Emergency Manual Stanford Version 2022

ad Asystole / PEA ..................
downlo
Bradycardia . . . . . . . . . . . . . . . . . . . . . 2
ACLS
SVT - Unstable and Stable . . . . . 3
e
Fre
VFIB / VTACH . . . . . . . . . . . . . . . . . . . . 4
Anaphylaxis . . . . . . . . . . . . . . . . . . . . . 5
Bronchospasm ................. 6
Delayed Emergence . . . . . . . . . . . . 7
Cognitive Aids for Perioperative Crises - V4.4 2022
EMERGENCY Difficult Airway / Cric . . . . . . . . . . 8

Stanford Anesthesia Cognitive Aid Program
Embolism - Pulmonary . . . . . . . . . 9
MANUAL Fire - Airway . . . . . . . . . . . . . . . . . . . . . 10
Fire - Non-Airway . . . . . . . . . . . . . . . 11
Hemorrhage .................... 12
High Airway Pressure . . . . . . . . . . 13
OTHER EVENTS
High Spinal . . . . . . . . . . . . . . . . . . . . . . 14
Hypertension ................... 15
Hypotension .................... 16
Hypoxemia . . . . . . . . . . . . . . . . . . . . . . 17
Local Anesthetic Toxicity ..... 18
Malignant Hyperthermia ..... 19
Myocardial Ischemia .......... 20
Oxygen Failure ................. 21
Pneumothorax ................. 22
Power Failure . . . . . . . . . . . . . . . . . . . 23
Right Heart Failure . . . . . . . . . . . . . 24
Transfusion Reaction . . . . . . . . . . 25
Trauma .......................... 26
RESOURCES
Crisis Resource Management . 27

Emergency Manual Use ....... 28
Phone List (Back Cover) Infusion List .................... 29
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2 Asystole / PEA
3 No pulse AND non-shockable rhythm on ECG
e.g. asystole or any non-VFIB/VTACH
4
5
TREATMENT
Task Actions
6 Crisis • Inform team • Identify leader
Resources
7 • Call a code • Call for code cart
8 • Assign team member to read cognitive aid out loud
CPR • Rate 100 - 120 compressions/min, minimize breaks
9
• Depth ≥ 5 cm; allow chest recoil; consider backboard
10 • Keep EtCO2 > 10 mmHg and diastolic BP > 20 mmHg
11 • Rotate compressors with rhythm check every 2 min.
Place defibrillator pads. If becomes shockable VF/VT:
12 defibrillate 200 J biphasic or 360 J monophasic
13 See VFIB/VTACH #4
• Check pulse ONLY if signs of ROSC (sustained increased
14 EtCO2, spontaneous arterial waveform, rhythm change)
15 • Prone CPR at lower edge of scapula OK if airway secured
• Place defibrillator pads and check rhythm every 2 min
16
Airway • 100% O2 10 - 15 L/min
17 • If mask ventilation: ratio 30 compressions to 2 breaths
18 • If airway secured: 10 breaths/min, tidal volume 6 -7 mL/kg
19 IV Access • Ensure functional IV or IO access

Meds • Turn off volatile anesthetic and vasodilating drips
20
• Epinephrine 1 mg IV push every 3 - 5 minutes
21 • If hyperkalemia: calcium chloride 1 g IV; sodium
22 bicarbonate 1 amp IV (50 mEq); regular insulin 5 - 10 units
IV with dextrose/D50 1 amp IV (25 g)
23 • If acidosis: sodium bicarbonate 1 amp IV (50 mEq)
24 • If hypocalcemia: calcium chloride 1 g IV
• If hypoglycemia: dextrose/D50 1 amp IV (25 g)
25
ECMO/CPB • Consider ECMO or cardiopulmonary bypass
26
Post Arrest • If ROSC: arrange ICU care and consider cooling
27 Causes • Explore H’s and T’s on next page
GO TO NEXT PAGE »
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Page 2 Asystole / PEA 2
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DIFFERENTIAL DIAGNOSIS TEE
/TEE/aTd
TTE Labs
and labs
will will aid diagnosis; Invite input from team
aid diagnosis
Heart Rate - Vagal Stimulus Hyperthermia 4
• Desufflate abdomen See Malignant Hyperthermia #19
• Remove surgical retractors 5
and sponges Hypothermia
• Remove pressure from eyes, neck, • Actively warm: forced air, warm IV 6
ears, and brain. Drain bladder fluid, warm room
• Consider ECMO or bypass 7
Hypovolemia
• Give rapid IV fluid bolus Toxins 8
• Check Hgb • Consider anesthetic overdose
• If anemia or hemorrhage: • Consider medication error 9
See Hemorrhage #12 • Turn off volatile anesthetic and
• Consider relative hypovolemia: vasodilating drips 10
- If auto-PEEP: disconnect circuit • If local anesthetic has been given:
- IVC compression See Local Anesthetic Toxicity 11
- Obstructive or distributive shock #18
See Anaphylaxis #5 12
Tamponade - Cardiac
See High Spinal #14 • Consider TEE / TTE 13
Hypoxemia • Perform pericardiocentesis
• O2 100% 10 - 15 L/min Tension - Pneumothorax
14
• Check breathing circuit connections • Check for asymmetric breath sounds,
• Confirm ETT placement with CO2 distended neck veins, deviated
15
• Check breath sounds trachea
• Suction ET tube • Consider ultrasound for normal lung
16
• Consider chest x-ray; bronchoscopy sliding, abnormal lung point
See Hypoxemia #17 • Consider chest x-ray, but do NOT
17
delay treatment
Hydrogen Ions - Acidosis • Perform empiric needle 18
• Consider bicarbonate decompression in 4th or 5th
• Balance increasing ventilation with intercostal space anterior to the 19
potential decrease in CPR quality mid-axillary line, then chest tube
See Pneumothorax #22 20
Hyperkalemia
• Calcium chloride 1g IV Thrombosis - Coronary 21
• Bicarbonate 1 amp IV (50 mEq) • Consider TEE / TTE to evaluate
• Insulin 5 - 10 units IV with D50 ventricular wall motion 22
1 amp IV (25g) and monitor glucose • Consider emergent coronary
• Consider emergent dialysis revascularization 23
Hypokalemia See Myocardial Ischemia #20
24
• Controlled potassium infusion Thrombosis - Pulmonary
• Magnesium sulfate 1 - 2 g IV
• Consider TEE / TTE to evaluate right 25
Hypoglycemia ventricular function and RVSP
• Dextrose/D50 1 amp (25 g) • Consider fibrinolytic agents or 26
• Monitor glucose pulmonary thrombectomy
See Embolism #9 27
Hypocalcemia See Right Heart Failure #24
• Calcium chloride 1 g IV 28
END 29
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Bradycardia 2
Pulse present, heart rate < 50 bpm, and inadequate perfusion 3
4
TREATMENT
Task Actions
5
Crisis • Inform team • Identify leader
Resources 6
• Call a code • Call for code cart
Pulse • If no pulse: start CPR and
7
Check See Asystole/PEA #1 8
Airway • 100% O2 10 - 15 L/min 9
• Confirm adequate ventilation and oxygenation
10
Stop Vagal • Desufflate abdomen
Stimuli
• Remove pressure from eyes, neck, ears, and brain 11
• Remove retractors, surgical sponges, and packing 12
• Drain bladder 13
IV Access • Ensure functional IV or IO access
14
Meds • Consider decreasing anesthetics or analgesics
• Atropine 0.5 - 1 mg IV every 3 min. May repeat, max 3 mg
15
• If atropine ineffective: epinephrine 5 - 10 mcg IV 16
• Consider dopamine infusion of 5 - 20 mcg/kg/min 17
• Consider epinephrine infusion of 0.02 - 0.3 mcg/kg/min
18
• If stable: consider glycopyrrolate 0.2 - 0.4 mg IV
Pacing • Place defibrillator pads 19
• Consider temporary transcutaneous, transvenous, 20
or esophageal pacing
21
• Set pacer rate to at least 80 bpm
• Increase current (mA) until electrical capture. 22
Confirm mechanical capture with patient pulse.
Set pacer output 10 mA above mechanical capture 23
• Consult ICU and/or Cardiology 24
Arterial • Consider arterial line placement
Line
25
Labs • Send ABG, Hgb, electrolytes, troponin 26
Ischemia • Obtain 12-lead ECG 27
Workup
• Consider checking BNP and serial troponins 28
END 29
2
3 SVT
4 Non-compensatory tachycardia and Pulse present
Often rate >150 or sudden onset
5
6
TREATMENT
Task Actions
Resources
8 • Call a code • Call for code cart
9 Pulse Check • If no pulse: start CPR and

See Asystole/PEA #1
10 Airway • 100% O2 10 - 15 L/min
11 • Confirm adequate ventilation and oxygenation
12 Defib Pads • Place defibrillator pads for possible cardioversion
13 Determine if • Unstable if ANY of the following:

UNSTABLE
• SBP < 75 mmHg
14
• Sudden SBP decrease below patient’s baseline
15 • Acute ischemia or chest pain
16 • Acute congestive heart failure
• Acutely altered mental status
17
• If stable: rule out sinus tachycardia & go to next page
18 • If unstable: continue below
19 UNSTABLE SVT:
20 Immediate • If patient is not anesthetized: consider sedation
Synchronized
• Cardiovert with settings depending on QRS complex
21 Cardioversion
(narrow or wide) and rhythm (regular or irregular)
22 • Narrow complex and regular:
Sync 50 - 100 J biphasic
23
• Narrow complex and irregular:
24 Sync 120 - 200 J biphasic
• Wide complex and regular:
25 Sync 100 J biphasic
26 • Wide complex and irregular:
Unsync 200 J biphasic
27 Refractory • Repeat synchronized shock with increased joules.
28 UNSTABLE Consider amiodarone 150 mg IV SLOW over 10 min
SVT
• If still unstable: End cognitive aid & consult expert STAT
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STABLE SVT ON NEXT PAGE »
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Page 2 SVT 2
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TREATMENT STABLE SVT - If unstable at any point: go to UNSTABLE SVT Page 1 4
• STAT Expert consult strongly recommended for rhythm diagnosis 5
and medication selection
• Obtain 12-lead ECG or print rhythm strip. Place defibrillator pads 6
• Consider arterial line placement, ABG, and electrolytes
• Rule out sinus tachycardia. Consider vagal maneuver before medication 7
Meds: • Adenosine (avoid if WPW or asthma) 8
Narrow push 6 mg IV, flush; monitor EKG. May follow with 12 mg IV
and 9
• If not converted, or slowing reveals afib/flutter, rate control:
Regular
• Esmolol (avoid if WPW, decreased EF, or asthma) 10
0.5 mg/kg IV over 1 min. May repeat after 1 min.
Then infusion of 50 - 300 mcg/kg/min 11
• Metoprolol (avoid if WPW, decreased EF, or asthma)
1 - 2.5 mg IV push. May repeat or double after 3 - 5 min 12
• Diltiazem (avoid if WPW or decreased EF) 13
10 - 20 mg IV over 2 min. May repeat after 5 min.
Then infusion of 5 - 10 mg/hr 14
Meds: • If CAD/MI, likely VT: SLOWLY give Amiodarone (avoid if
WPW) 150 mg IV over 10 min to avoid cardiovascular 15
Wide
and collapse. May repeat once. Then infusion of 1 mg/min
16
Regular • If SVT with aberrancy: Adenosine (avoid if WPW or asthma)
push 6 mg IV, flush; monitor EKG. May follow with 12 mg IV 17
• May add Procainamide (avoid if decreased EF or increased 18
QT interval) 20 - 50 mg/min IV (max 17 mg/kg) until
arrhythmia suppressed. Then infusion of 1 - 4 mg/min 19
Meds: • Rate control:
Narrow • Esmolol (avoid if WPW, decreased EF, or asthma)
20
and 0.5 mg/kg IV over 1 min. May repeat after 1 min.
Irregular Then infusion of 50 - 300 mcg/kg/min
21
• Metoprolol (avoid if WPW, decreased EF, or asthma) 22
1 - 2.5 mg IV push. May repeat or double after 3 - 5 min
• Diltiazem (avoid if WPW or decreased EF) 23
10 - 20 mg IV over 2 min. May repeat after 5 min.
Then infusion of 5 - 10 mg/hr 24
• Consider SLOWLY giving Amiodarone (avoid if WPW) 25
150 mg IV over 10 min to avoid cardiovascular collapse.
May repeat once. Then infusion of 1 mg/min 26
If Wide • This is likely polymorphic VT: Consult Cardiology STAT
27
and • Consider Magnesium for Torsades de Pointes
Irregular 28
END 29
2
3 VFIB / VTACH
4 No pulse AND VFIB or VTACH
5
TREATMENT
Task Actions
6
7 Resources
• Call a code • Call for code cart
8 CPR • Rate 100 - 120 compressions/min, minimize breaks
9 • Depth ≥ 5 cm; allow chest recoil; consider backboard
10 • Keep EtCO2 > 10 mmHg and diastolic BP > 20 mmHg

• Rotate compressors with rhythm check every 2 min.
11 If changes to non-shockable rhythm:
12 See Asystole/PEA #1
13 EtCO2, spontaneous arterial waveform, rhythm change)
14 • Prone CPR at lower edge of scapula OK if airway secured
Airway • 100% O2 10 - 15 L/min
15
• Defibrillation is higher priority than intubation. Mask
16 ventilate with ratio of 30 compressions to 2 breaths
• If airway secured: 10 breaths/min; tidal volume 6 -7 mL/kg
17
Defib • Place pads and immediately defibrillate: 120-200 J
18 biphasic or 360 J monophasic
19 • Resume CPR. Increase electrical energy and repeat shock
every 2 min
20
IV Access • Ensure functional IV or IO access
21 Meds • Turn off volatile anesthetic and vasodilating drips
22 • After 2nd shock: epinephrine 1 mg IV every 3 - 5 min
• After 3rd shock: amiodarone 300 mg IV push or
23 lidocaine 1 - 1.5 mg/kg IV. May redose:
24 amiodarone 150 mg or lidocaine 0.5 - 0.75 mg/kg
• If hypomagnesemia or torsades: magnesium 1 - 2 g IV
25
• If hyperkalemia: calcium chloride 1 g IV; sodium
26 bicarbonate 1 amp IV (50 mEq); regular insulin 5 - 10 units
IV with dextrose/D50 1 amp IV (25 g)
27 H’s & T’s • Consider treatable causes on next page
28 ECMO/CPB • Consider ECMO or cardiopulmonary bypass
29 Post Arrest • If ROSC: arrange ICU care and consider cooling
GO TO NEXT PAGE »
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Page 2 VFIB / VTACH 2
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DIFFERENTIAL DIAGNOSIS TEE / TTE and labs will aid diagnosis; Invite input from team
Heart Rate - Vagal Stimulus Hyperthermia 4
• Desufflate abdomen See Malignant Hyperthermia #19
• Remove surgical retractors 5
and sponges Hypothermia
• Remove pressure from eyes, neck, • Actively warm: forced air, warm IV 6
ears, and brain. Drain bladder fluid, warm room
Hypovolemia
• Consider ECMO or bypass 7
• Give rapid IV fluid bolus Toxins
• Check Hgb • Consider anesthetic overdose
8
• If anemia or hemorrhage: • Consider medication error 9
See Hemorrhage #12 • Turn off volatile anesthetic and
vasodilating drips
• Consider relative hypovolemia:
• If local anesthetic has been given:
10
- If auto-PEEP: disconnect circuit
- IVC compression See Local Anesthetic Toxicity 11
- Obstructive or distributive shock #18
See Anaphylaxis #5
Tamponade - Cardiac 12
See High Spinal #14 • Consider TEE / TTE
• Perform pericardiocentesis
13
Hypoxemia
• O2 100% 10 - 15 L/min Tension - Pneumothorax 14
• Check breathing circuit connections • Check for asymmetric breath sounds,
• Confirm ETT placement with CO2 distended neck veins, deviated 15
• Check breath sounds trachea
• Suction ET tube • Consider ultrasound for normal lung 16
• Consider chest x-ray; bronchoscopy sliding, abnormal lung point
See Hypoxemia #17 • Consider chest x-ray, but do NOT 17
delay treatment
Hydrogen Ions - Acidosis • Perform empiric needle 18
• Consider bicarbonate decompression in 4th or 5th
• Balance increasing ventilation with intercostal space anterior to the 19
potential decrease in CPR quality mid-axillary line, then chest tube
Hyperkalemia
• Calcium chloride 1g IV Thrombosis - Coronary 21
• Bicarbonate 1 amp IV (50 mEq) • Consider TEE / TTE to evaluate
• Insulin 5 - 10 units IV with D50 ventricular wall motion 22
1 amp IV (25g) and monitor glucose • Consider emergent coronary
• Consider emergent dialysis revascularization 23
Hypokalemia See Myocardial Ischemia #20
• Controlled potassium infusion 24
Thrombosis - Pulmonary
• Magnesium sulfate 1 - 2 g IV
• Consider TEE / TTE to evaluate right 25
Hypoglycemia ventricular function and RVSP
• Dextrose/D50 1 amp (25 g) • Consider fibrinolytic agents or 26
• Monitor glucose pulmonary thrombectomy
Hypocalcemia
See Embolism #9 27
See Right Heart Failure #24
• Calcium chloride 1 g IV 28
END 29
2
3 Anaphylaxis
4 Severe hypotension Angioedema Rash
Cardiac arrest Airway swelling Itching
5 Bronchospasm Tachycardia Hives (or no skin
Wheezing Arrhythmia findings)
6 High inspiratory pressure Flushing
7
TREATMENT
Task Actions
9 Resources
• Call for code cart • Consider pausing procedure
10 Airway • 100% O2 10 - 15 L/min
11 • Secure airway. If angioedema: consider early intubation

IV Access • Ensure functional large bore IV or IO access
12
Primary • Give epinephrine to prevent mast cell degranulation:
13 Meds
• Epinephrine 10 - 100 mcg IV (if no IV: 500 mcg IM);
14 Increase IV dose every 2 min until clinical improvement.
May require > 1mg. Start early epinephrine infusion
15 • See Infusion List #29
16 • If hypotensive: turn off volatile anesthetics and vasodilating
drips and consider amnestic agent (e.g. midazolam)
17 Fluid • Give rapid IV fluid bolus. May require many liters
18 • Consider head down position; elevate legs
19 Stop • Remove allergens: e.g. antibiotics, muscle relaxants,

Allergens chlorhexidine, dyes, blood products, latex, contrast,
20 colloids, protamine, sugammadex
ACLS • Check pulse. If no pulse or SBP < 50 mmHg:
21
• CPR rate 100 - 120 compressions/min
22 • Depth ≥ 5 cm; allow chest recoil; consider backboard
23 • Keep EtCO2 > 10 mmHg and diastolic BP > 20
mmHg
24
• Rotate compressors with rhythm check every 2 min
25 • Check pulse ONLY if signs of ROSC (sustained increased
EtCO2, spontaneous arterial waveform, rhythm change)
26
• If mask ventilation: ratio 30 compressions to 2 breaths
27 • If airway secure: 10 breaths/min; tidal volume 6 -7 mL/kg
28 • Place defibrillator pads in case rhythm changes
• Consider ECMO or cardiopulmonary bypass
29
GO TO NEXT PAGE »
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Page 2 Anaphylaxis 2
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RULE OUT • Anesthetic overdose • Hypotension
See Local Anesthetic Toxicity #18 See Hypotension #16 4
• Aspiration • Myocardial infarction 5
• Distributive or obstructive shock See Myocardial Ischemia #20
• Pneumothorax
6
• Embolism e.g. air, clot, fat
See Embolism #9 See Pneumothorax #22 7
• Hemorrhage • Sepsis
See Hemorrhage #12 8
9
TREATMENT
Task Actions
10
Additional • Consider additional IV access
Access
• Consider arterial line placement 11
Secondary • If hypotension: Continue epinephrine infusion. 12
Meds May add vasopressin and/or norepinephrine
13
See Infusion List #29
• If bronchospasm, give bronchodilator: 14
• If unable to ventilate, treat intravenously: 15
epinephrine 5 - 10 mcg IV (or 200 mcg subq) or
ketamine 10 - 50 mg IV (or 40mg IM) or 16
magnesium sulfate 1 - 2 g IV
• If able to ventilate: 17
albuterol 4 - 8 puffs MDI or 2.5 mg nebulized and
sevoflurane titrated to 1 MAC 18
• If persistent bronchospasm, consider: 19
• H1 antagonist: diphenhydramine 25 - 50 mg IV
20
• H2 antagonist: famotidine 20 mg IV
• Corticosteroid: hydrocortisone 100 mg IV or
21
methylprednisolone 125 mg IV 22
ECHO • Consider TEE / TTE to assess volume status and function
23
Labs • Send peak serum tryptase 1 - 2 hr after reaction onset
24
Dispo • Monitor for at least 6 hr. If severe, biphasic response is
more likely so monitor in ICU for 12 - 24 hours 25
• If intubated: consider keeping intubated
26
Allergy • Consider adding allergens to patient’s allergy list
Follow-up
• Refer the patient for follow-up allergy testing
27
28
END
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Bronchospasm 2
Inability to ventilate Increased EtCO2 SIGNS 3
High peak inspiratory pressure Upsloping EtCO2 waveform
Wheezing Decreased tidal volumes 4
Absent breath sounds if severe Hypotension if air-trapping
Increased expiratory time 5
6
TREATMENT
Task Actions
7
Resources 8
• Consider pausing procedure • Calling for code cart
Early • If hypotensive, may be air-trapping: briefly disconnect 9
Actions circuit
10
• If hypotension, tachycardia, and/or rash:
See Anaphylaxis #5 11
Airway • 100% O2 10 - 15 L/min 12
• If stridor or hypoxemia: consider intubation
13
• Optimize exhalation: change I:E ratio (e.g. 1:3 or 1:4)
minimize PEEP (0 - 5 cmH20); 14
avoid hyperinflation (goal tidal volume is 6 mL/kg)
Deepen • Bolus propofol; increase sevoflurane or isoflurane
15
Anesthesia 16
• Consider additional neuromuscular blockade
Check • Check CO2 waveform to confirm airway placement 17
Airway
• Auscultate lungs to check for endobronchial intubation
18
• Soft suction ET tube to check for kinking or mucous plug
• Check for malpositioned supraglottic airway 19
Meds • If severe: epinephrine 5 - 10 mcg IV every 3 - 5 min or 20
200 mcg subq, escalate doses as needed. Consider
adding glycopyrrolate 0.2 - 0.4 mg IV. Monitor for 21
tachycardia and hypertension
22
• If stridor or tachycardia concerns: give nebulized racemic
L-epinephrine 0.5 mL of 2.25% soln in 3 mL saline 23
• If able to ventilate, give bronchodilators:
albuterol 4 - 8 puffs MDI or 2.5 mg nebulized with or 24
without ipratropium
25
• Consider giving ketamine 10 - 50 mg IV, magnesium
sulfate 1 - 2 g IV, or hydrocortisone 100 mg IV 26
Labs • Consider ABG and serum tryptase 27
ECMO/CPB • If severe: consider ECMO or cardiopulmonary bypass
28
END 29
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Delayed Emergence 2
Patient less responsive than expected during emergence SIGNS 3
Abnormal neurological exam in postoperative period
4
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TREATMENT
Task Actions
Crisis • Inform team 6
Resources
7
Stop Meds • Confirm all volatile and IV anesthetics are off
Vital Signs • Check for and correct any hypoxemia, hypercarbia,
8
hypothermia, or hypotension 9
• Check for signs of high ICP: widened pulse pressure
(increased systolic, decreased diastolic), bradycardia, 10
irregular respirations
11
Paralysis • Check for and reverse residual neuromuscular paralysis
with sugammadex or neostigmine with glycopyrrolate 12
Neuro • Perform neurological exam 13
Exam
• Check for pupil changes, motor asymmetry, and gag
14
• If abnormal or suspect stroke: Call Stroke Code or
equivalent if available, obtain STAT head CT scan and/or 15
STAT Neurology/Neurosurgery consult
Med • Consider opioid reversal: naloxone 40 mcg IV; may 16
Reversal double dose and repeat every 2 minutes up to 400 mcg 17
• Consider benzodiazepine reversal:
flumazenil 0.2 mg IV every 1 minute; max dose 1 mg 18
• Consider anticholinergic syndrome (e.g. scopolamine): 19
physostigmine 1 mg IV with atropine available for
cholinergic crisis with severe bradycardia 20
• Re-treat because reversal agents have short half lives
21
Sugar • Check for and correct hypoglycemia
22
Labs • Send ABG plus electrolytes to evaluate for hypercarbia,
hyponatremia, hypernatremia, and hypercalcemia 23
Medication • Check for possible medication error
24
• Consider delayed med clearance (e.g. hepatic, renal)
25
Rare • Consider high spinal, serotonin syndrome, malignant
Causes hyperthermia, myxedema coma, seizure, thyroid storm, 26
and hepatic/uremic encephalopathy
Follow-up • If residual mental status abnormalities, monitor patient in 27
ICU with neurologic follow up
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END 29
2
3 Difficult Airway / Cric
4 Failed laryngoscopy or difficulty oxygenating or ventilating
5
TREATMENT
Task Actions
6 Crisis • Inform team • Call for airway help
7 Resources
• Call for anesthesia tech • Call for difficult airway cart
8 Optimize • Ensure paralysis (e.g. rocuronium 1.2 mg/kg)
Conditions
9 • Ensure anesthetic depth (e.g. re-bolus or infuse propofol)
• Optimize positioning
10 (e.g. sniffing position, head of bed elevation to 30°,
neck extension, bed height)
11
Oxygenate • Do not fixate on intubation
12 • Monitor CO2 return by capnography and SpO2
13 • If SpO2 critically low at any time: go to red box
below
14 • Consider oxygenation modalities (max 2 attempts each):
15 • Mask: use two-handed grip; insert oral/nasal airway
16 • Supraglottic airway SGA/LMA: optimize size and
fit (change position of head or device, cuff inflation);
17 consider 2nd generation
• Laryngoscopy: video preferred. Consider alternate
18 blade, rigid stylet, bougie, external laryngeal
manipulation, release of cricoid pressure
19
• Choose experienced operator and familiar equipment
20
Cannot Intubate,
Can Oxygenate:
21 Cannot Oxygenate (CICO):
• Monitor CO2 return by capnography • Priority is cutting the
22 and SpO2 neck!
23 • If cannot oxygenate at any time: • Call for Cric-capable help
go to red box • Get Cric kit: scalpel (e.g. #10
24
• While oxygenating, options include: blade), bougie, and 6.0 ET
25 tube
• Awaken patient
• Additional operator can
26 • Finish case with SGA/LMA or mask attempt to oxygenate from
• Intubate through SGA/LMA above (e.g. mask, SGA/LMA,
27 video laryngoscopy)
• Combined video/fiberoptic
28 • Start Cric/eFONA
• Other advanced airway techniques (next page)
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CRIC / eFONA ON NEXT PAGE »
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Page 2 Difficult Airway / Cric 2
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CRIC / EMERGENCY FRONT OF NECK ACCESS (eFONA) Inform Team • Announce emergency cric / front of neck access
4
Call for Help • ENT, Gen Surgery, ICU, Anesthesiology, Code Team
5
Prep • Expose and extend neck
• Obtain scalpel, bougie, and lubricated 6.0 ET tube 6
Meds • Give paralytic and anesthetic 7
Oxygenate • Additional operator can attempt to oxygenate from 8
and Monitor above (e.g. mask, SGA/LMA, video laryngoscopy)
• Monitor vital signs and pulse 9
10
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12
1. Expose and 2. Make 8 cm long 3. Palpate 4. Stab horizontally
extend neck. vertical midline cricothyroid through 13
Laryngeal skin incision. membrane cricothyroid
handshake to Cut away from membrane. Extend 14
identify midline your hand to width of trachea
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CO2
17
5. Rotate scalpel 6. Insert bougie 7. Pass 6.0 ET 8. Inflate cuff, 18
90° (blade toward along scalpel. tube over ventilate,
patient’s feet) and Remove scalpel bougie confirm CO2, check 19
pull toward you breath sounds
20
21
If risks for difficult airway, make contingency plans and consider:
PREVENTION
• Advanced airway equipment in room (e.g. difficult airway cart, second 22

generation SGA/LMA, intubating SGA/LMA, intubation catheter,
fiberoptic bronchoscope, rigid bronchoscope, scalpel/bougie cric kit) 23
• Awake intubation 24
• High flow apneic oxygenation
25
• Video laryngoscopy as first attempt
• ENT or General Surgery in room 26
• Awake tracheostomy (in consultation with surgeon) 27
• ECMO pre-cannulation with perfusionist in room 28
END 29
2
3 Embolism - Pulmonary
4 Sudden decrease in EtCO2, BP, or SpO2
Sudden increase in central venous pressure
5 Dyspnea, respiratory distress, or cough in awake patient
Increased risk in long bone orthopedic surgery, pregnancy, cancer
6 (especially renal tumor), high BMI, laparoscopic surgery, or surgical site
above level of the heart
7
TREATMENT
8 Task Actions
Resources
• Call for help • Get code cart
10
• Consider terminating procedure
11
Pulse Check • If no pulse: start CPR, check rhythm, and follow
12 appropriate algorithm
See Asystole/PEA #1 VFIB/VTACH #4
13
Airway • 100% O2 10 - 15 L/min
14
Circulation • Turn off volatile anesthetic and vasodilating drips
15
• Give IV vasopressor bolus to support circulation
16 • Consider rapid fluid bolus
17 Evaluate • If unstable or RV function decreased on TEE / TTE, use
Right Heart medication and diuresis to:
18 • Maintain sinus rhythm
19 • Maintain normal RV volume status
20 • Maintain RV contractility
• Decrease RV afterload
21
22 ECMO/CPB • If severe decompensation: consider ECMO or
cardiopulmonary bypass
23
RULE OUT
24 Consider other causes:

• Anaphylaxis • Distributive shock
25 See Anaphylaxis # 5 • Hypovolemia
26 • Bone cement implantation syndrome • Myocardial ischemia
• Bronchospasm See Myocardial Ischemia #20
27 See Bronchospasm #6 • Pneumothorax
28 • Cardiac tamponade See Pneumothorax #22
• Cardiogenic shock • Pulmonary edema
29
GO TO NEXT PAGE »
1
Page 2 Embolism - Pulmonary 2
3
TREATMENT Further management depends on embolism type:
4
Pulmonary Thromboembolism:
5
Risk Factors • Chronic illness, neoplasm, immobility, missed
anticoagulation 6
Treatment • Discuss feasibility and safety of urgent thrombolysis 7
vs. thrombectomy with surgical team
• Thrombolysis: If safe, use recombinant tissue
8
plasminogen activator (rtPA) alteplase 10 mg IV 9
followed by infusion of 90 mg over 2 hours
• Thrombectomy: Consider STAT Cardiovascular 10
Surgery consult (open) or STAT Interventional
Radiology consult (percutaneous) 11
• Supportive treatment: airway, breathing, circulation 12
Air or CO2 Embolism:
13
Signs • Air visible on TEE / TTE
14
Treatment • Limit entrainment of air: check IV lines for air; flood
surgical field with saline; consider placing surgical site 15
below heart; consider left lateral decubitus position
• Attempt removal of air: aspirate air from central line if
16
present 17
• Supportive treatment: airway, breathing, circulation
18
• Consider hyperbaric oxygen treatment
Cement or Fat Embolism: 19
Signs • Petechial rash 20
• Confusion or irritability if awake 21
Treatment • Supportive treatment: airway, breathing, circulation 22
Amniotic Fluid Embolism:
23
Signs • Peripartum patient with maternal or fetal compromise:
altered mental status, hypotension, hypoxemia, seizures, 24
coagulopathy
25
Treatment • Supportive treatment: airway, breathing, circulation
26
• Monitor fetus and consider urgent Cesarean section
• Monitor for and treat seizures and DIC 27
END 28
29
2
3 Fire - Airway
4 Sudden pop, spark, flame, smoke, heat, or odor
5
TREATMENT
Task Actions
6
7 Resources
• Call for help
8 Anesthesia • Disconnect breathing circuit from the anesthesia
Professional machine to prevent torch formation
9 Immediate
• Stop fresh gas flow
Response
10
Surgeon • If clamp immediately available: clamp ET tube.
11 Immediate If clamp not available: fold (kink) ET tube
Response (prevents torch formation if circuit not yet
12 disconnected)
13 • Immediately remove ET tube and any airway
foreign bodies
14 • Pour saline into airway and suction debris
15 Check Extent of • If fire spreads beyond airway (e.g. to drapes, patient):
Fire See Fire - Non-Airway #11
16
After Fire • Re-establish oxygenation when fire is
17 Extinguished extinguished
18 • Minimize FiO2 as much as possible. Consider air
ventilation
19 • Consider prompt reintubation with
ET tube ≥ 7.0 mm ID prior to swelling
20
• Ensure adequate anesthesia: e.g. propofol infusion
21 • Perform bronchoscopic examination of entire airway
to assess injury and remove residual debris
22
• Inspect ET tube pieces to verify none left in airway
23 • Save all materials for later investigation
24 • Consider steroid: e.g. dexamethasone 8 mg IV
25 Disposition • ICU care for prolonged mechanical ventilation and
airway observation
26
27 FIRE PREVENTION ON NEXT PAGE »
28
29
1
Page 2 Fire - Airway 2
3
PREVENTION Fire Risk = Fuel Source + Oxidizer + Ignition Source
4
For All • Discuss fire prevention and response during time out
High Risk 5
• Avoid FiO2 > 0.3 and avoid N2O
Procedures
• Anesthesia provider: communicate FiO2 changes
6
• Surgeon: communicate use of laser or electrocautery 7
For Laser • Use laser resistant ET tube (single or double cuff) 8
Surgery of
• Ensure ET tube cuff is sufficiently below vocal cords
Vocal Cord or 9
Larynx • Consider filling proximal ET tube cuff with methylene
blue-tinted saline 10
• Surgeon: keep laser in standby when not in use
11
• Surgeon: protect ET tube cuff with wet gauze
• Surgeon: check FiO2 < 0.3 and N2O not in use before
12
lasering or electrocauterizing 13
• Anesthesia provider: communicate FiO2 changes
14
For Non-laser • Regular PVC ET tube may be used
Surgery in
• Surgeon: protect ET tube with wet gauze 15
Oropharyx
• Consider continuous suctioning inside oropharynx 16
• Surgeon: confirm FiO2 < 0.3 and no N2O prior to 17
electrocautery use
• Anesthesia provider: communicate FiO2 changes 18
19
END 20
21
22
23
24
25
26
27
28
29
2
3 Fire - Non-Airway
4 Sudden pop, spark, flame, smoke, heat, or odor
5
TREATMENT
Task Actions
6
Crisis • Inform team • Call for help
7 Resources
• Activate fire alarm • Call code red
8 • Get CO2 fire extinguisher
9 Prevent • Stop fresh gas flow
Airway Fire
10 • Disconnect breathing circuit from the anesthesia
machine to stop all airway gas flow
11 • Ventilate with portable self-inflating bag (Ambu) on
room air
12
Prevent • Remove all burning and flammable materials
13 Patient (e.g. drapes, fabrics) from patient and onto floor;
Harm extinguish any flames
14
Extinguish • If non-electrical fire: use CO2 fire extinguisher (safe for
15 Flames wound) and saline or water (e.g. from basin, bottles, IV
(PASS) bags)
16 • If electrical fire: use only CO2 fire extinguisher
17 • PULL: Pull the pin
• AIM: Aim for the base of the fire
18
• SQUEEZE: Squeeze the trigger in five second bursts
19 • SWEEP: Sweep from side-to-side to put out fire
20 Care for • Assess for injuries; monitor vital signs
Patient
21 • Ensure adequate anesthesia e.g. propofol infusion
22 Consider • If continued smoke or fire: evacuate patient and staff

Evacuation
• If no smoke or fire: stay and shelter in place
23
Contain Fire • Close operating room doors
24 • Turn off external gas supply valves for O2 and N2O
25 Check Extent • If fire spreads to airway:
of Fire See Fire - Airway #10
26
Team Recap • Discuss with surgeon and OR leadership the
27 implications of fire for this patient and OR schedule
28
FIRE PREVENTION ON NEXT PAGE »
29
1
Page 2 Fire - Non-Airway 2
3
PREVENTION Fire Risk = Fuel Source + Oxidizer + Ignition Source
4
For All • Discuss fire prevention and management during time
High Risk out 5
Procedures
• Avoid FiO2 > 0.3 and avoid N2O 6
• Communicate FiO2 changes and electrocautery or laser
use throughout case 7
For Highest • Use minimum O2 concentration for adequate SpO2 8
Risk: MAC
Head
• Use nasal cannula instead of face mask if able 9
and Neck • If high O2 concentration required: use LMA or ET tube
Procedures 10
• Configure drapes to avoid O2 build up, consider active
scavenging if required 11
• Allow complete drying of alcohol skin prep solutions
12
END 13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
2
3 Hemorrhage
4 Increased suction volume Tachycardia
Increased surgical sponge use Hypotension
5
6
TREATMENT
Task Actions
Resources
8 • Call for Anesthesiology, Surgery, and Nursing help
• Activate Massive Transfusion Protocol (MTP)
9
Early • Give IV fluid bolus (e.g. crystalloid, colloid). If significant
10 Response hemorrhage: prioritize transfusion of blood products
11 • Establish large bore IV access: consider IO or central
venous access
12 • Temporize severe hypotension with vasopressor bolus
13 • Consider head down position or leg elevation
Airway • 100% O2 10 - 15 L/min
14
• Consider intubation prior to airway swelling
15
Critical • If severe hemodynamic instability at any point:
16 Response
• Inform surgeon and suggest surgical
temporizing measures
17 (e.g. packing, major vessel compression or
18 crossclamp, hemostatic agents: thrombin or fibrin
glue)
19 • Get additional surgical help
(e.g. Trauma, Vascular, Cardiac, Gyn-Onc,
20 or General Surgery)
21 Rapid • Delegate setup of:
Infuser and
• Rapid infusion system
22 Cell Saver
• Cell saver (if surgical site is not contaminated or
23 cancerous)
24 Transfuse • If significant bleeding: transfuse, do not wait for lab
results
25 • Check all blood
26 • Based on clinical picture: transfuse with ratio of
1-2 PRBC : 1 FFP : 1 Platelet pack
27 • Adjust empiric transfusion for any clinical or laboratory
28 signs of coagulopathy
29 GO TO NEXT PAGE »
1
Page 2 Hemorrhage 2
3
TREATMENT Task Actions 4
Normothermia • Warm room, use warm fluid, forced air, and blankets
5
Arterial Line • Consider arterial line placement for monitoring and
serial lab draws 6
Urine Output • Place foley. Urine output goal ≥ 0.5 mL/kg/hr 7
Labs • Monitor resuscitation adequacy with clinical stability 8
and serial labs: Hgb, platelets, coagulation, acid base
status, base deficit, electrolytes, lactate, TEG, Rotem 9
• Actively maintain normal calcium level
10
BLOOD PRODUCTS AND THERAPEUTIC ADJUNCTS
PRBC • Give if Hgb < 7 - 10 g/dL depending on hemodynamic 11

stability, coronary disease, and rate of blood loss
• Each unit should raise Hgb ~ 1g/dL or HCT ~ 3% 12
FFP • Give if INR or PTT > 1.5x normal 13
• Give FFP 10 - 15 mL/kg then recheck labs and continue 14
with 1:1 PRBC : FFP ratio
Platelets • Give if platelets < 50 - 100 K/uL and ongoing bleeding 15
• Each apheresis unit should raise platelet count 16
~50 K/uL
17
Cryo- • Give if fibrinogen < 80 - 100 mg/dL
precipitate (< 300 mg/dL peripartum) 18
• Each 10 units of cryoprecipitate should raise fibrinogen
level ~50 mg/dL 19
Fibrinogen • If cryoprecipitate unavailable: consider fibrinogen 20
Concentrate concentrate 0.5 - 1 g IV. May repeat to fibrinogen goal
• Each gram should raise fibrinogen level ~50 mg/dL
21
Tranexamic • Consider TXA in all major bleeding cases 22
Acid
• Give 1 g IV over 10 min then 1 g IV over 8 hours 23
Prothrombin • Consider PCC in patients with warfarin induced 24
Complex bleeding or persistent deranged INR (PT)
Concentrate 25
• Give 25 - 50 units/kg IV
Factor VIIa • Consider Factor VIIa if life-threatening, refractory 26
Concentrate coagulopathy
• Seek hematology or pharmacy advice for dosing 27
28
END
29
2
3 High Airway Pressure
4 Increased peak airway pressures > 5 cm H2O above baseline
or > 35 cm H2O
5
May be accompanied by:
6 Wheezing and upsloping CO2 waveform (if bronchospasm)
Increased EtCO2
7 Decreased tidal volumes
Hypotension (if air-trapping)
8
9
TREATMENT
Task Actions
Resources
11 • Call for help
12 Airway • 100% O2 10 - 15 L/min

• Confirm presence of CO2
13
• Evaluate capnography waveform:
14 • Upward slope suggests obstruction
15 • Curare cleft near end of expiratory phase suggests
insufficient neuromuscular blockade
16 • Starting at patient: inspect breathing circuit including
valves, connections, and sample line
17
Rule Out • Disconnect breathing circuit from ET tube or SGA/LMA to
18 Air Trapping rule out air-trapping (i.e. auto-PEEP)
19 Localize • During disconnect, squeeze reservoir bag.
Problem If pressure is:
20 • High (machine or circuit is obstructed):
21 Switch to self-inflating bag (Ambu)
connected to O2 source and gas sampling line
22 • Low or zero (problem is with the ET tube or lungs):
Reconnect anesthesia machine circuit
23
Optimize • Consider increasing anesthetic: e.g. propofol 20 mg IV
24 Compliance
• Consider additional neuromuscular blockade
25 • If abdominal insufflation: decrease or release pressure
26 • Evaluate patient position. If head down: consider level or

head-up positioning. If prone: consider turning supine
27 • If surgical retraction contributing: notify surgeon
28 • Check for shift in patient position
(e.g. slipping off prone position supports)
29
GO TO NEXT PAGE »
1
Page 2 High Airway Pressure 2
3
TREATMENT Task Actions
4
Manually • Manually ventilate using anesthesia machine to assess
Ventilate compliance 5
• Check and adjust adjustable pressure-limiting valve (APL) 6
Check for • Pass soft suction catheter to rule out kinked ET tube or
ET Tube thick secretions (i.e. mucous plug) 7
Obstruction
• Consider bronchoscopy to evaluate ET tube and airway 8
• If unable to clear ET tube obstruction: replace ET tube 9
Auscultate • If asymmetric:
Breath 10
• Rule out endobronchial intubation
Sounds
• Rule out pneumothorax 11
• If symmetric but abnormal breath sounds:
13
• If wheezing or decreased breath sounds: consider
bronchospasm treatment 14
See Bronchospasm #6
• If crackles: consider pulmonary edema treatment
15
16
RULE OUT
Potential Causes 17
ET tube or lungs: • Light anesthesia
• Abdominal compartment syndrome • Mucous plug 18
• Abdominal insufflation • Muscle tone 19
• Abnormal anatomy • Patient positioning
(e.g. kyphoscoliosis) 20
• Pleural effusion
• Airway foreign body 21
• Pneumothorax/hemothorax
• Airway tumor
• Anaphylaxis
• Pulmonary edema 23
See Anaphylaxis #5
• Thoracic insufflation
• Aspiration 24
• Bronchospasm Machine or breathing
circuit: 25
See Bronchospasm #6
• Chest wall rigidity
• Circuit obstruction 26
• Scavenger closed
• Kinked ET tube or circuit 27
• Ventilator valve malfunction
• Laryngospasm
28
END 29
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
This space is
18
19
20
21
22
23
24
25
26
27
28
29
1
High Spinal 2
After neuraxial anesthesia or analgesia: 3
Sensory or motor blockade higher or faster than expected
Upper extremity numbness or weakness (hand grip) 4
Dyspnea or apnea
Nausea or vomiting 5
Difficulty swallowing
Cardiovascular collapse: bradycardia and/or hypotension 6
Loss of consciousness
7
8
TREATMENT
Task Actions
Crisis • Inform team • Identify leader 9
Resources
• Call a code • Get code cart
10
Pulse • If no pulse: start CPR and see
Check Asystole/PEA #1 or VFIB/VTACH #4 11
Airway • 100% O2 10 - 15 L/min 12
• Support oxygenation and ventilation; intubate if necessary 13
as respiratory compromise may last several hours. Patient
may be conscious and need reassurance and an amnestic 14
agent, such as midazolam, to prevent awareness
15
Circulation • If severe bradycardia or hypotension:
epinephrine 10 - 100 mcg IV, increase as needed 16
• If mild bradycardia: consider atropine 0.5 - 1 mg or
glycopyrrolate 0.2 - 0.4 mg, but progress quickly to 17
epinephrine if needed. Phenylephrine unlikely to be
effective 18
Rapid • Give rapid IV bolus with pressure bag. May require 19
Preload several liters
20
• Raise both legs to increase preload
• Maintain neutral position. Head down position increases 21
venous return but increases already high spinal level
22
Pregnancy • Ensure left uterine displacement
Specific
• Call OB and Neonatology teams
23
Care
• Prepare for emergent or perimortem Cesarean 24
• Monitor fetal heart tones 25
26
RULE OUT
• If local anesthetic toxicity is possible: give lipid emulsion 20% rapidly and
See Local Anesthetic Toxicity #18 27
28
END 29
2
3 Hypertension
4 High systolic or diastolic blood pressure refractory to initial
intervention
5
TREATMENT
6 Task Actions
Resources
• Call for help • Consider pausing procedure
8
Airway • 100% O2 10 - 15 L/min
9
Check BP • Check arterial line transducer position; consider zeroing
10 Accuracy
• Check NIBP cuff position; cuff or cable compression
11
RULE OUT
Periop • Surgical stimulus: inspect surgical field

12 Causes
• Recent epinephrine (e.g. local anesthesia, pledgets) or
13 another vasopressor (e.g. vasopressin) given in surgical field
• Carotid or aortic clamping
14
• Full bladder / kinked urine catheter
15 • Hypercarbia
16 • Inadequate anesthesia or analgesia, including empty
vaporizer or failure to deliver IV anesthetic
17 • Inappropriate arterial line transducer height
18 • Medication error
19 • Pneumoperitoneum
• Prolonged tourniquet time
20
• Rebound hypertension in known hypertensive patient
21
TREATMENT
Task Actions
22
Treat • If acute self-limited cause (e.g. epinephrine): consider
23 Reversible waiting
Causes
24 • Treat reversible causes before giving
antihypertensive
25 • If treatable cause (e.g. tourniquet, full bladder):
treat cause
26
Temporize • Depending on clinical context and heart rate:
27
• Increase anesthetic depth
28 • Consider head up position
29
GO TO NEXT PAGE »
1
Page 2 Hypertension 2
3
4
Meds • Ensure functional IV; directly treat blood pressure:
• Labetalol 5 - 10 mg IV, wait 5 min for next dose 5
• Hydralazine 2 - 5 mg IV, wait 15 min for next dose 6
• Nitroglycerin 20 - 50 mcg IV, wait 3 min for next dose
7
• Nitroprusside 20 - 50 mcg IV, wait 3 min for next dose
• Infusion with carrier to maintain blood pressure control:
8
e.g. clevidipine infusion starting at 1 - 5 mg/hr 9
Arterial • If severe or sustained hypertension: consider placing
10
Access arterial line for monitoring and labs 11
Labs • Send samples for ABG, Hgb, electrolytes, lactate, troponin
12
ECG • Follow for signs of myocardial ischemia:
(e.g. ST changes, T-wave inversions, or new arrhythmias) 13
See Myocardial Ischemia #20
14
Team • Discuss patient condition with surgeon and team
Recap
• Discuss adjustments of surgical plan
15
Disposition • Arrange ICU care if vasoactive infusions or prolonged 16
arterial line blood pressure monitoring indicated
17
18
RULE OUT
Rare • Autonomic hyperreflexia: spinal cord injury above T6,

Causes painful stimuli below cord injury level, reflex bradycardia
• Ischemia: new arrhythmia, ST change or T-wave inversion
19
See Myocardial Ischemia #20 20
• Malignant hyperthermia: muscle rigidity; profound mixed
respiratory and metabolic acidosis 21
See Malignant Hyperthermia #19 22
• Neuroleptic malignant syndrome: medical history of
dopamine antagonist use, muscle rigidity, hyperthermia 23
• Pheochromocytoma: episodic, resistant to treatment 24
• Preeclampsia: pregnant, proteinuria, edema
25
• Raised ICP: dilated pupil(s), bradycardia, trauma
• Serotonin syndrome: hyperthermia, tachycardia, rigidity 26
• Stroke 27
• Thyroid storm: tachycardia, diaphoresis 28
END 29
2
3 Hypotension
4 Low blood pressure refractory to intervention or unclear cause
5
TREATMENT
Task Actions
6
Crisis • Inform team • Consider pausing procedure
7 Resources
• Call for help • Consider calling for code cart
8 Pulse and • Check for vital sign and EtCO2 abnormalities
Monitor
9 • If no pulse or abnormal rate or rhythm, consider:
Check
Asystole/PEA #1 Bradycardia #2
10
SVT #3 VFIB/VTACH #4
11
• Check arterial line, transducer position, and cycle NIBP
12 Inspect • Check for visible or concealed hemorrhage; consider FAST
Surgical
13 Field
See Hemorrhage #12
• Check surgical field for pressure on heart or great vessels
14
Early • Ensure functional IV or IO access; start rapid crystalloid
15 Actions or colloid bolus
16 • Consider head down position or leg elevation

Meds • Turn anesthetic down or off
17
• If ephedrine 5 - 20 mg IV or
18 phenylephrine 100 - 300 mcg IV is not effective:
consider epinephrine 10 - 50 mcg IV and/or
19 vasopressin 0.5 - 1 units IV. May repeat or start infusion
• Consider slow bolus of calcium chloride 1 g or
20 calcium gluconate 1 - 3 g
21 • Consider treating adrenal insufficiency: hydrocortisone
100 mg IV or methylprednisolone 125 mg IV
22 • Consider treating vasoplegia:
23 methylene blue 1.5 - 2 mg/kg over 20 min - 1 hour
Airway • 100% O2 10 - 15 L/min
24
Cardiac • Consider TEE / TTE to differentiate causes
25 Workup
• If persistent hypotension: consider ECMO or bypass
26 Access • Consider additional large bore IV access
27 • Consider arterial line placement
28 Labs • Check ABG, Hgb, Plt, glucose, calcium, potassium, lactate

Output • Place foley catheter and monitor urine output
29
GO TO NEXT PAGE »
1
Page 2 Hypotension 2
3
DIFFERENTIAL DIAGNOSIS Rule out rapidly lethal causes:
• Anaphylaxis • IVC compression: prone, obese, 4
See Anaphylaxis #5 pregnant, surgical manipulation
5
• Auto-PEEP: disconnect circuit • Local anesthetic toxicity
See High Airway Pressure #13 See Local Anes Toxicity #18 6
• Pneumoperitoneum or
• Cardiovascular: consider TEE / TTE to
pneumopericardium 7
evaluate volume status, LV/RV function,
valvular disease, LV outflow obstruction • Pneumothorax 8
See Embolism #9 • Cardiac tamponade
See Myocardial Ischemia #20 See Pneumothorax #22 9
See Right Heart Failure #24 • Vasodilators: check doses of 10
• Hemorrhage or concealed hemorrhage volatile/IV anesthetics and drips
See Hemorrhage #12 11
Explore Other Causes By Physiologic Differential: 12
• Blood Pressure = Systemic Vascular Resistance (SVR) x Cardiac Output (CO)
• Cardiac Output (CO) = Heart Rate (HR) x Stroke Volume (SV) 13
• Stroke Volume (SV) components: Preload, Inotropy, Afterload
14
Low SVR • Anaphylaxis • Shock (septic/spinal/neurogenic)
See Anaphylaxis #5 • Transfusion reaction 15
• Neuraxial block See Transfusion Reaction #25
16
See High Spinal #14 • Vasodilators
Low HR • Bradycardia/heart block • High spinal 17
• Vagal stimulus See High Spinal #14 18
Low • Auto-PEEP • Pericardial tamponade
Preload • Embolism e.g.air,clot,fat • Pneumothorax 19
See Embolism #9 See Pneumothorax #22 20
• Hypovolemia • Right heart failure
See Hemorrhage #12 See Right Heart Failure #24
21
• IVC compression • Vasodilators 22
Low • Acidosis • Local anesthetic toxicity
Inotropy 23
• Arrhythmias See Local Anes Toxicity #18
• Cardiomyopathy • Myocardial depressants 24
• Hypoxemia • Myocardial ischemia
25
See Hypoxemia #17 See Myocardial Ischemia #20
High • Stenotic valvular disease 26
Afterload • LVOT obstruction
27
Low Forward • Regurgitant valvular disease
Flow 28
END 29
2
3 Hypoxemia
4 Low SpO2 and/or PaO2 refractory to intervention or unclear cause
5
TREATMENT
Task Actions
6
7 Resources
• Call for help • Consider calling for code cart
8
Oxygenate • 100% O2 10 - 15 L/min
9 Check • Check gas analyzer to rule out low FiO2 or high N2O
Monitors
10 and Vitals
See Oxygen Failure #21
• Check SpO2 waveform, probe positioning, limb perfusion
11
• Check vitals: ECG, cycle NIBP, check pulse, airway pressure
12 • Check CO2 waveform, look for circuit disconnection
13 Initial ETT • Manually ventilate to check compliance
Check
14 • Consider using self-inflating (Ambu) bag with
non-machine O2 source (e.g. e-cylinder) or nothing
15 (room air) to rule out machine or oxygen supply
issue. Connect sample line and consider IV anesthetic
16 • Check ET tube position and auscultate breath sounds
17 See Bronchospasm #6
• Soft suction ET tube to assess secretions and patency
18
Recruit • Perform recruitment breaths
19 Alveoli
• Consider PEEP. If hypotensive: use caution
20 • Increase FRC: head up position, desufflate abdomen
21 Meds • If BP stable: deepen anesthetic with propofol or volatile

• If wheezing: albuterol 4 - 8 puffs MDI or
22 2.5 mg nebulized. If severe: epinephrine 5 - 10 mcg IV,
or ketamine 10 - 20 mg IV
23
• Consider additional neuromuscular blockade or reversal
24 Advanced • Fiberoptic bronchoscopy: confirm tracheal rings, check
Evaluation for endobronchial intubation or obstruction
25
• Lung ultrasound: check for pneumothorax, effusion
26 consolidation, interstitial edema
27 Access • Consider arterial line placement and ABG
X-Ray • Consider STAT portable chest x-ray
28
ECMO/CPB • If persistent: consider ECMO or bypass
29
GO TO NEXT PAGE »
1
Page 2 Hypoxemia 2
3
DIFFERENTIAL DIAGNOSIS Low FiO2: V/Q Mismatch:
• If gas analyzer reads low FiO2 Shunt = perfused, but not ventilated 4
despite “100% O2,” then likely O2 (less responsive to O2)
pipeline failure or crossover Dead space = ventilated, but not perfused
5
See Oxygen Failure #21 (more responsive to O2)
6
Hypoventilation: • Common causes:
• Aspiration 7
• Spontaneously breathing:
• Atelectasis
• Bronchospasm
• Bronchospasm 8
• Excess anesthetic
• High spinal See Bronchospasm #6
• See High Spinal #14 • Endobronchial intubation 9
• Laryngospasm • Mucus plug
• Obstructed airway
• One lung ventilation 10
• Pleural effusion
• Opioid
• Pain
• Pulmonary edema 11
• Rare but critical:
• Pulmonary edema
• Residual neuromuscular
• Anaphylaxis 12
blockade See Anaphylaxis #5
• Mechanically ventilated: • Embolism: e.g. air, clot, fat 13
• High pressure alarm: See Embolism #9
• Asynchronous breathing • Pneumothorax
14
• Bronchospasm
See Bronchospasm #6
• Right heart failure
• High peak airway pressure See Right Heart Failure #24 16
See High Airway Pressure • Severe hypotension
#13
See Hypotension #16 17
• Insufficient neuromuscular
blockade Increased O2 Demand: 18
• Obstructed or kinked ET tube • Iatrogenic hyperthermia
• Ventilator on manual, APL • Malignant hyperthermia 19
closed See Malignant Hyperthermia
• Low pressure alarm: #19 20
• ET tube dislodged or cuff tear • Neuroleptic Malignant Syndrome
• Circuit leak • Sepsis
21
• Low TV or RR setting • Thyrotoxicosis
• Ventilator on manual and 22
APL open SpO2 Artifact:
• Confirm with ABG 23
Diffusion abnormality: • Poor SpO2 waveform:
• Usually chronic lung disease • Cautery interference 24
Hemoglobinopathy: • Cold or poorly perfused digit
• Carboxyhemoglobin: • Light interference 25
SpO2 often normal • Probe malposition
• Methemoglobin: SpO2 ~85% • Dyes: 26
• If suspected, send lab co-oximetry • Blue nail polish
• Indigo carmine 27
• Methylene blue
28
END 29
2
3 Local Anesthetic Toxicity
4 Can present with any combination of:
5 Neurologic symptoms: Cardiac symptoms:

Seizures Cardiovascular collapse
6 Altered mental status Hypotension
Tinnitus Arrhythmia (e.g. ectopy, asystole,
7 Metallic taste bradycardia, VFIB, VTACH)
Perioral numbness
8
9
TREATMENT
Task Actions
10 Crisis • Inform team • Call for help
Resources
11 • Call for lipid emulsion 20% (IntralipidTM) STAT
• If unstable: consider early call for ECMO or bypass
12
Stop • Stop any local anesthetic injection or infusion
13 Triggers
14 CPR • If pulseless: start CPR. May require prolonged
CPR +/- ECMO
15 • 100% O2 10 - 15 L/min
16 • Start lipid emulsion, then intubate if indicated
17 Lipid • Bolus lipid emulsion 20%
Emulsion 100 mL IV over 2 - 3 min
18 (If < 70 kg: give 1.5 mL/kg IV bolus)
• Infuse lipid emulsion 20%
19 250 mL IV over 15 - 20 min
(If < 70kg: infuse 0.25 mL/kg/min for 20 min)
20
• If unstable: repeat bolus and double the infusion
21 until stable. Maximum lipid emulsion 20% dose:
12 mL/kg
22 • Once stable, continue infusion for at least 15 minutes
23 Post-event • Continue PACU/ICU-level monitoring for at least:
Care
24 • 2 hours after seizure
• 6 hours after hemodynamic instability
25
• 24 - 48 hours after cardiac arrest
26
Consult • For latest recommendations: http://www.asra.com
27 ASRA
Next page: Treatment depending on LAST presentation
28
1
Page 2 Local Anesthetic Toxicity 2
3
TREATMENT If Seizure:
4
Recovery • Place patient lateral and head down to prevent aspiration;
Position prevent falls and head injury 5
Meds • Give benzodiazepine to break seizure: midazolam 2 - 4 mg 6
IV. If refractory, give neuromuscular blockade: rocuronium
• If benzodiazepines not available and BP stable: give 7
propofol 20 mg IV. May repeat until seizure stops
8
Airway • Support breathing; intubate if appropriate
9
If Arrhythmia or Hypotension:
Rhythm • If persistent arrhythmia: give amiodarone 150 mg IV slowly
10
Meds over 10 - 15 min. Avoid calcium channel blockers, beta 11
blockers, local anesthetics, and any negative inotrope
Meds • Treat hypotension with low dose epinephrine: 12
start with 0.2 - 1 mcg/kg IV; avoid vasopressin
13
If Cardiac Arrest:
14
CPR • Rate 100 - 120 compressions/min
• Depth ≥ 5 cm; allow chest recoil; consider backboard 15
• Keep EtCO2 > 10 mmHg and diastolic BP > 20 mmHg 16
• Rotate compressors with rhythm check every 2 min 17
EtCO2, spontaneous arterial waveform, rhythm change) 18
• Place defib pads 19
Airway • If mask ventilation: ratio 30 compressions to 2 breaths
20
• If airway secured: 10 breaths/min; tidal volume 6 - 7 mL/kg
21
Defib • If VFIB or unstable VTACH: immediately defibrillate
120-200 J biphasic or 360 J monophasic 22
• Resume CPR immediately
23
• Reasonable to increase energy of repeat shock every
2 min 24
Meds • Give LOW DOSE epinephrine: start at 0.2 - 1 mcg/kg IV 25
• If VFIB/VTACH unresponsive to defibrillation:
amiodarone 300 mg IV push. 26
May redose amiodarone 150 mg IV push. Avoid lidocaine
27
ECMO/CPB • If prolonged need for CPR: consider ECMO or bypass
28
END 29
2
3 Malignant Hyperthermia
4 May be Mixed (metabolic and respiratory) acidosis
early signs: Increased EtCO2 , heart rate, respiratory rate
5 Hyperthermia
Masseter spasm/trismus
6 Muscle rigidity without shivering, tremor, or clonus
7 May be Myoglobinuria
late signs: Arrhythmias including hyperkalemic cardiac arrest
8
9
TREATMENT
Task Actions
10 Crisis • Inform team • Get MH cart with dantrolene

Resources
• Call for help • Consider pausing procedure
11
Stop MH • Stop volatile anesthetic and succinylcholine
12 Triggers
• Do NOT change machine or circuit
13 • 100% O2 10 - 15 L/min
14 • If easily available, add charcoal filters to breathing circuit
Airway • Maximize minute ventilation. Mechanical ventilation is
15 preferred. Avoid air-trapping
16 Give • Initial dantrolene dose is 2.5 mg/kg IV. Formulations:
Antidote
17 Rapidly
• Concentrated, easily soluble formulation:
Ryanodex: Dilute one 250 mg vial in
18 5 mL preservative-free sterile water.
70 kg patient dose: 175 mg = 3.5 mL
19 • Non-concentrated formulation:
Dantrium or Revonto: Assign several people to
20 prepare. Dilute each 20 mg vial in
60 mL preservative-free sterile water.
21 70 kg patient dose: 175 mg = 9 VIALS
22 • Repeat dantrolene 2.5 mg/kg every 5 min until hypercarbia
and rigidity are resolved and temperature is not increasing.
23 May need > 10 mg/kg
24 Team • If appropriate, stop procedure
Recap
• Give non-triggering maintenance anesthetic or
25 sedation (e.g. propofol, benzodiazepine, opioid)
26
RULE OUT
• CO2 insufflation • Illicit stimulants • Pheochromocytoma

27 • Light anesthesia • Serotonin syndrome
• Hypoventilation
28 • Hypoxemia • Neuroleptic • Thyroid storm
malignant syndrome
• Iatrogenic warming
29
GO TO NEXT PAGE »
1
Page 2 Malignant Hyperthermia 2
3
4
Treat • Calcium chloride 10 mg/kg IV, max 2 g
Hyper- 5
• Regular insulin 5 - 10 units IV with dextrose/D50 1 amp IV
K+
(25 g); monitor glucose 6
• Albuterol 8 - 12 puffs MDI or 2.5 mg nebulized
7
• Sodium bicarbonate: 0.5 amp (25 mL) at a time; maintain
minute ventilation to exhale additional CO2 produced 8
• If severe: consider emergent dialysis
9
Treat • Treat arrhythmias with amiodarone 150 mg IV over 10 - 15
Rhythm min, esmolol 10 - 20 mg IV bolus followed by infusion, 10
or magnesium sulfate 1 g IV; avoid calcium channel
blockers and sodium channel blockers (e.g. verapamil, 11
diltiazem, lidocaine, procainamide)
12
• If unstable, call for code cart and also see ACLS event:
Asystole/PEA #1 Bradycardia #2 SVT #3 VFIB/VTACH #4 13
Active • If core temperature > 38° C: actively cool with cold IV fluid
Cooling (20 - 30 ml/kg normal saline or plasmalyte)
14
• Additional cooling: Stop active warming; set forced air on 15
ambient; cool room; put ice packs on head, axilla, and groin;
wet skin; cool lavage if open abdomen or peritoneal catheter 16
(avoid bladder lavage to preserve urine output measurement)
17
Access • Consider additional IV access and arterial line placement
18
Labs • Send ABG, K+, CK, urine myoglobin, coagulation panel, lactate
Urine • Place Foley catheter and monitor urine output: 19
Output goal 1 - 2 mL/kg/hr; consider IV fluids and diuretics
20
MH • Call 24/7 for expert consultation: 1-800-MH-HYPER
Hotline (1-800-644-9737) http://www.mhaus.org 21
ICU • Transport with experienced personnel after stabilization 22
Care
• Mechanical ventilation commonly required because
20% of MH events relapse within 16 hours. Extubate 23
once metabolically and hemodynamically stable
24
• Continue dantrolene: 1 mg/kg bolus every 4 - 6 hours
or 0.25 mg/kg/hr infusion for up to 24 hours 25
• Monitor for rhabdo, DIC, hyperK+, compartment syndrome 26
Post • Complete AMRA (Adverse Metabolic Reaction to Anesthesia):
Event https://anest.ufl.edu/namhr/ 27
• Test genes: https://www.mhaus.org/testing/genetic-testing/ 28
END 29
2
3 Myocardial Ischemia
4 ST segment depression or elevation
T-wave inversion
5 Arrhythmias: conduction abnormality (e.g. new LBBB), irregular
rhythm, tachycardia, bradycardia, or hypotension
6 Regional wall motion abnormality
New or worsened mitral regurgitation
7 Chest pain, dyspnea, nausea, or diaphoresis
8
TREATMENT
Task Actions
9
Crisis • Inform team • Get code cart
10 Resources
• Call for Cardiac Anesthesiology or Cardiology help
11 Airway • Set supplemental O2 to maintain SpO2 ≥ 95%
12 Monitor • Get 12-lead ECG; verify ECG leads in correct position
13 • Expand ECG monitor view to leads II, V5, and others
• Prepare for arrhythmia: apply defibrillator pads and leads
14
Team • Pause or stop procedure if possible
15 Recap
• Discuss bleeding and risk of anticoagulation
16 Meds • Treat any tachycardia, bradycardia, hypotension or
hypertension
17
18 • Discuss with surgeon the explicit contraindications and
benefits of dual antiplatelet therapy and anticoagulation:
19
• Aspirin 160 - 325 mg PO, nasogastric, or rectal
20 • P2Y12 ADP receptor inhibitor:
e.g. clopidogrel 300 mg PO, prasugrel 60 mg PO,
21 or ticagrelor 180mg PO
22 • Heparin infusion
23 • Treat pain with narcotics: fentanyl or morphine
• Consider nitroglycerin paste or infusion. Avoid if
24 hypotensive
25 • Consider beta blocker to slow heart rate and allow
coronary perfusion. Esmolol preferred because it can be
26 stopped if it precipitates CHF. Avoid if bradycardia, 1st or
2nd degree heart block, or hypotensive
27 • If acute pulmonary edema, consider diuresis:
furosemide 10 - 40 mg IV. Monitor urine output
28
1
Page 2 Myocardial Ischemia 2
3
4
Cardiology • If STEMI: consult Cardiology for possible emergent
Consult coronary revascularization or fibrinolysis 5
• Consider emergent transfer to Cath Lab or PCI Center 6
Access • Consider additional IV access
7
• Place arterial line for monitoring and labs
• Consider central line placement 8
Labs • Send ABG, electrolytes, Hgb, troponin, coagulation panel 9
ECHO • Consider TEE / TTE to assess volume status, wall motion, 10
ventricular function, and valvular disease
• Use contractility to guide vasoactive infusion 11
choice
12
ECMO/CPB • Consider ECMO, cardiopulmonary bypass, or intra-aortic
balloon pump 13
Disposition • May require ICU care 14
END 15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
This space is
18
19
20
21
22
23
24
25
26
27
28
29
1
Oxygen Failure 2
Audible or visible O2 failure alarm 3
Inappropriately low FiO2 value on gas analyzer
Flow meter reads abnormally low 4
5
TREATMENT
Task Actions
6
Resources 7
• Call for help • Get code cart with O2 cylinder
Non-Machine • Disconnect patient from machine and ventilate with 8
Ventilation self-inflating bag (Ambu) on room air
9
• Do NOT connect self-inflating bag (Ambu) to
machine auxiliary oxygen because it has the same 10
faulty O2 source
11
• Consider assigning capable person to manual
ventilation 12
Pulse Check • If no pulse: start CPR and
13
See Asystole/PEA #1
Non-Machine • Attach self-inflating bag (Ambu) to: 14
O2 Source
• Nozzle on transport O2 e-cylinder 15
OR
• Nothing (continue ventilating on room air)
16
Attach Gas • Connect gas sampling line with elbow connector 17
Sampling between patient and self-inflating bag (Ambu)
Line 18
• Verify correct airway placement with CO2
• Verify patient is receiving expected O2 concentration on 19
gas analyzer: 100% if on e-cylinder, 21% if on room air 20
Low Pressure • Confirm orogastric/nasogastric tube not in trachea
21
Non-Machine • Maintain anesthesia with IV medications
Anesthetic
• Turn off volatile anesthetic
22
Conserve O2 • Use lowest possible fresh gas flow and FiO2 23
Report • Inform Charge Nurse, Anesthesia Lead, and all ORs 24
Problem
• Contact bio-engineering to: 25
• Report problem; ask for help with diagnostics and
repair while you focus on patient care 26
• Find out if issue is system wide 27
Team Recap • Discuss plan for this patient and OR schedule
28
END 29
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
This space is
18
19
20
21
22
23
24
25
26
27
28
29
1
Pneumothorax 2
Increased peak inspiratory pressures (PIPs) 3
Tachycardia
Hypotension or hypoxemia 4
Decreased or asymmetric breath sounds
Hyperresonance to chest percussion 5
Tracheal deviation (late sign)
Increased JVD/CVP
6
Decompensation upon initiation of mechanical ventilation or central
line placement
7
Higher incidence in trauma, COPD, cardiothoracic, and upper
abdominal surgery patients
8
9
TREATMENT
Task Actions
10
Resources 11
• Call Trauma, General, or Cardiothoracic Surgery STAT
12
Airway • 100% O2 10 - 15 L/min 13
Fast Checks • Exclude endobronchial intubation: 14
listen to breath sounds and check ET tube depth
15
• Exclude ET tube obstruction: pass soft suction catheter
• Exclude auto-PEEP: briefly disconnect breathing circuit 16
Decompress • If unstable and chest tube is not immediately available: 17
Emergently
• Place 14 (or 16) gauge IV catheter in
4th or 5th intercostal space between anterior 18
and mid-AXILLARY line per ATLS 2018 (may hear
a whoosh of air if under tension)
19
• Leave IV catheter in place while awaiting chest tube 20
• Have appropriate personnel place chest tube 21
Advanced • Fiberoptic bronchoscopy to evaluate for endobronchial
Checks intubation, ET tube obstruction 22
• Lung ultrasound: 23
Lung sliding (normal) vs. lung point (pneumothorax)
seashore sign (normal) vs. barcode (pneumothorax) 24
• Consider STAT portable chest x-ray; do not delay 25
treatment
Disposition • Consider ICU care for respiratory monitoring and 26
chest tube management
27
END 28
29
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
This space is
18
19
20
21
22
23
24
25
26
27
28
29
1
Power Failure 2
Sudden darkness 3
Loss of electrically powered equipment
4
5
TREATMENT
Task Actions
Crisis • Inform team 6
Resources
• Call for help 7
Obtain • Use any available light sources:
Light laryngoscope, cell phone, flashlight, ambient light from 8
Source opening door or shades 9
Confirm • Ventilator may have temporary (~30 minute) battery.
Ventilator Consider utilizing transport ventilator 10
• If ventilator is not working: 11
• Consider converting to spontaneous ventilation
12
• Ventilate with self-inflating bag (Ambu)
• Convert to TIVA with battery operated pump or 13
dial-a-flow / manual flow regulator
14
Confirm • If monitors fail:
Monitor 15
• Assign person for continuous pulse check
• Perform manual blood pressure measurement 16
• Use transport monitor or defibrillator monitor 17
Confirm • If power failure affects oxygen supply or alarms: 18
Backup O2 See Oxygen Failure #21
Confirm • Ensure generator-supplied emergency power outlets are
19
Backup functional 20
Power
• Connect all life-sustaining equipment to emergency outlets
21
• Disconnect non-life-sustaining equipment from emergency
outlets 22
Report • Inform Charge Nurse, Anesthesia Lead, and all ORs
Problem
23
• Call bio-engineering to:
• Report problem; ask for help with diagnostics and
24
repair while you focus on patient care: if only in your 25
OR, suggest checking if circuit breaker was tripped
• Find out if issue is system wide 26
Team • Discuss with surgeon and team the implications of power 27
Recap failure for this patient and OR schedule
28
END 29
2
3 Right Heart Failure
4 Dyspnea, dizziness, edema, right upper abdominal discomfort
Hypotension
5 ECG with RV strain
TEE / TTE with dilated RV, reduced RV function
6 Flattening of interventricular septum
Decompensation after hypoxemia, hypercarbia, or acidosis
7 Decompensation upon initiation of mechanical ventilation
8
TREATMENT
Task Actions
9
Crisis • Inform team
10 Resources
• Call for a pulmonary vasodilator such as nitric oxide
(e.g. INOmax) or epoprostenol (e.g. Flolan, Veletri)
11
• Call for code cart and TEE / TTE
12 • Call for Cardiac Anesthesiology, Cardiology, or ICU help
13 Airway • 100% O2 10 - 15 L/min
14 • Decrease tidal volume and increase respiratory rate to
lower intrathoracic pressure and avoid hypercarbia.
15 Avoid breath stacking
• Minimize PEEP if tolerated; avoid hypoxemia
16
ECHO • Assess key TEE / TTE findings:
17 • Decreased RV function:
Tricuspid Annular Plane Systolic Excursion (TAPSE):
18 severely reduced < 6mm; normal 16-20 mm
19 • RV volume/pressure overload:
Flattened interventricular septum makes left ventricle
20 appear D-shaped
21 • RV dilation and/or hypertrophy
• Underfilled LV despite adequate preload
22
RULE OUT
23 Consider Life-Threatening Causes of RV Failure
24 • Cardiac tamponade: perform emergent pericardiocentesis

• Protamine: stop administration
25 • Embolism: e.g. air, clot, fat
See Embolism #9
26
• RV infarction
27 See Myocardial Ischemia #20
28 • Tension pneumothorax
See Pneumothorax #22
29
GO TO NEXT PAGE »
1
Page 2 Right Heart Failure 2
3
4
ECMO/CPB • If significant instability: consider ECMO or
cardiopulmonary bypass 5
Decrease RV • Offload RV by decreasing pulmonary vascular 6
Afterload resistance (PVR):
• Give inhaled prostacyclin derivatives, 7
inhaled nitric oxide, or intravenous pulmonary 8
vasodilators
• Avoid hypoxemia, hypercarbia, acidosis, or 9
excessive intrathoracic pressure
10
Maintain RV • Avoid hypotension to maintain myocardial perfusion
Contractility
• If decreased RV contractility:
11
consider epinephrine 12
• If normal RV contractility:
consider vasopressin or norepinephrine 13
See Infusion List #29 14
• If refractory hypotension:
consider intra-aortic balloon pump (IABP) to 15
maintain coronary perfusion
16
Maintain • RV overload is more dangerous than mild
Normal RV hypovolemia 17
Volume
• RV overload suggested by CVP > 20mmHg and/or 18
Status
SvO2 < 65%
• If RV overload: consider diuresis and 19
seek expert advice
20
• If RV under-filled: careful volume replacement with
blood or crystalloid per HCT 21
Maintain • Avoid bradycardia or extreme tachycardia to maintain 22
Normal Sinus cardiac output
Rhythm 23
• Identify and treat electrolyte abnormalities
• Maintain atrial kick to augment cardiac output 24
• If irregular rhythm:
25
See SVT #3
26
END
27
28
29
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
This space is
18
19
20
21
22
23
24
25
26
27
28
29
1
Transfusion Reaction 2
Hemolytic Reaction: Febrile Reaction: Anaphylactic Reaction: 3
Fever Fever Hypotension
Back/flank pain Chills Urticaria 4
Tachycardia Rigors Other rash
Tachypnea Headache Wheezing 5
Hypotension Vomiting Tachycardia
Dark urine 6
Oozing or DIC
7
8
TREATMENT
Task Actions
Stop • Stop transfusion(s) 9
Transfusion
• Retain blood product bag(s) 10
Resources 11
• Call for help • Call for code cart
12
• Consider pausing procedure
Airway • 100% O2 10 - 15 L/min
13
• If no ET tube in place: consider intubation 14
Circulation • Consider IV fluid bolus 15
• If hypotensive:
16
• Turn anesthetic down or off
• Treat with vasopressor bolus (e.g. phenylephrine, 17
ephedrine)
18
• If severe: give epinephrine 10 - 100 mcg IV
and/or vasopressin 0.5 - 1 units IV 19
Blood Bank • Send appropriate labs and return units per local protocol 20
Specific • Hemolytic Reaction: monitor for signs of DIC; maintain
Reaction urine output with IV fluids, diuretics
21
Treatments 22
• Febrile Reaction: treat with antipyretic
acetaminophen 1000 mg IV; rule out hemolysis;
rule out bacterial contamination 23
• Anaphylactic Reaction: give epinephrine bolus and 24
then infusion. Consider steroid:
dexamethasone 4 - 8 mg IV or hydrocortisone 100 mg 25
and antihistamine: diphenhydramine 25 - 50 mg IV and
famotidine 20 mg IV 26
See Anaphylaxis #5
27
Disposition • May require ICU care
28
END
29
2
3 Trauma
4 Blunt force or penetrating injury to major organs
5
TREATMENT - TRAUMA BAY
Task Actions
6
Crisis • Call trauma code • Activate trauma operating room
7 Resources
• Activate massive transfusion protocol (MTP)
8 On • All team members state name and role. Use clear, closed-
Arrival to loop communication; record events
9 Trauma
• Check pulse. If no pulse: start ACLS while transfusing
Bay
10 and performing primary survey to find and treat
cause
11 • Place standard monitors and obtain large-bore IV access
12 • Maintain c-spine precautions with all movement
13 Primary • Airway and Breathing:

Survey
• Evaluate airway, ensure oxygenation and ventilation
14
• Intubate in indicated. Recommend RSI with video
15 laryngoscopy, in-line stabilization, and capnography.
If hypotensive: modify or GCS
16 eliminate induction medication. Eye opening:
If indicated, surgical airway 4 - Spontaneous
17 • Treat pneumo or hemothorax 3 - To speech
with emergent chest tubes 2 - To pain
18 1 - None
• Circulation:
19 • Control external hemorrhage.
Verbal response:
5 - Oriented
20 Transfusion preferred over crystalloid 4 - Confused

bolus. Do FAST: Focused Assessment 3 - Inappropriate
21 with Sonography for Trauma words

2 - Sounds
• Disability:
22 1 - None
• Assess level of consciousness, Motor response:
23 pupils, glucose, and 6 - Obeys
Glasgow Coma Scale (GCS), on right 5 - Localizes to pain
24 • Exposure:
4 - Flexion to pain
3 - Abnormal flexion
25 • Fully expose to assess injury then 2 - Abnormal extension
cover to prevent hypothermia 1 - None
26
Secondary • AMPLE History: Allergies, Meds, Past medical history, Last
27 Survey meal, Events leading to injury
• AT MIST: Age, Time of injury, Mechanism of injury, Injuries
28 sustained, Systemic review, Treatments
29 • Head-to-toe physical exam and radiologic evaluation
GO TO NEXT PAGE »
1
Page 2 Trauma 2
3
TREATMENT - TRAUMA OR Task Actions
4
Trauma • Warm OR to > 25° C (77° F) to maintain normothermia
OR Setup 5
• Setup: machine, suction, monitors, airway (video
(Prep in
laryngoscope and surgical airway), IV and IO kits, rapid 6
infusion device, ultrasound machine, code cart, invasive
advance
and
monitoring equipment (e.g. arterial line, CVP), cell saver 7
check • Meds: e.g. midazolam, ketamine, propofol, etomidate,
before scopolamine, succinylcholine, rocuronium, epinephrine, 8
patient vasopressin, ephedrine, phenylephrine, calcium, antibiotics
arrival) 9
• Check: crystalloid, colloid, and blood products (MTP)
10
Induction • Place standard ASA monitors and preoxygenate
and
• If patient conscious: briefly reassure them 11
Airway
• Discuss among team (e.g. Anesthesiology, Surgery, 12
Nursing, others) timing and order of priorities including IV
and arterial access, inducing anesthesia, securing airway, 13
hemorrhage resuscitation, and incision
• Perform RSI with c-spine precautions
14
• Place additional IVs and arterial line 15
• If stable: anesthetic maintenance with volatile anesthetic. 16
If unstable, maintenance with benzodiazepine or ketamine
Temporize • If severe instability: inform surgeon; discuss 17
temporizing measures (e.g. packing, aortic compression,
aortic crossclamp, thrombin, fibrin glue, REBOA)
18
Transfuse • Based on clinical picture: transfuse with ratio of 19
1-2 PRBC : 1 FFP : 1 Platelet pack
20
• Coagulopathy may require cryo, fibrinogen, calcium, TXA
Traumatic • Maintain CPP while decreasing ICP: MAP ≥ 80, SBP ≥
21
Brain 100 mmHg, SpO2 ≥ 90%, EtCO2 35 - 40 mmHg, mannitol or 22
Injury hypertonic saline, head up position, and burst suppression
Labs • Crossmatch, serial ABG, lytes, lactate, coags 23
Meds • If < 3 hours since injury give tranexamic acid (TXA): 24
1g IV over 10 min, then 1g every 8 hrs
25
• Give calcium for coagulation and blood pressure
• Treat hyperkalemia: calcium chloride 1 g IV; sodium 26
bicarbonate 1 amp IV (50 mEq); regular insulin 5 - 10 units
IV with dextrose/D50 1 amp IV (25 g) 27
Post Event • ICU care for continued resuscitation 28
END 29
2
3
4CRISIS RESOURCE MANAGEMENT
5
6
7
8
Call for
9
Designate Help Early Anticipate
10
Leadership and Plan
11
12
13 Establish Know the
Role Clarity Environment
CRM
14
15
16
17
Distribute
the
KEY Use All
Available
18
19
Workload POINTS Information
20
Allocate
21 Communicate
Attention
Effectively
22 Wisely
Use
23 Mobilize
Cognitive
24 Resources
Aids
25
26
27
28
29 ©2008 Diagram: S. Goldhaber-Fiebert, K. McCowan, K. Harrison, R. Fanning, S. Howard, D. Gaba
1
2
CRISIS RESOURCE MANAGEMENT 3
4
Call for Help Early
• Call for help early enough to make a difference
5
• Err on the side of getting more help
• Mobilize early personnel with special skills if they may be needed 6
7
Designate Leadership Anticipate and Plan 8
• Establish clear leadership • Plan & prepare for high work-load periods
• Inform team members who is in charge during low work-load periods 9
• 'Followers' should be active in asking who • Know where you are likely headed during
is leading the crisis and make backup plans early 10
11
Know the Environment
• Maintain situational awareness 12
• Know how things work and where things are
Establish Role Clarity • Be aware of strengths and vulnerabilities of 13
environment
• Determine who will do what
• Assign areas of responsibility appropriate
14
to knowledge, skills, and training Use All Available Information 15
• Active followers may offer specific roles
• Monitor multiple streams of data and
information 16
• Check and cross check information
17
Distribute the Workload Allocate Attention Wisely 18
• Assign specific tasks to team members • Eliminate or reduce distractions 19
according to their abilities • Monitor for task saturation & data overload
• Revise the distribution if there is task
overload or failure
•
•
Avoid getting fixated
Recruit others to help w/ monitoring
20
21
Mobilize Resources
22
• Activate all helpful resources including
equipment and additional personnel
23
Communicate Effectively
• Command and request clearly 24
• Seek confirmation of request (close the loop)
• Avoid “thin air” statements Use Cognitive Aids 25
• Foster input and atmosphere of open
information exchange among all personnel • Be familiar with content, format, and
location
26
• Support the effective use of cognitive aids
27
©2008 Diagram: S. Goldhaber-Fiebert, K. McCowan, K. Harrison, R. Fanning, S. Howard, D. Gaba
28
29
2
3 Emergency Manual V4 - Design Overview
4
• ACLS events in red and listed
5 Asystole / PEA ..................
Bradycardia . . . . . . . . . . . . . . . . . . . . .
1
2 first
ACLS
SVT - Unstable and Stable . . . . . 3
6 VFIB / VTACH . . . . . . . . . . . . . . . . . . . . 4 • Combined event for
Anaphylaxis . . . . . . . . . . . . . . . . . . . . . 5
Unstable and Stable SVT
EMERGENCY
Cognitive Aids for Perioperative Crises - V4 2021
7 Bronchospasm ................. 6
Stanford Anesthesia Cognitive Aid Program
E
MANUAL Delayed Emergence . . . . . . . . . . . . 7
Difficult Airway / Cric . . . . . . . . . . 8
8 Embolism - Pulmonary . . . . . . . . . 9 • Other events in gray and listed
PL Fire - Airway . . . . . . . . . . . . . . . . . . . . . 10
alphabetically for easy access
9 Fire - Non-Airway . . . . . . . . . . . . . . . 11
Hemorrhage .................... 12
• Content updated for all events
10
High Airway Pressure . . . . . . . . . . 13
after in-depth literature review
OTHER EVENTS
High Spinal . . . . . . . . . . . . . . . . . . . . . . 14
15
Hypertension
• New events:
...................
11
M
Hypotension 16
Hypertension, High Airway
....................
Hypoxemia . . . . . . . . . . . . . . . . . . . . . . 17
Local Anesthetic Toxicity 18 Pressure, Right Heart Failure,
12
.....
Malignant Hyperthermia ..... 19 Trauma

Myocardial Ischemia 20
SA
..........
13 Oxygen Failure ................. 21 • Combined event for multiple

Pneumothorax ................. 22
Embolism etiologies
Power Failure . . . . . . . . . . . . . . . . . . . 23
14 Right Heart Failure . . . . . . . . . . . . . 24
Transfusion Reaction . . . . . . . . . . 25
• Important resources in teal:
15 Trauma .......................... 26
Crisis Resource Management
RESOURCES
Crisis Resource Management . 27

Cognitive Aid Information 28
(CRM), Cognitive Aid
16
....
Phone List (Back Cover) Infusion List 29

Information, and Infusion List
....................
17 2
3 Embolism - Pulmonary • Each event title is followed by
18 4
5
Sudden decrease in EtCO2, BP, or SpO2
Sudden increase in central venous pressure
Dyspnea, respiratory distress, or cough in awake patient
potential signs and symptoms
Increased risk in long bone orthopedic surgery, pregnancy, cancer
so you know if you are on the
19
6 (especially renal tumor), high BMI, laparoscopic surgery, or surgical site
7
above level of the heart
right track
TREATMENT
8 Task Actions
20
E

Resources
10
• Blue “Treatment” boxes list
21
• Consider terminating procedure
11
critical tasks and actions in order
PL
Pulse Check • If no pulse: start CPR, check rhythm, and follow

12 appropriate algorithm
See Asystole/PEA #1 VFIB/VTACH #4 of importance, starting with
22 13
14 Airway • 100% O2 10 - 15 L/min Crisis Resource Management
15
Circulation • Turn off volatile anesthetic and vasodilating drips
(CRM) key points
23 16
• Give IV vasopressor bolus to support circulation
• Consider rapid fluid bolus
• Can be used during a crisis, to
M
17 Evaluate • If unstable or RV function decreased on TEE / TTE, use
24 anticipate and plan, for teaching,

Right Heart medication and diuresis to:
18 • Maintain sinus rhythm
19 • Maintain normal RV volume status and for post-event debriefing
25 20 • Maintain RV contractility
• “Task” categories with “Actions”

SA
• Decrease RV afterload
21
to be completed in order or
26
22 ECMO/CPB • If severe decompensation: consider ECMO or
23
cardiopulmonary bypass
sampled for specific information
RULE OUT
24 Consider other causes:
27 25
• Anaphylaxis
See Anaphylaxis # 5
• Distributive shock
• Hypovolemia
• “See Event #” highlights help you
26 • Bone cement implantation syndrome • Myocardial ischemia consider other relevant events
28
• Bronchospasm See Myocardial Ischemia #20
27 See Bronchospasm #6 • Pneumothorax
28 • Cardiac tamponade See Pneumothorax #22
• Cardiogenic shock • Pulmonary edema
29 29
GO TO NEXT PAGE »
• Gray boxes assist with diagnosis
or prevention tips
1
Emergency Manual V4 - Use and Implementation 2
3
Use: Recent research suggests that Emergency Manual (EM) use improves teamwork, facilitates
coordination, decreases stress, and enables delivery of better patient care.1 The Stanford EM, and other 4
similar tools, are used effectively in both clinical and educational settings:
Clinical: 5
• Pre-event for ‘just in time’ review for at-risk patients
6
• During event for crisis management
• Post-event for team debriefing 7
Educational:
• Self-review
8
• 1:1 or small group teaching 9
• Studying for oral exams
• During simulation cases and debrief sessions 10
We welcome your feedback and continuously learn from our community of users. 11
Implementation: These websites include a number of tips and free resources to support EM
implementation by your interprofessional team: 12
• Stanford EM - https://emergencymanual.stanford.edu/
Download the EM in English or another language, find implementation tips, and learn more 13
• Emergency Manual Implementation Collaborative (EMIC) - https://www.emergencymanuals.org/
14
• EM Implementation Toolkit - https://www.implementingemergencychecklists.org
This resource-rich guide, developed with Ariadne Labs, includes videos you can use or adapt, and
other training materials.
15
Stanford EM Formats: 16
• Large (8 ½ x 11”) hanging printed version (most popular), with or without event number tabs*
• Small (4 ¼ x 5 ½”) printed pocket version* 17
• PDF with hyperlinks (accessible on a computer, mobile device, or an electronic health record) 18
• E-book
*Our printed versions are operating room safe (wipeable, and MRI-safe). You can use any 19
printer you choose. See our website for information about our printer.
20
EM Customization - See our website for templates to customize for your setting:
• Infusion List (inside back cover) 21
• Phone List (outside back cover)
EM Training:
22
• EM Reader: reads aloud to team/leader to interactively ensure vital actions are performed, 23
medication doses correct, diagnoses considered, find specific desired information, while
allowing leader to maintain situational awareness and team communication.2
24
• Train team members to ask empowering questions: Would you like me to get/read the
emergency manual? Which event in the emergency manual are we dealing with? These can help 25
the leader remember the EM is available and can trigger its use. In our experience, leaders often
answer, “Yes,” and had forgotten about the EM due to the stress of the crisis. 26
1. Goldhaber-Fiebert SN, Howard SK, Gaba DM, et al. Clinical Uses and Impacts of Emergency Manuals During Perioperative
Crises. Anesth Analg. 2020 Dec;131(6):1815-1826. 27
2. Burden AR, et al. Does every code need a “reader?” Improvement of rare event management with a cognitive aid “reader”
during a simulated emergency: a pilot study. Simul Healthc. 2012 Feb;7(1):1-9. 28
29
2
3 Emergency Manual V4 - Publication Details
4
Stanford Anesthesia Cognitive Aid Program (SACAP) EM V4 Team:
5 Ellile Sultan, MD
Amanda Burden, MD
6 Barbara K. Burian, PhD
Naola S. Austin, MD
7 Kyle Harrison, MD
Sara Goldhaber-Fiebert, MD
8 Steven K. Howard, MD
David M. Gaba, MD
9
Summer Reid, BA (Administrative Associate)
10 Acknowledgements: Iterative simulation testing and integration of feedback from clinical uses of
V3 were integral to the development of V4. Meredith Hutton MD and Vladimir Nekhendzy MD made
11 author-level contributions to content and usability of the Difficult Airway / Cric event. We appreciate the
leadership, faculty, trainees, and staff at Stanford for their support of the development, implementation,
12 and improvement of this emergency manual over the past decade. Many individuals contributed over
the years. For this version, we especially appreciate the detailed reviews of content, design, and usability,
13 by 38 global expert physicians from 16 institutions and 8 countries. For more information on current
and past contributions, please visit our website: https://emergencymanual.stanford.edu/
14 References: Citations are not written on each event given usability priorities, but you can visit our
website if interested in relevant content literature. We strive to integrate the most pertinent clinical
15 information from published literature and clinical practice guidelines.
16 Citation: Stanford Anesthesia Cognitive Aid Program,* Emergency Manual: Cognitive aids for
perioperative crises, Version 4, 2021. See http://emergencymanual.stanford.edu for latest version.
Creative Commons BY-NC-ND (https://creativecommons.org/licenses/by-nc-nd/4.0/legalcode).
17 *Goldhaber-Fiebert SN, Austin N, Sultan E, Burian BK, Burden A, Howard SK, Gaba DM, Harrison TK.
18 Local Modifications and Creative Commons Licensing: Research supports that local customization
of cognitive aids is helpful for many reasons. We allow all needed modifications for use at your local
19 institution, without further permissions. You should keep original authorship attribution and add
‘Adapted By ___.’ For more than minor PDF modifications or local phone list for back cover, we suggest
requesting our original InDesign file: Email EMadminanes@lists.stanford.edu. We are not responsible for
20 any errors introduced and caution that there are usability cons to adding too much information. See this
review for an overview of effective cognitive aid design.1 No derivatives may be shared beyond local use
21 without explicit permission (e.g. translations or hospital systems that contact us first), and all use must be
non-commercial. We use Creative Commons 4.0 International Licensing, With Attribution,
22 Non-Commercial, and No Derivatives; See details at https://creativecommons.org/licenses/by-nc-nd/4.0/
Disclaimers: The material in this Manual is not intended to be a substitute for sound medical
23 knowledge and training. Clinicians should always use their clinical judgment and decision making for
patient management. Departure from the information presented here is encouraged as appropriate,
24 since situations can vary widely.
25 We use generic medication names whenever possible and include some brand names, which might be
better known to clinicians, to support effective use during crises. To reduce potentially distracting visual
clutter, TM superscripts have not been included with brand name medications in the cognitive aids.
26
Enabling clinical uses during crises requires systematic implementation efforts beyond simply hanging
27 emergency manuals (EM) in operating rooms, as EMs can be forgotten when under stress. Use the
resources on the previous page to efficiently and effectively integrate EMs into your practice.
28 1. Burian BK, Clebone A, Dismukes K, Ruskin KJ. More Than a Tick Box: Medical Checklist Development, Design, and Use. Anesth
Analg. 2018 Jan;126(1):223-232.
29
1
Infusion List 2
Amiodarone Lidocaine (XylocaineTM) 3
1200 mg in 250 mL D5W 2 g in 250 mL NS
4.8 mg/mL 8 mg/mL 4
Load 150 mg over 10min; Load 1-1.5 mg/kg
300 mg bolus if pulseless Infuse 1-2 mg/kg/hr 5
Infuse 1 mg/min (no weight calc)
6
Clevidipine (CleviprexTM) Milrinone (PrimicorTM)
25 mg in 50 mL 20 mg in 100 mL D5W 7
0.5 mg/mL 200 mcg/mL
Infuse 1-16 mg/hr (no weight calc) Load 50-75 mcg/kg over 10 min 8
Infuse 0.375-0.75 mcg/kg/min
Dexmedetomidine (PrecedexTM) Nesiritide (BNP) 9
400 mcg in 100 mL NS 1.5 mg in 250 mL D5W
4 mcg/mL 6 mcg/mL 10
Load 0.5-1 mcg/kg over 10 min Load 2 mcg/kg over 1 min
Infuse 0.2-1.5 mcg/kg/hr Infuse 0.01 mcg/kg/min 11
Diltiazem (CardizemTM) Nicardipine (CardeneTM) 12
125 mg in 100 mL NS/D5W 40 mg in 200 mL
1.25 mg/mL 0.2 mg/mL 13
Load 2.5 mg up to 25 mg Infuse 5-15 mg/hr (no weight calc)
Infuse 2-10 mg/hr (no weight calc) 14
Dobutamine Nitroglycerin (Tridil )
TM
500 mg in 250 mL D5W 50 mg in 250 mL D5W 15

2000 mcg/mL (2 mg/mL) 200 mcg/mL
Infuse 2-20 mcg/kg/min Infuse 0.1-1 mcg/kg/min 16
Dopamine Nitroprusside (NiprideTM) 17
400 mg in 250 mL D5W 50 mg in 250 mL NS
Infuse 2-10 mcg/kg/min Infuse 0.1-1 mcg/kg/min
19
Epinephrine Norepinephrine (LevophedTM)
4 mg in 250 mL NS 4 mg in 250 mL NS 20
16 mcg/mL 16 mcg/mL
Infuse 0.02-0.3 mcg/kg/min Infuse 0.02-0.3 mcg/kg/min 21
(20-300 nanograms/kg/min) (20-300 nanograms/kg/min)
Esmolol (BreviblocTM) Phenylephrine (NeosynephrineTM) 22
2500 mg in 250 mL NS 40 mg in 250 mL NS
10 mg/mL 160 mcg/mL 23
Infuse 0.05-0.3 mg/kg/min Infuse 0.1-1 mcg/kg/min
(50-300 mcg/kg/min) (or 5-100 mcg/min) 24
Fenoldopam (CorlopamTM) Remifentanil (UltivaTM) 25
10 mg in 250 mL NS/D5W 2000 mcg (2 mg) in 40 mL NS
Infuse 0.05-0.20 mcg/kg/min Infuse 0.01-0.2 mcg/kg/min
Isoproterenol (IsuprelTM) Vasopressin 27
1 mg in 250 mL NS/D5W 60 units in 100 mL NS
4 mcg/mL 0.6 units/mL 28
Infuse 1-5 mcg/min (no weight calc) Infuse 0.01-0.1 units/min (no weight calc)
29
EMERGENCY MANUAL
Stanford Phone Numbers
EMERGENCY or CODE, including Stroke Code, STEMI, Code Blue, Airway Code → Dial 211
Full Prefix: (650) 721-, 723-, 724-, 725-, 736-, 497-, 498-
Interv. Platform Number Operator Operating Rms Number
Anes Scheduler Operator Inside: 288 500P (XX = OR#)
500P/After 5pm 6-0249 Operator Outside (650) 723-4000 Circulator 6-37XX
300P 3-3430 Circ. (OR 29) 7-6251
Lane Surgery Ctr (LSC) 4-8812 Emergency MDs Number Anes. OR 1 7-3083
Anes Tech 300P Airway Pgr #12640 OR 2 7-3085
500P 4-0219 500P Airway Pgr #12605 OR 3 7-3007
300P 6-1850 ENT Pgr #27087 OR 4 7-3091
LSC 6-2120 Interv. Rad. Pgr #27237 OR 6 7-3475
ENDO/MRI 4-6359 Neurology Pgr #27191 OR 7 7-3508
CATH/CT 4-4587 Regional Block Pgr #25625 OR 8 7-3512
Biomed. Engineering Acute Pain Pgr #27246 OR 9 7-3483
500P 628-273-3352 Periop Resident Pgr #22637 OR 10 7-3480
300P 5-7454 OR 11 7-3477
LSC 5-8186 LPCH Number OR 12 7-3119
Cath Lab 500P/300P 7-2595 Peds Control Desk 1-2820 OR 14 7-3120
Charge Nurse Peds Anes Scheduler 1-9705 OR 15 7-3124
500P 650-788-5784 Peds Anes Emergency 1-9706 OR 16 7-3126
300P 4-4590 OB/L&D Front Desk 3-5403 OR 17 7-3210
LSC 4-9420 OB Anes Attending 1-0865 OR 18 7-3212
Clinical Lab 3-6671/3-6111
Phone list
OB Anes Fellow 1-0866 OR 19 7-3097
Phone List
Control Desk OB Anes Resident 1-0867 OR 20 7-3101
500P 3-7251 OR 21 7-3104
300P 7-5468
placeholder ICU Number OR 22 7-3093
Placeholder
LSC 5-6102 E2 (300P) Front Desk 5-7122 OR 23 7-3094
Cath Lab 500P 7-1896 M4 Front Desk 7-3294 OR 24 7-3096
Cath Lab 300P 3-7676 J4 Front Desk 7-3301 OR 25 7-3113
LSC IR Scheduler 5-3615 K4 Front Desk 7-3313 OR 26 7-3118
LSC Brachytherapy 5-4371 J2 (CVICU) Front Desk 7-3325 OR 27 7-3468
Endoscopy 650-823-6841 MICU Triage Fellow 4-8820 OR 28 7-3472
PET-CT/NucMed 5-8263 SICU Resident 5-3234 OR 29 7-6241
MRI 500P/300P 3-6335 OR 30 7-3105
Emergency Dept 3-7337 Location Number 300P (XX = OR#)
Pharmacy Blood Bank (MTG) 3-6444/3-6445 Circulator 4-70XX
500P 7-1723 Transfusion MD Pgr #12027 Anes. ORs 5-72XX
300P/LSC 5-5923 Charge Nurse 7-1351 Anes. (OR 21) 8-2121
Preop/Holding Blood Gas 5-4382 LSC (XX = OR#)
500P 7-3187 EPIC/IT Help 3-3333 Circulator 6-88XX
300P 5-8742 Interpreter Service 7-7780 Anes. A1 6-8813
LSC 3-5991 Interpreter Phone 1-800-523-1786 A2 6-8814
Cath Lab 500P 7-3181 Code 201273 A3 5-9869
Cath Lab 300P 4-5428 Occup. Health 3-5922 A4 8-7973
PACU Needle Stick Pgr #17849 A5 5-5349
500P 7-3133 Preop Clinic 4-1429 A6 5-5350
300P 3-6631 Radiology Rdg Room 6-1173 A7 5-5354
LSC 3-5917 RT Resource 3-7709 A8 5-3067
Cath Lab 500P 7-3113 RT Supervisor 650-867-9312 A9 5-3066
Cath Lab 300P 4-5428 Risk Management 3-6824 A10 3-7815
288 for on-call manager or pgr #16210 A11 3-4901
Security 3-7222 A12 5-9391

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ad Asystole / PEA ..................

EMERGENCY Difficult Airway / Cric . . . . . . . . . . 8

Crisis Resource Management . 27

19 IV Access • Ensure functional IV or IO access

9 Pulse Check • If no pulse: start CPR and

13 Determine if • Unstable if ANY of the following:

10 • Keep EtCO2 > 10 mmHg and diastolic BP > 20 mmHg

11 • Secure airway. If angioedema: consider early intubation

19 Stop • Remove allergens: e.g. antibiotics, muscle relaxants,

• Advanced airway equipment in room (e.g. difficult airway cart, second 22

24 Consider other causes:

22 Consider • If continued smoke or fire: evacuate patient and staff

PRBC • Give if Hgb < 7 - 10 g/dL depending on hemodynamic 11

12 Airway • 100% O2 10 - 15 L/min

26 • Evaluate patient position. If head down: consider level or

Periop • Surgical stimulus: inspect surgical field

Rare • Autonomic hyperreflexia: spinal cord injury above T6,

16 • Consider head down position or leg elevation

28 Labs • Check ABG, Hgb, Plt, glucose, calcium, potassium, lactate

21 Meds • If BP stable: deepen anesthetic with propofol or volatile

5 Neurologic symptoms: Cardiac symptoms:

10 Crisis • Inform team • Get MH cart with dantrolene

• CO2 insufflation • Illicit stimulants • Pheochromocytoma

23 Consider Life-Threatening Causes of RV Failure

24 • Cardiac tamponade: perform emergent pericardiocentesis

13 Primary • Airway and Breathing:

20 Transfusion preferred over crystalloid 4 - Confused

21 with Sonography for Trauma words

Malignant Hyperthermia ..... 19 Trauma

13 Oxygen Failure ................. 21 • Combined event for multiple

Crisis Resource Management . 27

Phone List (Back Cover) Infusion List 29

9 Crisis • Inform team • Identify leader

Pulse Check • If no pulse: start CPR, check rhythm, and follow

24 anticipate and plan, for teaching,

• “Task” categories with “Actions”

24 Consider other causes:

500 mg in 250 mL D5W 50 mg in 250 mL D5W 15

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