 = "Yes"]] [[I don't know|das7c][$q6 = "Got help"]] <<timed 59s>> <<goto das7c>> <</timed>> <<countdownTimer 60 "das7c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 - 5>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% "Give me the facemask." "OK, but lets give this size 4 second generation LMA a go first." Again nothing. What next? [[Try again with a different SAD or size i-gel|das7b][$q6 = "No"]] [[Try facemask ventilation|das7a][$q6 = "Yes"]] [[I don't know|das7c][$q6 = "Got help"]] <<timed 59s>> <<goto das7c>> <</timed>> <<countdownTimer 60 "das7c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 - 5>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% "Give me another iGel." "That's not working, we need to try something else." "OK I'll facemask ventialte." You apply the mask to the patient's face with both hands. The ODP squeezes the bag. Nothing. What next? [[Give more muscle relaxant|das8a][$q7 = "Yes"]] [[Wake them up|das8b][$q7 = "No"]] [[I don't know|das8c][$q7 = "Got help"]] <<timed 59s>> <<goto das8c>> <</timed>> <<countdownTimer 60 "das8c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 - 2>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% "I need the face mask." You slip in an OP airway and hold the mask to the patient's face with both hands. The ODP squeezes the bag. Nothing. What next? [[Give more muscle relaxant|das8a][$q7 = "Yes"]] [[Wake them up|das8b][$q7 = "No"]] [[I don't know|das8c][$q7 = "Got help"]] <<timed 59s>> <<goto das8c>> <</timed>> <<countdownTimer 60 "das8c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 - 5>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% "How about you try again with the video scope?" The ODP is holding the device out to you. When you look down you still see this: <center> <img src="images/cormacklehane4.jpg" style="max-width: 400px;"/> </center> What next? [[Change something and try again|das4b][$q3 = "No"]] [[Put down an SAD|das4a][$q3 = "Yes"]] [[I don't know|das4c][$q3 = "Got help"]] SAD = supraglotic airway device <<timed 59s>> <<goto das4c>> <</timed>> <<countdownTimer 60 "das4c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 - 5>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% The ODP reads your expression. "Lets try to optimise head and neck position and I'll give you some external larygeal manipulation so you get a better view." When you look down you still see this: <center> <img src="images/cormacklehane4.jpg" style="max-width: 400px;"/> </center> What next? [[Change something and try again|das3a][$q2 = "Yes"]] [[Put down an SAD|das3b][$q2 = "No"]] [[I don't know|das3c][$q2 = "Got help"]] SAD = supraglottic airway device <<timed 59s>> <<goto das3c>> <</timed>> <<countdownTimer 60 "das3c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 - 5>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% Your mind is blank. "I've got a size 4 i-gel open, let's try that." The ODP hands you the device. iGel in. Again nothing. What next? [[Try again with a different SAD or size i-gel|das6a][$q5 = "Yes"]] [[Try facemask ventilation|das6b][$q5 = "No"]] [[I don't know|das6c][$q5 = "Got help"]] <<timed 59s>> <<goto das6c>> <</timed>> <<countdownTimer 60 "das6c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 - 5>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% "I've got a size 4 second generation LMA ready, give it a go." Again nothing. What next? [[Try again with a different SAD or size i-gel|das7b][$q6 = "No"]] [[Try facemask ventilation|das7a][$q6 = "Yes"]] [[I don't know|das7c][$q6 = "Got help"]] <<timed 59s>> <<goto das7c>> <</timed>> <<countdownTimer 60 "das7c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 - 5>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% The ODP holds out the facemask to you. You slip in an OP airway and hold the mask to the patient's face with both hands. The ODP squeezes the bag. Nothing. What next? [[Give more muscle relaxant|das8a][$q7 = "Yes"]] [[Wake them up|das8b][$q7 = "No"]] [[I don't know|das8c][$q7 = "Got help"]] <<timed 59s>> <<goto das8c>> <</timed>> <<countdownTimer 60 "das8c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 - 2>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% "Let's give a dose of rocuronium." You give them everything left in the rocuronium syringe and more propofol. Take a breath. What next? [[Try facemask ventilation|das9b][$q8 = "No"]] [[Front of neck access|das9a][$q8 = "Yes"]] [[I don't know|das9c][$q8 = "Got help"]] <<timed 59s>> <<goto das9c>> <</timed>> <<countdownTimer 60 "das9c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 - 5>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% "I'm going to wake them up." "You can't wake them, their sats are <<print $sats1>>. Let's make sure they're paralysed." You give them everything left in the rocuronium syringe and more propofol. Take a breath. What next? [[Try facemask ventilation|das9b][$q8 = "No"]] [[Front of neck access|das9a][$q8 = "Yes"]] [[I don't know|das9c][$q8 = "Got help"]] <<timed 59s>> <<goto das9c>> <</timed>> <<countdownTimer 60 "das9c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 - 5>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% "We can't bag them so we can't wake them. Why don't you make sure they're paralysed?" You give them everything left in the rocuronium syringe and more propofol. Take a breath. What next? [[Try facemask ventilation|das9b][$q8 = "No"]] [[Front of neck access|das9a][$q8 = "Yes"]] [[I don't know|das9c][$q8 = "Got help"]] <<timed 59s>> <<goto das9c>> <</timed>> <<countdownTimer 60 "das9c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 - 2>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% "I need to do emergency front of neck access." What next? [[Scalpel, bougie, tube|das10a][$q9 = "Yes"]] [[Cannula technique|das10b][$q9 = "No"]] [[I don't know|das10c][$q9 = "Got help"]] <<timed 59s>> <<goto das10c>> <</timed>> <<countdownTimer 60 "das10c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 - 5>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% "$firstname, you need to do emergency front of neck access." "I've never..." "Me neither, let's get on with it." What next? [[Scalpel, bougie, tube|das10a][$q9 = "Yes"]] [[Cannula technique|das10b][$q9 = "No"]] [[I don't know|das10c][$q9 = "Got help"]] <<timed 59s>> <<goto das10c>> <</timed>> <<countdownTimer 60 "das10c">> <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<run forget("countdown")>> <<set $sats1 to $sats1 - 2>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% Stab Twist Bougie Tube "OK, I'm in. Cuff up. Where's the circuit?" [[Next|das11a]] <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<run forget("countdown")>> <<set $sats1 to $sats1 - 5>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% "We don't have that kit. It's standard scalpel, bougie, tube." The ODP is holding out the kit. "It's up to you!" Stab Twist Bougie Tube "OK, I'm in. Cuff up. Where's the circuit?" [[Next|das11a]] <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<run forget("countdown")>> <<set $sats1 to $sats1 - 5>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% "Come on $firstname. We have to do this, scalpel, bougie, tube." The ODP is holding out the kit. "It's up to you!" Stab Twist Bougie Tube "OK, I'm in. Cuff up. Where's the circuit?" [[Next|das11a]] <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>>

<<set $sats1 to $sats1 + 10>> !!!SpO~~2~~   <span class="blink"><<print $sats1>>  </span>% "Blimey! Nice one $firstname. That's it. We've got CO~~2~~!" [[Feedback on how I did|feedbackdas]] [[I want another emergency|emerg1]] <<if $sats1 < 81>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" volume 0.3 loop play>> <<elseif $sats1 < 86>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow3" pause>> <<audio "monitorlow2" volume 0.3 loop play>> <<elseif $sats1 < 91>> <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" pause>> <<audio "monitorlow1" volume 0.3 loop play>> <<elseif $sats1 < 96>> <<audio "monitor" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" pause>> <<audio "monitorlow" volume 0.3 loop play>> <</if>> <<set $id to "dasIAC">> <<set $q10 to "-">> <<set $q11 to "-">> <<set $q12 to "-">> <<set $q13 to "-">> <<set $q14 to "-">> <<set _data = {randomid: $randomid, id: $id, q1: $q1, q2: $q2, q3: $q3, q4: $q4, q5: $q5, q6: $q6, q7: $q7, q8: $q8, q9: $q9, q10: $q10, q11: $q11, q12: $q12, q13: $q13, q14: $q14 }>> <<run sendData(_data)>>

<center> !!!@@.navytext;Can’t intubate, can’t oxygenate@@ <img src="images/das.jpg" style="max-width: 100%;"/> ''Figure 1: Difficult Airway Society guideline for management of an unanticipated difficult tracheal intubation in adults.'' </center> <p style="text-align:justify">@@.navytext;The continuous visual and audio SpO~~2~~ readings as well as timed passages in this scenario are intended to replicate emergencies where it is common to be presented with more information than can be processed. Following the Difficult Airway Society (DAS) guideline (see figure 1) at each decision point progressed this scenario with the highest patient SpO~~2~~. Indecision or decisions which deviated from the guideline caused greater reductions in SpO~~2~~. The impact of human factors during any crisis, including cognitive overload and task fixation, are reduced by using cognitive aids and guidelines to support decision making. For any strategy to work in an emergency it must be known and rehearsed by the whole of the team.@@</p> <div class="navy">''Plan A:'' Facemask ventilation and tracheal intubation</div> @@.navytext;''Your answers:''@@ 1st intubation attempt: ''Yes'' Made change and 2nd intubation attempt: ''<<print $q1>>'' Made change and 3rd intubation attempt: ''<<print $q2>>'' <p style="text-align:justify">@@.navytext;''Feedback:''@@ All patients should be optimally positioned and pre-oxygenated before induction. If the first attempt is met with difficulty, a call for help should be made early. It is essential to be trained in the use of a videolaryngoscope with the device immediately available for use. Every attempt at laryngoscopy has the potential to cause trauma, with the chance of successful intubation decreasing with each attempt. Blind use of a bougie with a grade 3b or 4 view is not recommended for this reason. Repeated attempts at laryngoscopy also make successful rescue with a SAD less likely. A maximum of three attempts by the 1st anaesthetist and a forth attempt by an experienced 2nd anaesthetist is recommended by DAS. After the third (+1) attempt, Failed Intubation should be declared and management should move on to Plan B. During repeated attempts the hypnotic effect of the induction agent declines and it is important to insure adequate anaesthesia.</p> <div class="navy">''Plan B:'' Maintaining oxygenation: SAD insertion</div> @@.navytext;''Your answers:''@@ 1st SAD insertion attempt: ''<<print $q3>>'' Changed device or size and 2nd SAD insertion attempt: ''<<print $q4>>'' Changed device or size and 3rd SAD insertion attempt: ''<<print $q5>>'' <p style="text-align:justify">@@.navytext;''Feedback:''@@ You and the ODP should know which SAD is Plan B before induction. Second generation devices (e.g. i-gel^^TM^^, Proseal^^TM^^, LMA or LMA Supreme^^TM^^) have greater efficacy and safety in large scale trials. During an RSI, cricoid pressure should be released to make space for insertion of the SAD. If successful oxygenation, and capnography confirmed ventilation is achieved, use the opportunity to stop and think about the most appropriate next action. For less experienced clinicians, this is often to wake the patient up and summon more experienced support. As for laryngoscopy, the chance of successful placement diminishes with each attempt. After the third attempt, Failed SAD ventilation should be declared, and management should move on to Plan C.</p> <div class="navy">''Plan C:'' Facemask ventilation</div> @@.navytext;''Your answers:''@@ Made final attempt at facemask ventilation: ''<<print $q6>>'' When facemask ventilation impossible paralysed: ''<<print $q7>>'' <p style="text-align:justify">@@.navytext;''Feedback:''@@ Even if facemask ventilation at earlier stages has been possible, trauma during repeated instrumentation of the airway can make previously easy facemask ventilation difficult or impossible. If oxygenation via facemask ventilation is possible, the patient should be woken up in all but the most exceptional circumstances. If oxygenation via facemask ventilation is not possible even after ensuring full paralysis, then a Can’t Intubate, Can’t Oxygenate situation (CICO) is called, and the need for front of neck access should be declared. Management should move on to Plan D before critical hypoxia develops.</p> <div class="navy">''Plan D:'' Emergency front of neck access</div> @@.navytext;''Your answers:''@@ Recognised need for emergency front of neck access: ''<<print $q8>>'' Equipment scalpel, bougie, tube: ''<<print $q9>>'' <p style="text-align:justify">@@.navytext;''Feedback:''@@ This is rare event and regular training is key for skill acquisition, reinforcement and retention. Cognitive processing and motor skills decline under stress, so a simple plan to rescue the airway using familiar equipment and rehearsed techniques gives the best chance of success. Scalpel cricothyroidotomy is the fastest and most reliable method of securing the airway in an CICO emergency. During plan D an assistant should continue to attempt rescue oxygenation via the upper airway.</p> <p style="text-align:justify">@@.navytext;Any airway management difficulties should be clearly documented in the patients medical record. The patient needs follow up to communicate the difficulties and provide alerts as per local policy. Discussion with local airway leads and via morbidity and mortality meetings is appropriate.@@</p> [[I want another emergency|emerg1]] [[I'm done|exit2]] [[Show me the evidence|dasref]] <<audio "monitor" pause>> <<audio "monitorlow" pause>> <<audio "monitorlow1" pause>> <<audio "monitorlow2" pause>> <<audio "monitorlow3" pause>>

Difficult Airway Society website [[here|https://das.uk.com/]] Frerk C, Mitchell V, McNarry C, et al. Difficult Airway Society 2015 guidlines for management of unanticipated difficult intubation in adults. //BJA//. 2015; 115(6):827–848 [[Back|feedbackdas]]

<br> 'The ODP gives you 'the look'. You can hear a high pitched inspratory sound. The patients chest is sea-sawing as they try to drag every breath into their chest. [[That's stridor|lary2a][$q1 = "Yes"]] [[That's wheeze|lary2b][$q1 = "No"]] [[I don't know what's going on|lary2c][$q1 = "Got help"]] <<timed 59s>> <<goto lary2c>> <</timed>> <<countdownTimer 60 "lary2c">> <<audio "stridor" loop play>>

<br> ''What are you going to do about it? [[Jaw thrust|lary3b][$q2 = "No"]] [[Suction|lary3b][$q2 = "No"]] [[PEEP|lary3b][$q2 = "No"]] [[Get help|lary3a][$q2 = "Yes"]] [[I don't know|lary3c][$q2 = "Got help"]]'' <<timed 59s>> <<goto lary3c>> <</timed>> <<countdownTimer 60 "lary3c">>

<br> "Are they wheezy?" The ODP listens for a second. "No $firstname, that's stridor. What are you going to do about it?" [[Jaw thrust|lary3b][$q2 = "No"]] [[Suction|lary3b][$q2 = "No"]] [[PEEP|lary3b][$q2 = "No"]] [[Get help|lary3a][$q2 = "Yes"]] [[I don't know|lary3c][$q2 = "Got help"]] <<timed 59s>> <<goto lary3c>> <</timed>> <<countdownTimer 60 "lary3c">>

<br> "What's going on?" The ODP listens for a second. "That's stridor $firstname, what are you going to do about it?" [[Jaw thrust|lary3b][$q2 = "No"]] [[Suction|lary3b][$q2 = "No"]] [[PEEP|lary3b][$q2 = "No"]] [[Get help|lary3a][$q2 = "Yes"]] [[I don't know|lary3c][$q2 = "Got help"]] <<timed 59s>> <<goto lary3c>> <</timed>> <<countdownTimer 60 "lary3c">>

<br> "Let's sort out this airway." "Do you want help on the way $firstname?" "Yes, good idea. Then... [[put in an OP airway or NP airway|lary4b][$q3 = "No"]] [[do an emergency reintubation|lary4d][$q3 = "No"]] [[do a jaw thrust and stop other stimulation|lary4a][$q3 = "Yes"]] [[I don't know|lary4c][$q3 = "Got help"]] <<timed 59s>> <<goto lary4c>> <</timed>> <<countdownTimer 60 "lary4c">>

<br> What next? [[OP airway or NP airway|lary4b][$q3 = "No"]] [[Emergency reintubation|lary4d][$q3 = "No"]] [[Jaw thrust and stop other stimulation|lary4a][$q3 = "Yes"]] [[I don't know|lary4c][$q3 = "Got help"]] <<timed 59s>> <<goto lary4c>> <</timed>> <<countdownTimer 60 "lary4c">>

<br> "Do you want help on the way $firstname?" "Yes, good idea. Then... [[put in an OP airway or NP airway|lary4b][$q3 = "No"]] [[do an emergency reintubation|lary4d][$q3 = "No"]] [[do a jaw thrust and stop other stimulation|lary4a][$q3 = "Yes"]] [[I don't know|lary4c][$q3 = "Got help"]] <<timed 59s>> <<goto lary4c>> <</timed>> <<countdownTimer 60 "lary4c">>

<br> "Have you got an OP airway there?" "No, I can get one? Why don't you try a jaw thrust and minimise other stimulation to see if that helps?" Not helped. Now what? [[Stimulate the patient to break the laryngospasm|lary5b][$q4 = "No"]] [[Remove anything stimulating or obstructing the airway|lary5a][$q4 = "Yes"]] [[Laryngoscopy to look for a foreign body|lary5b][$q4 = "No"]] [[I don't know|lary5c][$q4 = "Got help"]] <<timed 59s>> <<goto lary5c>> <</timed>> <<countdownTimer 60 "lary5c">>

<br> Not helped. Now what? [[Stimulate the patient to break the laryngospasm|lary5b][$q4 = "No"]] [[Remove anything stimulating or obstructing the airway|lary5a][$q4 = "Yes"]] [[Laryngoscopy to look for a foreign body|lary5b][$q4 = "No"]] [[I don't know|lary5c][$q4 = "Got help"]] <<timed 59s>> <<goto lary5c>> <</timed>> <<countdownTimer 60 "lary5c">>

<br> You don't know what to do next. The ODP must be reading your thoughts "Why don't you try a jaw thrust and minimise other stimulation to see if that helps?" Not helped. Now what? [[Stimulate the patient to break the laryngospasm|lary5b][$q4 = "No"]] [[Remove anything stimulating or obstructing the airway|lary5a][$q4 = "Yes"]] [[Laryngoscopy to look for a foreign body|lary5b][$q4 = "No"]] [[I don't know|lary5c][$q4 = "Got help"]] <<timed 59s>> <<goto lary5c>> <</timed>> <<countdownTimer 60 "lary5c">>

<br> You reach for the laryngoscope, it will stimulate the patient and you can look for a FB at the same time. "Try this first." The ODP is holding out the yanker sucker. You suction the oropharynx under direct vision and reapply the facemask. Now what? [[High pressure ventilation with 100% oxygen|lary6b][$q5 = "No"]] [[CPAP with 100% oxygen|lary6a][$q5 = "Yes"]] [[I don't know|lary6c][$q5 = "Got help"]] <<timed 59s>> <<goto lary6c>> <</timed>> <<countdownTimer 60 "lary6c">>

<br> You suction the oropharynx under direct vision and reapply the facemask. Now what? [[High pressure ventilation with 100% oxygen|lary6b][$q5 = "No"]] [[CPAP with 100% oxygen|lary6a][$q5 = "Yes"]] [[I don't know|lary6c][$q5 = "Got help"]] <<timed 59s>> <<goto lary6c>> <</timed>> <<countdownTimer 60 "lary6c">>

<br> "Try this." The ODP is holding out the yanker sucker. You suction the oropharynx under direct vision and reapply the facemask. Now what? [[High pressure ventilation with 100% oxygen|lary6b][$q5 = "No"]] [[CPAP with 100% oxygen|lary6a][$q5 = "Yes"]] [[I don't know|lary6c][$q5 = "Got help"]] <<timed 59s>> <<goto lary6c>> <</timed>> <<countdownTimer 60 "lary6c">>

<br> "I'm going to try high pressure hand ventilation with the facemask." "They'll end up with belly full of air and then we'll have an aspiration to deal with too. Try some CPAP." The CPAP doesn't brake the laryngospasm. What do you do? [[Continue CPAP|lary7a][$q6 = "Yes"]] [[Stop CPAP|lary7b][$q6 = "No"]] [[I don't know|lary7c][$q6 = "Got help"]] <<timed 59s>> <<goto lary7c>> <</timed>> <<countdownTimer 60 "lary7c">>

<br> The CPAP hasn't broken the laryngospasm. What do you do? [[Continue CPAP|lary7a][$q6 = "Yes"]] [[Stop CPAP|lary7b][$q6 = "No"]] [[I don't know|lary7c][$q6 = "Got help"]] <<timed 59s>> <<goto lary7c>> <</timed>> <<countdownTimer 60 "lary7c">>

<br> "Try some CPAP $firstname, that always seems to work." The CPAP doesn't brake the laryngospasm. What do you do? [[Continue CPAP|lary7a][$q6 = "Yes"]] [[Stop CPAP|lary7b][$q6 = "No"]] [[I don't know|lary7c][$q6 = "Got help"]] <<timed 59s>> <<goto lary7c>> <</timed>> <<countdownTimer 60 "lary7c">>

<br> You continue the CPAP with 100% O~~2~~ "We need to... [[give sugammadex|lary8b][$q7 = "No"]] [[give neostigmine|lary8b][$q7 = "No"]] [[deepen them|lary8a][$q7 = "Yes"]] [[I don't know|lary8c][$q7 = "Got help"]] <<timed 59s>> <<goto lary8c>> <</timed>> <<countdownTimer 60 "lary8c">>

<br> "You need to keep going with the CPAP with 100% O~~2~~, it could still work. I'll get what you need." "OK, OK, we need to... [[give sugammadex|lary8b][$q7 = "No"]] [[give neostigmine|lary8b][$q7 = "No"]] [[deepen them|lary8a][$q7 = "Yes"]] [[I don't know|lary8c][$q7 = "Got help"]] <<timed 59s>> <<goto lary8c>> <</timed>> <<countdownTimer 60 "lary8c">>

<br> "You already gave reversal, we need to get them deeper to break this. What do you need?" [[Sevoflurane 8%|lary9b][$q8 = "No"]] [[Propofol 0.5 mg/kg|lary9a][$q8 = "Yes"]] [[I don't know|lary9c][$q8 = "Got help"]] <<timed 59s>> <<goto lary9c>> <</timed>> <<countdownTimer 60 "lary9c">>

<br> "We need to get them deeper to break this." What are you going to use? [[Sevoflurane 8%|lary9b][$q8 = "No"]] [[Propofol 0.5 mg/kg|lary9a][$q8 = "Yes"]] [[I don't know|lary9c][$q8 = "Got help"]] <<timed 59s>> <<goto lary9c>> <</timed>> <<countdownTimer 60 "lary9c">>

<br> "We need to get them deeper to break this. What do you need?" [[Sevoflurane 8%|lary9b][$q8 = "No"]] [[Propofol 0.5 mg/kg|lary9a][$q8 = "Yes"]] [[I don't know|lary9c][$q8 = "Got help"]] <<timed 59s>> <<goto lary9c>> <</timed>> <<countdownTimer 60 "lary9c">>

<br> "I'll put them back on the volatile." "Just listen $firstname, there isn't any gas going in!" "OK, propofol then." The patient's chest continues to see-saw. "They're going to develop negative pressure pulmonary oedema." "OK, we need to... [[Give a neuromuscular blocker|lary10a][$q9 = "Yes"]] [[Deepen them further|lary10b][$q9 = "No"]] [[I don't know|lary10c][$q9 = "Got help"]] <<timed 59s>> <<goto lary10c>> <</timed>> <<countdownTimer 60 "lary10c">>

<br> The patient's chest continues to see-saw. "They're going to develop negative pressure pulmonary oedema $firstname!" "OK, we need to... [[Give a neuromuscular blocker|lary10a][$q9 = "Yes"]] [[Deepen them further|lary10b][$q9 = "No"]] [[I don't know|lary10c][$q9 = "Got help"]] <<timed 59s>> <<goto lary10c>> <</timed>> <<countdownTimer 60 "lary10c">>

<br> "There isn't any gas going in, you are going to have to give them propofol" "OK, propofol then." The patient's chest continues to see-saw. "They're going to develop negative pressure pulmonary oedema $firstname!" "OK, we need to... [[Give a neuromuscular blocker|lary10a][$q9 = "Yes"]] [[Deepen them further|lary10b][$q9 = "No"]] [[I don't know|lary10c][$q9 = "Got help"]] <<timed 59s>> <<goto lary10c>> <</timed>> <<countdownTimer 60 "lary10c">>

<br> "Pass me the emergency drugs, we need to paralyse them." What are you going to give? [[Suxamethonium|lary11a][$q10 = "Yes"]] [[Rocuronium|lary11a][$q10 = "Yes"]] [[Atracurium|lary11a][$q10 = "Yes"]] [[I don't know|lary_none][$q10 = "Got help"]] <<timed 59s>> <<goto lary_none>> <</timed>> <<countdownTimer 60 "lary_none">>

<br> "Pass me the emergency drugs, we need to get them deeper." "They've had the propofol, you need to paralyse them $firstname. What are you going to give?" [[Suxamethonium|lary11a][$q10 = "Yes"]] [[Rocuronium|lary11a][$q10 = "Yes"]] [[Atracurium|lary11a][$q10 = "Yes"]] [[I don't know|lary_none][$q10 = "Got help"]] <<timed 59s>> <<goto lary_none>> <</timed>> <<countdownTimer 60 "lary_none">>

<br> The ODP goes to grab the emergency drugs but trips. They reach out to save themselves taking the drip stand down with them to the floor. "I’m OK, I’m OK, here’s the drugs." You both look to the floor, the cannula dangling on the end of the drip line, out of the patient. There’s no IV access. [[Get a line in|lary12b][$q11 = "No"]] [[Grab the IO gun|lary12b][$q11 = "No"]] [[Sux into the tongue|lary12a][$q11 = "Yes"]] [[I don't know|lary12c][$q11 = "Got help"]] <<timed 59s>> <<goto lary12c>> <</timed>> <<countdownTimer 60 "lary12c">>

<br> "We've got sux in the emergency drugs and there's half a syringe of rocuronium from the induction. Hang on. I'll go grab them." [[Next|lary11a]] <<timed 59s>> <<goto lary11a>> <</timed>> <<countdownTimer 60 "lary11a">>

<br> "There isn't time $firstname. Give the sux IM." How much? [[1.5 mg/kg|lary13b][$q12 = "No"]] [[2 mg/kg|lary13b][$q12 = "No"]] [[3.5 mg/kg|lary13b][$q12 = "No"]] [[4 mg/kg|lary13a][$q12 = "Yes"]] [[I don't know|lary13b][$q12 = "Got help"]] <<timed 59s>> <<goto lary13c>> <</timed>> <<countdownTimer 60 "lary13c">>

<<run forget("countdown")>> "It's 4 mg/kg straight into the tongue with a blue needle." You give the suxamethonium and try again with CPAP via the facemask. "Do we need to re-intubate?" Asks the ODP. [[Next|lary14]] <<audio "stridor" stop>> <<audio "stridor2" play>>

<<run forget("countdown")>> You give 4 mg/kg suxamethonium straight into the tongue with a blue needle and try again with CPAP via the facemask. "Do we need to re-intubate?" Asks the ODP. [[Next|lary14]] <<audio "stridor" stop>> <<audio "stridor2" play>>

<center> !!!@@.greentext;Laryngospasm in anaesthesia@@ <img src="images/lary.jpg" style="max-width: 100%;"/> ''Figure 1: Management of laryngospasm and stridor. From the Association of Anaesthetists Quick Reference Handbook (see refs)'' </center> <div class="notes">''Start''</div> @@.greentext;''Your answer:''@@ Correctly identified stridor: ''<<print $q1>>'' @@.greentext;''Feedback:''@@ Laryngospasm is an airway reflex causing sustained closure of the vocal cords and partial or complete airway obstruction. The incidence is ~ 1:100 rising to 1:5 in tonsillectomy/adenoidectomy. Risk factors: * Light anaesthesia at time of stimulus * Less experienced anaesthetist * Extubation > intubation * Irritant volatile used (des > iso > enf > sevo) * Soiling of the airway * Airway manipulation * Younger patients * Airway hyper-reactivity: asthma, smoker, passive smoking, URTI, reflux * Airway abnormalities * Surgery: anything with a shared airway, thyroid, oesophageal, cervical or anal dilation, I&D abscess <p style="text-align:justify">Pre-emptively deepening or analgising the patient just before peak surgical stimulation (e.g. the knife going into an abscess), relies on an understanding of the procedure, and having good communication with the operating surgeon. Use the team brief to discuss and plan. However most cases are precipitated by direct airway stimulation. Induction is the highest risk period with SAD, and emergence with ETT. The use of opioids decreases the incidence on induction, while extubating fully awake and gently decreases the incidence on emergence. Common signs of laryngospasm are inspiratory stridor, increased respiratory effort, tracheal tug, paradoxical chest/abdominal movements (see-saw breathing), desaturation with or without bradycardia, or complete airway obstruction See Figure 1, Box b for alternatives and mimics of laryngospasm.</p> <div class="notes">''1: Call for help and inform theatre team of problem''</div> @@.greentext;''Your answer:''@@ Called for help:''<<print $q2>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ Knowing where your help is coming from is as important as knowing where the defibrillator is. Make the theatre team aware of the problem as soon as identified.</p> <div class="notes">''2: Perform jaw thrust and stop any other stimulation''</div> @@.greentext;''Your answer:''@@ Perform jaw thrust and stop any other stimulation: ''<<print $q3>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ Laryngospasm is often precipitated by stimulation when the patient is light. Stop any stimulation including airway devices that may be stimulating the larynx. A jaw thrust will lift the tongue off the back pharyngeal wall and can improve airflow. Note: If you can see a cuffed ETT through the vocal cords, it means it isn’t laryngospasm, see Figure 1, Box B.</p> <div class="notes">''3: Remove airway devices and anything stimulating or obstructing the airway''</div> @@.greentext;''Your answer:''@@ Remove airway devices and anything stimulating or obstructing the airway: ''<<print $q4>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ Ensure the upper airway is patient while avoiding unnecessary stimulation. Gentle suction may be needed to clear soiling of the airway, but any airway stimulation can perpetuate and worsen the laryngospasm.</p> <div class="notes">''4: Gave CPAP with 100% oxygen and facemask''</div> @@.greentext;''Your answer:''@@ Gave CPAP with 100% oxygen and facemask: ''<<print $q5>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ Tighten the APL valve, use two hands to seal the facemask to the patient’s face, control the pressure by letting it out from under the mask. Avoid vigorous attempts at ventilation, it will fill the stomach, splint the diaphragm, and risks regurgitation. Sustained CPAP is frequently enough to relive laryngospasm.</p> <div class="notes">''5: When problem persists''</div> @@.greentext;''Your answers:''@@ Continued CPAP while taking further actions: ''<<print $q6>>'' Deepened anaesthesia when patient did not respond to CPAP: ''<<print $q7>>'' Deepened anaesthesia using suitable agent: ''<<print $q8>>'' Aware of need for neuromuscular blocking drug when no response to previous measures: ''<<print $q9>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ If the problem continues after removing the stimulus and applying CPAP, the next step is to deepen the patient. Propofol suppresses laryngeal reflexes and resolves laryngospasm in the majority of cases, particularly when airway manoeuvres have failed. While the laryngospasm is ongoing, delivery of volatile is unreliable so is not useful to rapidly deepen the patient. In spontaneously breathing patients this may lead to apnoea.</p> <div class="notes">''Box A: Drug doses for treatment of laryngospasm''</div> @@.greentext;''Your answer:''@@ Knew appropriate neuromuscular blocking drug to give IV: ''<<print $q10>>'' Aware of rescue route when IV access not available: ''<<print $q11>>'' Gave correct dose of IM suxamethonium: ''<<print $q12>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ Suxamethonium into the tongue will take several minutes for full paralysis, however when given IM the laryngospasm should break before peak effect within ~75 seconds. Be prepared for critical changes, see Figure 1, Box C. Hypoxia develops in over half of patients with significant laryngospasm, bradycardia in 6%, pulmonary oedema in 4%, and pulmonary aspiration in 3%. If the patient is bradycardic/hypotensive/in cardiac arrest, IM drugs may not get to their site of action. Even in profound hypoxia, the vocal cords may remain closed. After successful treatment, manage the precipitants. Decompress the stomach with a nasogastric tube. Make sure you have the right support for waking the patient. In some cases the patient may need re-intubation, especially when airway soiling or negative pressure pulmonary oedema has occurred. Bilateral vocal cord paralysis can present with stridor on extubation and will not get better with standard airway manoeuvres. The patient will require reintubation, and possibly tracheostomy.</p> [[I want another emergency|emerg1]] [[I'm done|exit2]] [[Show me the evidence|laryref]]

# The Association of Anaesthetists Quick Reference Handbook, available [[here|https://anaesthetists.org/Portals/0/PDFs/QRH/QRH_complete_January%202021.pdf?ver=2021-01-05-140039-337]] # Popat M, Mitchell V, Dravid R, et al. Difficult Airway Society Guidlines for the management of tracheal extubation. //Anaesth//. 2012; 67:318–340 # Gavel G, Walker R. Laryngospasm in anaesthesia. //CEACCP//. 2014; 14(2):47-51 [[Back|feedbacklary]]

<br> "We need to do an emergency re-intubation." "Hang on, why don't you try a jaw thrust and minimise other stimulation to see if that helps?" Not helped. Now what? [[Stimulate the patient to break the laryngospasm|lary5b][$q4 = "No"]] [[Remove anything stimulating or obstructing the airway|lary5a][$q4 = "Yes"]] [[Laryngoscopy to look for a foreign body|lary5b][$q4 = "No"]] [[I don't know|lary5c][$q4 = "Got help"]] <<timed 59s>> <<goto lary5c>> <</timed>> <<countdownTimer 60 "lary5c">>

<div class="leftcolumn"> The surgeon is itching to start. Let them? [[No|hot2a][$q1 = "Yes"]] [[Yes|hot2b][$q1 = "No"]] [[I don't know what's going on|hot2c][$q1 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''98''</span>@@ ^^%SpO2^^  <span class="blink2">''96''</span> @@.whitetext;^^CO~~2~~^^ ''6.2''@@</div></p></div> <<timed 59s>> <<goto hot2c>> <</timed>> <<countdownTimer 60 "hot2c">> <<audio "monitorfast" volume 0.3 loop play>>

<div class="leftcolumn"> "Hang on a second. We might have a problem let's... [[Get help on the way|hot3a][$q2 = "Yes"]] [[Get them deeper|hot3b][$q2 = "No"]] [[Abandon surgery and wake them|hot3b][$q2 = "No"]] [[I don't know what's going on|hot3c][$q2 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''102''</span>@@ ^^%SpO2^^  <span class="blink2">''94''</span> @@.whitetext;^^CO~~2~~^^ ''6.3''@@</div></p></div> <<timed 59s>> <<goto hot3c>> <</timed>> <<countdownTimer 60 "hot3c">>

<div class="leftcolumn"> "Hang on a second." The ODP nods to the anaesthetic machine monitor. "Actually we might have a problem let's... [[Get help on the way|hot3a][$q2 = "Yes"]] [[Get them deeper|hot3b][$q2 = "No"]] [[Abandon surgery and wake them|hot3b][$q2 = "No"]] [[I don't know what's going on|hot3c][$q2 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''102''</span>@@ ^^%SpO2^^  <span class="blink2">''94''</span> @@.whitetext;^^CO~~2~~^^ ''6.3''@@</div></p></div> <<timed 59s>> <<goto hot3c>> <</timed>> <<countdownTimer 60 "hot3c">>

<div class="leftcolumn"> "You can start." "Hang on a second $firstname." The ODP nods to the anaesthetic machine monitor. "Actually we might have a problem let's... [[Get help on the way|hot3a][$q2 = "Yes"]] [[Get them deeper|hot3b][$q2 = "No"]] [[I don't know what's going on|hot3c][$q2 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''102''</span>@@ ^^%SpO2^^  <span class="blink2">''94''</span> @@.whitetext;^^CO~~2~~^^ ''6.3''@@</div></p></div> <<timed 59s>> <<goto hot3c>> <</timed>> <<countdownTimer 60 "hot3c">>

<div class="leftcolumn"> "They're a bit light, we need to get them deeper." You increase the Fi O~~2~~ back to 1 while you work out what's going on. "Hey, $firstname. Look at this... <center> <img src="images/hot.jpg" style="max-width: 100%;"/> </center> ...we need to get some help on the way." What are you going to do next? [[Repeat the reading|hot4b][$q3 = "No"]] [[Check their core temp|hot4a][$q3 = "Yes"]] [[I don't know what's going on|hot4c][$q3 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''101''</span>@@ ^^%SpO2^^  <span class="blink2">''93''</span> @@.whitetext;^^CO~~2~~^^ ''6.6''@@</div></p></div> <<timed 59s>> <<goto hot4c>> <</timed>> <<countdownTimer 60 "hot4c">>

<div class="leftcolumn"> You increase the Fi O~~2~~ to 1 "Hey, $firstname. Look at this..." <center> <img src="images/hot.jpg" style="max-width: 100%;"/> </center> What are you going to do next? [[Repeat the reading|hot4b][$q3 = "No"]] [[Check their core temp|hot4a][$q3 = "Yes"]] [[I don't know what's going on|hot4c][$q3 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''101''</span>@@ ^^%SpO2^^  <span class="blink2">''93''</span> @@.whitetext;^^CO~~2~~^^ ''6.6''@@</div></p></div> <<timed 59s>> <<goto hot4c>> <</timed>> <<countdownTimer 60 "hot4c">>

<div class="leftcolumn"> "Hey, $firstname. Look at this... <center> <img src="images/hot.jpg" style="max-width: 100%;"/> </center> ...we need to get some help on the way." What are you going to do next? [[Repeat the reading|hot4b][$q3 = "No"]] [[Check their core temp|hot4a][$q3 = "Yes"]] [[I don't know what's going on|hot4c][$q3 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''101''</span>@@ ^^%SpO2^^  <span class="blink2">''93''</span> @@.whitetext;^^CO~~2~~^^ ''6.6''@@</div></p></div> <<timed 59s>> <<goto hot4c>> <</timed>> <<countdownTimer 60 "hot4c">>

<div class="leftcolumn"> The IR thermometer just reads Hi again so you try to slip down an oesophageal temperature probe. "Could you give me a hand getting their mouth open? Their teeth are clamped. Got it." The probe goes down. The reading comes up on the anaesthetic machine monitor. What's the most common cause of perioperative hyperthermia? [[Sepsis|hot5b][$q4 = "No"]] [[Iatrogenic warming|hot5a][$q4 = "Yes"]] [[Phaeochromocytoma|hot5b][$q4 = "No"]] [[Thyrotoxicosis|hot5b][$q4 = "No"]] [[Transfusion reactions|hot5b][$q4 = "No"]] [[I don't know|hot5c][$q4 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''104''</span>@@ ^^%SpO2^^  <span class="blink2">''94''</span> @@.whitetext;^^CO~~2~~^^ ''6.9'' ^^Temp^^ ''38.1''@@</div></p></div> <<timed 59s>> <<goto hot5c>> <</timed>> <<countdownTimer 60 "hot5c">>

<div class="leftcolumn"> "Could you give me a hand getting their mouth open. It's really tight?" You slip down an oesophageal temperature probe. The reading comes up on the anaesthetic machine monitor. What's the most common cause of perioperative hyperthermia? [[Sepsis|hot5b][$q4 = "No"]] [[Iatrogenic warming|hot5a][$q4 = "Yes"]] [[Phaeochromocytoma|hot5b][$q4 = "No"]] [[Thyrotoxicosis|hot5b][$q4 = "No"]] [[Transfusion reactions|hot5b][$q4 = "No"]] [[I don't know|hot5c][$q4 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''104''</span>@@ ^^%SpO2^^  <span class="blink2">''94''</span> @@.whitetext;^^CO~~2~~^^ ''6.9'' ^^Temp^^ ''38.1''@@</div></p></div> <<timed 59s>> <<goto hot5c>> <</timed>> <<countdownTimer 60 "hot5c">>

<div class="leftcolumn"> "This could just be faulty?" "No, they're hot, the ECG pads would'nt stick earlier." "Could you give me a hand getting their mouth open. It's really tight?" You slip down an oesophageal temperature probe. The reading comes up on the anaesthetic machine monitor. What's the most common cause of perioperative hyperthermia? [[Sepsis|hot5b][$q4 = "No"]] [[Iatrogenic warming|hot5a][$q4 = "Yes"]] [[Phaeochromocytoma|hot5b][$q4 = "No"]] [[Thyrotoxicosis|hot5b][$q4 = "No"]] [[Transfusion reactions|hot5b][$q4 = "No"]] [[I don't know|hot5c][$q4 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''104''</span>@@ ^^%SpO2^^  <span class="blink2">''94''</span> @@.whitetext;^^CO~~2~~^^ ''6.9'' ^^Temp^^ ''38.1''@@</div></p></div> <<timed 59s>> <<goto hot5c>> <</timed>> <<countdownTimer 60 "hot5c">>

<div class="leftcolumn"> "This could be anaphylaxis, or a phaeo, or a thyroid storm?!! Have they had blood? Is it a transfusion reaction?" "Hold your horses $firstname, lets make sure we haven’t done this, is the heated mattress on? And check the chart and make sure they weren’t already febrile." The ODP is under the operating table for a moment. "No, it's off, and these fluids are cold. What are you thinking $firstname?" [[Sepsis|hot6b][$q5 = "No"]] [[Anaphylaxis|hot6b][$q5 = "No"]] [[Malignant hyperthermia|hot6a][$q5 = "Yes"]] [[I don't know|hot6c][$q5 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''108''</span>@@ ^^%SpO2^^  <span class="blink2">''95''</span> @@.whitetext;^^CO~~2~~^^ ''7.2'' ^^Temp^^ ''38.2''@@</div></p></div> <<timed 59s>> <<goto hot6c>> <</timed>> <<countdownTimer 60 "hot6c">>

<div class="leftcolumn"> "Is the warming mattress on?" "No, it's off, and these fluids are cold. What are you thinking $firstname?" [[Sepsis|hot6b][$q5 = "No"]] [[Anaphylaxis|hot6b][$q5 = "No"]] [[Malignant hyperthermia|hot6a][$q5 = "Yes"]] [[I don't know|hot6c][$q5 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''108''</span>@@ ^^%SpO2^^  <span class="blink2">''95''</span> @@.whitetext;^^CO~~2~~^^ ''7.2'' ^^Temp^^ ''38.2''@@</div></p></div> <<timed 59s>> <<goto hot6c>> <</timed>> <<countdownTimer 60 "hot6c">>

<div class="leftcolumn"> "Lets make sure we haven’t done this $firstname, is the heated mattress on? And check the chart and make sure they weren’t already febrile." The ODP is under the operating table for a moment. "No, it's off, and these fluids are cold. What are you thinking $firstname?" [[Sepsis|hot6b][$q5 = "No"]] [[Anaphylaxis|hot6b][$q5 = "No"]] [[Malignant hyperthermia|hot6a][$q5 = "Yes"]] [[I don't know|hot6c][$q5 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''108''</span>@@ ^^%SpO2^^  <span class="blink2">''95''</span> @@.whitetext;^^CO~~2~~^^ ''7.2'' ^^Temp^^ ''38.2''@@</div></p></div> <<timed 59s>> <<goto hot6c>> <</timed>> <<countdownTimer 60 "hot6c">>

<div class="leftcolumn"> "Would that present like this, the elevated CO~~2~~, rising temp, and increased oxygen consumption?" "When you put it like that, this could be malignant hyperthermia." "OK, so what do you need?" "More help, get the arrest trolly and the... [[Intralipid|hot7b][$q6 = "No"]] [[Dantrolene|hot7a][$q6 = "Yes"]] [[Sugammadex|hot7b][$q6 = "No"]] [[I don't know|hot7c][$q6 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''108''</span>@@ ^^%SpO2^^  <span class="blink2">''96''</span> @@.whitetext;^^CO~~2~~^^ ''7.4'' ^^Temp^^ ''38.4''@@</div></p></div> <<timed 59s>> <<goto hot7c>> <</timed>> <<countdownTimer 60 "hot7c">>

<div class="leftcolumn"> "This could be malignant hyperthermia." "OK, what do you need?" "More help, get the arrest trolly and the... [[Intralipid|hot7b][$q6 = "No"]] [[Dantrolene|hot7a][$q6 = "Yes"]] [[Sugammadex|hot7b][$q6 = "No"]] [[I don't know|hot7c][$q6 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''108''</span>@@ ^^%SpO2^^  <span class="blink2">''96''</span> @@.whitetext;^^CO~~2~~^^ ''7.4'' ^^Temp^^ ''38.4''@@</div></p></div> <<timed 59s>> <<goto hot7c>> <</timed>> <<countdownTimer 60 "hot7c">>

<div class="leftcolumn"> "Think $firstname, what would present like this, the elevated CO~~2~~, rising temp, and increased oxygen consumption?" "When you put it like that, this could be malignant hyperthermia." "OK, so what do you need?" "More help, get the arrest trolly and the... [[Intralipid|hot7b][$q6 = "No"]] [[Dantrolene|hot7a][$q6 = "Yes"]] [[Sugammadex|hot7b][$q6 = "No"]] [[I don't know|hot7c][$q6 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''108''</span>@@ ^^%SpO2^^  <span class="blink2">''96''</span> @@.whitetext;^^CO~~2~~^^ ''7.4'' ^^Temp^^ ''38.4''@@</div></p></div> <<timed 59s>> <<goto hot7c>> <</timed>> <<countdownTimer 60 "hot7c">>

<div class="leftcolumn"> "It's dantrolene in the MH kit, one of the scrub team can go and get that?" "OK, yes, dantrolene." "Do you want the vapour-free anaesthetic machine?" the scrub nurse asks on her way out of the door. [[No|hot8a][$q7 = "Yes"]] [[Yes|hot8b][$q7 = "No"]] [[I don't know|hot8c][$q7 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''110''</span>@@ ^^%SpO2^^  <span class="blink2">''95''</span> @@.whitetext;^^CO~~2~~^^ ''7.6'' ^^Temp^^ ''38.6''@@</div></p></div> <<timed 59s>> <<goto hot8c>> <</timed>> <<countdownTimer 60 "hot8c">>

<div class="leftcolumn"> "Do you want the vapour-free anaesthetic machine?" One of the scrub team asks." [[No|hot8a][$q7 = "Yes"]] [[Yes|hot8b][$q7 = "No"]] [[I don't know|hot8c][$q7 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''110''</span>@@ ^^%SpO2^^  <span class="blink2">''95''</span> @@.whitetext;^^CO~~2~~^^ ''7.6'' ^^Temp^^ ''38.6''@@</div></p></div> <<timed 59s>> <<goto hot8c>> <</timed>> <<countdownTimer 60 "hot8c">>

<div class="leftcolumn"> "No, but we do need to get rid of the vaporiser, and set up TIVA. Can you get charcoal filters on both limbs of the circuit? I'll turn up the fresh gas flows to flush it, and hyperventilate to... [[1-2 x normal minute ventilation|hot9b][$q8 = "No"]] [[2-3 x normal minute ventilation|hot9a][$q8 = "Yes"]] [[3-4 x normal minute ventilation|hot9b][$q8 = "No"]] [[I don't know|hot9c][$q8 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''108''</span>@@ ^^%SpO2^^  <span class="blink2">''96''</span> @@.whitetext;^^CO~~2~~^^ ''7.8'' ^^Temp^^ ''38.9''@@</div></p></div> <<timed 59s>> <<goto hot9c>> <</timed>> <<countdownTimer 60 "hot9c">>

<div class="leftcolumn"> The ODP interrupts. "No, just get the kit, the machine is for known MH cases. We do need to get rid of the vaporiser, and set up TIVA. I can get you charcoal filters for both limbs of the circuit?" "OK, let's do that. I'll turn up the fresh gas flows to flush it, and hyperventilate to... [[1-2 x normal minute ventilation|hot9b][$q8 = "No"]] [[2-3 x normal minute ventilation|hot9a][$q8 = "Yes"]] [[3-4 x normal minute ventilation|hot9b][$q8 = "No"]] [[I don't know|hot9c][$q8 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''108''</span>@@ ^^%SpO2^^  <span class="blink2">''96''</span> @@.whitetext;^^CO~~2~~^^ ''7.8'' ^^Temp^^ ''38.9''@@</div></p></div> <<timed 59s>> <<goto hot9c>> <</timed>> <<countdownTimer 60 "hot9c">>

<div class="leftcolumn"> The ODP sees your indecision. "No, just get the kit, the machine is for known MH cases. We do need to get rid of the vaporiser, and set up TIVA. I can get you charcoal filters for both limbs of the circuit?" "OK, let's do that. I'll turn up the fresh gas flows to flush it, and hyperventilate to... [[1-2 x normal minute ventilation|hot9b][$q8 = "No"]] [[2-3 x normal minute ventilation|hot9a][$q8 = "Yes"]] [[3-4 x normal minute ventilation|hot9b][$q8 = "No"]] [[I don't know|hot9c][$q8 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''108''</span>@@ ^^%SpO2^^  <span class="blink2">''96''</span> @@.whitetext;^^CO~~2~~^^ ''7.8'' ^^Temp^^ ''38.9''@@</div></p></div> <<timed 59s>> <<goto hot9c>> <</timed>> <<countdownTimer 60 "hot9c">>

<div class="leftcolumn"> The ODP watches you changing the RR and TV. "I'd go for 2-3 x MV $firstname. It says it on the protocol out of the MH box." The ICU SpR and recovery staff come crashing through the anaesthetic room door with the arrest trolly and the dantrolene. "The consultants are both on their way in $firstname." What do you need to do? [[Hand over to the SpR|hot10b][$q9 = "No"]] [[Allocate jobs to the team|hot10a][$q9 = "Yes"]] [[Get the patient to ICU|hot10b][$q9 = "No"]] [[I don't know|hot10c][$q9 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''112''</span>@@ ^^%SpO2^^  <span class="blink2">''99''</span> @@.whitetext;^^CO~~2~~^^ ''8.2'' ^^Temp^^ ''39.1''@@</div></p></div> <<timed 59s>> <<goto hot10c>> <</timed>> <<countdownTimer 60 "hot10c">>

<div class="leftcolumn"> The ICU SpR and recovery staff come crashing through the anaesthetic room door with the arrest trolly and the dantrolene. "The consultants are both on their way in $firstname." What do you need to do? [[Hand over to the SpR|hot10b][$q9 = "No"]] [[Allocate jobs to the team|hot10a][$q9 = "Yes"]] [[Get the patient to ICU|hot10b][$q9 = "No"]] [[I don't know|hot10c][$q9 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''112''</span>@@ ^^%SpO2^^  <span class="blink2">''99''</span> @@.whitetext;^^CO~~2~~^^ ''8.2'' ^^Temp^^ ''39.1''@@</div></p></div> <<timed 59s>> <<goto hot10c>> <</timed>> <<countdownTimer 60 "hot10c">>

<div class="leftcolumn"> The ODP watches your hand hovering over the ventilator settings. "I'd go for 2-3 x MV $firstname. It says it on the protocol out of the MH box." The ICU SpR and recovery staff come crashing through the anaesthetic room door with the arrest trolly and the dantrolene. "The consultants are both on their way in $firstname." What do you need to do? [[Hand over to the SpR|hot10b][$q9 = "No"]] [[Allocate jobs to the team|hot10a][$q9 = "Yes"]] [[Get the patient to ICU|hot10b][$q9 = "No"]] [[I don't know|hot10c][$q9 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''112''</span>@@ ^^%SpO2^^  <span class="blink2">''99''</span> @@.whitetext;^^CO~~2~~^^ ''8.2'' ^^Temp^^ ''39.1''@@</div></p></div> <<timed 59s>> <<goto hot10c>> <</timed>> <<countdownTimer 60 "hot10c">>

<div class="leftcolumn"> The ICU SpR gives you a reasuring half smile. "It's OK. Let’s get them a bit more sorted here, what do you need everyone to do? What do you need me to do?" "Can you get an arterial line in please and get a gas?" The ICU SpR nods. Then to the ortho SpR "Can you start active cooling?" "We're on it." the SpR replies and there are nods from the scrub team. "Recovery team can you start making up the dantrolene?" "No problem, what dose do we start with?" [[100 mg|hot11b][$q10 = "No"]] [[200 mg|hot11a][$q10 = "Yes"]] [[300 mg|hot11b][$q10 = "No"]] [[400 mg|hot11b][$q10 = "No"]] [[I don't know|hot11c][$q10 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''110''</span>@@ ^^%SpO2^^  <span class="blink2">''97''</span> @@.whitetext;^^CO~~2~~^^ ''8.4'' ^^Temp^^ ''39.3''@@</div></p></div> <<timed 59s>> <<goto hot11c>> <</timed>> <<countdownTimer 60 "hot11c">>

<div class="leftcolumn"> "Can you get an arterial line in please and get a gas?" The ICU SpR nods. Then to the ortho SpR "Can you start active cooling?" "We're on it." the SpR replies and there are nods from the scrub team. "Recovery team can you start making up the dantrolene?" "No problem, what dose do we start with?" [[100 mg|hot11b][$q10 = "No"]] [[200 mg|hot11a][$q10 = "Yes"]] [[300 mg|hot11b][$q10 = "No"]] [[400 mg|hot11b][$q10 = "No"]] [[I don't know|hot11c][$q10 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''110''</span>@@ ^^%SpO2^^  <span class="blink2">''97''</span> @@.whitetext;^^CO~~2~~^^ ''8.4'' ^^Temp^^ ''39.3''@@</div></p></div> <<timed 59s>> <<goto hot11c>> <</timed>> <<countdownTimer 60 "hot11c">>

<div class="leftcolumn"> The ODP is rapidly typing into the calculator on their phone. "err...it's 2-3 mg/kg so I make that,...err...round it to 200 mg?" "OK, 200 mg then, get that in." "$firstname, after that do you want us to make more?" [[Yes|hot12a][$q11 = "Yes"]] [[No|hot12b][$q11 = "No"]] [[I don't know|hot12c][$q11 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''112''</span>@@ ^^%SpO2^^  <span class="blink2">''98''</span> @@.whitetext;^^CO~~2~~^^ ''8.6'' ^^Temp^^ ''39.4''@@</div></p></div> <<timed 59s>> <<goto hot12c>> <</timed>> <<countdownTimer 60 "hot12c">>

<div class="leftcolumn"> "The first lot of dantrolene is in $firstname, do you want us to make more?" [[Yes|hot12a][$q11 = "Yes"]] [[No|hot12b][$q11 = "No"]] [[I don't know|hot12c][$q11 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''112''</span>@@ ^^%SpO2^^  <span class="blink2">''98''</span> @@.whitetext;^^CO~~2~~^^ ''8.6'' ^^Temp^^ ''39.4''@@</div></p></div> <<timed 59s>> <<goto hot12c>> <</timed>> <<countdownTimer 60 "hot12c">>

<div class="leftcolumn"> "What dose do you want me to give this time?" [[1 mg/kg|hot13a][$q12 = "Yes"]] [[2 mg/kg|hot13b][$q12 = "No"]] [[3 mg/kg|hot13b][$q12 = "No"]] [[I don't know|hot13c][$q12 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''114''</span>@@ ^^%SpO2^^  <span class="blink2">''99''</span> @@.whitetext;^^CO~~2~~^^ ''8.0'' ^^Temp^^ ''39.4''@@</div></p></div> <<timed 59s>> <<goto hot13c>> <</timed>> <<countdownTimer 60 "hot13c">>

<div class="leftcolumn"> The ICU SpR shakes their head. "Temp is still above 38.5 and the CO~~2~~ above six so I'd definitely give more every five minutes." The recovery nurse nods. "What dose do you want me to give this time?" [[1 mg/kg|hot13a][$q12 = "Yes"]] [[2 mg/kg|hot13b][$q12 = "No"]] [[3 mg/kg|hot13b][$q12 = "No"]] [[I don't know|hot13c][$q12 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''114''</span>@@ ^^%SpO2^^  <span class="blink2">''99''</span> @@.whitetext;^^CO~~2~~^^ ''8.0'' ^^Temp^^ ''39.4''@@</div></p></div> <<timed 59s>> <<goto hot13c>> <</timed>> <<countdownTimer 60 "hot13c">>

<div class="leftcolumn"> The ICU SpR gestures towards the monitor. "Temp is still above 38.5 and the CO~~2~~ above six so I'd definitely give more every five minutes." The recovery nurse nods. "What dose do you want me to give this time?" [[1 mg/kg|hot13a][$q12 = "Yes"]] [[2 mg/kg|hot13b][$q12 = "No"]] [[3 mg/kg|hot13b][$q12 = "No"]] [[I don't know|hot13c][$q12 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''114''</span>@@ ^^%SpO2^^  <span class="blink2">''99''</span> @@.whitetext;^^CO~~2~~^^ ''8.0'' ^^Temp^^ ''39.4''@@</div></p></div> <<timed 59s>> <<goto hot13c>> <</timed>> <<countdownTimer 60 "hot13c">>

<div class="leftcolumn"> "$firstname, here's that gas" <center> <img src="images/abg.jpg" style="max-width: 100%;"/> </center> The ICU SpR looks over "How is it?" "We need to... [[...give bicarbonate|hot14a][$q13 = "Yes"]] [[...start CVVH|hot14b][$q13 = "No"]] [[...repeat this gas|hot14b][$q13 = "No"]] [[I don't know|hot14c][$q13 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink3">''120''</span>@@ ^^%SpO2^^  <span class="blink3">''97''</span> @@.whitetext;^^CO~~2~~^^ ''8.5'' ^^Temp^^ ''39.5''@@</div></p></div> <<timed 59s>> <<goto hot14c>> <</timed>> <<countdownTimer 60 "hot14c">>

<div class="leftcolumn"> "Protocol says 1 mg/kg. Ahh...here's that gas" <center> <img src="images/abg.jpg" style="max-width: 100%;"/> </center> The ICU SpR looks over "How is it?" "We need to... [[...give bicarbonate|hot14a][$q13 = "Yes"]] [[...start CVVH|hot14b][$q13 = "No"]] [[...repeat this gas|hot14b][$q13 = "No"]] [[I don't know|hot14c][$q13 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink3">''120''</span>@@ ^^%SpO2^^  <span class="blink3">''97''</span> @@.whitetext;^^CO~~2~~^^ ''8.5'' ^^Temp^^ ''39.5''@@</div></p></div> <<timed 59s>> <<goto hot14c>> <</timed>> <<countdownTimer 60 "hot14c">>

<div class="leftcolumn"> "OK. I'll put in another cannula. What bloods do you want $firstname?" "FBC, U&E, coagulation and... [[...TFT|hot15b][$q14 = "No"]] [[...metanephrines|hot15b][$q14 = "No"]] [[...CK|hot15a][$q14 = "Yes"]] [[...troponin|hot15b][$q14 = "No"]] [[I don't know|hot15c][$q14 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''108''</span>@@ ^^%SpO2^^  <span class="blink2">''99''</span> @@.whitetext;^^CO~~2~~^^ ''8.3'' ^^Temp^^ ''39.4''@@</div></p></div> <<timed 59s>> <<goto hot15c>> <</timed>> <<countdownTimer 60 "hot15c">>

<div class="leftcolumn"> The ICU SpR has been reading it over your shoulder. "They might need to go on the filter down the line, but for now lets give some bicarb as a stopgap at least. I'll put in another cannula. What bloods do you want $firstname?" "FBC, U&E, coagulation and... [[...TFT|hot15b][$q14 = "No"]] [[...metanephrines|hot15b][$q14 = "No"]] [[...CK|hot15a][$q14 = "Yes"]] [[...troponin|hot15b][$q14 = "No"]] [[I don't know|hot15c][$q14 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''108''</span>@@ ^^%SpO2^^  <span class="blink2">''99''</span> @@.whitetext;^^CO~~2~~^^ ''8.3'' ^^Temp^^ ''39.4''@@</div></p></div> <<timed 59s>> <<goto hot15c>> <</timed>> <<countdownTimer 60 "hot15c">>

<div class="leftcolumn"> "Don't forget to get a CK. These patients can go on to develop rhabdomyolysis and need fasciotomies." "OK, yes please, add that." [[Next|hot16]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox"> @@.lightgreentext;^^HR^^  <span class="blink2">''108''</span>@@ ^^%SpO2^^  <span class="blink2">''98''</span> @@.whitetext;^^CO~~2~~^^ ''8.2'' ^^Temp^^ ''38.7''@@</div></p></div> <<run forget("countdown")>>

Two hours later your patient is stable on ICU. The ICU and anaesthetic consultants are both in. You are grabbing a hot drink and having a bit of an informal debrief with the ICU SpR. "Well done $firstname, not easy, hopefully that’s a once in a career event for both of us!" [[Feedback on how I did|feedbackhot]] [[I want another emergency|emerg1]] <<audio "monitorfast" pause>> <<set $id to "mhIAC">> <<set _data = {randomid: $randomid, id: $id, q1: $q1, q2: $q2, q3: $q3, q4: $q4, q5: $q5, q6: $q6, q7: $q7, q8: $q8, q9: $q9, q10: $q10, q11: $q11, q12: $q12, q13: $q13, q14: $q14 }>> <<run sendData(_data)>>

<center> !!!@@.greentext;Malignant hyperthermia crisis@@ <img src="images/hotpic.jpg" style="max-width: 100%;"/> ''Figure 1: Management of malignant hyperthermia crisis. From the Association of Anaesthetists Quick Reference Handbook (see refs)'' </center> <div class="notes">''1: Call for help and inform theatre team of problem, note the time''</div> @@.greentext;''Your answer:''@@ Identified problem and did not start surgery: ''<<print $q1>>'' Informed theatre team of problem and called for help: ''<<print $q2>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ The elevated heart rate and CO~~2~~ at this point could reflect a number of issues. However these physiological derangements need an explanation and management before proceeding with surgery. A rapid assessment of OABCD: * Oxygen delivery * Airway secure, and patent, with a normal capnograph trace * Breathing assessment including SpO~~2~~, measured tidal volumes, and ETCO~~2~~. Listen to the chest. Feel the airway pressure using the reservoir bag and APL valve, but only for a couple of breaths. Holding onto the reservoir bag is not a surrogate for action. * Circulation assessment of rate, rhythm, re-check BP, CRT * Depth of anaesthesia and NMB? When the abnormalities do not immediately respond to simple measures, call for help sooner rather than later. You should already know where your help is coming from. Note the time.</p> <div class="notes">''2: Measure and record core temperature''</div> @@.greentext;''Your answer:''@@ Aware of need for core temperature: ''<<print $q3>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ When an abnormal peripheral temperature is identified, a core temperature should be measured and recorded.</p> ''Quickly assess:'' * Febrile hyperthermia (e.g. sepsis): cool/vasoconstricted peripheries ''OR'' * Non-febrile hyperthermia (e.g. iatrogenic warming): warm/vasodilated peripheries <div class="notes">''3: Make an initial diagnosis of the cause as this affects further management''</div> @@.greentext;''Your answer:''@@ Knows the most common causes of perioperative hyperthermia and rapidly rules these out: ''<<print $q4>>'' Correctly identifies MH as a possible cause of elevated CO~~2~~, increased oxygen consumption and tachycardia: ''<<print $q5>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ The most common causes of hyperthermia: * Iatrogenic warming (e.g. warm fluids, over insulated, warming devices, diathermy) * Prolonged epidural anaesthesia * Sepsis * Transfusion reactions * Allergic reactions including anaphylaxis There is limited history for this patient, but they are having an ORIF radius/ulnar and the anaesthetic has only just started which can eliminate a number of these diagnoses immediately.</p> ''Consider MH when unexplainined:'' <center> !! <img src="images/arrow.jpg" style="max-width: 25px;"/> ETCO~~2~~ + <img src="images/arrow.jpg" style="max-width: 25px;"/> HR + <img src="images/arrow.jpg" style="max-width: 25px;"/> oxygen consumption ''+/- muscle rigidity (esp masseter muscle spasm)'' <img src="images/arrow.jpg" style="max-width: 15px;"/> ''core temp may be small and/or a late sign'' </center> <p style="text-align:justify">MH is an inherited myopathy due to a genetic mutation in the ryanodine receptor gene (RYR1), or a mutation in the gene encoding the L-type voltage-gated calcium channel that activates RYR~~1~~. The presence of a trigger agent causes sustained calcium release in skeletal muscle. Calcium accumulation leads to muscle rigidity, increasing metabolic demand, and CO~~2~~ and heat production. * MH is RARE occurring in 1:30,000 to 1:200,000 anaesthetics (RCoA) * Other causes are more common and should be considered * ''Previous uneventful exposure to trigger agents doesn’t rule out MH'' (one individual developed MH on their 31^^st^^ exposure) * Associated with myotonia congenita and both Duchenne muscular dystrophy and Becker's muscular dystrophy * Onset can be immediate or after several hours of exposure to trigger agent * ''Triggers:'' volatiles and suxamethonium ''Differentials include:'' pre-existing sepsis, anaphylaxis, tourniquet ischaemia, prolonged or high pressure CO~~2~~ insufflation), neuromuscular disorders, phaeochromocytoma, thyroid storm, serotonin syndrome, neuroleptic malignant syndrome.</p> <div class="notes">''Call for MH treatment pack/dantrolene and cardiac arrest trolley''</div> @@.greentext;''Your answer:''@@ Asked for dantrolene: ''<<print $q6>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ Dantrolene reduces the accumulation of calcium within muscle cells. Departments will have agreed stocks of dantrolene. To avoid wastage this may be shared between several areas where anaesthetics are given, with each area detailing where other vials are located. With ongoing reactions 50+ vials may be needed.</p> <div class="notes">''Eliminate trigger drug''</div> @@.greentext;''Your answer:''@@ Took the correct steps to remove trigger agents: ''<<print $q7>>'' Hyperventilated to 2-3 x normal minute ventilation: ''<<print $q8>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ Volatile-free anaesthetic machines are for use in patients with known susceptibility. There would be a delay collecting and setting up the machine and the patient’s lungs are now full of volatile which would contaminate it for subsequent use. ''Actions:'' * Remove the vaporiser from the anaesthetic machine * Turn up to 100% oxygen, max flow rate * Place activated charcoal filters on both inspiratory and expiratory limb of the circuit * When time allows, change the soda lime and circuit, but be aware soda lime may be rapidly exhausted with ↑CO~~2~~ production * Maintain anaesthesia with TIVA and non-depolarizing muscle relaxant If no charcoal filters are immediately available manually hyperventilate the patient’s lungs using a non-rebreathing circuit (e.g. self-inflating bag) and oxygen. Flush the machine with maximum oxygen and air flows for 5 min while not attached to the patient, change circuit, change soda lime, then go back on machine.</p> <div class="notes">''Allocate enough team members to perform tasks simultaneously''</div> @@.greentext;''Your answer:''@@ Allocated roles to the team so tasks occur simultaneously: ''<<print $q9>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ See Boxes A to C in figure 1 above. Prioritise: * Eliminating trigger drug * Giving dantrolene * Active cooling </p> <div class="notes">''Dantrolene''</div> @@.greentext;''Your answer:''@@ Gave correct loading dose of dantrolene for an adult: ''<<print $q10>>'' Repeated dantrolene after five minutes when physiological parameters did not improve: ''<<print $q11>>'' Gave correct repeat dose: ''<<print $q12>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ Dantrolene: first dose 2-3 mg/kg, repeat doses 1 mg/kg Dantrolene comes as an orange powder in 20 mg vials each to be dissolved with 60 ml of water for injection. It’s hard to mix and the first dose in an average adult is around 10 vials. Dedicate enough people to the task. Repeat doses every five minutes until ETCO~~2~~ under 6 kPa and core temp under 38.5^^o^^C. Be ready to re-start dantrolene as the hypermetabolic reaction can reoccur for many hours after the initial resolution.</p> <div class="notes">''Seek and treat complications''</div> @@.greentext;''Your answer:''@@ Identified ABG abnormalities and gave bicarbonate: ''<<print $q13>>'' Requested appropriate urgent blood tests including creatinine kinase: ''<<print $q14>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ Complications are common (see Box D, figure 1 above for initial management). Cardiac arrest should be managed as per ALS guidelines. Calcium channel blockers should be avoided as they may cause severe myocardial depression in combination with dantrolene. After the immediate crisis, thoroughly document events and work with the team to ensure correct ongoing care and follow up. The RCoA have an MH patient information leaflet available [[here|https://rcoa.ac.uk/sites/default/files/documents/2021-02/FS_MaligHyperthermia2021web.pdf]] @@.greentext;''St James's Hospital Leeds is the national centre for malignant hyperthermia and provides investigation and anaesthetic advice for patients with known or suspected MH. They provide a 24 hour "hot line" service (correct as of September 2023):''@@</p> <center> !!!Direct Line: 0113 20 65270 !!!Emergency 24 hour Hot-Line: 07947 609601 </center> [[I want another emergency|emerg1]] [[I'm done|exit2]] [[Show me the evidence|hotref]]

# The Association of Anaesthetists Quick Reference Handbook, available [[here|https://anaesthetists.org/Portals/0/PDFs/QRH/QRH_complete_January%202021.pdf?ver=2021-01-05-140039-337]] # Gupta P, Hopkins P. Diagnosis and management of malignant hyperthermia. //BJA//. 2017; 17(7):249-254 [[Back|feedbackhot]]

<div class="leftcolumn">"We can give this a good washout and...is everything OK?" [[Stop surgery a minute|hypo2a][$q1 = "Yes"]] [[Their MAC is too high|hypo2b][$q1 = "No"]] [[I don't know what's going on|hypo2c][$q1 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink2">''98''</span>@@ ^^NIBP^^ @@.delayed;''91/62''@@</div></p></div> <<timed 59s>> <<goto hypo2c>> <</timed>> <<countdownTimer 60 "hypo2c">> <<audio "monitor" pause>> <<audio "monitorfast" volume 0.3 loop play>>

<div class="leftcolumn">What's your priority? [[Give metaraminol|hypo3b][$q2 = "No"]] [[Finish surgery|hypo3b][$q2 = "No"]] [[Reduce their MAC|hypo3b][$q2 = "No"]] [[Oxygen delivery|hypo3a][$q2 = "Yes"]] [[Give ephedrine|hypo3b][$q2 = "No"]] [[I don't know what's going on|hypo3c][$q2 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink2">''102''</span>@@ ^^NIBP^^ @@.delayed;''91/62''@@</div></p></div> <<timed 59s>> <<goto hypo3c>> <</timed>> <<countdownTimer 60 "hypo3c">>

<div class="leftcolumn">"They're just a bit deep, it's dropped their pressure." The ODP raises an eyebrow. "With that heart rate?" The ODP nods towards the monitor. "Look, if the heart rate is greater than the systolic BP somethings not right." What's your priority? [[Give metaraminol|hypo3b][$q2 = "No"]] [[Finish surgery|hypo3b][$q2 = "No"]] [[Reduce their MAC|hypo3b][$q2 = "No"]] [[Oxygen delivery|hypo3a][$q2 = "Yes"]] [[Give ephedrine|hypo3b][$q2 = "No"]] [[I don't know what's going on|hypo3c][$q2 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink2">''102''</span>@@ ^^NIBP^^ @@.delayed;''91/62''@@</div></p></div> <<timed 59s>> <<goto hypo3c>> <</timed>> <<countdownTimer 60 "hypo3c">>

<div class="leftcolumn">"I'm not sure?" The ODP nods towards the monitor. "Look, if the heart rate is greater than the systolic BP somethings not right." What's your priority? [[Give metaraminol|hypo3b][$q2 = "No"]] [[Finish surgery|hypo3b][$q2 = "No"]] [[Reduce their MAC|hypo3b][$q2 = "No"]] [[Oxygen delivery|hypo3a][$q2 = "Yes"]] [[Give ephedrine|hypo3b][$q2 = "No"]] [[I don't know what's going on|hypo3c][$q2 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink2">''102''</span>@@ ^^NIBP^^ @@.delayed;''91/62''@@</div></p></div> <<timed 59s>> <<goto hypo3c>> <</timed>> <<countdownTimer 60 "hypo3c">>

<div class="leftcolumn">You change the FGF to 100% O~~2~~ and quickly scan the circuit. The CO~~2~~ trace is normal. The age adjusted MAC is just over 1. "Do you want me to call for help?" The ODP asks. [[No|hypo4b][$q3 = "No"]] [[Yes|hypo4a][$q3 = "Yes"]] [[I don't know|hypo4c][$q3 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink3">''118''</span>@@ ^^NIBP^^ @@.delayed;''91/62''@@</div></p></div> <<timed 59s>> <<goto hypo4c>> <</timed>> <<countdownTimer 60 "hypo4c">> <<audio "monitorfast" pause>> <<audio "monitor120" volume 0.3 loop play>>

<div class="leftcolumn">"Let's get the surgery done, I can wake them up. In the meantime I'll give some uppers." "Shall I turn the oxygen up?" The ODP pointedly asks. "No I'm on it." You change the FGF to 100% O~~2~~ and quickly scan the circuit. The CO~~2~~ trace is normal. The age adjusted MAC is just over 1. "Do you want me to call for help?" [[No|hypo4b][$q3 = "No"]] [[Yes|hypo4a][$q3 = "Yes"]] [[I don't know|hypo4c][$q3 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink3">''118''</span>@@ ^^NIBP^^ @@.delayed;''91/62''@@</div></p></div> <<timed 59s>> <<goto hypo4c>> <</timed>> <<countdownTimer 60 "hypo4c">> <<audio "monitorfast" pause>> <<audio "monitor120" volume 0.3 loop play>>

<div class="leftcolumn">"Shall I turn the oxygen up?" The ODP pointedly asks. "No I'm on it." You change the FGF to 100% O~~2~~ and quickly scan the circuit. The CO~~2~~ trace is normal. The age adjusted MAC is just over 1. "Do you want me to call for help?" The ODP asks. [[No|hypo4b][$q3 = "No"]] [[Yes|hypo4a][$q3 = "Yes"]] [[I don't know|hypo4c][$q3 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink3">''118''</span>@@ ^^NIBP^^ @@.delayed;''91/62''@@</div></p></div> <<timed 59s>> <<goto hypo4c>> <</timed>> <<countdownTimer 60 "hypo4c">> <<audio "monitorfast" pause>> <<audio "monitor120" volume 0.3 loop play>>

<div class="leftcolumn">"It would be worth getting help on the way $firstname. Better a false alarm than leave it too late." You have a quick listen to the chest and notice a red flush across the patient's throat. Their breath sounds are coarse and wheezy. "I think this is... [[...sepsis|hypo5b][$q4 = "No"]] [[...pulmonary oedema|hypo5b][$q4 = "No"]] [[...anaphylaxis|hypo5a][$q4 = "Yes"]] [[I don't know what's going on|hypo5c][$q4 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink3">''122''</span>@@ ^^NIBP^^ @@.delayed;''87/50''@@</div></p></div> <<timed 59s>> <<goto hypo5c>> <</timed>> <<countdownTimer 60 "hypo5c">> <<audio "monitorfast" pause>> <<audio "monitor120" volume 0.3 loop play>>

<div class="leftcolumn">You have a quick listen to the chest and notice a red flush across the patient's throat. Their breath sounds are coarse and wheezy. "I think this is... [[...sepsis|hypo5b][$q4 = "No"]] [[...pulmonary oedema|hypo5b][$q4 = "No"]] [[...anaphylaxis|hypo5a][$q4 = "Yes"]] [[I don't know what's going on|hypo5c][$q4 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink3">''122''</span>@@ ^^NIBP^^ @@.delayed;''87/50''@@</div></p></div> <<timed 59s>> <<goto hypo5c>> <</timed>> <<countdownTimer 60 "hypo5c">> <<audio "monitorfast" pause>> <<audio "monitor120" volume 0.3 loop play>>

<div class="leftcolumn">"Why don't we get help on the way $firstname. Better a false alarm than leave it too late." You have a quick listen to the chest. Their breath sounds are coarse and wheezy. "I think this is... [[...sepsis|hypo5b][$q4 = "No"]] [[...pulmonary oedema|hypo5b][$q4 = "No"]] [[...anaphylaxis|hypo5a][$q4 = "Yes"]] [[I don't know what's going on|hypo5c][$q4 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink3">''122''</span>@@ ^^NIBP^^ @@.delayed;''87/50''@@</div></p></div> <<timed 59s>> <<goto hypo5c>> <</timed>> <<countdownTimer 60 "hypo5c">> <<audio "monitorfast" pause>> <<audio "monitor120" volume 0.3 loop play>>

<div class="leftcolumn">"Their chest sound's terrible, this could be sepsis, or maybe flash pulmonary oedema?" "They were systemically well when I saw them in the ED $firstname?" The plastics SpR chips in. "No medical history either, works as a tree surgeon." "OK. Then I think this is anaphylaxis. I need..." [[...the anaphylaxis kit|hypo6b][$q5 = "No"]] [[...the arrest trolly|hypo6b][$q5 = "No"]] [[...more help|hypo6b][$q5 = "No"]] [[...all of these things|hypo6a][$q5 = "Yes"]] [[...someone to tell me what to do next|hypo6c][$q5 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink3">''122''</span>@@ ^^NIBP^^ @@.delayed;''87/50''@@</div></p></div> <<timed 59s>> <<goto hypo6c>> <</timed>> <<countdownTimer 60 "hypo6c">>

<div class="leftcolumn">"I think this is anaphylaxis. I need..." [[...the anaphylaxis kit|hypo6b][$q5 = "No"]] [[...the arrest trolly|hypo6b][$q5 = "No"]] [[...more help|hypo6b][$q5 = "No"]] [[...all of these things|hypo6a][$q5 = "Yes"]] [[...someone to tell me what to do next|hypo6c][$q5 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink3">''122''</span>@@ ^^NIBP^^ @@.delayed;''87/50''@@</div></p></div> <<timed 59s>> <<goto hypo6c>> <</timed>> <<countdownTimer 60 "hypo6c">>

<div class="leftcolumn">"Their chest sounds terrible. I'm not sure what's going on." "They were systemically well when I saw them in the ED $firstname?" The plastics SpR chips in. "No medical history either, works as a tree surgeon." "OK. Then I think this is anaphylaxis. I need..." [[...the anaphylaxis kit|hypo6b][$q5 = "No"]] [[...the arrest trolly|hypo6b][$q5 = "No"]] [[...more help|hypo6b][$q5 = "No"]] [[...all of these things|hypo6a][$q5 = "Yes"]] [[...someone to tell me what to do next|hypo6c][$q5 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink3">''122''</span>@@ ^^NIBP^^ @@.delayed;''87/50''@@</div></p></div> <<timed 59s>> <<goto hypo6c>> <</timed>> <<countdownTimer 60 "hypo6c">>

<div class="leftcolumn">"If I'm going to sort that, would it be best if I just get everything at the same time?" The scrub nurse asks on her way to the door. The plastics SpR looks uneasy. "Anaphylaxis? Was it the teicoplanin?" "That's the obvious one but could be... [[...the NSAID|hypo7b][$q6 = "No"]] [[...rocuronium|hypo7b][$q6 = "No"]] [[...latex|hypo7b][$q6 = "No"]] [[...chlorhexidine|hypo7b][$q6 = "No"]] [[...colloid|hypo7b][$q6 = "No"]] [[...all of the above|hypo7a][$q6 = "Yes"]] [[I don't know|hypo7c][$q6 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink3">''119''</span>@@ ^^NIBP^^ @@.delayed;''77/46''@@</div></p></div> <<timed 59s>> <<goto hypo7c>> <</timed>> <<countdownTimer 60 "hypo7c">>

<div class="leftcolumn">The scrub nurse goes to get the anaphylaxis treatment pack and the arrest trolly. "Anaphylaxis? Was it the teicoplanin?" "That's the obvious one but could be... [[...the NSAID|hypo7b][$q6 = "No"]] [[...rocuronium|hypo7b][$q6 = "No"]] [[...latex|hypo7b][$q6 = "No"]] [[...chlorhexidine|hypo7b][$q6 = "No"]] [[...colloid|hypo7b][$q6 = "No"]] [[...all of the above|hypo7a][$q6 = "Yes"]] [[I don't know|hypo7c][$q6 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink3">''119''</span>@@ ^^NIBP^^ @@.delayed;''77/46''@@</div></p></div> <<timed 59s>> <<goto hypo7c>> <</timed>> <<countdownTimer 60 "hypo7c">>

<div class="leftcolumn">"There's an anaphylaxis kit next to the arrest trolly, let's get both in here, and all the help we can get." the ODP nods to the scrub nurse who's already part way to the door. The plastics SpR looks uneasy. "Anaphylaxis? Was it the teicoplanin?" "That's the obvious one but could be... [[...the NSAID|hypo7b][$q6 = "No"]] [[...rocuronium|hypo7b][$q6 = "No"]] [[...latex|hypo7b][$q6 = "No"]] [[...chlorhexidine|hypo7b][$q6 = "No"]] [[...colloid|hypo7b][$q6 = "No"]] [[...all of the above|hypo7a][$q6 = "Yes"]] [[I don't know|hypo7c][$q6 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink3">''119''</span>@@ ^^NIBP^^ @@.delayed;''77/46''@@</div></p></div> <<timed 59s>> <<goto hypo7c>> <</timed>> <<countdownTimer 60 "hypo7c">>

<div class="leftcolumn">The anaphylaxis kit isn't here yet. You give metaraminol from the emergency drugs, raise the leg end of the table, and open the roller-clamp on the fluid line. What are you going to do next? [[Another cannula|hypo8b][$q7 = "No"]] [[Change the airway|hypo8a][$q7 = "Yes"]] [[Art line|hypo8b][$q7 = "No"]] [[Central line|hypo8b][$q7 = "No"]] [[I don't know|hypo8c][$q7 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink3">''124''</span>@@ ^^NIBP^^ @@.delayed;''66/46''@@</div></p></div> <<timed 59s>> <<goto hypo8c>> <</timed>> <<countdownTimer 60 "hypo8c">>

<div class="leftcolumn">"You concentrate on securing the airway $firstname, I can put another line in." The plastics SpR offers. You give muscle relaxant and intubate. "Here's the anaphylaxsis kit $firstname." You have your hands on a pre-filled 1:10,000 adrenaline and quickly give... [[1 ml IM|hypo9b][$q8 = "No"]] [[1 ml IV|hypo9b][$q8 = "No"]] [[0.5 ml IM|hypo9b][$q8 = "No"]] [[0.5 ml IV|hypo9a][$q8 = "Yes"]] [[I don't know|hypo9c][$q8 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink3">''124''</span>@@ ^^NIBP^^ @@.delayed;''66/46''@@</div></p></div> <<timed 59s>> <<goto hypo9c>> <</timed>> <<countdownTimer 60 "hypo9c">>

<div class="leftcolumn">"Let's make sure the airway is secure, the plastics SpR can put another line in." The ODP suggests. You give muscle relaxant and intubate. "Here's the anaphylaxsis kit $firstname." You have your hands on a pre-filled 1:10,000 adrenaline and quickly give... [[1 ml IM|hypo9b][$q8 = "No"]] [[1 ml IV|hypo9b][$q8 = "No"]] [[0.5 ml IM|hypo9b][$q8 = "No"]] [[0.5 ml IV|hypo9a][$q8 = "Yes"]] [[I don't know|hypo9c][$q8 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink3">''124''</span>@@ ^^NIBP^^ @@.delayed;''66/46''@@</div></p></div> <<timed 59s>> <<goto hypo9c>> <</timed>> <<countdownTimer 60 "hypo9c">>

<div class="leftcolumn">"Here's the anaphylaxsis kit $firstname." You have your hands on a pre-filled 1:10,000 adrenaline and quickly give... [[1 ml IM|hypo9b][$q8 = "No"]] [[1 ml IV|hypo9b][$q8 = "No"]] [[0.5 ml IM|hypo9b][$q8 = "No"]] [[0.5 ml IV|hypo9a][$q8 = "Yes"]] [[I don't know|hypo9c][$q8 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink3">''124''</span>@@ ^^NIBP^^ @@.delayed;''66/46''@@</div></p></div> <<timed 59s>> <<goto hypo9c>> <</timed>> <<countdownTimer 60 "hypo9c">>

<div class="leftcolumn">"Errr...there's a laminated guidline in here that says. 0.5 ml of 1:10,000 IV." The ODP offers the sheet. "OK, le'ts give that." "What do you need me to do?" The plastics SpR asks while staring fixedly at the monitor. [[Give hydrocortisone|hypo10b][$q9 = "No"]] [[Give chlorphenamine|hypo10b][$q9 = "No"]] [[Take a sample for serum tryptase|hypo10b][$q9 = "No"]] [[Start chest compressions|hypo10a][$q9 = "Yes"]] [[I don't know|hypo10c][$q9 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink4">''152''</span>@@ ^^NIBP^^ @@.delayed;''46/-''@@</div></p></div> <<timed 59s>> <<goto hypo10c>> <</timed>> <<countdownTimer 60 "hypo10c">> <<audio "monitor120" pause>> <<audio "monitor150" volume 0.3 loop play>>

<div class="leftcolumn">"What do you need me to do?" The plastics SpR asks while staring fixedly at the monitor. [[Give hydrocortisone|hypo10b][$q9 = "No"]] [[Give chlorphenamine|hypo10b][$q9 = "No"]] [[Take a sample for serum tryptase|hypo10b][$q9 = "No"]] [[Start chest compressions|hypo10a][$q9 = "Yes"]] [[I don't know|hypo10c][$q9 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink4">''155''</span>@@ ^^NIBP^^ @@.delayed;''46/-''@@</div></p></div> <<timed 59s>> <<goto hypo10c>> <</timed>> <<countdownTimer 60 "hypo10c">> <<audio "monitor120" pause>> <<audio "monitor150" volume 0.3 loop play>>

<div class="leftcolumn">"Errr...there's a laminated guidline in here that says. 0.5 ml of 1:10,000 IV." The ODP offers the sheet. "OK, let's give that." "What do you need me to do?" The plastics SpR asks while staring fixedly at the monitor. [[Give hydrocortisone|hypo10b][$q9 = "No"]] [[Give chlorphenamine|hypo10b][$q9 = "No"]] [[Take a sample for serum tryptase|hypo10b][$q9 = "No"]] [[Start chest compressions|hypo10a][$q9 = "Yes"]] [[I don't know|hypo10c][$q9 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink4">''155''</span>@@ ^^NIBP^^ @@.delayed;''46/-''@@</div></p></div> <<timed 59s>> <<goto hypo10c>> <</timed>> <<countdownTimer 60 "hypo10c">> <<audio "monitor120" pause>> <<audio "monitor150" volume 0.3 loop play>>

<div class="leftcolumn">"With that BP someone needs to get on the chest $firstname!" The scrub nurse and plastics SpR oblige. You give two further 0.5 ml of 1:10,000 adrenaline and a further rapid bolus of crystallioid. "BP is back up, I can feel a decent carotid pulse. You can stop compressions." "Thank goodness, what now $firstname?" [[Start an adrenaline infusion|hypo11a][$q10 = "Yes"]] [[Give IM adrenaline|hypo11b][$q10 = "No"]] [[Give further IV adrenaline boluses|hypo11b][$q10 = "No"]] [[I don't know|hypo11c][$q10 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink4">''155''</span>@@ ^^NIBP^^ @@.delayed;''39/-''@@</div></p></div> <<timed 59s>> <<goto hypo11c>> <</timed>> <<countdownTimer 60 "hypo11c">>

<div class="leftcolumn">You give two further 0.5 ml of 1:10,000 adrenaline and a further rapid bolus of crystallioid. "BP is back up, I can feel a decent carotid pulse. You can stop compressions." "Thank goodness, what now $firstname?" [[Start an adrenaline infusion|hypo11a][$q10 = "Yes"]] [[Give IM adrenaline|hypo11b][$q10 = "No"]] [[Give further IV adrenaline boluses|hypo11b][$q10 = "No"]] [[I don't know|hypo11c][$q10 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink4">''155''</span>@@ ^^NIBP^^ @@.delayed;''76/43''@@</div></p></div> <<timed 59s>> <<goto hypo11c>> <</timed>> <<countdownTimer 60 "hypo11c">>

<div class="leftcolumn">"With that BP someone needs to get on the chest $firstname!" The scrub nurse and plastics SpR oblige. You give two further 0.5 ml of 1:10,000 adrenaline and a further rapid bolus of crystallioid. "BP is back up, I can feel a decent carotid pulse. You can stop compressions." "Thank goodness, what now $firstname?" [[Start an adrenaline infusion|hypo11a][$q10 = "Yes"]] [[Give IM adrenaline|hypo11b][$q10 = "No"]] [[Give further IV adrenaline boluses|hypo11b][$q10 = "No"]] [[I don't know|hypo11c][$q10 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink4">''152''</span>@@ ^^NIBP^^ @@.delayed;''39/-''@@</div></p></div> <<timed 59s>> <<goto hypo11c>> <</timed>> <<countdownTimer 60 "hypo11c">>

<div class="leftcolumn">The adrenaline infusion is running. "Do you want blood for serum tryptase $firstname?" "Yes, thanks." "Errr...do you know which bottle...? [[Citrate (UK blue top)|hypo12b][$q11 = "No"]] [[EDTA (UK purple top)|hypo12b][$q11 = "No"]] [[SST (UK gold top)|hypo12a][$q11 = "Yes"]] [[Don't know, whatever's in the kit?|hypo12c][$q11 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink2">''92''</span>@@ ^^NIBP^^ @@.delayed;''105/43''@@</div></p></div> <<timed 59s>> <<goto hypo12c>> <</timed>> <<countdownTimer 60 "hypo12c">> <<audio "monitor150" pause>> <<audio "monitorfast" volume 0.3 loop play>> <<audio "monitor120" pause>> <<audio "monitor150" pause>>

<div class="leftcolumn">"The protocol says to start and adrenaline infusion. Do you want me to make it up $firstname?" "Yes, get that running." The surgical SpR is getting another cannula in "I'll take a serum tryptase...Errr...do you know which bottle...?" [[Citrate (UK blue top)|hypo12b][$q11 = "No"]] [[EDTA (UK purple top)|hypo12b][$q11 = "No"]] [[SST (UK gold top)|hypo12a][$q11 = "Yes"]] [[Don't know, whatever's in the kit?|hypo12c][$q11 = "Got help"]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink2">''149''</span>@@ ^^NIBP^^ @@.delayed;''68/42''@@</div></p></div> <<timed 59s>> <<goto hypo12c>> <</timed>> <<countdownTimer 60 "hypo12c">> <<audio "monitor150" pause>> <<audio "monitorfast" volume 0.3 loop play>>

<div class="leftcolumn">"The box is full of SST bottles $firstname?" "OK, it's probably that one then...yep says on the guidline. Lets send everything though, FBC, U&E and coag." [[Next|hypo13]]</div><div class="rightcolumn"><p style="text-align:right"><div class="pulseox3"> @@.lightgreentext;^^HR^^  <span class="blink2">''90''</span>@@ ^^NIBP^^ @@.delayed;''101/48''@@</div></p></div> <<audio "monitor150" pause>> <<audio "monitorfast" volume 0.3 loop play>> <<run forget("countdown")>>

The plastics SpR takes an extra SST along with the rest of the bloods. [[Next|hypo13]] <<run forget("countdown")>> <<audio "monitor150" pause>> <<audio "monitorfast" pause>>

<center> !!!@@.greentext;Anaphylaxis@@ <img src="images/resus1.jpg" style="max-width: 100%;"/> ''Figure 1: Resuscitation Council UK emergency treatment of anaphylaxis guideline 2021'' <img src="images/resus2.jpg" style="max-width: 100%;"/> ''Figure 2: Resuscitation Council UK treatment of refractory anaphylaxis guideline 2021'' <img src="images/anaph.jpg" style="max-width: 100%;"/> ''Figure 3: Anaphylaxis. From the Association of Anaesthetists Quick Reference Handbook (see refs).'' </center> <div class="notes">''1: Call for help, note time, stop or do not start non-essential surgery''</div> @@.greentext;''Your answers:''@@ Identified a problem: ''<<print $q1>>'' Prioritised oxygen delivery: ''<<print $q2>>'' Called for help: ''<<print $q3>>'' <p style="text-align:justify">@@.greentext;''Feedback''@@ Hypotension is commonly due to unnecessarily deep anaesthesia, the autonomic effects of neuraxial block, hypovolaemia or combined causes. There is no common ‘cut-off’ point when BP is ‘too low’. The pressure required to perfuse vital organs will vary between patients and maintaining a BP appropriate to the individual is key to preventing harm. For healthy patients, renal autoregulation is maintained at systolic pressures of 70-80 mmHg. In patients with hypertension, myocardial disease, or other systemic conditions, a higher BP may be required to maintain organ flow. As a guide the intraoperative BP should be maintained at 75-80% of the patients normal awake BP. Severe intraoperative hypotension is an anaesthetic emergency, even a few minutes of mean arterial pressures of ≤ 55 mmHg is associated with morbidity. You should rapidly: exclude a problem in adequate oxygen delivery; airway and breathing first; and get help.</p> <div class="notes">''2: Rapid assessment and consider causes''</div> @@.greentext;''Your answers:''@@ Correctly identified signs of anaphylaxis: ''<<print $q4>>'' <p style="text-align:justify">The World Allergy Organisation Anaphylaxis Committee defines anaphylaxis as: ''//"A serious systemic hypersensitivity reaction that is usually rapid in onset and may cause death. Severe anaphylaxis is characterized by potentially life-threatening compromise in airway, breathing and/or the circulation, and may occur without typical skin features or circulatory shock being present."//''</p> <center> ''Anaphylaxis is characterised by unexplained:'' !! <img src="images/arrowdown.jpg" style="max-width: 25px;"/> BP + bronchospasm + <img src="images/arrowdown.jpg" style="max-width: 25px;"/>/<img src="images/arrow.jpg" style="max-width: 25px;"/> HR </center> ''Presenting feature(s):'' * Hypotension 46% * Bronchospasm 18% * Tachycardia 9.8% * Flushing/non-urticarial rash 6.6% * Cardiac arrest 1.2% * 80% presented within 10 min of exposure to trigger * 2% presented over an hour after exposure * 4% mortality <div class="notes">''3: Call for arrest trolley, anaphylaxis kit, and remove causative agents''</div> @@.greentext;''Your answers:''@@ Requested anaphylaxis kit, cardiac arrest trolley, and further assistance: ''<<print $q5>>'' Correctly identified potential triggers: ''<<print $q6>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ It important to recognise and remove the trigger to avoid an increasingly severe reaction. ''The most common causes of perioperative anaphylaxis identified in NAP6:'' * Antibiotics (47%) * Muscle relaxants (33%) * Chlorhexidine (9%) * Patent blue dye (5%) Teicoplanin has the highest risk of triggering perioperative anaphylaxis, twice the risk of co-amoxiclav. Teicoplanin is often given due to a history of penicillin allergy which is unfounded in > 90% of cases. Taking a good drug and allergy history can avoid the additional risk. While there is a temporal relationship between this patient’s reaction and the antibiotic, they have also been exposed to chlorhexidine in skin preparations for cannulation and potentially the surgical site. They have not had colloid, or a muscle relaxant as noted at the start of the case. The incidence of reactions to NSAIDs and latex is extremely low, with a single case of anaphylaxis related to NSAID and no cases related to latex in the 3 million anaesthetics recorded by NAP6.</p> <div class="notes">''4: Give 100% oxygen and ensure adequate ventilation''</div> @@.greentext;''Your answers:''@@ Recognised the potential for airway compromise and the need for a definitive airway: ''<<print $q7>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ Maintain the airway and if necessary, secure it with tracheal tube is a key part of management. Severe laryngeal oedema may occur rapidly during anaphylaxis. It is worth noting that airway problems were rarely seen in NAP6 with only 1 patient needing a front of neck airway to manage laryngeal oedema. The administration of adrenaline should not be delayed while performing intubation.</p> <div class="notes">''Give drugs to treat hypotension''</div> @@.greentext;''Your answers:''@@ Gave the correct dose of IV adrenaline: ''<<print $q8>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ Adrenaline is the most important drug for the treatment of anaphylaxis. Delayed administration is associated with protracted reactions, hypotension and death.</p> <center> ''Adrenaline in adult anaphylaxis'' !!!@@.greentext;1 mg/ml (1:1000), found in ampules and auto-injectors <u>0.5 ml IM</u>@@ ''OR'' !!!@@.greentext;100 micrograms/ml (1:10,000) IV on the cardiac arrest trolly <u>0.5 ml IV</u>@@ </center> <p style="text-align:justify">The Resuscitation Council UK say: ''//"Healthcare providers with experience in the use and titration of vasopressors in their normal clinical practice (e.g. anaesthetists, critical care practitioners) may choose to administer adrenaline by the IV route. Both IM and IV routes are recommended for use in treating perioperative anaphylaxis, although international guidelines recommend IM adrenaline for first-line treatment of anaphylaxis in all settings."//'' In this scenario the patient has a rapidly life-threatening reaction and cautious use of IV adrenaline is appropriate for experienced clinicians in a highly monitored setting. In the event of cardiac arrest, usual ALS guidelines apply. ''Corticosteroids'' (e.g. hydrocortisone) are no longer advised by the Resus Council for the routine emergency treatment of anaphylaxis. ''Antihistamines'' are not recommended as part of the initial emergency treatment for anaphylaxis. Non-sedating oral antihistamines (e.g. cetirizine) can be given to treat ongoing cutaneous symptoms after the patient is stabilised. ''Glucagon'' 1 mg repeated as necessary in patients taking betablockers unresponsive to adrenaline ''Salbutamol/ipratropium'' may be used in patients with ongoing bronchospasm, but is not a substitute for adrenaline.</p> <div class="notes">''If systolic blood pressure < 50 mmHg or cardiac arrest, start CPR immediately''</div> @@.greentext;''Your answers:''@@ Started chest compressions when BP less than 50 mmHg: ''<<print $q9>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ During anaphylaxis at systolic BP < 50 mmHg in adults, even without cardiac arrest, chest compressions should be started with simultaneous treatment with adrenaline, and aggressive fluid resuscitation. A third of the intravascular volume may leave the circulation during an anaphylactic reaction and several 20 ml/kg of crystalloid may be necessary (3-5 litres in severe reactions).</p> <div class="notes">''Consider adrenaline infusion''</div> @@.greentext;''Your answer:''@@ Commenced an adrenaline infusion when indicated: ''<<print $q10>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ A single dose of adrenaline (by any route) is unlikely to be sufficient in severe reactions. The Resus Council recommend patients with no improvement in respiratory and/or cardiovascular symptoms due to anaphylaxis, despite two appropriate doses of adrenaline, should be started on an adrenaline infusion (the Association of Anaesthetists recommend after three IV doses). See figure 2 and 3 above for suggested regimens and follow local protocols.</p> <div class="notes">''Take 5-10 ml clotted blood sample for serum tryptase as soon as patient is stable''</div> @@.greentext;''Your answers:''@@ Ensured correct follow up investigations: ''<<print $q11>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ Mast cell tryptase should be measured in all patients with suspected anaphylaxis. Samples are needed as close to onset as practicable, 1-2h and >24h. These require a clotted blood sample usually in an SST bottle which is gold top in the UK. Check local protocols. Serial samples have better specificity and sensitivity than a single measurement in confirming a diagnosis of anaphylaxis. Patients with severe anaphylaxis should be admitted to critical care. Events should be clearly documented and steps taken to avoid re-administration of trigger agents while awaiting assessment by an appropriate allergy service.</p> [[I want another emergency|emerg1]] [[I'm done|exit2]] [[Show me the evidence|hyporef]]

# The Association of Anaesthetists Quick Reference Handbook, available [[here|https://anaesthetists.org/Portals/0/PDFs/QRH/QRH_complete_January%202021.pdf?ver=2021-01-05-140039-337]] # Harper NJN, Cook TM, Garcez T et al. Anaesthesia, Surgery and Life-Threatening Allergic Reactions: Management and outcomes in the 6th National Audit Project (NAP6). 2018. Available [[here|https://www.nationalauditprojects.org.uk/NAP6Report#pt]] # Resuscitation Council UK. Emergency treatment of anaphylactic reactions: Guidelines for healthcare providers. London, 2021. Available [[here|https://www.resus.org.uk/library/additional-guidance/guidance-anaphylaxis/emergency-treatment]] [[Back|feedbackhypo]]

<br> Ten minutes later and you are just leaving your case in safe hands in recovery. "Ah, $firstname. I was just going to bleep you. Are you happy for Mrs Last to go to the ward?" "How are you feeling Mrs Last?" "A bit lightheaded but otherwise fine doctor. I have a very funny taste in my mouth, like I've been sucking a penny." [[Go to the ward|fit2b][$q1 = "No"]] [[Keep in recovary|fit2a][$q1 = "Yes"]] [[I don't know what's going on|fit2c][$q1 = "Got help"]] <<timed 59s>> <<goto fit2c>> <</timed>> <<countdownTimer 60 "fit2c">>

<br> "Let's keep Mrs Last here. I'm just going to..." [[...get a coffee|fit3b][$q2 = "No"]] [[...ask if she has any other symptoms|fit3a][$q2 = "Yes"]] [[I don't know what's going on|fit3c][$q2 = "Got help"]] <<timed 59s>> <<goto fit3c>> <</timed>> <<countdownTimer 60 "fit3c">>

<br> "Mrs Last can go to the ward. I'm just going to quickly..." [[...get a coffee|fit3b][$q2 = "No"]] [[...ask if she has any other symptoms|fit3a][$q2 = "Yes"]] [[I don't know what's going on|fit3c][$q2 = "Got help"]] <<timed 59s>> <<goto fit3c>> <</timed>> <<countdownTimer 60 "fit3c">>

<br> "It will take a while for the porters to come up anyway so we can keep an eye on her here for a bit longer." The recovery practitioner offers "OK. I'm just going to quickly..." [[...get a coffee|fit3b][$q2 = "No"]] [[...ask if she has any other symptoms|fit3a][$q2 = "Yes"]] [[I don't know what's going on|fit3c][$q2 = "Got help"]] <<timed 59s>> <<goto fit3c>> <</timed>> <<countdownTimer 60 "fit3c">>

<br> "OK, where can we get hold of you?" "Coffee first. Then I'm going to be... [[...down helping in obs|fit4b][$q3 = "No"]] [[...just across the way|fit4a][$q3 = "Yes"]] [[I don't know what's going on|fit4c][$q3 = "Got help"]] <<timed 59s>> <<goto fit4c>> <</timed>> <<countdownTimer 60 "fit4c">> <<audio "emergency" pause>>

<br> "I can't seem to focus my eyes, but I am very tired. I've been up since seven this morning and I haven't got my glasses with me." "OK, we will keep an eye on you a bit longer" then to the recovery practitioner. "Let me know if anything changes. I'll be..." [[...down helping in obs|fit4b][$q3 = "No"]] [[...just across the way|fit4a][$q3 = "Yes"]] [[I don't know what's going on|fit4c][$q3 = "Got help"]] <<timed 59s>> <<goto fit4c>> <</timed>> <<countdownTimer 60 "fit4c">> <<audio "emergency" pause>>

<br> "Well actually doctor I can't seem to focus my eyes and do feel a bit strange." "OK, we will keep an eye on you a bit longer." then to the recovery practitioner, "Let me know if anything changes. I'll be..." [[...down helping in obs|fit4b][$q3 = "No"]] [[...just across the way|fit4a][$q3 = "Yes"]] [[I don't know what's going on|fit4c][$q3 = "Got help"]] <<timed 59s>> <<goto fit4c>> <</timed>> <<countdownTimer 60 "fit4c">> <<audio "emergency" pause>>

<br> You are barely out of the room when the emergency alarm goes off. Crashing back through the doors into recovery you glance quickly at the two occupied bed spaces. Mrs Last is fitting. In a second you are at her side. You glance at the monitor. !!@@.redtext;^^NIBP^^ 187/103@@ !!@@.lightgreentext;   ^^HR^^ 162@@ The ECG trace is a mess of movement artefact. "What do we do $firstname?" the recovery practitioner asks desperately. [[Oxygen-ABC|fit5a][$q4 = "Yes"]] [[6 mg IV lorazepam|fit5b][$q4 = "No"]] [[I don't know|fit5c][$q4 = "Got help"]] <<timed 59s>> <<goto fit5c>> <</timed>> <<countdownTimer 60 "fit5c">> <<audio "emergency" volume 0.3 loop play>>

<br> "Shall I get more help?" [[No, we can manage this|fit6b][$q5 = "No"]] [[Yes, get more help|fit6a][$q5 = "Yes"]] [[I don't know|fit6c][$q5 = "Got help"]] ...and can someone stop that emergency alarm?!!" <<timed 59s>> <<goto fit6c>> <</timed>> <<countdownTimer 60 "fit6c">>

<br> "We need to terminate this seizure. Lets give 6 mg lorazepam IV." "That seems a big dose $firstname? Are you sure? I'll increase the oxygen and maintain her airway. Do you want more help?" [[No, we can manage this|fit6b][$q5 = "No"]] [[Yes, get more help|fit6a][$q5 = "Yes"]] [[I don't know|fit6c][$q5 = "Got help"]] ...and can someone stop that emergency alarm?!!" <<timed 59s>> <<goto fit6c>> <</timed>> <<countdownTimer 60 "fit6c">>

<br> "I'll increase the oxygen and maintain her airway. Do you want more help $firstname?" [[No, we can manage this|fit6b][$q5 = "No"]] [[Yes, get more help|fit6a][$q5 = "Yes"]] [[I don't know|fit6c][$q5 = "Got help"]] ...and can someone stop that emergency alarm?!!" <<timed 59s>> <<goto fit6c>> <</timed>> <<countdownTimer 60 "fit6c">>

<br> "Actually I've already..." ODP is suddenly at the bedside. "Hi $firstname, boss is on their way in. What's going on?" "I think this is... [[...epilepsy|fit7b][$q6 = "No"]] [[...local anaesthetic toxicity|fit7a][$q6 = "Yes"]] [[...because of a head injury|fit7b][$q6 = "No"]] [[...alcohol withdrawal|fit7b][$q6 = "No"]] [[...hypoglycaemia|fit7b][$q6 = "No"]] [[I don't know|fit7c][$q6 = "Got help"]] <<audio "emergency" pause>> <<timed 59s>> <<goto fit7c>> <</timed>> <<countdownTimer 60 "fit7c">>

<br> The ODP is first to arrive to help. "Hi $firstname, boss is on their way in. What's going on?" "I think this is... [[...epilepsy|fit7b][$q6 = "No"]] [[...local anaesthetic toxicity|fit7a][$q6 = "Yes"]] [[...because of a head injury|fit7b][$q6 = "No"]] [[...alcohol withdrawal|fit7b][$q6 = "No"]] [[...hypoglycaemia|fit7b][$q6 = "No"]] [[I don't know|fit7c][$q6 = "Got help"]] <<audio "emergency" pause>> <<timed 59s>> <<goto fit7c>> <</timed>> <<countdownTimer 60 "fit7c">>

<br> "I really could do with some help. So I've already..." ODP is suddenly at the bedside. "Hi $firstname, boss is on their way in. What's going on?" "I think this is... [[...epilepsy|fit7b][$q6 = "No"]] [[...local anaesthetic toxicity|fit7a][$q6 = "Yes"]] [[...because of a head injury|fit7b][$q6 = "No"]] [[...alcohol withdrawal|fit7b][$q6 = "No"]] [[...hypoglycaemia|fit7b][$q6 = "No"]] [[I don't know|fit7c][$q6 = "Got help"]] <<audio "emergency" pause>> <<timed 59s>> <<goto fit7c>> <</timed>> <<countdownTimer 60 "fit7c">>

<br> The ODP looks a bit sceptical "Looking at the preassessment and recovery chart I’m not sure there’s evidence for that?" "She said she had a metallic taste and blurry vision. What are they a symptom of?" The recovery pratitioner adds. "This could be LA toxicity, so we need intralipid and the cardiac arrest trolly." You respond. "OK, would propofol do? It's a lipid emulsion and looks the same?" [[Yes|fit8b][$q7 = "No"]] [[No|fit8a][$q7 = "Yes"]] [[I don't know|fit8c][$q7 = "Got help"]] <<timed 59s>> <<goto fit8c>> <</timed>> <<countdownTimer 60 "fit8c">>

<br> "This is LA toxicity and we need intralipid and the cardiac arrest trolly." "OK, would propofol do? It's a lipid emulsion and looks the same?" [[Yes|fit8b][$q7 = "No"]] [[No|fit8a][$q7 = "Yes"]] [[I don't know|fit8c][$q7 = "Got help"]] <<timed 59s>> <<goto fit8c>> <</timed>> <<countdownTimer 60 "fit8c">>

<br> "She said she had a metallic taste and blurry vision. What are they a symptom of?" The recovery pratitioner adds. "This could be LA toxicity, so we need intralipid. and the cardiac arrest trolly." You respond. "OK, would propofol do? It's a lipid emulsion and looks the same?" [[Yes|fit8b][$q7 = "No"]] [[No|fit8a][$q7 = "Yes"]] [[I don't know|fit8c][$q7 = "Got help"]] <<timed 59s>> <<goto fit8c>> <</timed>> <<countdownTimer 60 "fit8c">>

<br> "We don't need to use propofol, we've got intralipid available." The recovery practitioner grabs the LA toxicity box. "What do you want me to give first $firstname?" "Let's give small incremental doses of IV... [[...diazepam|fit9b][$q8 = "No"]] [[...valproate|fit9b][$q8 = "No"]] [[...midazolam|fit9b][$q8 = "No"]] [[...lorazepam|fit9a][$q8 = "Yes"]] [[...levetiracetam|fit9b][$q8 = "No"]] [[I don't know|fit9c][$q8 = "Got help"]] <<timed 59s>> <<goto fit9c>> <</timed>> <<countdownTimer 60 "fit9c">>

<br> "No, she's got CNS and cardiovascular toxicity we need the intralipid available." "What do you want me to give first $firstname?" "Let's give small incremental doses of IV... [[...diazepam|fit9b][$q8 = "No"]] [[...valproate|fit9b][$q8 = "No"]] [[...midazolam|fit9b][$q8 = "No"]] [[...lorazepam|fit9a][$q8 = "Yes"]] [[...levetiracetam|fit9b][$q8 = "No"]] [[I don't know|fit9c][$q8 = "Got help"]] <<timed 59s>> <<goto fit9c>> <</timed>> <<countdownTimer 60 "fit9c">>

<br> "We don't stock it, they normally use lorazepam first line?..." !!@@.redtext;^^NIBP^^ 64/~@@ !!@@.lightgreentext;   ^^HR^^ 32@@ "...That's five minutes since the last lorazepam. What do we do? She's going to arrest?!" "Give the atropine and ephedrine out of the emergency drugs, have adrenaline ready. Let's give intralipid. What is she? 70 kg? Bolus... [[70 ml|fit10b][$q9 = "No"]] [[100 ml|fit10a][$q9 = "Yes"]] [[200 ml|fit10b][$q9 = "No"]] [[300 ml|fit10b][$q9 = "No"]] [[I don't know|fit10c][$q9 = "Got help"]] <<timed 59s>> <<goto fit10c>> <</timed>> <<countdownTimer 60 "fit10c">>

!!@@.redtext;^^NIBP^^ 64/~@@ !!@@.lightgreentext;   ^^HR^^ 32@@ "That's five minutes since the last lorazepam. What do we do? She's going to arrest?!" "Give the atropine and ephedrine out of the emergency drugs, have adrenaline ready. Let's give intralipid. What is she? 70 kg? Bolus... [[70 ml|fit10b][$q9 = "No"]] [[100 ml|fit10a][$q9 = "Yes"]] [[200 ml|fit10b][$q9 = "No"]] [[300 ml|fit10b][$q9 = "No"]] [[I don't know|fit10c][$q9 = "Got help"]] <<timed 59s>> <<goto fit10c>> <</timed>> <<countdownTimer 60 "fit10c">>

<br> "We keep lorazepam in recovery, they normally use that first line?..." !!@@.redtext;^^NIBP^^ 64/~@@ !!@@.lightgreentext;   ^^HR^^ 32@@ "...That's five minutes since the last lorazepam. What do we do? She's going to arrest?!" "Give the atropine and ephedrine out of the emergency drugs, have adrenaline ready. Let's give intralipid. What is she? 70 kg? Bolus... [[70 ml|fit10b][$q9 = "No"]] [[100 ml|fit10a][$q9 = "Yes"]] [[200 ml|fit10b][$q9 = "No"]] [[300 ml|fit10b][$q9 = "No"]] [[I don't know|fit10c][$q9 = "Got help"]] <<timed 59s>> <<goto fit10c>> <</timed>> <<countdownTimer 60 "fit10c">>

<br> "Hang on, there's an Association Anaesthetists laminated guideline here that says give a 1.5 ml/kg of 20% intralipid. So 70 x 1.5. Err...105...there's 100 ml in these bottles? So one of these?" "Do you just want the bolus $firstname?" [[Yes|fit11b][$q10 = "No"]] [[No|fit11a][$q10 = "Yes"]] [[I don't know|fit10c][$q9 = "Got help"]] <<timed 59s>> <<goto fit11c>> <</timed>> <<countdownTimer 60 "fit11c">>

"Do you just want the bolus $firstname?" [[Yes|fit11b][$q10 = "No"]] [[No|fit11a][$q10 = "Yes"]] [[I don't know|fit10c][$q9 = "Got help"]] <<timed 59s>> <<goto fit11c>> <</timed>> <<countdownTimer 60 "fit11c">>

<br> "Hang on, there's an Association Anaesthetists laminated guideline here that says give a 1.5 ml/kg of 20% intralipid. So 70 x 1.5. Err...105...there's 100 ml in these bottles? So one of these?" "Do you just want the bolus $firstname?" [[Yes|fit11b][$q10 = "No"]] [[No|fit11a][$q10 = "Yes"]] [[I don't know|fit11c][$q10 = "Got help"]] <<timed 59s>> <<goto fit11c>> <</timed>> <<countdownTimer 60 "fit11c">>

<br> "Oh hang on, it says here start an infusion at 17.5 ml.min^^-1^^ for a 70 kg adult..." !!@@.redtext;^^NIBP^^ 64/~@@ !!@@.lightgreentext;   ^^HR^^ 32@@ "...That seems to have stopped the seizure. But she's more brady and hypotensive! What do we do?!" "Let's give more ephedrine, repeat the intralipid bolus and increase infusion rate to... [[...15 ml/kg/hr|fit12b][$q11 = "No"]] [[...30 ml/kg/hr|fit12a][$q11 = "Yes"]] [[...45 ml/kg/hr|fit12a][$q11 = "Yes"]] [[...60 ml/kg/hr|fit12b][$q11 = "No"]] [[I don't know|fit12c][$q11 = "Got help"]] <<timed 59s>> <<goto fit12c>> <</timed>> <<countdownTimer 60 "fit12c">>

!!@@.redtext;^^NIBP^^ 61/~@@ !!@@.lightgreentext;   ^^HR^^ 33@@ "That seems to have stopped the seizure. But she's still brady and hypotensive! What do we do?!" "Give more ephedrine and let's repeat the intralipid bolus and increase infusion rate to... [[...15 ml/kg/hr|fit12b][$q11 = "No"]] [[...30 ml/kg/hr|fit12a][$q11 = "Yes"]] [[...45 ml/kg/hr|fit12a][$q11 = "No"]] [[...60 ml/kg/hr|fit12b][$q11 = "No"]] [[I don't know|fit12c][$q11 = "Got help"]] <<timed 59s>> <<goto fit12c>> <</timed>> <<countdownTimer 60 "fit12c">>

<br> "Oh hang on, it says here start an infusion at 17.5 ml.min^^-1^^ for a 70 kg adult..." !!@@.redtext;^^NIBP^^ 64/~@@ !!@@.lightgreentext;   ^^HR^^ 32@@ "...That seems to have stopped the seizure. But she's more brady and hypotensive! What do we do?!" "Let's give more ephedrine, repeat the intralipid bolus and increase infusion rate to... [[...15 ml/kg/hr|fit12b][$q11 = "No"]] [[...30 ml/kg/hr|fit12a][$q11 = "Yes"]] [[...45 ml/kg/hr|fit12a][$q11 = "No"]] [[...60 ml/kg/hr|fit12b][$q11 = "No"]] [[I don't know|fit12c][$q11 = "Got help"]] <<timed 59s>> <<goto fit12c>> <</timed>> <<countdownTimer 60 "fit12c">>

<br> "This sheet says 30 ml/kg/hr." "Let's increase to that." The recovery practitioner alters the infusion rate. "She's had about 300 ml so far. What's the maximum dose of intralipid?" [[6 ml/kg|fit12d][$q12 = "No"]] [[12 ml/kg|fit13a][$q12 = "Yes"]] [[18 ml/kg|fit12d][$q12 = "No"]] [[24 ml/kg|fit12d][$q12 = "No"]] [[I don't know|fit12e][$q12 = "Got help"]] <<timed 59s>> <<goto fit13c>> <</timed>> <<countdownTimer 60 "fit13c">>

<br> The recovery practitioner alters the infusion rate. "She's had about 300 ml so far. What's the maximum dose of intralipid?" [[6 ml/kg|fit12d][$q12 = "No"]] [[12 ml/kg|fit13a][$q12 = "Yes"]] [[18 ml/kg|fit12d][$q12 = "No"]] [[24 ml/kg|fit12d][$q12 = "No"]] [[I don't know|fit12e][$q12 = "Got help"]] <<timed 59s>> <<goto fit13c>> <</timed>> <<countdownTimer 60 "fit13c">>

"Err $firstname...the sheet says...12 ml/kg?" "Can I just hold the sheet?" [[Next|fit13b]]

!!@@.redtext;^^NIBP^^ 118/63@@ !!@@.lightgreentext;   ^^HR^^ 68@@ "That's better. What do we need to keep an eye out for while she's wating for a bed in critical care?" [[Intralipid will mess with blood tests|fit14a][$q13 = "No"]] [[She might develop pancreatitis|fit14a][$q13 = "No"]] [[There is a risk of DVT|fit14a][$q13 = "No"]] [[All of the above|fit14a][$q13 = "Yes"]] [[I don't know|fit14a][$q13 = "Got help"]] <<timed 59s>> <<goto fit14a>> <</timed>> <<countdownTimer 60 "fit14a">>

"Err $firstname...the sheet says...12 ml/kg?" "Can I just hold the sheet?" [[Next|fit13b]]

<<run forget("countdown")>> "I came as soon as I could. What happened?" The senior trainee is back from obs. You quickly run through events. "I'll do a datex and a yellow card." They look pretty downcast. "Not sure if it was cumulative doses from the haematoma block and the supraclavicular or maybe a miscalculation somewhere? Anyhow I'll double-check the bupivicaine amps if I can find them. Thank you for saving the day $firstname." [[Feedback on how I did|feedbackfit]] [[I want another emergency|emerg1]] [[I'm done|exit2]] <<set $id to "laIAC">> <<set $q14 to "-">> <<set _data = {randomid: $randomid, id: $id, q1: $q1, q2: $q2, q3: $q3, q4: $q4, q5: $q5, q6: $q6, q7: $q7, q8: $q8, q9: $q9, q10: $q10, q11: $q11, q12: $q12, q13: $q13, q14: $q14 }>> <<run sendData(_data)>>

<center> !!!@@.greentext;Local anaesthetic systemic toxicity (LAST)@@ <img src="images/last.jpg" style="max-width: 100%;"/> ''Figure 1: Local anaesthetic toxicity. From Association of Anaesthetists Quick Reference Handbook (see refs).'' </center> <div class="notes">''Identified signs of toxicity''</div> @@.greentext;''Your answers:''@@ Identified subtle issues that could indicate a problem: ''<<print $q1>>'' Used targeted questioning to look for other evidence: ''<<print $q2>>'' Remained available to offer assistance while responsible for patients in recovery area: ''<<print $q3>>'' Recognised the signs and symptoms associated with severe local anaesthetic toxicity: ''<<print $q6>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ ''Doses of commonly used local anaesthetics:'' <center> ||@@.greentext;''max dose mg/kg<br>no adrenaline''@@|@@.greentext;''max dose mg/kg <br>with adrenaline''@@| |Lidocaine|      3|      7| |Bupivacaine  |      2|      2| |Ropivacaine|      3|      3| |Prilocaine|      6|      -| </center> Clearly if you inadvertently inject into a vessel that’s the highest rate of vascular spread otherwise this varies between sites. ''Absorption from fastest to slowest:'' * Intercostal and paravertebral nerve blocks * Epidural * Brachial plexus and upper extremity nerve blocks * Trunk/lower extremity nerve blocks ''Patient-dependent risk factors for LAST:'' * Organ dysfunction * Serum level of the binding proteins * Age * Malnutrition Mrs Last has had a haematoma block in the emergency department for her Colles fracture. Often a rapid onset agent (lidocaine or prilocaine) is used but a longer-acting agent like bupivacaine may be added for pain relief. Then has had a supraclavicular block in theatre with bupivacaine. There was no information provided on whether the surgeon also provided local infiltration at any point during, or at the end of the procedure. Any unusual cardiovascular or neurological signs after administration of local anaesthetic should raise suspicion of LAST. ''Early signs and symptoms include (underlined where in our scenario):'' * <u>Metallic taste</u> * <u>Difficulty with visual focus</u> * <u>Dizziness or light headedness</u> * Tinnitus * Anxiety, agitation, confusion, disorientation * Perioral and/or tongue numbness or tingling * Slurred speech This initial excitatory state can be absent, but can be severe and lead to seizure activity. CNS excitation can then be followed by a depressive phase of drowsiness, reduced GCS and respiratory depression. In the cardiovascular system an initial period of hypertension and tachycardia can be followed by myocardial depression and hypotension. In the most severe reactions, peripheral vasodilatation, severe hypotension, and a variety of tachy and brady arrhythmias and conduction blocks are seen with some patients presenting with sudden cardiac collapse or cardiac arrest. While the majority of cases occur within minutes, toxicity can have a delayed onset of greater than 1 hour.</p> <div class="notes">''Call for help and inform immediate clinical team of problem''</div> @@.greentext;''Your answers:''@@ Called for help: ''<<print $q5>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ Because LAST can proceed to cardiac arrest enough expert help is crucial for early treatment and management. The half life of most anaesthetics is > 2h and recovery may take hours. In the event of cardiac arrest prolonged CPR may be necessary, and cardiopulmonary bypass should be considered if available. In the unstable patient with LAST the necessary expertise and advice for this should be sort early.</p> <div class="notes">''Give 100% oxygen and ensure adequate lung ventilation''</div> @@.greentext;''Your answers:''@@ Commenced high flow oxygen and rapidly assessed ABC: ''<<print $q4>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ Standard procedures and supportive care are the mainstay of treatment. Hypoxaemia, hypercarbia and acidosis all exacerbate cardiac and CNS toxicity. </p> <div class="notes">''Control seizures with small incremental dose of benzodiazepine, thiopental or propofol''</div> @@.greentext;''Your answers:''@@ Treats seizures with appropriate first line agent: ''<<print $q8>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ For isolated seizure activity in otherwise haemodynamically stable patients, intravenous benzodiazepines may be used. Propofol or thiopentone may compound the cardiac depression that can occur with LAST.</p> <div class="notes">''Lipid emulsion regimen''</div> @@.greentext;''Your answers:''@@ Aware that propofol is not a substitute for 20% intralipid: ''<<print $q7>>'' Knows the first dose of 20% intralipid is 1.5 ml/kg, ~100 ml for a 70 kg adult: ''<<print $q9>>'' Starts an infusion of 20% intralipid alongside the initial bolus dose: ''<<print $q10>>'' Increases infusion rate to 30 ml/kg/hr when ongoing cardiovascular instability: ''<<print $q11>>'' Knows the maximum cumulative dose of 20% intralipid is 12 ml/kg: ''<<print $q12>>'' Aware of the risks associated with 20% intralipid treatment: ''<<print $q13>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ Intralipid exerts a scavenging effect taking up the lipophilic local anaesthetic. It also has beneficial direct cardiac effects. Propofol is not a suitable alternative as the doses required are a significant propofol overdose with associated depressant effects. Several makes of lipid emulsion are manufactured as a rescue therapy. Intralipid (Fresenius Kabi Runcorn, UK) is the most widely studied for use in LAST. ''Intralipid is contraindicated in patients with:'' * an impaired ability to metabolise fat, such as in severe liver damage and acute shock * hypersensitivity to egg-, soya- or peanut protein or to any of the active substances or excipients Laboratory staff must be made aware of lipid contamination for efficient sample handling and to obtain rapid, accurate results. Tests affected include albumin, magnesium assays, amylase, lipase, phosphate, creatinine, total protein, ALT, CK, and bilirubin. Glucose may be affected. Fat is cleared after a fat-free interval of 5 to 6 hours in most patients when samples will return to normal. 20% Intralipid is rarely associated with deep vein thrombosis and pancreatitis. LAST is rare, occurring in approximately 1:1000 regional blocks, but is one of the reasons regional and neuraxial anaesthesia should only take place after a comprehensive preoperative assessment, evaluation of the risks and benefits, and discussion of these with the patient. Monitoring during and after the procedure should be as per the Association of Anaesthetists minimum monitoring standards, venous access must be in place and capable support should be immediately available. If the intervention is amenable to the use of ultrasound this may reduce the risk of LAST but does not completely remove the risk. Finally adequate post procedure care and documentation can help prevent delayed or missed diagnosis. </p> [[I want another emergency|emerg1]] [[I'm done|exit2]] [[Show me the evidence|fitref]]

# The Association of Anaesthetists Quick Reference Handbook, available [[here|https://anaesthetists.org/Portals/0/PDFs/QRH/QRH_complete_January%202021.pdf?ver=2021-01-05-140039-337]] # Christie L, Picard J, Weinberg G. Local anaesthetic systemic toxicity. //BJA//. 2015; 15(3):136-142 # NYSORA. Local anaesthetic systemic toxicity. Available [[here|https://www.nysora.com/foundations-of-regional-anesthesia/complications/local-anesthetic-systemic-toxicity/]] [[Back|feedbackfit]]

The day team have handed over a single case for CEPOD. Have a look at the patients notes [[here|https://www.virtualanaesthetics.com/IACModule%206/news.pdf]] Once that's done click [[here|sepsis1]]

<br> "The next case is in theatre hold. An appendectomy?" asks the ODP in the anaesthetic room. "Is he OK?" [[No|sepsis2b][$q1 = "No"]] [[Yes|sepsis2a][$q1 = "Yes"]] [[I don't know what's going on|sepsis2c][$q1 = "Got help"]] <<timed 59s>> <<goto sepsis2c>> <</timed>> <<countdownTimer 60 "sepsis2c">>

<br> "He looks pretty unwell from the end of the bed. Resp rate is a little high. He must be feeling ropy with a WCC of 18, he's put his lactate up a bit with it. Do you know what his NEWS is?" [[0|sepsis3b][$q2 = "No"]] [[3|sepsis3a][$q2 = "Yes"]] [[6|sepsis3b][$q2 = "No"]] [[I don't know|sepsis3c][$q2 = "Got help"]] <<timed 59s>> <<goto sepsis3c>> <</timed>> <<countdownTimer 60 "sepsis3c">>

<br> "Do we know a NEWS score for him?" [[0|sepsis3b][$q2 = "No"]] [[3|sepsis3a][$q2 = "Yes"]] [[6|sepsis3b][$q2 = "No"]] [[I don't know|sepsis3c][$q2 = "Got help"]] <<timed 59s>> <<goto sepsis3c>> <</timed>> <<countdownTimer 60 "sepsis3c">>

<br> "He looks pretty unwell from the end of the bed. Resp rate is a little high. He must be feeling ropey with a WCC of 18, he's put his lactate up a bit with it. Do you know what his NEWS is?" [[0|sepsis3b][$q2 = "No"]] [[3|sepsis3a][$q2 = "Yes"]] [[6|sepsis3b][$q2 = "No"]] [[I don't know|sepsis3c][$q2 = "Got help"]] <<timed 59s>> <<goto sepsis3c>> <</timed>> <<countdownTimer 60 "sepsis3c">>

<br> "Hang on there's a table on the back of the chart. Err...he just scores a 3 for resps. What are you worried about?" [[Pain despite opioid analgesia|sepsis4b][$q3 = "No"]] [[Dehydration from prolonged NBM|sepsis4b][$q3 = "No"]] [[Moderate to high risk sepsis|sepsis4a][$q3 = "Yes"]] [[Perforation due to delayed presentation|sepsis4b][$q3 = "No"]] [[His notes are incomplete|sepsis4b][$q3 = "No"]] [[I don't know|sepsis4c][$q3 = "Got help"]] <<timed 59s>> <<goto sepsis4c>> <</timed>> <<countdownTimer 60 "sepsis4c">>

<br> "What are you worried about?" [[Pain despite opioid analgesia|sepsis4b][$q3 = "No"]] [[Dehydration from prolonged NBM|sepsis4b][$q3 = "No"]] [[Moderate to high risk sepsis|sepsis4a][$q3 = "Yes"]] [[Perforation due to delayed presentation|sepsis4b][$q3 = "No"]] [[His notes are incomplete|sepsis4b][$q3 = "No"]] [[I don't know|sepsis4c][$q3 = "Got help"]] <<timed 59s>> <<goto sepsis4c>> <</timed>> <<countdownTimer 60 "sepsis4c">>

<br> "I'd be worried about that too but right now he looks ashen grey and you know what young healthy people are like, they compensate. His lactate is up, I'd be thinking sepsis, so what do we need to do first?" [[Expedite surgery|sepsis5b][$q4 = "No"]] [[Discuss with critical care|sepsis5b][$q4 = "No"]] [[Arrange immediate senior review|sepsis5a][$q4 = "Yes"]] [[I don't know|sepsis5c][$q4 = "Got help"]] <<timed 59s>> <<goto sepsis5c>> <</timed>> <<countdownTimer 60 "sepsis5c">>

<br> "Sepsis? What do we need to do first?" [[Expedite surgery|sepsis5b][$q4 = "No"]] [[Discuss with critical care|sepsis5b][$q4 = "No"]] [[Arrange immediate senior review|sepsis5a][$q4 = "Yes"]] [[I don't know|sepsis5c][$q4 = "Got help"]] <<timed 59s>> <<goto sepsis5c>> <</timed>> <<countdownTimer 60 "sepsis5c">>

<br> "Right now he looks ashen grey and you know what young healthy people are like, they compensate. His lactate is up, I'd be thinking sepsis, so what do we need to do first?" [[Expedite surgery|sepsis5b][$q4 = "No"]] [[Discuss with critical care|sepsis5b][$q4 = "No"]] [[Arrange immediate senior review|sepsis5a][$q4 = "Yes"]] [[I don't know|sepsis5c][$q4 = "Got help"]] <<timed 59s>> <<goto sepsis5c>> <</timed>> <<countdownTimer 60 "sepsis5c">>

<br> "I agree that may be necessary, but lets escalate this to the SpR or duty consultant to get their input." You contact the team. The surgical SpR is with a poly trauma in resus, the anaesthetic SpR is with a CAT 1 section in obs. The surgical and anaesthetic consultants are on their way in. "Do you want me to put them on oxygen?" [[Yes, nasal cannula|sepsis6b][$q5 = "No"]] [[Yes, 8L via facemask|sepsis6b][$q5 = "No"]] [[Yes, 15L via non-rebreathe mask|sepsis6b][$q5 = "No"]] [[No|sepsis6a][$q5 = "Yes"]] [[I don't know|sepsis6c][$q5 = "Got help"]] <<timed 59s>> <<goto sepsis6c>> <</timed>> <<countdownTimer 60 "sepsis6c">>

<br> The surgical SpR is with a poly trauma in resus, the anaesthetic SpR is with a CAT 1 section in obs. The surgical and anaesthetic consultants are on their way in. "Do you want me to put them on oxygen?" [[Yes, nasal cannula|sepsis6b][$q5 = "No"]] [[Yes, 8L via facemask|sepsis6b][$q5 = "No"]] [[Yes, 15L via non-rebreathe mask|sepsis6b][$q5 = "No"]] [[No|sepsis6a][$q5 = "Yes"]] [[I don't know|sepsis6c][$q5 = "Got help"]] <<timed 59s>> <<goto sepsis6c>> <</timed>> <<countdownTimer 60 "sepsis6c">>

<br> "Lets escalate this to the SpR or duty consultant to get their input." You contact the team. The surgical SpR is with a poly trauma in resus, the anaesthetic SpR is with a CAT 1 section in obs. The surgical and anaesthetic consultants are on their way in. "Do you want me to put them on oxygen?" [[Yes, nasal cannula|sepsis6b][$q5 = "No"]] [[Yes, 8L via facemask|sepsis6b][$q5 = "No"]] [[Yes, 15L via non-rebreathe mask|sepsis6b][$q5 = "No"]] [[No|sepsis6a][$q5 = "Yes"]] [[I don't know|sepsis6c][$q5 = "Got help"]] <<timed 59s>> <<goto sepsis6c>> <</timed>> <<countdownTimer 60 "sepsis6c">>

<br> "As well as the gas it looks like he's had FBC, U&E, creatinine, CRP, and a coag. Do you want any other bloods $firstname?" [[Amylase|sepsis7b][$q6 = "No"]] [[LFTs|sepsis7b][$q6 = "No"]] [[Blood cultures|sepsis7a][$q6 = "Yes"]] [[I don't know|sepsis7c][$q6 = "Got help"]] <<timed 59s>> <<goto sepsis7c>> <</timed>> <<countdownTimer 60 "sepsis7c">>

<br> "Actually Noah's sats are 98% on RA so we could leave off supplemental O~~2~~ at the minute." The ODP is looking at the notes. "As well as the gas it looks like he's had FBC, U&E, creatinine, CRP, and a coag. Do you want any other bloods $firstname?" [[Amylase|sepsis7b][$q6 = "No"]] [[LFTs|sepsis7b][$q6 = "No"]] [[Blood cultures|sepsis7a][$q6 = "Yes"]] [[I don't know|sepsis7c][$q6 = "Got help"]] <<timed 59s>> <<goto sepsis7c>> <</timed>> <<countdownTimer 60 "sepsis7c">>

<br> "Ah hang on looks like he had LFTs and amylase in the ED. No cultures though? And what about antibiotics, he's not had anything yet?" [[Yes as per local micro formulary|sepsis8a][$q7 = "Yes"]] [[Yes maximum dose broad spectrum|sepsis8b][$q7 = "No"]] [[Wait and check with the surgeon|sepsis8b][$q7 = "No"]] [[No - prioritise definative treatment|sepsis8b][$q7 = "No"]] [[I don't know|sepsis8c][$q7 = "Got help"]] <<timed 59s>> <<goto sepsis8c>> <</timed>> <<countdownTimer 60 "sepsis8c">>

<br> "Cultures are done. What about antibiotics, he's not had anything yet?" [[Yes as per local micro formulary|sepsis8a][$q7 = "Yes"]] [[Yes maximum dose broad spectrum|sepsis8b][$q7 = "No"]] [[Wait and check with the surgeon|sepsis8b][$q7 = "No"]] [[No - prioritise definative treatment|sepsis8b][$q7 = "No"]] [[I don't know|sepsis8c][$q7 = "Got help"]] <<timed 59s>> <<goto sepsis8c>> <</timed>> <<countdownTimer 60 "sepsis8c">>

<br> "He looks really sick, we should certainly give something...erm wouldn’t it be best to stick to the local micro formulary for what to give?" "OK, let's go with what the micro guide says." "Great, and I've started a fluid chart. At least his systolic is ok, so does he need fluids before we get to theatre?" [[Yes - maintenance|sepsis9b][$q8 = "No"]] [[Yes - 500 ml crystalloid|sepsis9a][$q8 = "Yes"]] [[Yes - 20 ml/kg crystalloid|sepsis9b][$q8 = "No"]] [[No|sepsis9b][$q8 = "No"]] [[I don't know|sepsis9c][$q8 = "Got help"]] <<timed 59s>> <<goto sepsis9c>> <</timed>> <<countdownTimer 60 "sepsis9c">>

<br> You write up and give the antibiotics recomended in your local micro formulary. "I've started a fluid chart. His systolic is ok so does he need fluids?" [[Yes - maintenance|sepsis9b][$q8 = "No"]] [[Yes - 500 ml crystalloid|sepsis9a][$q8 = "Yes"]] [[Yes - 20 ml/kg crystalloid|sepsis9b][$q8 = "No"]] [[No|sepsis9b][$q8 = "No"]] [[I don't know|sepsis9c][$q8 = "Got help"]] <<timed 59s>> <<goto sepsis9c>> <</timed>> <<countdownTimer 60 "sepsis9c">>

<br> "He looks really sick, we should certainly give antibiotics. It would be best to stick to the local micro formulary for what to give. "OK, let's go with what the micro guide says." "Great, and I've started a fluid chart. At least his systolic is ok, so does he need fluids before we get to theatre?"At least his systolic is ok, so does he need fluids before we get to theatre?" [[Yes - maintenance|sepsis9b][$q8 = "No"]] [[Yes - 500 ml crystalloid|sepsis9a][$q8 = "Yes"]] [[Yes - 20 ml/kg crystalloid|sepsis9b][$q8 = "No"]] [[No|sepsis9b][$q8 = "No"]] [[I don't know|sepsis9c][$q8 = "Got help"]] <<timed 59s>> <<goto sepsis9c>> <</timed>> <<countdownTimer 60 "sepsis9c">>

<br> Noah is complaining of feeling really unwell and thirsty, so you give some crystalloid. "Here's the latest ABG $firstname..." <center> <img src="images/abg2.jpg" style="max-width: 50%;"/> </center> [[This gas is fine|sepsis10b][$q9 = "No"]] [[Discuss with critical care|sepsis10a][$q9 = "Yes"]] [[Wait and discuss with the anaesthetic cons|sepsis10b][$q9 = "No"]] [[I don't know|sepsis10c][$q9 = "Got help"]] <<timed 59s>> <<goto sepsis10c>> <</timed>> <<countdownTimer 60 "sepsis10c">>

<br> You take another gas once the fluid is in... <center> <img src="images/abg2.jpg" style="max-width: 50%;"/> </center> [[This gas is fine|sepsis10b][$q9 = "No"]] [[Discuss with critical care|sepsis10a][$q9 = "Yes"]] [[Wait and discuss with the anaesthetic cons|sepsis10b][$q9 = "No"]] [[I don't know|sepsis10c][$q9 = "Got help"]] <<timed 59s>> <<goto sepsis10c>> <</timed>> <<countdownTimer 60 "sepsis10c">>

<br> Noah is complaining of feeling really unwell and thirsty, so you give some crystalloid. Once the fluid is in you do another ABG... <center> <img src="images/abg2.jpg" style="max-width: 50%;"/> </center> [[This gas is fine|sepsis10b][$q9 = "No"]] [[Discuss with critical care|sepsis10a][$q9 = "Yes"]] [[Wait and discuss with the anaesthetic cons|sepsis10b][$q9 = "No"]] [[I don't know|sepsis10c][$q9 = "Got help"]] <<timed 59s>> <<goto sepsis10c>> <</timed>> <<countdownTimer 60 "sepsis10c">>

<br> "I don't think we have time to hang around $firstname, his lactate is climbing." "OK let's repeat the fluid bolus, get him fully monitored and discuss him with ICU." "What's our priority now?" [[Stabilise on ICU|sepsis11b][$q10 = "No"]] [[Expidite surgery|sepsis11a][$q10 = "Yes"]] [[I don't know|sepsis11b][$q10 = "Got help"]] <<timed 59s>> <<goto sepsis11b>> <</timed>> <<countdownTimer 60 "sepsis11b">>

<br> "Let's repeat the fluid bolus, get him fully monitored and discuss him with ICU." "What's our priority?" [[Stabilise on ICU|sepsis11b][$q10 = "No"]] [[Expidite surgery|sepsis11a][$q10 = "Yes"]] [[I don't know|sepsis11b][$q10 = "Got help"]] <<timed 59s>> <<goto sepsis11b>> <</timed>> <<countdownTimer 60 "sepsis11b">>

<br> "I don't think we have time to hang around $firstname, his lactate is climbing. He looks really sick. Why don't we repeat the fluid bolus, get him fully monitored and discuss him with ICU." "OK, let's make ICU aware, then our priority is to..." [[Stabilise on ICU|sepsis11b][$q10 = "No"]] [[Expidite surgery|sepsis11a][$q10 = "Yes"]] [[I don't know|sepsis11b][$q10 = "Got help"]] <<timed 59s>> <<goto sepsis11b>> <</timed>> <<countdownTimer 60 "sepsis11b">>

"He has surgical pathology, we need source control $firstname." "OK, then we need a surgeon. And an anaesthetic senior!" [[Next|sepsis12]] <<run forget("countdown")>>

Thankfully at that moment Dr Franklin, the anaesthetic consultant, puts his head round the door. "Busy shift $firstname? You can fill me in. The surgeons are on their way up from resus as we speak." [[Next|sepsis12]] <<run forget("countdown")>>

<center> !!!@@.greentext;Sepsis in adults@@ @@.greentext;''Sepsis'' = //a life-threatening organ dysfunction caused by a dysregulated host response to infection// ''Septic shock'' = //subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality//@@ <img src="images/sepsis.jpg" style="max-width: 100%;"/> ''Figure 1: NICE sepsis risk stratification tool (see refs).'' <img src="images/sepsis2.jpg" style="max-width: 100%;"/> ''Figure 2: The Sepsis Trust - The Sepsis Six (see refs).'' <img src="images/hourbundle.jpg" style="max-width: 100%;"/> ''Figure 3: The Surviving Sepsis Campaign - The 1 hour bundle (see refs).'' </center> <div class="notes">''Identifying people with suspected sepsis''</div> @@.greentext;''Your answers:''@@ Identified signs of physiological derangement: ''<<print $q1>>'' Calculated the NEWS2 score: ''<<print $q2>>'' Correctly identified patient as having moderate to high risk sepsis: ''<<print $q3>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ ''Risk factors for sepsis?'' * Impaired immunity e.g. chemotherapy, steroids, diabetes, splenectomy, sickle cell disease * Chronic kidney and liver disease * Problems with skin e.g. burns, sores, wounds * Surgery or invasive procedures in the last 6 weeks * Indwelling catheters or lines * People who misuse IV drugs * Under 1 and over 75 years old * Pregnancy or recently given birth ''How bad is it?'' <center> <img src="images/chart2.jpg" style="max-width: 100%;"/> ''Figure 4: NICE risk stratification tool for adults, children and young people aged 12 years and over with suspected sepsis (see refs)'' </center> ''BUT'' patient factors can make these signs/symptoms unreliable indicators, therefore NICE recommends temperature is not used to rule sepsis either in or out and physiological parameters are interpreted in the context of the individual e.g. baseline heart rate may be lower in young people and adults who are fit, or may be affected by drugs such as beta-blockers. The Royal College of Physicians (RCP) launched the National Early Warning Score (NEWS) in 2012 to improve the outcomes of patients with acute illness: <center> <img src="images/chart.jpg" style="max-width: 100%;"/> ''Figure 5: The NEWS2 scoring system'' </center> A NEWS of ''5-6'' is a key trigger threshold and should prompt urgent review by a suitably qualified clinician. ''7+'' needs emergency assessment from the clinical team/critical care outreach. Furthermore a NEWS of ''3'' in any parameter should prompt urgent review. The RCP emphasise the utility of NEWS to identify serious sepsis in patients with known or suspected infection, or at high risk of infection. Patients with a score of 5+ are at serious risk of clinical deterioration and a poor clinical outcome, and need urgent assessment and intervention. Even with a reassuringly low NEWS, if your patient tells you they feel very unwell, or they look unwell, or you/a colleague are concerned they are unwell, then they need further clinical assessment ''even if their observations are currently normal''. Definitions and scores do not capture every patient with sepsis. Keep a high level of suspicion. Use your clinical judgment. </p> <div class="notes">''01 Ensure senior clinician attends''</div> @@.greentext;''Your answers:''@@ Aware of the need for review by senior clinical decision-maker: ''<<print $q4>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ Morbidity and mortality of sepsis is high and experienced clinicians should be involved in these patients care at an early stage. Discuss with critical care any patient with suspected sepsis and a systolic BP < 90 mmHg or a lactate > 4 mmol/L.</p> <div class="notes">''02 Oxygen if required''</div> @@.greentext;''Your answers:''@@ Assesses need for oxygen, not required: ''<<print $q5>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ Give oxygen to achieve a target saturation of 94−98% for adult patients or 88−92% for those at risk of hypercapnic respiratory failure. </p> <div class="notes">''03 Obtain IV access, take bloods''</div> @@.greentext;''Your answers:''@@ Takes blood cultures before, but without delaying, antibiotics: ''<<print $q6>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ For patients with suspected sepsis and 2 or more moderate to high risk criteria, or systolic blood pressure 91–100 mmHg carry out a ''venous'' blood tests for the following: * blood gas including glucose and lactate measurement * blood cultures * FBC * CRP * U&E * creatinine * clotting screen Lactate is a surrogate measure of tissue perfusion and should be remeasured hourly if initial level > 2 mmol/L. RCT have demonstrated a significant reduction in mortality with lactate-guided resuscitation. </p> <div class="notes">''04 Give IV antibiotics''</div> @@.greentext;''Your answers:''@@ Give intravenous antibiotics without delay (within a maximum of 1 hour): ''<<print $q7>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ Sterilisation of blood cultures can occur within minutes of the first dose of antibiotics so take blood cultures first but do not delay administration of a suitable antibiotic. Check allergy status. For all people with suspected sepsis where the source of infection is clear use existing local antimicrobial guidance. When empirical intravenous antibiotics are needed in patients with no confirmed diagnosis, use your local formulary and prescribe in line with local (where available) or national guidelines. Consider the need for anti viral/antifungal. These pathogens can also cause sepsis.</p> <div class="notes">''05 Give IV fluids''</div> @@.greentext;''Your answers:''@@ Give intravenous fluid (bolus injection) without delay and within 1 hour: ''<<print $q8>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ NICE CG174 //Intravenous fluid therapy in adults in hospital// recommends crystalloids that contain sodium in the range 130–154 mmol/l, with a bolus of 500 ml over less than 15 minutes for resuscitation. Repeat boluses should be guided by lactate and physiological parameters. 30 ml/kg or more may be needed during the initial resuscitation.</p> <div class="notes">''06 Monitor''</div> @@.greentext;''Your answers:''@@ Discuss with critical care if lactate over 4 mmol/L OR systolic blood pressure less than 90 mmHg: ''<<print $q9>>'' Knows the importance of source control for effective management of sepsis: ''<<print $q10>>'' <p style="text-align:justify">@@.greentext;''Feedback:''@@ Monitor people with suspected sepsis who meet any high risk criteria continuously, or a minimum of once every 30 minutes depending on setting. A consultant should attend any patient with suspected sepsis and any high risk criteria who fails to respond within 1 hour of initial antibiotic and/or intravenous fluid resuscitation. Failure to respond is indicated by any of: * Systolic BP < 90 mmHg * Reduced level of consciousness * RR > 25 * Lactate not reduced by 20% of its original value within one hour In patients poorly responsive to initial fluid resuscitation urgent restoration of organ perfusion is vital. Invasive monitoring is needed and vasopressors should be started within the first hour to attain a mean arterial pressure of ≥ 65 mmHg. These patients are at high risk of death and need the input of senior clinicians. Source control must be implemented as soon as medically and logistically practical after the diagnosis of is made (e.g. drainage of abscess, debridement of necrotic tissue, removal of infected devices/lines). Senior decision makers should be involved in determining the nature and timing of any procedure, e.g. open surgical vs laparoscopic vs interventional radiology.</p> [[I want another emergency|emerg1]] [[I'm done|exit2]] [[Show me the evidence|sepsisref]]

# ''The Surviving Sepsis Campaign'' joint initiative of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM). Available [[here|https://www.sccm.org/SurvivingSepsisCampaign/Home]] # ''UK Sepsis Trust'' professional resources available [[here|https://sepsistrust.org/professional-resources/]] # National Institute for Health and Care Excellence. Sepsis: recognition, diagnosis and early management. NICE guideline No. 51. 2017. Available [[here|https://www.nice.org.uk/guidance/ng51 ]] # Levy M, Evans L, Rhodes A. Surviving sepsis campaign: 2018 update. //Int Care Med//. 2018; 44:925-928 # National Institute for Health and Care Excellence. Intravenous fluid therapy in adults in hospital. NICE Clinical guideline No. 174. 2013. Available [[here|https://www.nice.org.uk/guidance/cg174 ]] [[Back|feedbacksepsis]]

<center> !!!BETA Virtual Anaesthetics_6 <<link [[What is Beta Testing?|beta]]>> <<set Dialog.setup("What is Beta Testing?")>> <<set Dialog.wiki("@@.greentext;Beta testing is an opportunity for real users to use a product in a production environment to uncover any bugs or issues before a general release. Beta testing is the final round of testing before releasing a product to a wide audience. The objective is to uncover as many bugs or usability issues as possible in this controlled setting.@@")>> <<set Dialog.open ()>> <</link>> !!![[Start scenario|Intro 1]] </center>

!!!@@.greentext; Welcome to the trainers area of this scenario@@ <<set _answer to "">> Please input the password to continue: <<textbox "_answer" "">> <<button "Check Password">> <<if _answer is "">> <<script>>UI.alert("You did not supply a password");<</script>> <<else>> <<set _answer to _answer.trim().toLowerCase()>> <<if _answer is "vatrainersarea">> <<goto "trainers_area2">> <<else>> <<script>>UI.alert("Incorrect password");<</script>> <<goto "trainers_area">> <</if>> <</if>> <</button>>

Trainer guide for this scenario available ''[[here|https://www.virtualanaesthetics.com/trainerguides/IACmodule6.pdf]]'' [[Back|Introduction]]

Suddenly you feel a give under your hands as the laryngospasm breaks. You gently hand ventilate the patient. Their chest rises and falls. "No, not right now anyway." "Well done $firstname!" [[Feedback on how I did|feedbacklary]] [[I want another emergency|emerg1]] <<audio "stridor" stop>> <<audio "stridor2" stop>> <<set $id to "laryIAC">> <<set $q13 to "-">> <<set $q14 to "-">> <<set _data = {randomid: $randomid, id: $id, q1: $q1, q2: $q2, q3: $q3, q4: $q4, q5: $q5, q6: $q6, q7: $q7, q8: $q8, q9: $q9, q10: $q10, q11: $q11, q12: $q12, q13: $q13, q14: $q14 }>> <<run sendData(_data)>>

You send a CK. You take a deep breath as the anaesthetic and ICU consultants arrive simultaniously. [[Next|hot16]] <<run forget("countdown")>>

A couple of hours later you're in the theatre staff room. The plastics SpR's bleep goes off. You pass over the phone. "Plastics, you bleeped me? Can I take a result?" They pull a list from the back pocket of their scrubs. "OK, go for it...serum tryptase...greater than...200 micrograms per ml. Great, thanks." [[Feedback on how I did|feedbackhypo]] [[I want another emergency|emerg1]] [[I'm done|exit2]] <<set $id to "anaphIAC">> <<set $q12 to "-">> <<set $q13 to "-">> <<set $q14 to "-">> <<set _data = {randomid: $randomid, id: $id, q1: $q1, q2: $q2, q3: $q3, q4: $q4, q5: $q5, q6: $q6, q7: $q7, q8: $q8, q9: $q9, q10: $q10, q11: $q11, q12: $q12, q13: $q13, q14: $q14 }>> <<run sendData(_data)>> <<audio "monitor120" pause>> <<audio "monitor150" pause>> <<audio "monitorfast" pause>>

A couple of days later you go to see how Noah is getting on the ward. He sees you coming. "$firstname! I'm glad you came. I wanted to thank you. It could have been much worse without you." [[Feedback on how I did|feedbacksepsis]] [[I want another emergency|emerg1]] [[I'm done|exit2]] <<set $id to "sepIAC">> <<set $q11 to "-">> <<set $q12 to "-">> <<set $q13 to "-">> <<set $q14 to "-">> <<set _data = {randomid: $randomid, id: $id, q1: $q1, q2: $q2, q3: $q3, q4: $q4, q5: $q5, q6: $q6, q7: $q7, q8: $q8, q9: $q9, q10: $q10, q11: $q11, q12: $q12, q13: $q13, q14: $q14 }>> <<run sendData(_data)>>

<img src="images/wing.png" style="max-width: 30px" alt="small wing"/>@@.name; Virtual Anaesthetics_6@@

''>'' On each page there are clickable links within the text. ''>'' Navigate using the links in the scenario or the forward and back arrows in the left menu bar NOT the forward and back arrows on your internet browser. ''>'' Each scenario should take around an hour. ''>'' Your time spent accessing the scenario is recorded on your completion certificate. ''>'' If you access the scenario several times the certificate will only show the duration of the most recent access. ''>'' For the best platform experience access from a larger screen device such as a tablet ''>'' ''Check you're not on mute''. ''>'' When printing your certificate from a mobile device turn to portrait orientation. [[Back|Intro 1]]

/* Update the time of the previous history record if there is one. */ <<if $history.length gt 0>> <<set $history.last().time to Date.now()>> <<else>> /* Record the time the first passage was shown. */ <<set $started to Date.now()>> <</if>> /* Add current passage's history record to the array, unless it has a 'no-history' passage tag. */ <<if not tags().includes('no-history')>> <<set $history.push({ "passage": passage(), "time": 0 })>> <</if>>