(6) BRONCHOSPASM (Intubated patient) (7) DELAYED EMERGENCE Signs: Management: Increased peak airway pressures All anesthetics Off Bilateral wheezing No residual muscle paralysis Go to Residual Paralysis Increased expiratory time algorithm Increased ETCO2 with upsloping ETCO2 tracing Hypoxemia/Hypercarbia Bag/Mask vs. Intubation Decreased volumes if pressure controlled Hypothermia: Warm Blankets and fluids, Bare hugger, Warm the room CALL FOR HELP ABG with electrolytes: If CO2 narcosis Intubate, Correct CODE CART? electrolytes Rule out medication swap or dosing error See below Treatment: If all of the above negative/normal: consider STAT Head If patient hypotensive, disconnect patient circuit (to CT and consult neurology/neurosurgery (If intubated, relieve air trapping) look for pupils, asymmetric movement, gagging) 100% O2 High Flow If residual mental status abnormalities, monitor Increase expiratory time in ICU with serial neurologic and repeat Deepen volatile anesthetic imaging as needed Suction ETT Medications: If suspect medication overdose: Give inhaled Albuterol +/- Ipratropium Opioid reversal: Naloxone 40 ug IV: Repeat q2 minutes If severe Epinephrine IV start 10 ug and up to 5 (200 ug total) escalate BZD reversal: Flumazenil 0.2 mg IV: Repeat q1 minutes Ketamine 0.2 1 mg/kg IV up to 5 doses (1 mg total) – Hydrocortisone 100 mg IV Scopolamine patch reversal: Physostigmine 1 mg IV Nebulized racemic epinephrine (Have Atropine ready for potential cholinergic crisis) Consider ABG Rule Out: Mainstem intubation Anaphylaxis Go to anaphylaxis algorithm
(6) BRONCHOSPASM (Intubated patient) Signs: Increased peak airway pressures Bilateral wheezing Increased expiratory time Increased ETCO2 with upsloping ETCO2 tracing Decreased volumes if pressure controlled CALL FOR HELP CODE CART? Treatment: If patient hypotensive, disconnect patient circuit (to relieve air trapping) 100% O2 High Flow Increase expiratory time Deepen volatile anesthetic Suction ETT Medications: Give inhaled Albuterol +/- Ipratropium If severe Epinephrine IV start 10 ug and escalate Ketamine 0.2 – 1 mg/kg IV Hydrocortisone 100 mg IV Nebulized racemic epinephrine Consider ABG Rule Out: Mainstem intubation Anaphylaxis Go to anaphylaxis algorithm (7) DELAYED EMERGENCE Management: All anesthetics Off No residual muscle paralysis Go to Residual Paralysis algorithm Hypoxemia/Hypercarbia Bag/Mask vs. Intubation Hypothermia: Warm Blankets and fluids, Bare hugger, Warm the room ABG with electrolytes: If CO2 narcosis Intubate, Correct electrolytes Rule out medication swap or dosing error See below If all of the above negative/normal: consider STAT Head CT and consult neurology/neurosurgery (If intubated, look for pupils, asymmetric movement, gagging) If residual mental status abnormalities, monitor in ICU with serial neurologic and repeat imaging as needed If suspect medication overdose: Opioid reversal: Naloxone 40 ug IV: Repeat q2 minutes up to 5 (200 ug total) BZD reversal: Flumazenil 0.2 mg IV: Repeat q1 minutes up to 5 doses (1 mg total) Scopolamine patch reversal: Physostigmine 1 mg IV (Have Atropine ready for potential cholinergic crisis)
Emergency%20Protocols.docx