Anaesthetics & Pain Management

7/31/2017 Anaesthetics & Pain Management - FRCEM Success
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Anaesthetics & Pain Management
Question 1 of 35 1 Unanswered
A 34 year old woman has been brought to the Emergency Department following a mixed 2 Unanswered
overdose of multiple medications. She has a reduced GCS (GCS 7) and her ABG shows a severe
3 Unanswered
metabolic acidosis. Your consultant wishes to perform a rapid sequence induction (RSI).
4 Unanswered
a. Describe the components of an ‘AMPLE’ history that should be taken before performing
RSI. (1 mark) 5 Unanswered
b. What is the minimum recommended standards of monitoring which are required
6 Unanswered
whenever anaesthesia is administered? (1 mark)
c. How can the patient be positioned to improve the effectiveness of preoxygenation? (1 7 Unanswered
mark)
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You did not answer this question
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11 Unanswered
Answer 12 Unanswered
a. All of:
A – Allergy
M – Medications
http://intermediate.frcemsuccess.com/rev/anaestheticspainmanagement/ 1/6
P – Past medical history

L – Last ate/drank
E – Events leading up to this situation
b. All of:
Waveform capnography
Inspired oxygen concentration (FiO2)
Pulse oximetry
Non-invasive blood pressure monitoring (NIBP)
Continuous ECG
c. Ideally the head-up or reverse Trendelenburg position (as this displaces weight from the anterior chest wall
decreasing the load on the thoracic cavity and reducing the pressure of intra-abdominal contents on the
diaphragm)
Notes
Rapid sequence induction (RSI) and tracheal intubation is the process of rapidly inducing hypnosis followed by
paralysis to facilitate the passing of an endotracheal tube. This is used when there is high risk of gastric
regurgitation.
Preparing for RSI
An RSI is a high risk procedure and adequate check and preparation must be performed.
PEACH is a useful mnemonic to remember the steps in preparing for RSI:
Positioning
Equipment
Attach – oxygen and monitoring
Checks – pre-procedural checklist, resuscitation, brief history, intravenous access and neurology
Help – who is available and what are their skills?
Positioning
Optimal positioning of the patient for RSI and tracheal intubation is intended to:
Improve pre-oxygenation
Improve pre-oxygenation
Decrease rate of desaturation following apnoea
Improve grade of laryngeal view at laryngoscopy
Positioning for pre-oxygenation:
Ideally the head-up or reverse Trendelenburg position as this displaces weight from the anterior chest wall
decreasing the load on the thoracic cavity and reducing the pressure of intra-abdominal contents on the diaphragm
(although some hypotensive patients may not tolerate this and the effect on cerebral perfusion must be considered
– consider concurrent leg elevation or uid/inotropic support)
Positioning for intubation:
During laryngoscopy, alignment of the oral, pharyngeal and laryngeal axes in the ‘snif ng the morning air’ position
can provide a clear view from the incisors to the laryngeal inlet
Equipment
The emergency airway trolley should contain:
Tilting trolley and pillow

Suction apparatus with wide-bore rigid suction end (e.g. Yankauer) for upper airway suction and a range of
smaller exible catheters for tracheal suction
Oxygen delivery apparatus including mask with reservoir, nasal cannulae and oxygen tubing
Backup oxygen supply
Airway adjuncts, including several sizes of oropharyngeal (sizes 2, 3, 4) and nasopharyngeal (size 6 and 7)
airways
Laryngoscope – generally a curved Macintosh blade (size 4 suitable for all but the smallest of adult patients
– size 3) and spare laryngoscope
Cuffed tracheal tubes (several sizes should be available – a 7.5 mm or 8.0 mm is usually suitable for adult
male and 7.0 mm or 7.5 mm for adult female) cut to length (22 – 24 cm for women, 24 – 26 cm for men)
20 mL syringe for cuff in ation
Water-soluble lubricant
Bougies and stylets
Magill’s forceps
Tie, tape or bandage to secure tube in position
Tie, tape or bandage to secure tube in position
Ventilation system (check high and low pressure alarms, the ventilation mode, respiratory rate, tidal volume,
inspiratory:expiratory ratio and positive end expiratory pressure)
Equipment for con rming correct placement of tube
Drugs in labelled syringes
Equipment for failed intubation
Supraglottic airways (+ lubricating gel and syringe to in ate device if required)
Needle cricothyroidotomy set
Surgical cricothyroidotomy set
Attach
Oxygen for pre-oxygenation:
High ow oxygen (15 L/min) through well tting mask with reservoir
Ideally an anesthetic breathing system, such as a Mapleson C circuit
Non-invasive respiratory support if patient requires this to maintain oxygenation prior to intubation
Monitoring:
The minimum recommended standards of monitoring which are required whenever anaesthesia is administered:
Inspired oxygen concentration (FiO2)
Pulse oximetry
Non-invasive blood pressure monitoring (NIBP)
Continuous ECG
Checks
Pre-procedural checklist:
Pre-procedural checklists and team brie ngs reduce errors and untoward incidents. Use intubation checklists for all
intubations of critically ill patients and identify backup plans.
Resuscitation:
Review ABC
Identify any reversible problems
Request any relevant laboratory tests
Optimise drug treatment of any medical condition, including analgesia
Document baseline physiology
Brief history:
Prior to RSI it is wise to brie y review the patient’s history. The pertinent points can be remembered using the
mnemonic AMPLE:
A – Allergy
M – Medications
P – Past medical history
L – Last ate/drank
E – Events leading up to this situation
Intravenous access:
Ensure there are two functioning IV lines before giving any anaesthetic drugs.
Neurology:
Undertake a brief neurological exam before induction of anaesthesia, including assessment of GCS, pupil
signs and motor response for each limb. Look for diaphragmatic breathing, inappropriate vasodilation or
priapism.
Help
An appropriately experienced individual should be present before undertaking advanced airway management in a
critically ill patient. If RSA is anticipated, summon expert help immediately.
RSI outside the operating room requires a minimum of three or four staff.
Question Navigator
A 45 year old man is brought into the Emergency Department following a fall from a height. 2 Current Question
Your consultant asks for your assistance in performing an RSI to facilitate transfer to the CT
3 Unanswered
scanner.
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a. What is the recommended dose of thiopental when performing an RSI in a
cardiovascularly stable patient? Give your answer in mg/kg. (1 mark) 5 Unanswered
b. Give one indication where thiopentone is the preferred induction agent. (1 mark)
6 Unanswered
c. By what mechanism can thiopentone cause bronchospasm? (1 mark)
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a. 2 – 7 mg/kg
12 Unanswered
b. Any one of:
Isolated head injury
Seizures
Status epilepticus
c. Histamine release
Notes
The four most commonly used induction agents are: etomidate, propofol, thiopental sodium and ketamine.
Etomidate
Indications:
Induction of anaesthesia in haemodynamically compromised patient
Dose 0.3 mg/kg
Induction characteristics:
5 – 15 secs onset
5 – 15 mins recovery
Myoclonic movement on injection (may be mistaken for seizures)
Pain on injection
Speci cs:
Relative haemodynamic stability
Adrenal suppression
Contraindicated in sepsis
Propofol
Indications:
Most commonly used drug for elective anaesthesia
Can be used by infusion for maintenance of anaesthesia or sedation
Sedation in intubated patients on ICU or during transport
Dose 1.5 – 2.5 mg/kg
20 – 40 secs onset (slow onset may lead to overdose)
5 – 10 min recovery
Apnoea after induction dose
Pain on injection
Induction often associated with involuntary movements
Speci cs:
Hypotension is common and may be severe in hypovolaemia, cardiovascular compromise and the
elderly
Occasionally severe bradycardia
Thiopental sodium
Indications:
Haemodynamically stable patient with isolated head injury, or seizures
Dose 2 – 7 mg/kg (1.5 – 2 mg/kg in haemodynamically unstable patients and the elderly)
5 – 15 secs onset
Speci cs:
Cerebroprotective because of dose dependent decrease in cerebral metabolic oxygen consumption,
cerebral blood ow and ICP
Maintenance of cerebral perfusion pressure
Causes histamine release: can induce or exacerbate bronchospasm
Causes hypotension and reduced urine output
Ketamine
Indications:
Trauma, particularly burns
Septic shock
Cardiovascularly compromised patient
Severe bronchospasm
Dose 1 – 2 mg/kg
15 – 30 secs onset
Lack of de ned end-point makes dose calculation dif cult
Excitatory phenomena
Speci cs:
Causes bronchodilation – agent of choice in severe asthma
Potent analgesic
Central sympathetic stimulation leading to increased heart rate and increased blood pressure
Secretions increased – pharyngeal and bronchial

Enhanced laryngeal re exes with potential for laryngospasm
Emergence phenomena e.g. agitation, hallucinations (commoner in adults and reduced by pre-
treatment with midazolam)
Causes less hypotension and respiratory depression than the other induction drugs
Comparison
Drug Etomidate Propofol Thiopental Ketamine
Dose 0.3 mg/kg 1.5 – 2.5 mg/kg 2 – 7 mg/kg 1 – 2 mg/kg
Onset 5 – 15 secs 20 – 40 secs 5 – 15 secs 15 – 30 secs
Recovery 5 – 15 mins 5 – 10 mins 5 – 15 mins 15 – 30 mins
CV + +++ ++ Minimal
depression
Notes Relatively Marked Cerebroprotective Potent

cardiovascularly hypotension in Useful in isolated analgesia
stable cardiovascular head injury Dissociative
Myoclonic compromise Anticonvulsant state
movements on Pain on Bronchospasm Bronchodilator
induction injection due to histamine Useful in acute
Adrenal Involuntary release asthma,
suppression movements on hypovolaemia,
Contraindicated induction trauma and
in sepsis Occasionally burns
severe Emergence
bradycardia phenomena
Hypertension
Question Navigator
A 67 year old woman presents to the ED following a fall. She describes slipping on an icy 2 Unanswered
pavement. An x-ray has con rmed a dorsally angulated distal radius fracture and your consultant
3 Current Question
advises you to perform a reduction using a Bier’s block.
4 Unanswered
a. What pressure should the double cuff be in ated to in Bier’s block? (1 mark)
b. What is the minimum time the cuff must remain in ated? (1 mark) 5 Unanswered
c. What drug must be immediately available when performing a Bier’s block, giving your
6 Unanswered
rationale? (1 mark)
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a. 100 mmHg above the systolic blood pressure, to a maximum of 300 mmHg
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b. The cuff should remain in ated for a minimum of 20 minutes (and a maximum of 45 minutes)
c. Intravenous lipid emulsion (Intralipid) – in order to treat local anaesthetic toxicity
Notes
Intravenous regional anaesthesia for distal forearm fractures (Bier’s block)
Indications
Reduction of wrist fractures, most commonly Colles’ fracture
Contraindications
Allergy to local anaesthetic

Children – consider whether appropriate on individual basis
Epilepsy
Hypertension >200mm Hg
Infection in the limb
Lymphoedema
Methaemoglobinaemia
Morbid obesity (as the cuff is unreliable on obese arms)
Peripheral vascular disease
Procedures needed in both arms
Raynaud’s phenomenon
Scleroderma
Sickle cell disease or trait
Uncooperative or confused patient
Drug and dose
The most commonly used local anaesthetic is 0.5% prilocaine (3 mg/kg), although 0.5% lignocaine without
adrenaline (3 mg/kg) can be used if prilocaine is unavailable.
Equipment
Peripheral venous access

Local anesthetic agent
Double cuff tourniquet (check for leaks prior to procedure)
ECG, BP and pulse oximetry monitoring
Access to resuscitative equipment
Access to emergency drugs, including intralipid in case of local anaesthetic toxicity
Procedure
Obtain consent
Obtain patient’s weight in kilograms and calculate drug dose
Transfer patient to resus or an appropriately sited well lit area with resuscitative equipment
Ensure ECG, BP and pulse oximetry monitoring in situ
Obtain IV access on both sides (distal to the cuff in the side to be anaesthetised)
Place double cuff tourniquet on upper arm
Elevate injured limb for three minutes to exsanguinate the limb
In ate the cuff to 100 mmHg above the systolic BP, up to a maximum of 300 mmHg, and record the time of
in ation
Check for the absence of a radial pulse
Inject 0.5% plain prilocaine, prepared according to patient weight, slowly and record the time of injection
Warn the patient about the cold/hot sensation and mottled appearance of the arm
Check for anaesthesia – may have touch but not pain, after ve minutes
(If anaesthesia inadequate initially, try ushing cannulae with 10 – 15 ml normal saline)
Once anaesthesia satisfactory, remove the cannula
Lower arm onto a pillow and check tourniquet not leaking
Perform the procedure and obtain check x-ray
If satis ed with the post reduction position of fracture, de ate the cuff observing the patient and monitor
Record the time of de ation and observe the patient and limb closely for signs of delayed toxicity until fully
recovered
Points to be aware of
Be aware of the location of stocked emergency drugs such as intralipid in case of local anesthetic toxicity
IV access must also be obtained on normal side in case of complications which require systemic drug
administration
Tourniquet must be under observation at all times
Cuff should be kept in ated for a minimum of 20 minutes and for a maximum of 45 minutes
Watch continuously for signs of toxicity
Check limb circulation prior to discharge and arrange patient follow up and analgesia as appropriate
Complications
Complications
Systemic toxicity
CNS
Subjective circumoral paraesthesia
Yawning, restlessness, anxiety and tremor
Nausea and vomiting
Muscle twitching, convulsions
Apnoea
Coma
CVS
Sweating, pallor, hypotension, circulatory collapse
Arrhythmias, especially bradycardia and asystolic cardiac arrest
Methaemoglobinaemia (problem speci c to prilocaine, usually in doses > 16 mg/kg)
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Question Navigator
A 45 year old woman is brought into ED in cardiac arrest. During resuscitation, your 2 Unanswered
consultant asks you to insert a femoral central line.
3 Unanswered
a. Describe the anatomical landmarks used to identify the femoral vein. (1 mark)
4 Current Question
b. Give two contraindications to femoral line insertion. (1 mark)
c. How can you improve the technique of central line insertion? (1 mark) 5 Unanswered
6 Unanswered
You did not answer this question 7 Unanswered
8 Unanswered
9 Unanswered
Answer
10 Unanswered
a. The surface anatomy of the femoral vein is identi ed for venipuncture by palpating the point of maximal
pulsation of the femoral artery immediately below the level of the inguinal ligament (at the mid-inguinal 11 Unanswered
point) and marking a point approximately 0.5 cm medial to this pulsation. 12 Unanswered
b. Any two of:
Absolute
Venous injury (known or suspected) at the level of the femoral veins or proximally (ie, iliac veins or
inferior vena cava)
Known or suspected thrombosis of the femoral or iliac veins on the proposed side of venous
cannulation
Ambulatory patient (because ambulation increases the risk of catheter fracture and migration)
Relative
Presence of bleeding disorders (innate or iatrogenic from the use of anticoagulants or
thrombolytics)
Distortion of anatomy due to local injury or deformity
Previous long-term venous catheterisation (which increases the risk of venous thrombosis)
Absence of a clearly palpable femoral artery
History of vasculitis
Previous injection of sclerosing agents
Previous radiation therapy
c. Ultrasound can be used as an adjunct for placement of central venous lines.
Notes
Femoral line insertion
Indications for central line
Resuscitation requiring a large bore IV line

Administration of irritant sclerosing infusions
High ow blood access for dialysis or plasmapheresis
Haemodynamic (CVP) monitoring
Venous access where peripheral access is unavailable
Long term venous access
Femoral lines are a useful alternative when there is a compelling reason to avoid an upper body central line, often
because of venous thrombosis, stenosis or a preexisting central line already residing in the SVC. The femoral site is
also the most accessible site during CPR.
Contraindications
Absolute
Venous injury (known or suspected) at the level of the femoral veins or proximally (i.e. iliac veins or
inferior vena cava)

Known or suspected thrombosis of the femoral or iliac veins on the proposed side of venous
cannulation
Ambulatory patient (because ambulation increases the risk of catheter fracture and migration)
Relative
Presence of bleeding disorders (innate or iatrogenic from the use of anticoagulants or thrombolytics)
Distortion of anatomy due to local injury or deformity
Previous long-term venous catheterisation (which increases the risk of venous thrombosis)
Absence of a clearly palpable femoral artery
History of vasculitis
Previous injection of sclerosing agents
Previous radiation therapy
Clinical anatomy
Locate the femoral vein by palpating the femoral artery; the femoral vein lies directly medial to the femoral
artery.
The femoral artery can be palpated in the femoral triangle (bounded superiorly by the inguinal ligament,
laterally by the sartorius muscle and medially by the medial border of the adductor longus muscle) as it
passes over the femoral head, just inferior to the inguinal ligament, midway between the anterior superior
iliac spine and the pubic symphysis (at the mid-inguinal point).
The surface anatomy of the femoral vein is identi ed for venipuncture by palpating the point of maximal
pulsation of the femoral artery immediately below the level of the inguinal ligament and marking a point
approximately 0.5 cm medial to this pulsation.
Keep a nger on the artery to facilitate anatomical location and avoid insertion of the catheter into an
artery.
Ultrasound can be used as an adjunct for placement of central venous lines.
Modi ed by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia Commons
Complications
Deep vein thrombosis

Infection
Arteriovenous stula
Air embolus
Haematoma
Haemorrhage
Stenosis
Arterial puncture/catheterisation
Central vein perforation

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A 43 year old man is brought into the ED following a high speed road traf c collision. He has 2 Unanswered
severe facial injuries. Your consultant has attempted to intubate the patient but has failed three
3 Unanswered
times despite the use of adjuncts. He is unable to ventilate the patient using a bag-valve mask.
He proceeds to perform needle cricothyroidotomy. 4 Unanswered
a. At what angle should the needle be inserted through the cricothyroid membrane. (1 5 Current Question
mark)
6 Unanswered
b. Describe the technique of ventilation through needle cricothyroidotomy. (1 mark)
c. Give two complications of needle cricothyroidotomy. (1 mark) 7 Unanswered
8 Unanswered
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Answer
12 Unanswered
a. 45 degrees
b. One second of oxygen supplied at a pressure of 400 kPa (4 bar) and ow of 15L/min, followed by a 4 second
pause to enable expiration via the upper airway (intermittent insuf ation)
c. Any two of:
Barotrauma from high pressure ventilation including pulmonary rupture with tension pneumothorax
Inadequate ventilation due to kinking or obstruction of the cannula
Aspiration of blood
Oesophageal laceration
Haematoma
Perforation of posterior tracheal wall
Subcutaneous and/or mediastinal emphysema
Thyroid perforation
Notes
Needle cricothyroidotomy involves insertion of a needle through the cricothyroid membrane to provide oxygen on a
short-term basis until a de nitive airway can be placed.
Indications
Can’t intubate, can’t oxygenate scenario
Advantages vs disadvantages
Disadvantages
Only a temporary measure – not a de nitive airway
Requires high-pressure oxygen source
May cause barotrauma, particularly in the presence of expiratory obstruction
Particularly ineffective in patients with trauma
Prone to failure because of kinking of the cannula
Unsuitable for maintaining oxygenation during patient transfer
Advantages
Quick and easy
Recommended in failed airway in child where surgical cricothyroidotomy is relatively contraindicated
because of risk of damaging cricoid cartilage
Procedure
Attach a 20 mL syringe to a stiff cannula and needle (minimum 14 gauge in adults)

Insert the cannula through the cricothyroid membrane into the airway at an angle of 45 degrees aiming
Insert the cannula through the cricothyroid membrane into the airway at an angle of 45 degrees aiming
caudally in the midline
Con rm cannula position by aspiration of air with the syringe and advance cannula fully over the needle into
the trachea
Remove the needle, and aspirate air from the cannula to con rm position
Hold cannula in place and attach ventilation system
One second of oxygen supplied at a pressure of 400 kPa (4 bar) and ow of 15L/min should be suf cient to
in ate adult lungs adequately
This is followed by a 4 second pause to enable expiration via the upper airway (expiration does not occur via
the cannula)
In children the intial ow rate should equal the child’s age in years, and this is increased in 1 L/min
increments until one second of oxygen ow causes the chest to rise
Look carefully for adequate exhalation through the upper airway (chest falls adequately with each
expiration)
The patient can be adequately oxygenated for 30 – 45 mins using this technique (because of inadequate
exhalation build up of CO2 occurs)
If ventilation fails, or complications occur, proceed immediately to surgical cricothyroidotomy
Complications
Barotrauma from high pressure ventilation including pulmonary rupture with tension pneumothorax
Inadequate ventilation due to kinking or obstruction of the cannula
Aspiration of blood
Haematoma
Thyroid perforation
Clinical anatomy
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Question Navigator
A 21 year old girl is brought to ED following a severe allergic reaction. Whilst in ED her lips 2 Unanswered
and tongue continue to swell despite appropriate treatment. The anaesthetic team attempt to
3 Unanswered
perform RSI, but are unable to intubate after several attempts with multiple airways. They are
unable to ventilate the patient with a bag-valve mask and the decision is made to proceed to 4 Unanswered
surgical cricothyrotomy.
5 Unanswered
a. Brie y describe how you would perform surgical cricothyroidotomy. Assume the patient
6 Current Question
and equipment has been prepared for the procedure. (2 marks)
b. Give two possible complications of surgical cricothyroidotomy. (1 mark) 7 Unanswered
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11 Unanswered
Answer
12 Unanswered
a. All of:
Palpate the thyroid notch, cricothyroid interval, and sternal notch for orientation
Make a horizontal stab incision through the cricothyroid membrane into the trachea
Open the incision with tracheal dilators or clip (with the scalpel blade still in situ)
Remove the scalpel blade and insert the intubating bougie into the trachea
Railroad the tracheal tube over the intubating bougie to place it in the trachea
In ate the cuff and con rm the tube position
Secure the tube to the patient to prevent dislodging
b. Any two of:
Aspiration of blood
Creation of false passage into the tissues
Subglottic stenosis/oedema
Laryngeal stenosis
Thyroid laceration
Haemorrhage or haematoma formation
Vocal cord paralysis, hoarseness
Notes
Surgical cricothyroidotomy is performed by making a skin incision that extends through the cricothyroid membrane.
Surgical cricothyroidotomy provides a de nitive airway that can be used to ventilate the lungs until semi-elective
intubation or tracheostomy is performed.
Indications
Can’t intubate, can’t oxygenate scenario
Advantages vs disadvantages
Advantages
De nitive airway
Enables ventilation and oxygenation
Enables suctioning of trachea
Disadvantages
Trauma to surrounding structures
Risk of creating false passage in soft tissues or oesophagus
Technically more dif cult than needle cricothyroidotomy
Procedure
Extension of the neck will improve surgical access and exposure

Palpate the thyroid notch, cricothyroid interval, and sternal notch for orientation
Make a horizontal stab incision through the cricothyroid membrane into the trachea
Open the incision with tracheal dilators or clip (with the scalpel blade still in situ)
Remove the scalpel blade and insert the intubating bougie into the trachea
Railroad the tracheal tube over the intubating bougie to place it in the trachea
In ate the cuff and con rm the tube position
Secure the tube to the patient to prevent dislodging
Complications
Aspiration of blood
Creation of false passage into the tissues
Subglottic stenosis/oedema
Laryngeal stenosis
Thyroid laceration
Haemorrhage or haematoma formation
Vocal cord paralysis, hoarseness
Clinical anatomy
By PhilippN [GFDL (http://www.gnu.org/copyleft/fdl.html), CC-BY-SA-3.0

(http://creativecommons.org/licenses/by-sa/3.0/) or CC BY-SA 2.5-2.0-1.0
(http://creativecommons.org/licenses/by-sa/2.5-2.0-1.0)], via Wikimedia Commons

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Question Navigator
A 33 year old man is intubated for airway protection following a large mixed overdose. He 2 Unanswered
remains ventilated in the ED whilst awaiting an ICU bed. 30 minutes after intubation, the nurse
3 Unanswered
notes the patient has become hypoxic with sats of 78%. Intubation was uneventful, there was no
suspicion of aspiration and he had sats of 100% both before and after intubation. 4 Unanswered
a. Give four causes of post-intubation hypoxia. (2 marks) 5 Unanswered

b. What is the immediate rst step in managing this patient? (1 mark)
6 Unanswered
7 Current Question
8 Unanswered
9 Unanswered
a. Any four of: 11 Unanswered

Position of ET tube (oesophageal or bronchial intubation, tube out of trachea)
12 Unanswered
Obstruction of ET tube (obstructed tubing, tracheal/bronchial obstruction or bronchoconstriction)
Patient (e.g. pneumothorax, PE, pulmonary oedema, atelectasis, bronchospasm, pleural effusion)
Equipment (incorrect kit or connections/equipment failure/inadequate gas ow)
Stacked breaths/Splinting (abdominal distension including stomach distension or poor paralysis)
b. Disconnect ventilator (allows release of trapped gas) and give high ow 100% oxygen through bag valve
mask.
Notes
Post-intubation hypoxia can be rapidly fatal without early intervention, which requires a structured approach to
concurrently identifying and treating the underlying cause.
Causes (POPES)
Position of ET tube (oesophageal or bronchial intubation, tube out of trachea)

Obstruction of ET tube (obstructed tubing, tracheal/bronchial obstruction or bronchoconstriction)
Patient (e.g. pneumothorax, PE, pulmonary oedema, atelectasis, bronchospasm)
Equipment (incorrect kit or connections/equipment failure/inadequate gas ow)
Stacked breaths/Splinting (abdominal distension including stomach distension or poor paralysis)
Structured approach
Disconnect the ventilator and administer high- ow 100% oxygen (FiO2 1.0) using a bag-valve-mask.
Disconnection allows the release of trapped air in a patient with severe bronchospasm (pushing down
on the chest can also help to relieve some of the pressure)
If patient is easy to hand ventilate and reoxygenate, then the problem probably lies with the ventilator
or circuit
Assess patient (MASH)
Movement of chest wall during ventilation ?adequate, symmetrical, hyperexpanded
Arterial saturation and PaO2 (obtain ABG)
Skin colour of patient
Haemodynamic stability
If the patient is dif cult to manually ventilate, determine if the problem lies with the endotracheal tube or
with the patient.
If there is little chest movement, a patient problem is still possible, but a problem with the ETT needs to be
be ruled out urgently:
Check ETCO2 and obtain chest x-ray to check position of ETT
Pass a suction catheter and/or bougie to ensure ETT is not obstructed
If in doubt, and hypoxia has not been rapidly resolved, take tube out and replace it
If there is reasonable chest movement, a patient problem is most likely. Perform a focused exam and
If there is reasonable chest movement, a patient problem is most likely. Perform a focused exam and
urgently seek and treat the following life-threatening diagnoses:
pneumothorax (look for asymmetrical chest movement)
lung collapse (look for asymmetrical chest movement)
pulmonary oedema
bronchospasm (chest wall movement may be minimal — look for hyperexpansion)
pulmonary embolism
If the patient is easy to ventilate with the bag and the hypoxemia rapidly resolves:
Check for disconnection of the ventilator/circuit
Check ventilator settings
Troubleshoot equipment failure

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Question Navigator
A 35 year old is brought to ED by ambulance complaining of cough and fever. She is noted to 14 Unanswered
be hypotensive and tachycardic. Chest x-ray con rms bilateral consolidation. The patient
15 Unanswered
continues to deteriorate in the department despite aggressive treatment. A decision is made to
transfer the patient to ITU for inotropic and ventilatory support. An RSI is performed in the 16 Unanswered
department.
17 Unanswered
a. What is the recommended dose of rocuronium when performing an RSI? Give your 18 Unanswered
answer in mg/kg. (1 mark)
b. Name the drug that can be used to reverse neuromuscular blockade caused by 19 Unanswered
rocuronium. (1 mark) 20 Unanswered
c. What is the onset time of rocuronium and why is it particularly important to be aware of
this? (1 mark) 21 Unanswered
22 Unanswered
24 Unanswered
Answer
a. 1.0 – 1.2 mg/kg
b. Sugammadex
c. 60 seconds; unlike suxamethonium, rocuronium does not cause fasciculations which can be used to indicate
effectiveness
Notes
Muscle relaxants can be divided into two categories: depolarising and non-depolarising agents. By speci c blockade
of the neuromuscular junction they enable light anaesthesia to be used with adequate relaxation of the muscles of
the abdomen and diaphragm. They also relax the vocal cords and allow the passage of a tracheal tube. Patients who
have received a neuromuscular blocking drug should always have their respiration assisted or controlled until the
drug has been inactivated or antagonised. They should also receive suf cient concomitant inhalational or
intravenous anaesthetic or sedative drugs to prevent awareness.
Drug Suxamethonium Rocuronium
Type Depolarising Non-

depolarising
Dose 1.5 – 2 mg/kg 1 – 1.2 mg/kg
Onset 10 – 15 sec fasciculation, 45 – 60 sec paralysis 1 min
Recovery 3 – 5 min rst return of respiratory activity 30 – 40 min

5 – 10 min return of effective spontaneous ventilation
Contraindications Known hyperkalaemia Nil

ECG changes suggestive of hyperkalaemia
Risk factors for hyperkalaemia (burns, peripheral neuropathy,
spinal cord injury, muscle dystrophy, UMN lesions or structural
brain damage, trauma, infection and desquamating skin
conditions)
Side effects Hyperkalaemia

http://intermediate.frcemsuccess.com/rev/anaestheticspainmanagement/ Anaphylactoid 2/5
Side effects Hyperkalaemia Anaphylactoid
Bradycardia reactions
Muscle fasciculation causing muscle pain (rare)
Histamine release causing hypotension
Anaphylaxis
Malignant hyperthermia
Prolonged neuromuscular blockade with repeated doses
Reversal agent Spontaneous recovery Sugammadex
Depolarising muscle relaxants
Depolarising muscle relaxants produce what appears to be a “persistent” depolarisation at the NMJ by binding to
ACh receptors and mimicking the effect of ACh but without dissociating from the receptors and being rapidly
hydrolysed by acetylcholinesterase. Propagation of an action potential is prevented by the area of inexcitability that
occurs around the ACh receptors.
Suxamethonium is the only depolarising muscle relaxant with clinical usefulness, has the most rapid onset of action
of any of the neuromuscular blocking drugs and is ideal if fast onset and brief duration of action are required.
Suxamethonium (at a dose of 1.5 – 2 mg/kg) remains the drug of choice for neuromuscular blockade during RSI.
Suxamethonium should be given after anaesthetic induction because paralysis is usually preceded by painful muscle
fasciculations due to the initial endplate depolarisation; asynchronous muscle bre twitches cause damage which
can result in muscle pains the next day. Initial depolarisation at the NMJ causes muscle fasciculation within 15
seconds (although this is not always seen) and complete paralysis after 45 – 60 secs.
Unlike the non-depolarising neuromuscular blocking drugs, its action cannot be reversed and anticholinesterases
such as neostigmine actually potentiate the neuromuscular block. Recovery from suxamethonium is spontaneous;
the drug is normally hydrolysed rapidly (3 – 5 mins rst return of respiratory activity and 5 – 10 mins return of
effective spontaneous ventilation) by plasma pseudocholinesterase. Reduced plasma cholinesterase synthesis in
end-stage hepatic disease or congenital de ciency may increase the duration of action resulting in prolonged
paralysis with apnoea.
While tachycardia occurs with single use, bradycardia may occur with repeated doses in adults and with the rst
dose in children. Premedication with glycopyrronium bromide or alternatively atropine sulfate, reduces
bradycardia, excessive salivation and other muscarinic effects associated with suxamethonium use.
After injection suxamethonium, the plasma concentration is increased by up to 0.5 mmol/L even in normal subjects.
This increase in potassium concentration may be greatly exaggerated in patients with certain pathological
conditions such as desquamating skin conditions, major trauma and burns, which may lead to hyperkalaemia,
arrhythmias and even cardiac arrest.
Malignant hyperthermia is a rare but often fatal complication in susceptible patients that results from a rapid
increase in muscle metabolism. About 50% of patients are genetically predisposed. It is characterised by tachycardia
and, among other manifestations, intense muscle spasm that results in a rapid and profound hyperthermia.
Non-depolarising muscle relaxants
Non-depolarising muscle relaxant drugs e.g. rocuronium compete with acetylcholine (ACh) molecules released from
the presynaptic membrane at the neuromuscular junction (NMJ), by binding with the ACh receptors on the
postsynaptic membrane of the motor endplate, blocking the action of ACh and preventing depolarisation and
muscle contraction.
None of these drugs cross the blood-brain barrier as they are water-soluble polar molecules and therefore have no
effect on the central nervous system; they have no sedative or analgesic effects and are not considered to trigger
malignant hyperthermia.
Non-depolarising neuromuscular blocking drugs have a slower onset of action than suxamethonium chloride and
can be classi ed by their duration of action as short-acting (15 – 30 mins), intermediate-acting (30 – 40 mins) and
long-acting (60 – 120 mins), although duration of action is dose-dependent.
All non-depolarising drugs should be used with care in patients suspected to be suffering with myasthenia gravis or
myasthenic syndrome, as patients with these conditions are extremely sensitive to their effects.
In situations where suxamethonium is contraindicated, rocuronium (at a dose of 1.0 – 1.2 mg/kg) can be used for
modi ed RSI. Anaphylaxis to rocuronium occurs but is less common than anaphylaxis to
suxamethonium. Rocuronium bromide has an onset time of about 60 seconds and a recovery time of 30 – 40
minutes. Its effect can be rapidly reversed with sugammadex. Sugammadex forms a complex with the muscle
relaxant in the plasma, thus reducing its ability to bind with receptors at the neuromuscular junction.
Other non-depolarising muscle relaxants are unlikely to be used during RSI but may be used for maintaining muscle
relaxation following recovery from suxamethonium.

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A 19 year old woman is brought in by ambulance after collapsing during a night out. Her 14 Unanswered
friends tell you she has drunk a very large quantity of alcohol and her GCS is 8.
15 Unanswered
a. Give two signs of airway obstruction that might be observed in this patient. (1 mark) 16 Unanswered
b. You note the above signs in this patient. Describe a basic airway manoeuvre that could
be used to improve this patient’s airway. (1 mark) 17 Unanswered
c. Your above manoeuvre is ineffective and you decide to insert an oropharyngeal airway. 18 Unanswered
Describe how you would estimate an appropriate size for the oropharyngeal airway and
how it should be inserted. (1 mark) 19 Unanswered
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Answer
24 Unanswered
a. Any two of:
Noisy breathing
Snoring (arises when pharynx is partially occluded by tongue or palate)
Gurgling (suggests presence of foreign material in upper airways)
Inspiratory stridor (suggests obstruction at or above laryngeal level)

Retractions, tracheal tug and use of accessory muscles of ventilation
Paradoxical chest and abdominal movements – ‘see-saw breathing’
Cyanosis (late sign)
b. Any one of:
Head tilt, chin lift manoeuvre: Place one hand on the patient’s forehead and tilt head back gently. Place
the ngertips of the other hand under the point of the patient’s chin and gently lift to stretch the
anterior neck structures.
Jaw-thrust manoeuvre: With the index and other ngers placed behind the angle of the mandible, apply
steady upwards and forward pressure to lift the mandible. Using the thumbs, slightly open the mouth
by downward displacement of the chin.
c. An estimate of the size required may be obtained by selecting an airway with a length corresponding to the
vertical distance between the patient’s incisors and the angle of the jaw (most common sizes 2, 3 and 4 for
small, medium and large adults respectively). Insert the airway in the ‘upside-down’ position as far as the
junction between the hard and soft palate and then rotate it through 180 degrees and advance over the
tongue (this rotation technique minimises the chance of pushing the tongue backwards and downwards.)
Notes
Causes of airway obstruction
Loss of consciousness
Vomit or blood following regurgitation of gastric contents or in trauma
Foreign bodies
Laryngeal oedema from burns, in ammation or anaphylaxis
Laryngeal spasm from upper airway stimulation or inhalation of foreign material
Direct injury to larynx
Extrinsic compression of airway e.g. from trauma, haematoma or tumour
Obstruction below larynx
Excessive bronchial secretions
Mucosal oedema
Bronchospasm
Pulmonary oedema
Aspiration of gastric contents
Objective signs of airway obstruction
Noisy breathing
Hoarseness (suggests functional laryngeal obstruction)
Expiratory wheeze (suggests obstruction of lower airways)
Agitation or altered consciousness
During apnoea, complete airway obstruction is recognised by failure to in ate lungs during attempted
positive pressure ventilation
Basic airway management
Remove any obvious obstructing foreign body

Airway opening techniques (head-tilt/chin lift, jaw thrust)
Clear secretions with suction and/or airway position
Carefully remove any obvious visible foreign body with Magills’ forceps or suction under direct visualisation
Where possible, give high-concentration oxygen during attempt to relieve airway obstruction
Airway adjuncts can be used to open an airway or maintain an airway requiring active manoeuvres
Airway manoeuvres
Head tilt, chin lift manoeuvre:
Place one hand on the patient’s forehead and tilt head back gently.
Place the ngertips of the other hand under the point of the patient’s chin and gently lift to stretch the
anterior neck structures.
Avoid head tilt in possible C-spine injury.
Jaw-thrust manoeuvre:
With the index and other ngers placed behind the angle of the mandible, apply steady upwards and
With the index and other ngers placed behind the angle of the mandible, apply steady upwards and
forward pressure to lift the mandible.
Using the thumbs, slightly open the mouth by downward displacement of the chin.
Use jaw thrust or chin lift in combination with manual in-line stabilisation in possible C-spine injury.
Airway adjuncts
Oropharyngeal airway:
Available in a variety of sizes (most common sizes 2, 3 and 4 for small, medium and large adults
respectively).
An estimate of the size required may be obtained by selecting an airway with a length corresponding to the
vertical distance between the patient’s incisors and the angle of the jaw.
Too small an airway may be ineffective, too large an airway may cause laryngospasm (slightly too big is more
bene cial than slightly too small).
Insert the airway in the ‘upside-down’ position as far as the junction between the hard and soft palate and
then rotate it through 180 degrees and advance over the tongue. This rotation technique minimises the
chance of pushing the tongue backwards and downwards.
Nasopharyngeal airway:
Often better tolerated than an oropharyngeal airway – can be used in patients with intact airway re exes
without the signi cant risk of gagging, vomiting or aspiration.
Sizes 6 – 7 mm are suitable for most adults (traditionally sizing methods are not accurate).
Select the nostril that appears larger and insert into the nostril directed posteriorly along the transverse
oor of the nose.
Contraindicated in basal skull fractures or signi cant facial injury with damage to the cribriform plate.
May cause signi cant haemorrhage from the vascular nasal mucosa.
If tube is too long, it may stimulate laryngeal or glossopharyngeal re exes to produce laryngospasm or
vomiting.
Supraglottic airways
In comparison with bag-mask ventilation alone, use of SGAs may enable more effective ventilation and reduce the
risk of gastric in ation, regurgitation and aspiration. Furthermore, SGAs are easier to insert than a tracheal tube,
and unlike tracheal intubation, they can generally be positioned without interrupting chest compressions.
and unlike tracheal intubation, they can generally be positioned without interrupting chest compressions.
Laryngeal mask airway:
Select appropriate size (size 5 for most men and size 4 for most women), de ate cuff fully and lubricate
outer face of cuff area with water-soluble gel
Flex patient’s neck slightly and extend head.
Holding the LMA like a pen, insert into the mouth, advance tip behind the upper incisors with the upper
surface applied to the palate until it reaches the posterior pharyngeal wall.
Press the mask backwards and downwards around the corner of the pharynx until a resistance is felt as it
locates in the back of the pharynx.
If possible get an assistant to apply a jaw thrust after the LMA has been inserted in the mouth to aid
successful placement.
Connect the in ating syringe and in ate cuff with air (up to 40 mL for size 5 LMA and up to 30 mL for size 4
LMA).
If insertion is satisfactory, the tube will lift 1 – 2 cm out of the mouth as the cuff nds its correct position and
the larynx is pushed forward.
A small air leak around cuff is acceptable provided chest rise is adequate.
Limitations:
In presence of high airway resistance or poor lung compliance, risk of signi cant leak and
hypoventilation
Uninterrupted chest compressions are likely to cause leak
Theoretical risk of gastric aspiration
Risk of coughing, straining or laryngeal spasm if patient is not fully unconscious
I-gel airway:
Insertion of i-gel is faster than most other airway devices.

Select appropriate size (size 4 for most adults, or size 3 for small females, and size 5 for tall men).
Lubricate back, sides and front of i-gel cuff with thin layer of lubricant.
Grasp i-gel rmly along the integral bite block and position device so that i-gel cuff outlet is facing towards
the chin of the patient.
Ensure the patient is in the ‘snif ng the morning air’ position with head extended and neck exed. Press chin
down before inserting i-gel.
Introduce the leading soft tip in the mouth in a direction towards the hard palate, glide the device
downwards and backwards along the hard palate with a continuous but gentle push until a de nitive
resistance is felt.
At this point the tip of the airway should be located at the upper esophageal opening and the cuff should be
located against the larynx. The incisors should be resting on the bite block.

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You have been asked to perform an RSI on a patient with a severe head injury. 14 Unanswered
15 Unanswered
a. You fail your initial attempt to pass the ETT and the patient begins to desaturate. What is
your immediate action in managing this patient? (1 mark) 16 Unanswered
b. Senior help arrives. How many further times can intubation be attempted? (1 mark)
17 Unanswered
c. Intubation has been attempted the maximum number of times. The option to awake the
patient is not possible due to their injuries. What the next most appropriate step in 18 Unanswered
managing this patient? (1 mark)
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a. Cease intubation attempts and reoxygenate the patient’s lungs using bag-mask ventilation before the SpO2 24 Unanswered
reaches the steep part of the oxyhaemoglobin dissociation curve: this point is 92%.
b. A maximum of three attempts at intubation are recommended.
c. Supraglottic airway device (SAD) insertion
Notes
Notes
Improving the laryngeal view
During intubation, if the laryngeal inlet and vocal cords cannot be seen immediately, the following interventions may
improve the grade of view:
Clear secretions, blood or debris rapidly with a wide-bore suction device

Ensure optimal positioning of the patient – ensure head is fully extended at atlanto-occipital joint and the
neck is exed
External back, upward and rightward pressure (BURP) manoeuvre on the larynx by an assistant (different to
cricoid pressure)
Use an alternative laryngoscope – this may be a variant of a standard blade e.g. McCoy blade or a
videolaryngoscope that is not reliant on an unobstructed straight-line view from the mouth to the larynx to
see the cords
Change practitioner
An intubating bougie will frequently be used to assist intubation with reduced view.
Failed attempt at intubation
Remember O HELP following a failed initial attempt at intubation:
Oxygenation
Head elevation
External laryngeal manipulation
Laryngoscope blade change
Pal – call for assistance
Ensure full muscle relaxation has occurred before attempting intubation. Continuous SpO2 monitoring is essential.
Cease intubation attempts and reoxygenate the patient’s lungs using bag-mask ventilation before the SpO2 reaches
the steep part of the oxyhaemoglobin dissociation curve: this point is 92%. A maximum of three attempts at
intubation are recommended.
‘Can’t intubate, can’t oxygenate’ (CICO) situation
Rescue technique of choice

Supraglottic airway device (SAD)
If oxygenation continues to deteriorate and above methods are unsuccessful
Needle cricothyroidotomy
Surgical cricothyroidotomy
Tracheostomy

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A 71 year old attends ED following a fall onto an outstretched hand. X-ray has con rmed 14 Unanswered
Colles fracture and you are being supervised performing a Bier’s block.
15 Unanswered
a. Give two contraindications to the use of the Bier’s block technique. (1 mark) 16 Unanswered
b. Give one drug that can be used for Bier’s block including dose and route. (1 mark)
c. Give two features of systemic toxicity from Bier’s block that should be observed for 17 Unanswered
during the procedure. (1 mark) 18 Unanswered
19 Unanswered
21 Unanswered
23 Unanswered
a. Any two of:
Allergy to local anaesthetic 24 Unanswered
Epilepsy
Hypertension > 200 mmHg
Lymphoedema
Methaemoglobinaemia
Scleroderma
Severe hypertension
b. Either 0.5% prilocaine (3 mg/kg) or 0.5% lidocaine (3 mg/kg) intravenously
c. Any two of:
CNS signs of excitation:
Yawning, restlessness, anxiety, tremor
Nausea and vomiting
CNS depression:
Apnoea
Coma
CVS features:
Notes
Intravenous regional anaesthesia for distal forearm fractures (Bier’s block)
Indications
Reduction of wrist fractures, most commonly Colles’ fracture
Contraindications

Epilepsy
Hypertension >200mm Hg
Lymphoedema
Methaemoglobinaemia
Scleroderma
Drug and dose
The most commonly used local anaesthetic is 0.5% prilocaine (3 mg/kg), although 0.5% lignocaine without
adrenaline (3 mg/kg) can be used if prilocaine is unavailable.
Equipment
Peripheral venous access

Local anesthetic agent
Double cuff tourniquet (check for leaks prior to procedure)
ECG, BP and pulse oximetry monitoring
Access to resuscitative equipment
Access to emergency drugs, including intralipid in case of local anaesthetic toxicity
Procedure
Obtain consent
Obtain patient’s weight in kilograms and calculate drug dose
Transfer patient to resus or an appropriately sited well lit area with resuscitative equipment
Ensure ECG, BP and pulse oximetry monitoring in situ
Obtain IV access on both sides (distal to the cuff in the side to be anaesthetised)
Place double cuff tourniquet on upper arm

Elevate injured limb for three minutes to exsanguinate the limb
In ate the cuff to 100 mmHg above the systolic BP, up to a maximum of 300 mmHg, and record the time of
in ation
Check for the absence of a radial pulse
Inject 0.5% plain prilocaine, prepared according to patient weight, slowly and record the time of injection
Warn the patient about the cold/hot sensation and mottled appearance of the arm
Check for anaesthesia – may have touch but not pain, after ve minutes
(If anaesthesia inadequate initially, try ushing cannulae with 10 – 15 ml normal saline)
Once anaesthesia satisfactory, remove the cannula
Lower arm onto a pillow and check tourniquet not leaking
Perform the procedure and obtain check x-ray
If satis ed with the post reduction position of fracture, de ate the cuff observing the patient and monitor
Record the time of de ation and observe the patient and limb closely for signs of delayed toxicity until fully
recovered
Points to be aware of
Be aware of the location of stocked emergency drugs such as intralipid in case of local anesthetic toxicity
IV access must also be obtained on normal side in case of complications which require systemic drug
administration
Tourniquet must be under observation at all times
Cuff should be kept in ated for a minimum of 20 minutes and for a maximum of 45 minutes
Watch continuously for signs of toxicity
Check limb circulation prior to discharge and arrange patient follow up and analgesia as appropriate
Complications
Systemic toxicity
CNS
Yawning, restlessness, anxiety and tremor
Nausea and vomiting
Apnoea
Coma
Coma
CVS
Methaemoglobinaemia (problem speci c to prilocaine, usually in doses > 16 mg/kg)

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A 54 year old man has fallen from a ladder whilst repairing his roof. He fell approximately 3 14 Unanswered
metres. Your consultant has performed a primary and secondary survey and the only injury
15 Unanswered
noted is an anterior dislocation of the right shoulder. Your consultant asks you to administer
procedural sedation to facilitate reduction. Whilst making your airway assessment you ask the 16 Unanswered
patient to open their mouth and protrude their tongue. An image is shown below:
17 Unanswered
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20 Unanswered
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22 Unanswered
23 Unanswered
24 Unanswered
Courtesy of Jmarchn (Own

work) [CC BY-SA 3.0
(http://creativecommons.org/lic
(http://creativecommons.org/lic
enses/by-sa/3.0) or GFDL
(http://www.gnu.org/copyleft/fd
l.html)], via Wikimedia
Commons
a. Give two external features of a patient that may predict a dif cult airway. (1 mark)
b. Describe two measurements that can be used to predict a dif cult airway. (1 mark)
c. What Mallampati classi cation is this patient? (1 mark)
Answer
a. Any two of:
Obese
Small mouth or jaw
Large overbite
Sunken cheeks
Receding lower jaw
Short neck
Narrow mouth
Facial burns or trauma
b. Any two of:
Distance between the patient’s incisor teeth (should be at least 3 nger breadths)
Distance between hyoid bone and chin (should be at least 3 nger breadths)
Distance between thyroid notch and oor of mouth (should be at least 2 nger breadths)
c. Mallampati II (soft palate, uvula, fauces visible)
Notes
Predicting dif cult airways

The LEMON mnemonic can be used to remember how to assess for dif cult intubation.
LEMON Assessment
Look Externally
Obese
Small mouth or jaw
Large overbite
Sunken cheeks
Receding lower jaw
Short neck
Narrow mouth
Internally
High arched palate
Edentulous
Prominent incisors
Trismus
Macroglossia
Insecure/loose teeth or dental prosthesis
Evaluate (3-3-2 Distance between the patient’s incisor teeth should be at least 3 nger breadths
rule) (3)
Distance between hyoid bone and chin should be at least 3 nger breadths (3)
Distance between thyroid notch and oor of mouth should be at least 2 nger
breadths (2)
Mallampati score Class I – Soft palate, uvula, fauces, pillars visible

Class II – soft palate, uvula, fauces visible
Class III – soft palate, base of uvula visible
Class IV – hard palate only visible
Obstruction of Peritonsillar abscess

airway Epiglottitis
Retropharyngeal abscess
LEMON Assessment
Trauma
Tumour
Burns
Infection
Anaphylaxis
Neck mobility Immobilised

C-spine injury
Stiff neck
Arthritides
Ankylosing spondylitis
Mallampati classi cation
Class I – Soft palate, uvula, fauces, pillars visible

Courtesy of Jmarchn (Own work) [CC BY-SA 3.0

(http://creativecommons.org/licenses/by-sa/3.0) or GFDL
(http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons
View at direct laryngoscopy
Via Wikimedia Commons
Cormack and Lehane classi cation of view at direct laryngoscopy
Grade I: vocal cords are fully visible

Grade II: vocal cords are only partly visible
Grade III: only epiglottis is seen
Grade IV: epiglottis can’t be seen
Dif cult airway

neck is exed
cricoid pressure)
see the cords
Reduce or release cricoid pressure
Change practitioner

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Question Navigator
Question 13 of 35 13 Current Question
A 27 year old man is brought into ED having been involved in a road traf c collision. He has 14 Unanswered
a reduced GCS and the trauma team make the decision to intubate the patient. The view seen at
15 Unanswered
laryngoscopy is shown below:
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CC BY-SA 2.5-2.0-1.0
(http://creativecommons.org/licenses/by-sa/2.5- 24 Unanswered
2.0-1.0)], via Wikimedia Commons
a. What Cormack-‐Lehane grade is this? (1 mark)

a. What Cormack-‐Lehane grade is this? (1 mark)
b. Name the four structures labelled. (2 marks)
Answer
a. Grade I (vocal cords are fully visible)
b. All four of:
A: vocal cords
B: trachea
C: epiglottis
D: piriform fossae
Notes
Predicting dif cult airways
The LEMON mnemonic can be used to remember how to assess for dif cult intubation.
LEMON Assessment
Look Externally
Obese
Small mouth or jaw
Large overbite
Sunken cheeks
Receding lower jaw
Short neck
Narrow mouth
Internally
High arched palate
High arched palate
Edentulous
Prominent incisors
Trismus
Macroglossia
Insecure/loose teeth or dental prosthesis
Evaluate (3-3-2 Distance between the patient’s incisor teeth should be at least 3 nger breadths
rule) (3)
Distance between hyoid bone and chin should be at least 3 nger breadths (3)
Distance between thyroid notch and oor of mouth should be at least 2 nger
breadths (2)
Mallampati score Class I – Soft palate, uvula, fauces, pillars visible

Obstruction of Peritonsillar abscess

airway Epiglottitis
Retropharyngeal abscess
LEMON Assessment
Trauma
Tumour
Burns
Infection
Anaphylaxis
Neck mobility Immobilised

C-spine injury
Stiff neck
Arthritides
Ankylosing spondylitis
Mallampati classi cation
Class I – Soft palate, uvula, fauces, pillars visible


(http://creativecommons.org/licenses/by-sa/3.0) or GFDL
(http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons
View at direct laryngoscopy
Via Wikimedia Commons
Cormack and Lehane classi cation of view at direct laryngoscopy
Grade I: vocal cords are fully visible

Grade II: vocal cords are only partly visible
Grade III: only epiglottis is seen
Grade IV: epiglottis can’t be seen
Dif cult airway

neck is exed
cricoid pressure)
see the cords
Reduce or release cricoid pressure
Change practitioner

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You have been asked to perform an RSI on a 51 year old man following a severe head injury. 14 Current Question
15 Unanswered
a. How long should a patient be preoxygenated for before attempting RSI? (1 mark)
b. Cricoid pressure should be applied with what amount of force during RSI? (1 mark) 16 Unanswered
c. What investigation should be performed soon after intubation and what should you look
17 Unanswered
for? (1 mark)
18 Unanswered
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Answer
22 Unanswered
a. Breathing 100% oxygen with normal tidal volumes and an adequate respiratory rate for 3 minutes before
23 Unanswered
induction of anaesthesia is suf cient for most patients.
b. The optimal force is 30 – 40 newtons – inadequate pressure will not occlude the oesophagus, excessive 24 Unanswered
pressure will deform larynx and make intubation more dif cult
c. Chest x-ray – position of tube tip and signs of pleural injury
Notes
Rapid sequence induction of anaesthesia (RSI) involves injecting an anesthetic induction drug to achieve hypnosis,
immediately followed by a neuromuscular blocking drug to produce complete paralysis. The lungs are not ventilated
between induction and intubation to prevent gastric in ation. The time from loss of consciousness to securing the
airway is minimised because the patient’s stomach is assumed to be full.
RSI Sequence
Preparation for intubation (PEACH)

Pre-oxygenation
Injection of precalculated dose of induction drug
Injection of precalculated dose of neuromuscular blocking drug
Commence apnoeic oxygenation
Cricoid pressure applied at loss of consciousness
Laryngoscopy and intubation
Con rmation of tracheal tube placement
Cricoid pressure removed
Ventilation established and tube secured
Post-intubation review
Pre-oxygenation
Effective pre-oxygenation greatly increases the oxygen reserve within the lungs. This maximises the time before
desaturation of arterial blood occurs during apnoea, and decreases the risk of severe hypoxaemia and its associated
morbidity and mortality.
Breathing 100% oxygen with normal tidal volumes and an adequate respiratory rate for 3 minutes before induction
of anaesthesia is suf cient for most patients. Use a 20 degree head-up tilt whenever possible – this increases the
time before desaturation occurs and may also reduce the risk of passive regurgitation of gastric contents.
Some ill patients are not adequately pre-oxygenated with this technique. A good airway management technique
with a well- tting mask and high- ow oxygen is essential. Gentle application (maximum 10 cmH2O) of PEEP may
augment pre-oxygenation in patients failing to achieve an arterial blood oxygen saturation above 95%; avoid
in ating the stomach, which increases risk of regurgitation and aspiration.
A patient with a low respiratory rate may not achieve suf cient alveolar ventilation and will require assisted
ventilation to achieve adequate pre-oxygenation.
Apnoeic oxygenation
Apnoeic oxygenation continues delivery of oxygen in the absence of ventilation , provided the airway is patent. It
increases signi cantly the time before desaturation of arterial blood occurs during anaesthesia. Nasal cannulae are
sited under the facemask during pre-oxygenation and the oxygen ow increased to 15 L/min at the onset of
anaesthesia. This technique is a useful adjunct to formal pre-oxygenation in patients at increased risk of hypoxaemia
during induction or where dif culty with intubation is anticipated. However if the nasal cannulae tubing prevents an
adequate seal being formed, this may be counterproductive since it will diminish the bene t of pre-oxygenation and
should be abandoned.
Cricoid pressure
Applied in an attempt to reduce passive re ux of gastric contents into the pharynx with subsequent
aspiration into the lungs
Should not be used in presence of active vomiting because it may cause oesophageal rupture
Cricoid ring should be identi ed (below the thyroid cartilage and cricothyroid membrane) by trained
assistant and stabilised between the thumb and middle nger before induction of anaesthesia
As consciousness is lost, rm pressure should be applied to the centre of the cricoid cartilage using the index
nger pressing directly backwards to compress the upper oesophagus between the cricoid and the cervical
vertebra posteriorly
The optimal force is 30 – 40 newtons – inadequate pressure will not occlude the oesophagus, excessive
Cricoid pressure should only be removed once correct tube placement has been con rmed
As a general rule, it is to be expected that when the tracheal tube is at the correct depth, the patient’s teeth will lie
between 20 and 21 cm in an adult female and 22 and 23 cm in an adult male.
Correct placement of the tube is con rmed by:
Clinical assessment
Condensation in the tube, symmetrical chest rise, bilateral breath sounds on auscultation of the chest
and inability to hear gas insuf ating the stomach on auscultation of the epigastrium
Once tracheal intubation is con rmed, release the cricoid pressure and secure the tube.
Reassess patient using ABC

Inject a long-acting neuromuscular blocking drug if indicated
Use a suction catheter to clear material from the proximal airways
Check monitors for HR, SpO2, BP, end tidal CO2 and peak inspiratory pressure
Request a chest x-ray to examine position of tube and withdraw or advance as required

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Question Navigator
A 45 year old woman is brought to ED with signs of severe sepsis. Despite aggressive 14 Unanswered
treatment, she continues to deteriorate and a decision is made to intubate the patient and
15 Current Question
transfer her to ITU. Anaesthetic colleagues perform a rapid sequence induction with the use of
ketamine and suxamethonium. Shortly after intubation, you note the patient is ushed, 16 Unanswered
tachycardic and her end tidal CO2 levels are rising. Nursing staff report the patient’s
17 Unanswered
temperature is 38°C.
18 Unanswered
a. What diagnosis should be considered in this patient? (1 mark)
b. What drug should be given as soon as this diagnosis is suspected? (1 mark) 19 Unanswered
c. Give two possible complications of this diagnosis. (1 mark)
20 Unanswered
21 Unanswered
22 Unanswered
23 Unanswered
a. Malignant hyperthermia
b. Dantrolene
c. Any two of:
Rhabdomyolysis
Rhabdomyolysis
AKI
Hyperkalaemia
Arrhythmias
Heart failure
Disseminated intravascular coagulation (DIC)
Cerebral oedema
Acute liver failure
Notes
Malignant hyperthermia (MH) is a life-threatening disorder of skeletal muscle homeostasis. Its inheritance is
autosomal dominant. The most common triggers are suxamethonium and volatile anaesthetics. Diagnosis can be
dif cult and it may present insidiously over hours, or as an acute life-threatening event at induction.
Signs:
Direct muscle effects

Prolonged masseter muscle spasm: MSS will cause trismus at a time when relaxation would normally
have been expected, but it does not usually persist long enough to hinder attempts at intubation)
Effects of increased metabolism
Unexplained increasing ETCO2
Concomitant tachycardia and arrhythmias
Decreasing oxygen saturation
Flushing
Hyperthermia (late feature)
Management:
Seek senior anaesthetic assistance immediately in all cases of suspected MH

Discontinue the precipitant
Hyperventilate with 100% oxygen
Give dantrolene as soon as the diagnosis is considered (initial dose 2.5 mg/kg, repeat doses of 1 mg/kg given
to a maximum of 10 mg/kg)
to a maximum of 10 mg/kg)
Active cooling
Treatment of hyperkalaemia, arrhythmias and DIC
Frequent monitoring of arterial blood gases, potassium, FBC and clotting and supportive therapy as
required
Complications:
Rhabdomyolysis
AKI
Hyperkalaemia
Arrhythmias
Heart failure
Disseminated intravascular coagulation (DIC)
Cerebral oedema
Acute liver failure
Muscle relaxants

depolarising
Dose 1.5 – 2 mg/kg 1 – 1.2 mg/kg


conditions)

Anaphylaxis
muscle contraction.

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Question Navigator
A 26 year old woman is brought into the Emergency Department after returning from 14 Unanswered
holiday. She is short of breath and chest x-ray shows upper lobe consolidation and collapse. Your
15 Unanswered
consultant suspects an atypical pneumonia. She is hypotensive and acidotic despite aggressive
uid resuscitation. Your consultant recommends internal jugular central line insertion. 16 Current Question
a. Give one indication for central line insertion. (1 mark) 17 Unanswered

b. Give two contraindications to central line insertion. (1 mark) 18 Unanswered
c. Give two complications of central line insertion. (1 mark)
19 Unanswered
20 Unanswered
21 Unanswered
22 Unanswered
a. Any one of: 24 Unanswered


b. Any two of:
Vein thrombosis
Vein stenosis
Raised ICP
Severe coagulopathy
Skin infection, abscess, trauma, burn, scarring or mass at site of neck
Distorted local anatomy (e.g. vascular injury, prior surgery, radiation history)
Uncooperative awake patient
c. Any two of:
Pneumothorax
Haemothorax
Venous thrombosis
Arteriovenous stula
Chylothorax
Infection
Air embolism
Haematoma
Haemorrhage
Cardiac arrhythmia
Tamponade
Stenosis
Embolised, fractured or irretrievable guide wires
Incorrect catheter tip position
Notes
Central line insertion
Indications

Sites of insertion
In the non-coagulopathic patient who is not in severe respiratory failure, a subclavian central line is usually the most
appropriate choice. That leaves the internal jugular vein as a useful site for patients with a coagulopathy or profound
respiratory failure providing they can lie at for the procedure. Femoral lines are useful as an alternative when there
is a compelling reason to avoid an upper body central line, often because of venous thrombosis, stenosis or a
preexisting central line already residing in the SVC, or as the most accessible site in CPR.
Site Advantages Disadvantages
Axillary Lower rates of infection, comfortable, leaves Noncompressible site, not suitable in
and SVC available for other lines, good ow rates coagulopathy, high rates of stenosis, highest
subclavian for dialysis rates of pleural injury
veins
Femoral Compressible site (although blood loss from Highest rate of infection, lowest rate of
vein femoral haemorrhage can be massive and success, highest rate of inadvertent arterial
concealed in the retroperitoneal space), no risk cannulation, impedes patient mobility,
of pleural injury, good ow rates for dialysis, unsuitable for measuring SVC pressures,
most accessible site during CPR caution in patients with an IVC lter
Internal Low rate of infection, very low risk of pleural Limited number of lumens, potential to
jugular injury, compressible and most suitable site for increase venous resistance and exacerbate
vein coagulopathic patients cerebral oedema, incompatible with rigid
cervical spine collar
Contraindications
No absolute contraindications
Relative contraindications
Vein thrombosis
Vein stenosis
Raised ICP
Severe coagulopathy (subclavian approach should be avoided)
Skin infection, abscess, trauma, burn, scarring or mass at site of neck
Distorted local anatomy (e.g. vascular injury, prior surgery, radiation history)
Uncooperative awake patient
Key considerations
Ultrasound can be used as an adjunct for the placements of central venous lines
A plain chest x-ray should be performed after each upper body central line to detect pleural injury and
con rm position of catheter tip
Complications
Pneumothorax
Haemothorax
Venous thrombosis
Arteriovenous stula
Chylothorax
Infection
Air embolism
Haematoma
Haemorrhage
Cardiac arrhythmia
Tamponade
Stenosis
Embolised, fractured or irretrievable guide wires
Incorrect catheter tip position
Question Navigator
A 56 year old woman is brought into the Emergency Department following an accident at 14 Unanswered
work. Paramedics describe that she was crushed between a wall and a fork-lift vehicle. She has
15 Unanswered
sustained chest and abdominal injuries. There is no evidence of head injury. The patient is
shocked and the decision is made to proceed directly to theatre. Your consultant wishes to 16 Unanswered
perform an RSI in the department and asks for your assistance.
17 Current Question
a. What is the recommended dose of ketamine when performing an RSI in a 18 Unanswered
cardiovascularly stable patient? Give your answer in mg/kg. (1 mark)
b. What property of ketamine makes it a good choice of induction agent in trauma? (1 19 Unanswered
mark) 20 Unanswered
c. Give two common side effects of ketamine. (1 mark)
21 Unanswered
22 Unanswered
23 Unanswered
24 Unanswered
Answer
a. 1 – 2 mg/kg IV
b. Ketamine is relatively cardiovascularly stable in comparison to the other induction agents
c. Any two of:

Dissociative state
Amnesia
Visual disturbance (diplopia and nystagmus)
Emergence phenomena
Hallucinations
Nightmares
Agitation
Other transient psychotic effects
Nausea or vomiting
Tachycardia
Hypertension
Notes
Etomidate
Indications:
Dose 0.3 mg/kg
5 – 15 secs onset
Pain on injection
Speci cs:
Adrenal suppression
Propofol
Indications:
Pain on injection
Speci cs:
elderly
Thiopental sodium
Indications:
5 – 15 secs onset
Speci cs:
Ketamine
Indications:
Septic shock
Severe bronchospasm
Dose 1 – 2 mg/kg
Speci cs:
Potent analgesic
Comparison
CV + +++ ++ Minimal
depression

movements on Pain on
http://intermediate.frcemsuccess.com/rev/anaestheticspainmanagement/
Bronchospasm Bronchodilator 4/5
severe Emergence
Hypertension

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Question Navigator
A 26 year old woman is brought into the Emergency Department after returning from 14 Unanswered
holiday. She is short of breath and chest x-ray shows upper lobe consolidation and collapse. Your
15 Unanswered
consultant suspects an atypical pneumonia. She is hypotensive and acidotic despite aggressive
uid resuscitation. Your consultant recommends arterial line insertion. 16 Unanswered
a. Give two indications for arterial cannulation. (1 mark) 17 Unanswered

b. Give two contraindications to arterial cannulation. (1 mark) 18 Current Question
c. Give two complications of arterial cannulation. (1 mark)
19 Unanswered
20 Unanswered
21 Unanswered
22 Unanswered
a. Any two of: 24 Unanswered

Continuous accurate BP monitoring
Inability to use non-invasive BP monitoring e.g. patient with severe burns, morbid obesity
Frequent blood sampling
Frequent arterial blood gas sampling
b. Any two of:

Absolute
Absent pulse
Full thickness burn at cannulation site
Inadequate circulation
Raynaud’s syndrome
Buerger disease
Relative
Anticoagulation
Atherosclerosis
Coagulopathy
Inadequate collateral ow
Infection at cannulation site
Partial thickness burn at cannulation site
Previous surgery in the area
Synthetic vascular graft
c. Any two of:
Pain
Haematoma/bleeding
Infection
Permanent ischaemic damage
Pseudoaneurysm formation
Thrombosis
Arteriovenous stula
Air embolism
Compartment syndrome
Nerve injury (median nerve)
Notes
Indications

Contraindications
Absolute
Absent pulse
Buerger disease
Relative
Anticoagulation
Atherosclerosis
Coagulopathy
Clinical anatomy
Arterial lines can be placed in multiple arteries, including the radial, ulnar, brachial, axillary, posterior tibial,
femoral, and dorsalis pedis arteries. The radial artery is the most commonly used, followed by the femoral
artery.
The radial artery originates in the cubital fossa from the brachial artery. It traverses the lateral aspect of the
forearm and gives rise to the palmar arches that provide vascular ow for the hand. At the wrist, the radial
artery sits proximal and medial to the radial styloid process and just lateral to the exor carpi radialis
tendon.
For the radial artery, the initial puncture site should be as distal as possible. A common location is over the
radial pulse at the proximal exor crease of the wrist. In any case, the puncture site should be at least 1 cm
proximal to the styloid process so as to keep from puncturing the retinaculum exorum and the small
super cial branch of the radial artery.
Allen test
Allen test
An Allen test should be performed before radial artery cannulation is initiated. This procedure is a simple
bedside test designed to evaluate for adequate collateral circulation to the palmar arches of the hand. In
most patients, the palmar arches are supplied by both the radial artery and the ulnar artery. This collateral
circulation allows perfusion of the hand should either of these vessels be injured.
To perform this test, the examiner elevates the hand and asks the patient to make a st for 30 seconds. With
the patient’s hand in a st, the examiner applies simultaneous pressure to the ulnar and radial arteries so as
to occlude them. The patient is then asked to open the hand, which should appear blanched as a
consequence of the occlusion of the radial and ulnar arteries.
Next, the pressure over the ulnar artery is released, and the circulation should be observed returning to the
hand i.e. it will ush pink. An alternative puncture site should be considered if the result is abnormal.
Complications
Pain
Haematoma/bleeding
Infection
Thrombosis
Arteriovenous stula
Air embolism
Arterial pressure monitoring
Reasons for dampened/no waveform:
Cannula displacement into tissues

Cannula clotting
Cannula kinking
Cannula tip against vessel wall
Bubbles in catheter or system
Improper zero or transducer calibration
Incorrect stopcock position

Loose connection
Compliant tubing
Loss of counterpressure from bag
Loss of IV uid
Tubing kink
Monitor off/incorrect settings

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Question Navigator
A 29 year old rugby player is brought to the ED after dislocating his left shoulder during a 14 Unanswered
match. Reduction has been attempted with the use of entonox, however has been unsuccessful
15 Unanswered
due to pain and muscle spasm. Your consultant recommends the use of propofol for procedural
sedation to attempt further reduction of the shoulder. 16 Unanswered
a. What is the mechanism of action of propofol as a sedative? (1 mark) 17 Unanswered

b. What is the minimum level of monitoring required for procedural sedation when using 18 Unanswered
propofol. (1 mark)
c. Give two criteria that must be met before the patient can be discharged following 19 Current Question
procedural sedation. (1 mark) 20 Unanswered
21 Unanswered
22 Unanswered
23 Unanswered
a. Positive modulation of GABA inhibitory neurotransmission

b. ECG, NIBP, pulse oximetry and waveform capnography
c. Any two of:
The patient has returned to their baseline level of consciousness

Vital signs are within normal limits for that patient
Respiratory status is not compromised
Nausea, vomiting, pain and discomfort have been adequately addressed
Notes
Effective procedural sedation requires:
Analgesia
Anxiolysis
Sedation
Amnesia
Depths of sedation
Sedation is a continuum which extends from normal alert consciousness to complete unresponsiveness.
Sedation Response Airway Ventilatory Cardiovascular

re exes function function
Minimal sedation e.g. Entonox Normal response to Maintained Maintained Maintained

verbal commands
Moderate (conscious) sedation Purposeful response to Maintained Usually Maintained

e.g. opioids/benzodiazepines verbal commands (+/- maintained
light stimuli)
Deep sedation e.g. propofol Purposeful response to May be May be Usually

repeated or painful stimuli impaired impaired maintained
General anaesthesia Patient unrousable Impaired Usually May be

impaired impaired
An important boundary exists between moderate or ‘conscious’ sedation, where the patient responds purposefully
to verbal commands, and deeper levels of sedation where the patient responds only to painful stimuli, or not at all.
Once verbal contact with the patient is lost it becomes dif cult to determine the level of unconsciousness, and over-
sedation with an associated risk of airway and cardio-respiratory complications is possible. Deeper levels of
sedation are, to all intents and purposes, indistinguishable from general anaesthesia and should therefore be
treated as such.
Dissociative sedation, caused by ketamine, is de ned as ‘a trance-like cataleptic state characterised by profound
analgesia and amnesia, with retention of protective airway re exes, spontaneous respirations, and cardiopulmonary
stability.’
Because sedation is a continuum, it is not always possible to predict how the individual patient will
respond. Practitioners intending to produce a given level of sedation must therefore be able to ‘rescue’ patients
from a deeper level of sedation than intended. For most procedures in the ED, the level of required sedation will be
moderate to deep, this should be determined in advance.
Requirements for procedural sedation and analgesia in the ED
Minimum staf ng levels:

One physician as sedationist
One physician as operator
One nurse
Location and facilities:
Resuscitation room facilities
Pre-procedure checks:
ASA grading
Pre-procedural assessment including prediction of dif culty in airway management
Pre-procedural fasting and risk bene t assessment
Fasting is not needed for minimal sedation, sedation with nitrous oxide (in oxygen) alone, or
moderate sedation where verbal contact is maintained
For procedures using all other sedation techniques (deep sedation, dissociative sedation and
moderate sedation where the patient might not maintain verbal contact with the healthcare
professional), apply the fasting rule used for general anaesthesia: two hours for clear uids and six
hours for solids
For an emergency procedure in someone who is not fasted, base the decision to proceed with
sedation on the urgency of the procedure and the target depth of sedation
Consent and documentation

Drug selection and preparation: benzodiazepine/opioid combinations, propofol, ketamine
Monitoring:
ECG, NIBP, pulse oximetry
The use of continuous quantitative capnography is recommended for conscious sedation and
mandatory for deep and dissociative sedation
Analgesia:
Pain experienced by the patient should be treated with analgesia rather than sedation
Pain should be assessed and managed prior to starting sedation using the WHO pain ladder principles
and the need for ongoing pain relief post-procedure considered
Where opiate pain relief has been given prior to PSA, doses of sedatives should be adjusted accordingly
Anxiolysis:
Non-pharmacological methods of reducing anxiety are often the most effective and include
consideration of the environment and patient comfort
Environment is particularly important for children and patients with dementia or learning dif culties
Family members often provide invaluable support and distraction
Most painful procedures are best performed with the patient supine
Oxygen:
Oxygen should be given from the start of sedative administration until the patient is ready for
discharge from the recovery area
Post-procedure:
All patients who have received sedation should continue to be managed in a clinical area that provides
the same level of facilities and monitoring as those required during the procedure, until the level of
consciousness and other vital signs have returned to pre-procedure baseline levels.
Discharge status:
Patients should be formally assessed for discharge suitability from the clinical area where sedation has
taken place.
Discharge criteria are as follows:
If there is a requirement to discharge the patient prior to meeting these criteria they should be
transferred to an appropriate clinical environment with continuation of periprocedural monitoring
standards.
Patients meeting discharge criteria following sedation who go on to be discharged home from the
Emergency Department should be discharged into the care of a responsible third party. Verbal and
written instructions should be given.
Pharmacological agents for PSA
Drug Propofol Midazolam Ketamine
Mode Positive Short-acting benzodiazepine NMDA-receptor antagonist

of modulation of
action GABA inhibitory
neurotransmission
Effects Sedation and Sedation and amnesia Dissociative sedation,

amnesia amnesia, analgesia
Side Hypotension, Respiratory depression, hypotension, Tachycardia, hypertension,

effects respiratory paradoxical disinhibition and agitation at low laryngospasm,
depression, pain at doses in children, accumulates in adipose hallucinations, nausea and
site of injection tissue which can prolong sedation (elderly, vomiting, hypersalivation,
obese and patients with hepatic or renal increased intracranial and
disease at risk) intraocular pressure
Route IV IV IV
Initial 30 sec – 1 min 1 – 2 min 30 sec – 1 min

onset
time
Peak 1 – 2 min 3 – 4 min 1 – 2 min

effect
time
Initial Adult: 0.5 Adult: 1 – 2 mg Adult: 1 mg/kg

dose – 1 mg/kg Elderly: 0.5 mg Elderly: 10 – 30 mg
Elderly: IM: 4 – 5 mg/kg
10 – 20
mg
Repeat Adult: 0.5 Adult: 1 – 2 mg after 2 – 5 mins Adult/Elderly: 0.25

dose
Drug mg/kg
Propofol Elderly: 0.5 mg
Midazolam – 0.5 mg/kg every 5
Ketamine
every 3 – – 10 min
5 mins IM: 2 – 2.5 mg/kg
Elderly: every 5 – 10 min
10 – 20
mg

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Question Navigator
A 64 year old man is brought in by ambulance after collapsing at home. His wife tells you he 14 Unanswered
was complaining of severe sudden onset of headache prior to collapsing. You suspect
15 Unanswered
subarachnoid haemorrhage. Your consultant asks you to perform an RSI to facilitate transfer to
CT scan. 16 Unanswered
a. What is the recommended dose of suxamethonium when performing an RSI? Give your 17 Unanswered
answer in mg/kg. (1 mark) 18 Unanswered
b. Give two contraindications to suxamethonium use. (1 mark)
c. Brie y describe the mechanism of action of suxamethonium. (1 mark) 19 Unanswered
20 Current Question
22 Unanswered
23 Unanswered
Answer
24 Unanswered
a. 1.5 – 2 mg/kg
b. Any two of the following:
Hyperkalaemia – lab con rmed or ECG suggestive
History of malignant hyperthermia
Risk factors for hyperkalaemia (burns, peripheral neuropathy, spinal cord injury, muscle dystrophy,
UMN lesions or structural brain damage, trauma, infection and desquamating skin conditions)
c. Depolarising muscle relaxant; causes depolarisation by mimicking the effects of acetylcholine (Ach) but
without being rapidly hydrolysed by acetylcholinesterase. Propagation of an action potential is prevented
by the area of inexcitability that occurs around the Ach receptors.
Notes

depolarising
Dose 1.5 – 2 mg/kg 1 – 1.2 mg/kg


conditions)

Anaphylaxis
muscle contraction.

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Question Navigator
A 21 year old man is brought into ED after being involved in a house re. He has partial 14 Unanswered
thickness burns to his face and neck.
15 Unanswered
a. Give two signs of airway obstruction that may be observed in this patient. (1 mark) 16 Unanswered
b. A decision is made to proceed to rapid sequence induction (RSI). Which induction drug is
contraindicated in burns and why? (1 mark) 17 Unanswered
c. You attempt to intubate the patient but your initial attempt fails. What two immediate 18 Unanswered
steps would you take following a failed initial attempt at intubation? (1 mark)
19 Unanswered
20 Unanswered
21 Current Question
22 Unanswered

Noisy breathing
Hoarseness (suggests functional laryngeal obstruction)

Expiratory wheeze (suggests obstruction of lower airways)
Agitation or altered consciousness
b. Suxamethonium – burns predispose to risk of hyperkalaemia
c. Re-oxygenate patient using bag-valve mask ventilation and call for help
Notes
Oxygenation
Head elevation

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Question Navigator
A 54 year old man with no past medical history presents to the Emergency Department 14 Unanswered
with a large laceration to his upper arm. Your consultant recommends the use of 1% lidocaine
15 Unanswered
with adrenaline to reduce the bleeding and allow closure.
16 Unanswered
a. Give the maximum safe dose of lidocaine that can be used with and without adrenaline.
(1 mark) 17 Unanswered
b. Give two advantages of the addition of adrenaline to local anaesthetic agents. (1 mark) 18 Unanswered
c. Give two situations where the addition of adrenaline to local anaesthetic agents should
be avoided. (1 mark) 19 Unanswered
20 Unanswered
22 Current Question
23 Unanswered
Answer
24 Unanswered
a. 3 mg/kg without adrenaline and 7 mg/kg with adrenaline
b. Any two of:
Causes vasoconstriction and reduced blood ow thereby
Prolonging anaesthetic effect by slowing rate of absorption
Reducing risk of LA toxicity by slowing rate of absorption

Reducing bleeding at site
c. Any two of:
Large wounds in patients with underlying conditions (eg, hyperthyroidism, pheochromocytoma, severe
hypertension, coronary artery disease, unstable cardiac rhythms) that may be exacerbated by systemic
epinephrine effects
Digital anesthesia in patients with compromised digital circulation
Periorbital in ltration in patients with narrow angle glaucoma
Patients with catecholamine sensitivity
Patients taking certain drugs e.g. beta-blockers
Notes
Indications for local anaesthetic
Topical anesthesia e.g. prior to venepuncture or venous cannulation or arterial puncture or cannulation
Local in ltration e.g. cleaning, exploration and closure of wounds
Nerve blocks e.g. femoral nerve block for femoral shaft fracture
Intravenous regional blocks e.g. Bier’s block for distal forearm fractures
Local anaesthetic agents
The most commonly used local anaesthetics in ED are lidocaine, bupivacaine and prilocaine.
The mode of action is via reversible sodium channel blockade, preventing propagation of action potentials in
excitable tissues.
Drug Uses Onset Duration Max Dose
Lidocaine Widely used for local 5 – 10 1 – 2 hours (without 3 mg/kg (without

in ltration, nerve blocks mins adrenaline), 2 – 4 hours adrenaline), 7 mg/kg
and topically (with adrenaline) (with adrenaline)
Prilocaine Intravenous regional 5 – 10 1 – 2 hours (without 6 mg/kg (without

blocks mins adrenaline), 2 – 4 hours adrenaline), 9 mg/kg
(with adrenaline) (with adrenaline)
Bupivacaine Nerve blocks 10 – 3 – 12 hours 2 mg/kg

15
mins
Topical anaesthetics
EMLA cream
50/50 mixture of 2.5% prilocaine and 2.5% lidocaine
Must be applied for at least an hour before venepuncture to achieve anesthesia which limits its use in
ED
Should not be applied to open wounds
Ametop gel
Tetracaine (amethocaine)
Acts more quickly than EMLA and causes vasodilation aiding venous cannulation
LAT gel
Lidocaine 4%, adrenaline 0.1% and tetracaine 0.5%
Can be applied to open wounds requiring cleaning and suturing
Reduces need to inject local anesthestic/sedation in paediatric patients
Should be applied for 30 mins prior to procedure and procedure should be completed within 15
minutes of removal of the gel
Effect of local anaesthetic and vasoconstrictor reduce potential for systemic absorption and hence
adverse effects
Adrenaline and local anesthetics
Local anaesthetics cause dilatation of blood vessels. The addition of a vasoconstrictor such as
adrenaline/epinephrine to the local anaesthetic preparation diminishes local blood ow, slowing the rate of
absorption and thereby prolonging the anaesthetic effect and reducing the risk of systemic toxicity. It also has the
advantage of reducing bleeding at the site.
Great care should be taken to avoid inadvertent intravenous administration of a preparation containing
adrenaline/epinephrine, and it is not advisable to give adrenaline/epinephrine with a local anaesthetic injection in
digits or appendages because of the risk of ischaemic necrosis.
Adrenaline/epinephrine must be used in a low concentration when administered with a local anaesthetic. Care must
also be taken to calculate a safe maximum dose of local anaesthetic when using combination products. In patients
with severe hypertension or unstable cardiac rhythm, the use of adrenaline/epinephrine with a local anaesthetic
may be hazardous; for these patients an anaesthetic without adrenaline/epinephrine should be used.
Local anaesthetic toxicity
Toxic effects after administration of local anaesthetics are a result of excessively high plasma concentrations; severe
toxicity usually results from inadvertent intravascular injection or too rapid injection. Following most regional
anaesthetic procedures, maximum arterial plasma concentration of anaesthetic develops within about 10 to 25
minutes, so careful surveillance for toxic effects is necessary during the rst 30 minutes after injection.
Techniques to reduce risk of toxicity:
Clear and accurate dose calculations

Dose reduction in frail patients or those at extremes of age
Local anaesthetic injected slowly and with regular aspiration (to avoid inadvertent intravascular injection)
Use of adrenaline as vasoconstrictor to reduce systemic absorption
Regional nerve blocks to anaesthetise large areas
Use of ultrasound to facilitate nerve blocks
Close observation and monitoring
Features of local anaesthetic toxicity include:

Metallic/altered taste
Tinnitus
Nausea and vomiting
CNS depression:
Apnoea
Drowsiness
Confusion
Coma
CVS features:
Sweating, pallor, hypotension, lightheadedness, circulatory collapse
Management of local anesthetic toxicity:
Local anaesthetic toxicity should be managed by:

stopping the administration of any local anaesthetic
supportive measures with oxygen, IV uid, airway and ventilatory support as required
benzodiazepines for seizure activity
treatment of any arrhythmias as per ALS
Intravenous lipid emulsion is recommended in local anaesthetic toxicity related cardiac arrest and should be
considered in circulatory collapse.

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Question Navigator
A patient with severe facial burns requires a rapid sequence induction (RSI). Your 14 Unanswered
consultant begins to attempt intubation when she reports to you that she sees a Grade 4
15 Unanswered
Cormack-Lehane view.
16 Unanswered
a. Give three ways in which the laryngeal view may be improved. (2 marks)
b. Despite the use of the above techniques your consultant is unable to pass an ET tube. 17 Unanswered
She attempts to pass a supraglottic airway (LMA) but is unable to satisfactorily ventilate 18 Unanswered
the patient. She returns to bag-mask ventilation which is equally ineffective. What is the
next step in managing this patient? (1 mark) 19 Unanswered
20 Unanswered
22 Unanswered
23 Current Question
Answer
24 Unanswered
a. Any three of:
Ensure optimal positioning of the patient – ensure head is fully extended at atlanto-occipital joint and
the neck is exed

videolaryngoscope
Change practitioner
b. Needle cricothyroidotomy or surgical cricothyroidotomy
Notes
Improving the laryngeal view

neck is exed
cricoid pressure)
see the cords
Change practitioner
An intubating bougie will frequently be used to assist intubation with reduced view.
Oxygenation
Head elevation
Cease intubation attempts and reoxygenate the patient’s lungs using bag-mask ventilation before the SpO2 reaches
the steep part of the oxyhaemoglobin dissociation curve: this point is 92%. A maximum of three attempts at
intubation are recommended.
‘Can’t intubate, can’t oxygenate’ (CICO) situation
Rescue technique of choice

Supraglottic airway device (SAD)
If oxygenation continues to deteriorate and above methods are unsuccessful
Needle cricothyroidotomy
Surgical cricothyroidotomy
Tracheostomy

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Question Navigator
You are working in the Minors area of your ED department. A 17 year old patient is brought 14 Unanswered
in by paramedics after falling from a skateboard. You suspect he has suffered a distal radius
15 Unanswered
fracture. He is currently using Entonox for pain relief.
16 Unanswered
a. What are the constituents of Entonox and in what proportions? (1 mark)
b. What colour(s) of bottle indicate the contents are Entonox. (1 mark) 17 Unanswered
c. Give two contraindications to the use of Entonox. (1 mark) 18 Unanswered
19 Unanswered
20 Unanswered
21 Unanswered
23 Unanswered
a. Nitrous oxide and oxygen in 50%/50% mixture
b. Entonox bottles are blue or blue/white, with a blue and white collar 24 Current Question
c. Any two of the following:
Air-containing closed space:
Pneumothorax
The presence of intracranial air after head injury
Entrapped air following recent underwater dive

Recent intraocular gas injection
Intestinal obstruction.
Patients with, or at risk of, raised intracranial pressure
Notes
Nitrous oxide is used for maintenance of anaesthesia and, in sub-anaesthetic concentrations, for analgesia.
Uses
For anaesthesia, nitrous oxide is commonly used in a concentration of around 50 – 66% in oxygen in association with
other inhalational or intravenous agents. Nitrous oxide cannot be used as the sole anaesthetic agent due to lack of
potency, but is useful as part of a combination of drugs since it allows reduction in dosage of other agents.
For analgesic purposes without the induction of anaesthesia, a mixture of nitrous oxide and oxygen containing 50%
of each gas (Entonox®, Equanox®) is used. Self-administration using a demand valve is popular in obstetric practice,
for changing painful dressings, as an aid to postoperative physiotherapy, and in emergency ambulances. Entonox
bottles are blue or blue/white in colour and should have a blue/white quartered collar.
Contraindications
Nitrous oxide must not be used in patients with an air-containing closed space as nitrous oxide diffuses into these
spaces with a resulting increase in pressure. This includes conditions such as pneumothorax, the presence of
intracranial air after head injury, entrapped air following recent underwater dive, recent intraocular gas injection or
intestinal obstruction. Nitric oxide also increases cerebral blood ow and should be avoided in patients with, or at
risk of, raised intracranial pressure.
Adverse effects
Hypoxia can occur immediately following the administration of nitrous oxide; additional oxygen should always be
given for several minutes after stopping the ow of nitrous oxide.
Exposure to nitrous oxide for prolonged periods, either by continuous or by intermittent administration, may result
in megaloblastic anaemia as a result of interference with the action of vitamin B12; neurological toxic effects can
occur without preceding overt haematological changes. Depression of white cell formation may also occur.
Question Navigator
You are working on an intensive care unit when a patient is admitted from an emergency 14 Unanswered
department following a large mixed overdose. Your consultant asks you to insert an arterial
15 Unanswered
radial line.
16 Unanswered
a. What test should be performed as a precaution before performing this procedure and
describe how this test should be performed? (1 mark) 17 Unanswered
b. After inserting an arterial line, you note the trace is inadequate. Give four reasons for 18 Unanswered
inadequate arterial tracing. (2 marks)
19 Unanswered
20 Unanswered
21 Unanswered
22 Unanswered
a. Allen’s test: 24 Unanswered

Elevate patient’s hand and ask patient to make a st for 30 seconds
With the patient’s hand in the air, occlude both the ulnar and radial arteries
Ask patient to open hand and observe for blanching of the hand
Release pressure over ulnar artery and observe for ushing of the hand
If hand does not ush, the circulation is inadequate and an alternative puncture site should be
considered
b. Any four of:
Cannula clotting
Cannula kinking
Loose connection
Compliant tubing
Loss of IV uid
Tubing kink
Notes
Indications

Contraindications
Absolute
Absent pulse
Buerger disease
Relative
Anticoagulation
Atherosclerosis
Coagulopathy
Clinical anatomy
Arterial lines can be placed in multiple arteries, including the radial, ulnar, brachial, axillary, posterior tibial,
femoral, and dorsalis pedis arteries. The radial artery is the most commonly used, followed by the femoral
artery.
The radial artery originates in the cubital fossa from the brachial artery. It traverses the lateral aspect of the
forearm and gives rise to the palmar arches that provide vascular ow for the hand. At the wrist, the radial
artery sits proximal and medial to the radial styloid process and just lateral to the exor carpi radialis
tendon.
For the radial artery, the initial puncture site should be as distal as possible. A common location is over the
radial pulse at the proximal exor crease of the wrist. In any case, the puncture site should be at least 1 cm
proximal to the styloid process so as to keep from puncturing the retinaculum exorum and the small
super cial branch of the radial artery.
Allen test
An Allen test should be performed before radial artery cannulation is initiated. This procedure is a simple
bedside test designed to evaluate for adequate collateral circulation to the palmar arches of the hand. In
most patients, the palmar arches are supplied by both the radial artery and the ulnar artery. This collateral
circulation allows perfusion of the hand should either of these vessels be injured.
To perform this test, the examiner elevates the hand and asks the patient to make a st for 30 seconds. With
the patient’s hand in a st, the examiner applies simultaneous pressure to the ulnar and radial arteries so as
to occlude them. The patient is then asked to open the hand, which should appear blanched as a
consequence of the occlusion of the radial and ulnar arteries.
Next, the pressure over the ulnar artery is released, and the circulation should be observed returning to the
hand i.e. it will ush pink. An alternative puncture site should be considered if the result is abnormal.
Complications
Pain
Haematoma/bleeding
Infection
Thrombosis
Arteriovenous stula
Air embolism
Arterial pressure monitoring
Reasons for dampened/no waveform:

Cannula clotting
Cannula kinking
Loose connection
Compliant tubing
Loss of IV uid
Tubing kink
Question Navigator
An 11 year old boy is brought into ED after play ghting with friends at school. He tells you 25 Unanswered
he fell onto his left arm and has a clearly deformed elbow which x-ray con rms is posteriorly
26 Current Question
dislocated. You assess the patient’s pain to be severe using the RCEM composite pain scoring
system. 27 Unanswered
a. The patient does not have IV access. What drug (including dose and route) would be 28 Unanswered
most appropriate to give to this patient? (1 mark)
29 Unanswered
b. Give two non-pharmacological adjuncts that can be used when managing pain in
children. (1 mark) 30 Unanswered
c. The patient requires IV access for procedural sedation to facilitate reduction of his
31 Unanswered
elbow. Give two agents that can be used to reduce the pain of intravenous cannulation.
(1 mark) 32 Unanswered
33 Unanswered
35 Unanswered
Answer
a. Any two of:
Parent and family member involvement

Child-friendly environment
Explanation with reassurance
Distraction with toys, blowing bubbles, reading or storytelling
Play specialist
Limb immobilisation and elevation
Cooling and dressings for burns
De nitive treatment e.g. reduction of pulled elbow
b. Intranasal diamorphine 0.2 ml volume containing 0.1 mg/kg
c. Any two of:
Ethyl chloride spray
EMLA cream
Ametop gel
Notes
Pain is commonly under-recognised, under-treated and treatment may be delayed. This is especially true in children.
Reasons include dif culty in assessing severity, the child may not appear distressed or have dif culty describing /
admitting to pain. Drug choice and dosage may also cause problems due to unfamiliarity. Recognition and alleviation
of pain should be a priority when treating ill and injured children. This process should start at the triage, be
monitored during their time in the ED and nish with ensuring adequate analgesia at, and if appropriate, beyond
discharge.
Managing pain
Psychological strategies:
Parent and family member involvement
Child-friendly environment
Explanation with reassurance
Distraction with toys, blowing bubbles, reading or storytelling
Play specialist
Non-pharmacological adjuncts:
Limb immobilisation and elevation
Cooling and dressings for burns
De nitive treatment e.g. reduction of pulled elbow
Pharmacological options:
Analgesia
Paracetamol
NSAIDs
Weak opioids
Strong opioids
Entonox
Topical anaesthesia
Ethyl chloride spray
EMLA cream
Ametop gel
LAT gel
Local or regional anaesthesia
Procedural sedation
Ketamine (IV/IM)
Midazolam (Oral/intranasal)
Pain assessment
The RCEM guideline for pain management in children includes a composite assessment tool for pain scoring. The
assessment tool uses established pain-scoring scales including the faces scale score, the ladder score and
behavioural scoring. Using this method of scoring it is possible to place the patient into one of four categories: no
pain, mild, moderate and severe pain.
Pharmacological management of pain
The RCEM Clinical Effectiveness Committee standard of analgesia for moderate & severe pain within 20 minutes of
arrival in the ED should be applied to children in all Emergency Departments. Patients in severe pain should have
the effectiveness of analgesia re-evaluated within 60 minutes of receiving the rst dose of analgesia.
In treating pain, pay attention to the other factors distressing the child such as fear of the unfamiliar environment
and people, parental distress, people in uniforms, needle avoidance, fear of injury severity etc.
Mild pain
Oral/rectal paracetamol 20 mg/kg loading dose, then 15 mg/kg 4 – 6 hourly OR
Oral ibuprofen 10 mg/kg 6 – 8 hourly
Oral ibuprofen 10 mg/kg 6 – 8 hourly
Moderate pain
As for mild pain PLUS
Oral/rectal diclofenac 1 mg/kg 8 hourly (unless already had ibuprofen) AND/OR
Oral codeine phosphate 1 mg/kg 4 – 6 hourly (over 12 years old only) OR
Oral morphine 0.2 – 0.5 mg/kg stat
Severe pain
Consider entonox as holding measure THEN
Intranasal diamorphine 0.2 ml (= 0.1 mg/kg) FOLLOWED BY/OR
IV morphine 0.1 – 0.2 mg/kg
Supplemented by oral analgesics

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Question Navigator
You are in ltrating local anaesthetic around a large wound on a patient’s thigh. The patient 25 Unanswered
begins to complain of a metallic taste in the mouth associated with numbness to the tongue.
26 Unanswered
a. What is the likely diagnosis and what is the most important immediate management 27 Current Question
step? (1 mark)
b. The patient becomes pale and poorly responsive. A member of nursing staff informs you 28 Unanswered
the patient’s blood pressure is unrecordable, however they can feel a weak central pulse. 29 Unanswered
What drug should be considered in this patient? (1 mark)
c. The above treatment is successful and the patient is transferred to the Intensive Care 30 Unanswered
Unit for observation. Give a recognised gastrointestinal complication relating to the use 31 Unanswered
of the above treatment. (1 mark)
32 Unanswered
33 Unanswered
34 Unanswered
35 Unanswered
Answer
a. Local anaesthetic toxicity. The most important step in the management of mild toxicity is to stop any
administration of local anaesthetic.
b. The patient has progressed to a state of circulatory collapse and cardiac arrest is an imminent possibility.
The Association of Anaesthetists of Great Britain and Ireland (AAGBI) recommends the use of intravenous
lipid emulsion (intralipid) in local anaesthetic toxicity related cardiac arrest and consideration of use in
circulatory collapse.
c. Pancreatitis is a recognised complication following the administration of intravenous lipid emulsion
(intralipid) and should be monitored for.
Notes
excitable tissues.



15
15
mins
EMLA cream
ED
Ametop gel
LAT gel
adverse effects


Tinnitus
Nausea and vomiting
CNS depression:
Apnoea
Drowsiness
Confusion
Coma
CVS features:


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Question Navigator
A 27 year old woman has sustained a laceration to her forearm. Your consultant 25 Unanswered
recommends you close the wound with sutures and asks you to in ltrate local anaesthetic.
26 Unanswered
a. Name two commonly used local anaesthetics in ED. (1 mark) 27 Unanswered
b. Outline the mechanism of action of commonly used local anaesthetics. (1 mark)
c. Give two techniques of minimising the risk of local anaesthetic toxicity when using local 28 Current Question
anaesthetic agents. (1 mark) 29 Unanswered
30 Unanswered
31 Unanswered
32 Unanswered

Lidocaine 35 Unanswered
Bupivacaine
Prilocaine
b. Reversible sodium channel blockage preventing propagation of action potentials
c. Any three of:

Local anaesthetic injected slowly and with regular aspiration (to avoid inadvertent intravascular
injection)
Notes
excitable tissues.



15
mins
EMLA cream
ED
Ametop gel
LAT gel
adverse effects


Tinnitus
Nausea and vomiting
CNS depression:
Apnoea
Drowsiness
Confusion
Coma
CVS features:


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Question Navigator
A 23 year old man is brought into the Emergency Department with features of severe 25 Unanswered
sepsis. He is requiring aggressive inotropic therapy to maintain a mean arterial blood pressure
26 Unanswered
>60 mmHg. Your consultant wishes to perform a rapid sequence induction (RSI) and asks for
your assistance in preparing the required drugs. 27 Unanswered
a. What is the recommended dose of etomidate when performing an RSI? Give your 28 Unanswered
answer in mg/kg. (1 mark)
29 Current Question
b. What advantage does etomidate have over other induction drugs? (1 mark)
c. What side effect of etomidate may limit its use in septic patients? (1 mark) 30 Unanswered
31 Unanswered
33 Unanswered
34 Unanswered
Answer
35 Unanswered
a. 0.3 mg/kg
b. Relatively cardiovascularly stable thus may be used for induction of anaesthesia in a haemodynamically
compromised patient
c. Adrenal suppression
Notes
Etomidate
Indications:
Dose 0.3 mg/kg
5 – 15 secs onset
Pain on injection
Speci cs:
Adrenal suppression
Propofol
Indications:
Pain on injection
Speci cs:
elderly
elderly
Thiopental sodium
Indications:
5 – 15 secs onset
Speci cs:
Ketamine
Indications:
Septic shock
Severe bronchospasm
Dose 1 – 2 mg/kg
Speci cs:
Potent analgesic

Comparison
CV + +++ ++ Minimal
depression

severe Emergence
Hypertension
Question Navigator
A 25 year old man is brought to ED after being involved in a road traf c collision. The 25 Unanswered
patient requires emergency laparotomy and needs transfer to theatre. The patient is to be
26 Unanswered
transferred with oxygen. He is currently on 10 L per minute and the operating room is 16
minutes away. 27 Unanswered
a. What monitoring is required en-route? (1 mark) 28 Unanswered

b. How much oxygen is required for transfer – show your calculation? (1 mark)
29 Unanswered
c. Which size oxygen cylinder will you need for transfer? (1 mark)
30 Current Question
31 Unanswered
32 Unanswered
33 Unanswered
a. Continuous ECG, non-invasive BP and pulse oximetry
35 Unanswered
b. 2 x [ ow (L/min) x length of transfer (min)] = 2 x [10 x 16] = 320 L
c. Size D oxygen cylinder
Notes
Intubated patients in the emergency department will usually require transfer from the resuscitation room to
another department in the hospital or to another hospital for de nitive care. Common destinations include the CT
scanner, operating room and ICU in the same hospital, and specialist centres such as neurosurgery in other
hospitals. During transfer the patient is at signi cant risk of adverse events.
Checklist for transfer
Airway safe, tube position con rmed by end tidal CO2 monitoring and chest x-ray
Patient paralysed, sedated and ventilated
Adequate gas exchange con rmed by ABG
Naso/orogastric tube in place
Chest tubes secured where applicable
Circulation stable, haemorrhage controlled
Abdominal injuries properly assessed and treated
Minimum of two routes of IV access well secured
Adequate haemoglobin concentration
Seizures controlled
Long bone and pelvic fractures stabilised
Temperature maintained
Acid-base, glucose and metabolic abnormalities corrected
Case notes, x-rays and transfer documentation
Cross-matched blood products with patient if appropriate
Appropriate equipment, drugs and personnel
Communication with receiving clinicians and relatives
Monitoring during transport
Physiological parameters, including continuous ECG, heart rate, blood pressure, oxygen saturation and
quantitative end tidal CO2 should be visible to the clinician at all times on a multiple parameter transport
monitor
The ability to measure central venous pressure and core temperature should also be available
Observations should be recorded regularly, usually at 15 minute intervals
Oxygen requirements for patient transfer
When transferring a ventilated patient, oxygen requirements can be calculated as:
2 x transport time in minutes x [(MV x FiO2) + ventilator driving gas (if appropriate)]
FiO2 is a proportion of 1 e.g. 60% = 0.6.
Ventilator driving gas varies but is commonly about 1 L/min (if using a gas-driven ventilator)
When using continuous ow oxygen directly from the cylinder i.e. no ventilator, oxygen requirements can be
calculated as:
2 x [ ow (L/min) x length of transfer (min)]
Oxygen cylinder Size
ZA 300 L
D 340 L
CD 460 L
ZD 600 L
E 680 L
F 1360 L
HX 2300 L
ZX 3040 L
G 3400 L
J 6800 L
Question Navigator
A 25 year old woman is brought into the ED with signs of severe sepsis. She was intubated 25 Unanswered
and transferred to ITU. You are now following up her progress a week later and you note she has
26 Unanswered
been diagnosed with ARDs.
27 Unanswered
a. Give two features that must be present to diagnose ARDS. (1 mark)
b. Give two features of lung protective ventilation strategy. (1 mark) 28 Unanswered
c. Give two mechanisms of ventilator induced lung injury. (1 mark)
29 Unanswered
30 Unanswered
31 Current Question
32 Unanswered

Acute onset (within 1 week of known clinical insult) 35 Unanswered
Bilateral opacities on chest x-ray (not explained by effusions, collapse or nodules)
Respiratory failure not fully explained by heart failure or uid overload
b. Both of:
Low tidal volume
Low end-inspiratory plateau pressure

c. Any two of:
Volutrauma (lung damage secondary to high tidal volume causing overdistension and rupture of alveoli)
Barotrauma (lung damage secondary to high airway pressure e.g. pneumothorax, pneumomediastinum)
Atelectrauma (lung damage secondary to shear and strain of collapsible lung units opening and closing)
Biotrauma (lung damage secondary to release of proin ammatory cytokines and immune-mediated
injury)
Notes
Acute respiratory distress syndrome (ARDS)
ARDS is diagnosed on the basis of:
Acute onset (within 1 week of known clinical insult)

Bilateral opacities on chest x-ray (not explained by effusions, collapse or nodules)
Respiratory failure not fully explained by heart failure or uid overload
Severity of ARDS:
Mild: PaO2/FiO2 < 300 with PEEP or CAP > 5 cmH2O

Moderate: PaO2/FiO2 < 200 with PEEP or CAP > 5 cmH2O
Severe: PaO2/FiO2 < 100 with PEEP or CAP > 5 cmH2O
Lung-protective ventilation should be used for mechanically ventilated patients with ARDS and those with risk
factors for developing ARDS. It is also a reasonable default ventilation strategy in all mechanically ventilated
patients.
Rationale
Low tidal volume ventilation reduces ventilator induced lung injury (VILI):
Volutrauma (lung damage secondary to high tidal volume causing overdistension and rupture of alveoli)
Barotrauma (lung damage secondary to high airway pressure e.g. pneumothorax, pneumomediastinum)
Atelectrauma (lung damage secondary to shear and strain of collapsible lung units opening and closing)
Biotrauma (lung damage secondary to release of proin ammatory cytokines and immune-mediated injury)
Biotrauma (lung damage secondary to release of proin ammatory cytokines and immune-mediated injury)
The mainstays of lung-protective ventilation are to:
limit tidal volume

limit end-inspiratory plateau pressure
provide adequate PEEP to keep the lung open and prevent alveolar collapse
limit FiO2
Ventilator setup
Calculate predicted body weight

Select any ventilator mode
Achieve a TV of 6 – 8 mL/kg predicted body weight
Set RR to maintain adequate MV of about 100 mL/kg (not > 35/min)
Set PEEP to at least 5 cmH2O (but much higher is probably better)
Set FiO2 to maintain SpO2 88 – 95% or PaO2 55 – 80 mmHg
Aim for plateau pressure (measured during an inspiratory hold of 0.5 sec) < 30 cmH2O and preferable as
low as possible while maintaining reasonable blood gas parameters
pH goal = 7.30 – 7.45 (if < 7.15 increase TV, give NaHCO3)

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A 35 year old man is brought into ED after developing a fever when returning from holiday 25 Unanswered
in Spain. He is haemodynamically compromised and a decision is made that he requires
26 Unanswered
intubation and transfer to ITU for inotropic and ventilatory support. Your consultant plans to
perform an RSI. 27 Unanswered
a. What position is optimal for pre-oxygenation prior to RSI? (1 mark) 28 Unanswered

b. What is the purpose of cricoid pressure in RSI? (1 mark)
29 Unanswered
c. What is the gold standard for con rmation of tracheal intubation? (1 mark)
30 Unanswered
31 Unanswered
32 Current Question
33 Unanswered
a. Use a 20 degree head-up tilt whenever possible – this increases the time before desaturation occurs and
35 Unanswered
may also reduce the risk of passive regurgitation of gastric contents.
b. Cricoid pressure is applied in an attempt to reduce passive re ux of gastric contents into the pharynx with
subsequent aspiration into the lungs
c. Waveform capnography
Notes
Rapid sequence induction of anaesthesia (RSI) involves injecting an anesthetic induction drug to achieve hypnosis,
immediately followed by a neuromuscular blocking drug to produce complete paralysis. The lungs are not ventilated
between induction and intubation to prevent gastric in ation. The time from loss of consciousness to securing the
airway is minimised because the patient’s stomach is assumed to be full.
RSI Sequence
Preparation for intubation (PEACH)

Pre-oxygenation
Injection of precalculated dose of induction drug
Injection of precalculated dose of neuromuscular blocking drug
Commence apnoeic oxygenation
Cricoid pressure applied at loss of consciousness
Laryngoscopy and intubation
Cricoid pressure removed
Ventilation established and tube secured
Pre-oxygenation
Effective pre-oxygenation greatly increases the oxygen reserve within the lungs. This maximises the time before
desaturation of arterial blood occurs during apnoea, and decreases the risk of severe hypoxaemia and its associated
morbidity and mortality.
Breathing 100% oxygen with normal tidal volumes and an adequate respiratory rate for 3 minutes before induction
of anaesthesia is suf cient for most patients. Use a 20 degree head-up tilt whenever possible – this increases the
time before desaturation occurs and may also reduce the risk of passive regurgitation of gastric contents.
Some ill patients are not adequately pre-oxygenated with this technique. A good airway management technique
with a well- tting mask and high- ow oxygen is essential. Gentle application (maximum 10 cmH2O) of PEEP may
augment pre-oxygenation in patients failing to achieve an arterial blood oxygen saturation above 95%; avoid
ventilation to achieve adequate pre-oxygenation.
Apnoeic oxygenation
Apnoeic oxygenation continues delivery of oxygen in the absence of ventilation , provided the airway is patent. It
increases signi cantly the time before desaturation of arterial blood occurs during anaesthesia. Nasal cannulae are
sited under the facemask during pre-oxygenation and the oxygen ow increased to 15 L/min at the onset of
anaesthesia. This technique is a useful adjunct to formal pre-oxygenation in patients at increased risk of hypoxaemia
during induction or where dif culty with intubation is anticipated. However if the nasal cannulae tubing prevents an
adequate seal being formed, this may be counterproductive since it will diminish the bene t of pre-oxygenation and
should be abandoned.
Cricoid pressure
Applied in an attempt to reduce passive re ux of gastric contents into the pharynx with subsequent
aspiration into the lungs
Should not be used in presence of active vomiting because it may cause oesophageal rupture
Cricoid ring should be identi ed (below the thyroid cartilage and cricothyroid membrane) by trained
assistant and stabilised between the thumb and middle nger before induction of anaesthesia
As consciousness is lost, rm pressure should be applied to the centre of the cricoid cartilage using the index
nger pressing directly backwards to compress the upper oesophagus between the cricoid and the cervical
vertebra posteriorly
The optimal force is 30 – 40 newtons – inadequate pressure will not occlude the oesophagus, excessive
Cricoid pressure should only be removed once correct tube placement has been con rmed
As a general rule, it is to be expected that when the tracheal tube is at the correct depth, the patient’s teeth will lie
between 20 and 21 cm in an adult female and 22 and 23 cm in an adult male.
Correct placement of the tube is con rmed by:
Clinical assessment
Clinical assessment
Condensation in the tube, symmetrical chest rise, bilateral breath sounds on auscultation of the chest
Once tracheal intubation is con rmed, release the cricoid pressure and secure the tube.
Reassess patient using ABC

Inject a long-acting neuromuscular blocking drug if indicated
Use a suction catheter to clear material from the proximal airways
Check monitors for HR, SpO2, BP, end tidal CO2 and peak inspiratory pressure
Request a chest x-ray to examine position of tube and withdraw or advance as required

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Question Navigator
A 32 year old carpenter has presented to the Emergency Department with a deep 25 Unanswered
laceration to the volar aspect of his right index nger. His neurovascular examination is normal
26 Unanswered
and there is no loss of exion or suggestion of tendon injury. Your consultant advises you
perform a digital nerve block using 1% lidocaine for wound cleaning and suturing. 27 Unanswered
a. What is the theoretical maximum dose of lidocaine that can be used in this patient? Give 28 Unanswered
your answer in both milligrams and millilitres of 1% solution. Assume the patient weighs
29 Unanswered
70 kg. (1 mark)
b. How many digital nerves run along each nger? (1 mark) 30 Unanswered
c. Give two possible complications of digital nerve block. (1 mark)
31 Unanswered
32 Unanswered
33 Current Question
34 Unanswered
a. The maximum dose of lidocaine is 3 mg/kg.

Therefore the maximum theoretical dose is 70 x 3 = 210 mg.
1% lidocaine solution contains 10 mg/ml, therefore the maximum safe volume of 1% lidocaine that can
be used in this patient is 21 ml.

(N.B. In practice a digital nerve block usually requires 2 – 4 ml of lidocaine).
b. Four, each nger has two dorsal and two palmar digital nerves.
c. Any two of:
Pain at injection site
Infection
Bleeding
Tendonitis from tendon injury
Distal paraesthesia from nerve injury
Distal infarction from vasospasm
Inadvertent intravascular injection
Allergic reactions
Notes
Digital nerve block
Indications
Treatment and repair of many acute conditions including:

Finger or toe lacerations
Nailbed injuries
Paronychias and ingrown nails
Nail avulsions
Foreign bodies of the digit
Digit dislocation or fracture
Contraindications
Compromised digital circulation

Infection of the skin or tissues through which the needle will pass
Allergy to the anaesthetic agent
Cautions
Avoid using an anaesthetic with adrenaline due to risk of vasoconstriction and ischaemia.

Avoid using an anaesthetic with adrenaline due to risk of vasoconstriction and ischaemia.
Consider other techniques when neurologic function of the digit has been previously compromised by an
injury.
Use small volumes of anesthetic to decrease the mechanical compression on nerves and blood vessels.
Limit the patient’s discomfort by using a smaller needle, injecting slowly, and using small amounts of
anesthetics.
Avoid injection directly into the nerve; excessive pain or paraesthesia suggests the needle is against or in a
nerve.
Avoid injection into the digital blood vessels that accompany the digital nerves; aspirate before injection.
Clinical anatomy
Each digit is innervated by four digital nerves. In order to achieve a complete anaesthetic effect, it is
necessary to block all four nerves.
The digital nerves of the ngers arise from either the median or ulnar nerves and divide in the palm into
palmar (or volar) branches. These nerves are accompanied by digital blood vessels as they run on both sides
of the exor tendon sheath to innervate each nger. The palmar nerves dominate by innervating all of the
nger and the nail bed except for the dorsum of the nger, which is innervated by the dorsal digital nerves
that run along the dorsolateral aspect of each nger.
The digital nerves of the toes run on both sides of each toe and represent the terminal branches of the tibial
and peroneal nerves.
By Dr. Johannes Sobotta [Public domain], via Wikimedia Commons
Complications
Pain at injection site

Infection
Bleeding
Tendonitis from tendon injury
Distal paraesthesia from nerve injury
Distal infarction from vasospasm
Inadvertent intravascular injection
Allergic reactions

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Question Navigator
A 45 year old man is brought into the Emergency Department following a mixed overdose. 25 Unanswered
The patient is profoundly acidotic and your consultant asks for your assistance in performing an
26 Unanswered
RSI. The patient is cardiovascularly stable.
27 Unanswered
a. What is the recommended dose of propofol when performing an RSI in a
cardiovascularly stable patient? Give your answer in mg/kg. (1 mark) 28 Unanswered
b. What is the most marked disadvantage of propofol as an induction agent? (1 mark)
29 Unanswered
c. What is the onset time and recovery time of propofol? (1 mark)
30 Unanswered
31 Unanswered
32 Unanswered
33 Unanswered
Answer 34 Current Question
a. 1.5 – 2.5 mg/kg 35 Unanswered
b. Hypotension due to vasodilation
c. Onset: 20 – 40 seconds and Recovery: 5 – 10 minutes
Notes
Etomidate
Indications:
Dose 0.3 mg/kg
5 – 15 secs onset
Pain on injection
Speci cs:
Adrenal suppression
Propofol
Indications:
Pain on injection
Speci cs:
elderly
Thiopental sodium
Indications:
5 – 15 secs onset
Speci cs:
Ketamine
Indications:
Septic shock
Severe bronchospasm
Dose 1 – 2 mg/kg
Speci cs:
Potent analgesic

Comparison
CV + +++ ++ Minimal
depression

severe Emergence
Hypertension
Question Navigator
A 21 year old woman is brought to the ED after falling from a table whilst intoxicated on a 25 Unanswered
night out. She has a clearly deformed left elbow and x-ray con rms a posterior dislocation of the
26 Unanswered
elbow. You decide to use procedural sedation to facilitate reduction.
27 Unanswered
a. Give two commonly used sedating agents. (1 mark)
b. What are the minimum staf ng levels required for procedural sedation. (1 mark) 28 Unanswered
c. Give two situations in which procedural sedation should be avoided. (1 mark)
29 Unanswered
30 Unanswered
31 Unanswered
32 Unanswered

Propofol 35 Current Question
Midazolam
Ketamine
b. Minimum staf ng levels:

One nurse
c. Any two of:
Lack of personnel experienced in airway management
Lack of appropriate monitoring equipment
Lack of resuscitation and airway management equipment
Allergy or sensitivity to the prescribed medication
Facial, dental or airway abnormalities which would preclude tracheal intubation
Patient at high risk of vomiting and aspiration
Haemodynamically or neurologically unstable patients
Notes
Effective procedural sedation requires:
Analgesia
Anxiolysis
Sedation
Amnesia
Depths of sedation
Sedation is a continuum which extends from normal alert consciousness to complete unresponsiveness.
Sedation Response Airway Ventilatory Cardiovascular

re exes function function
Minimal sedation e.g. Entonox Normal response to Maintained Maintained Maintained

verbal commands
Moderate (conscious) sedation Purposeful response to Maintained Usually Maintained

e.g. opioids/benzodiazepines verbal commands (+/- maintained
light stimuli)

repeated or painful stimuli impaired impaired maintained
General anaesthesia Patient unrousable Impaired Usually May be

impaired impaired
to verbal commands, and deeper levels of sedation where the patient responds only to painful stimuli, or not at all.
Once verbal contact with the patient is lost it becomes dif cult to determine the level of unconsciousness, and over-
sedation with an associated risk of airway and cardio-respiratory complications is possible. Deeper levels of
sedation are, to all intents and purposes, indistinguishable from general anaesthesia and should therefore be
treated as such.
Dissociative sedation, caused by ketamine, is de ned as ‘a trance-like cataleptic state characterised by profound
analgesia and amnesia, with retention of protective airway re exes, spontaneous respirations, and cardiopulmonary
stability.’
Because sedation is a continuum, it is not always possible to predict how the individual patient will
respond. Practitioners intending to produce a given level of sedation must therefore be able to ‘rescue’ patients
from a deeper level of sedation than intended. For most procedures in the ED, the level of required sedation will be
moderate to deep, this should be determined in advance.
Requirements for procedural sedation and analgesia in the ED
Minimum staf ng levels:

One nurse
Location and facilities:
Resuscitation room facilities
Pre-procedure checks:
ASA grading
Pre-procedural assessment including prediction of dif culty in airway management
Pre-procedural fasting and risk bene t assessment
Fasting is not needed for minimal sedation, sedation with nitrous oxide (in oxygen) alone, or
For procedures using all other sedation techniques (deep sedation, dissociative sedation and
moderate sedation where the patient might not maintain verbal contact with the
healthcare professional), apply the fasting rule used for general anaesthesia: two hours for clear
uids and six hours for solids
For an emergency procedure in someone who is not fasted, base the decision to proceed with
sedation on the urgency of the procedure and the target depth of sedation
Consent and documentation
Drug selection and preparation: benzodiazepine/opioid combinations, propofol, ketamine
Monitoring:
ECG, NIBP, pulse oximetry
The use of continuous quantitative capnography is recommended for conscious sedation and
mandatory for deep and dissociative sedation
Analgesia:
Pain experienced by the patient should be treated with analgesia rather than sedation
Pain should be assessed and managed prior to starting sedation using the WHO pain ladder principles
and the need for ongoing pain relief post-procedure considered
Where opiate pain relief has been given prior to PSA, doses of sedatives should be adjusted accordingly
Anxiolysis:
Non-pharmacological methods of reducing anxiety are often the most effective and include
consideration of the environment and patient comfort
Environment is particularly important for children and patients with dementia or learning dif culties
Family members often provide invaluable support and distraction
Most painful procedures are best performed with the patient supine
Oxygen:
Oxygen should be given from the start of sedative administration until the patient is ready for
discharge from the recovery area
Post-procedure:
All patients who have received sedation should continue to be managed in a clinical area that
provides the same level of facilities and monitoring as those required during the procedure, until the
level of consciousness and other vital signs have returned to pre-procedure baseline levels.
Discharge status:
Patients should be formally assessed for discharge suitability from the clinical area where sedation
has taken place.
Discharge criteria are as follows:
If there is a requirement to discharge the patient prior to meeting these criteria they should
be transferred to an appropriate clinical environment with continuation of periprocedural monitoring
standards.
Patients meeting discharge criteria following sedation who go on to be discharged home from
the Emergency Department should be discharged into the care of a responsible third party. Verbal
and written instructions should be given.
Pharmacological agents for PSA
Drug Propofol Midazolam Ketamine
Mode Positive Short-acting benzodiazepine NMDA-receptor antagonist

of modulation of
action GABA inhibitory
neurotransmission
Effects Sedation and Sedation and amnesia Dissociative sedation,

amnesia amnesia, analgesia
Side Hypotension, Respiratory depression, hypotension, Tachycardia, hypertension,

effects respiratory paradoxical disinhibition and agitation at low laryngospasm,
depression, pain at doses in children, accumulates in adipose hallucinations, nausea and
site of injection tissue which can prolong sedation (elderly, vomiting, hypersalivation,
obese and patients with hepatic or renal increased intracranial and
disease at risk) intraocular pressure
Route IV IV IV
Initial 30 sec – 1 min 1 – 2 min 30 sec – 1 min

onset
time
Peak 1 – 2 min 3 – 4 min 1 – 2 min

effect
time
Initial Adult: 0.5 Adult: 1 – 2 mg Adult: 1 mg/kg

Elderly: IM: 4 – 5 mg/kg
10 – 20
mg
Repeat Adult: 0.5 Adult: 1 – 2 mg after 2 – 5 mins Adult/Elderly: 0.25

dose
Drug mg/kg
Propofol Elderly: 0.5 mg
Midazolam – 0.5 mg/kg every 5
Ketamine
every 3 – – 10 min
5 mins IM: 2 – 2.5 mg/kg
Elderly: every 5 – 10 min
10 – 20
mg
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7/31/2017 Anaesthetics & Pain Management - FRCEM Success

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P – Past medical history

Preparing for RSI

PEACH is a useful mnemonic to remember the steps in preparing for RSI:

Positioning for pre-oxygenation:

Positioning for intubation:

The emergency airway trolley should contain:

Tilting trolley and pillow

Oxygen for pre-oxygenation:

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Secretions increased – pharyngeal and bronchial

Drug Etomidate Propofol Thiopental Ketamine

Dose 0.3 mg/kg 1.5 – 2.5 mg/kg 2 – 7 mg/kg 1 – 2 mg/kg

Onset 5 – 15 secs 20 – 40 secs 5 – 15 secs 15 – 30 secs

Recovery 5 – 15 mins 5 – 10 mins 5 – 15 mins 15 – 30 mins

Notes Relatively Marked Cerebroprotective Potent

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Intravenous regional anaesthesia for distal forearm fractures (Bier’s block)

Reduction of wrist fractures, most commonly Colles’ fracture

Allergy to local anaesthetic

Drug and dose

Peripheral venous access

Access to emergency drugs, including intralipid in case of local anaesthetic toxicity

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You did not answer this question 7 Unanswered

Femoral line insertion

Indications for central line

Resuscitation requiring a large bore IV line

inferior vena cava)

Deep vein thrombosis

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Can’t intubate, can’t oxygenate scenario

Attach a 20 mL syringe to a stiff cannula and needle (minimum 14 gauge in adults)

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Can’t intubate, can’t oxygenate scenario

Technically more dif cult than needle cricothyroidotomy

Extension of the neck will improve surgical access and exposure

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a. Give four causes of post-intubation hypoxia. (2 marks) 5 Unanswered

a. Any four of: 11 Unanswered

Position of ET tube (oesophageal or bronchial intubation, tube out of trachea)

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Drug Suxamethonium Rocuronium

Type Depolarising Non-

Dose 1.5 – 2 mg/kg 1 – 1.2 mg/kg

Onset 10 – 15 sec fasciculation, 45 – 60 sec paralysis 1 min

Recovery 3 – 5 min rst return of respiratory activity 30 – 40 min

Contraindications Known hyperkalaemia Nil

Anaesthetics & Pain Management

Anaesthetics & Pain Management