Emergency Anaesthesia

Prepared by Dr. Mahmudul Hasan

Assistant Professor Dept. of Anaesthesia, Ragib-rabeya Medical College, Sylhet.

Introduction
Pt. scheduled for elective surgery are usually1. Optimal physical and mental condition 2. Definitive surgical diagnosis 3. Well controlled coexisting medical diseases In contrast, Pt. with a surgical emergency may have1. Uncertain diagnosis 2. Uncontrolled coexisting diseases 3. Cardiovascular, resp. And metabolic derangements

Introduction(contd)
Thus in practice of emergency anaesthesia to be prepared for all potential complications including vomiting Regurgitation hypovolumia Haemorrage Abnormal reaction of drugs Electrolyte disturbance Renal impairment etc.

Pre operative assesment

The objective of emergency anaesthesia: 1. Correction of the surgical pathology 2. Minimum risk to the patient
These require adequate and accurate pre operative evaluation of patients general conditions with attention of specific problems that may influence anaesthetic management.

Pre operative preparation and method of anaesthesia will depend on1. Surgical diagnosis 2. Magnitude of proposed surgery 3. How urgently surgery is required

Pre operative assesment (contd)

A pertinent medical and drugs history is important. In particular enquiry is made into the presence and severity of specific symptoms relevant to cardiovascular reserve: Angina Productive cough Dyspnoea on effort Orthopnoea Nocturnal caughing bouts Such symptoms should provoke details enquiry into CVS and respiratory systems.

Pre operative assessment (contd)

Physical examination: To identify cardiopulmonary dysfunction which increases significant risk of anaesthesia includingBasal crepitation Raised JVP Arrhythmia Abnormal heart sound

Pre operative assesment (contd)

Airway evaluation is important if rapid sequence of induction is contemplated Irregular dentition Limitation of mouth opening Poor range of movement at the atlantooccipital joint. Reduced distance between the hyoid bone and mental symphysis -associated with difficult laryngeoscopy.

Pre operative assesment(contd)

Review of lab investigations and urgent requests are made for additional test may help in management of patient

Assessment of volaemic status

Assessment of intravascular volume is essential, as underestimated hypovolaemia may lead to circulatory collapse during induction of anaesthesia. Intravascular volume deficit: - Assessment of blood loss may be made from history and clinical evaluation.

Clinical indices of extent of blood loss:

Class of 1 hypovolaemia Minimal
% of blood lost Vol. lost in (mL) 10 500

2 Mild
20 1000

3 Moderate
30 1500

4 Severe
Over 40 2000+

Heart rate (beat/min)

Arterial pressure (mm Hg)

Normal
Normal

100-120
Orthostatic hypotension

120-140
Systolic below 100

Over 140
Systolic below 80

Urinary output(mL/hr)

Normal (1 mL/kg/hr)
Normal Normal

20-30

10-20

Nil

sensorium State of peripheral circulation

Normal Cool and pale

Restless Cold and pale, slow capillary refill

Impaired consciousness Cold and clammy peripheral

Extacellular fluid deficit:

Assessment of extracellular fluid deficit is difficult as considerable losses occur before clinical signs are apparent.

Guidance is obtained from Nature of surgical condition Duration of impaired fluid intake Symptoms associated with volume loss(vomiting)

Extracellular fluid deficit (contd)

Extracellular fluid loss may be graded into 4 degree of severity. The loss is expressed as percentage of body weight loss as fluid.

Indices of extent of loss of extracellular fluid:

% body weight lost as water Over 4% (mild) mL of fluid lost per 70 kg Over 2500 Signs and symptoms Thirst, reduced skin elasticity, decreased intraocular pressure, dry tongue, reduced swOver 4% (mild)

Over 6% (mild)

Over 4200

As above, plus orthostatic pypotension, reduced feeling of peripheral veins, oliguria, low CVP, apathy, haemoconcentration As above, plus hypotension, thready pulse with cool peripheries

Over 8% (moderate)

Over 5600

Over 10-15% (severe)

Over 7000-10500

Coma, shock followed by death

The full stomach

Vomiting and regurgitation of gastric contents followed by aspiration into trachubronchial tree is a potential problem during induction of emergency anaesthesia. Most important factors determining the extent of gastric regurgitation1. Lower oesophagel sphincter 2. Rate of gastric emptying.

Lower oesophagel sphincter

It is an area (2-5 cm) with high resting intraluminal pressure in the region of cardia. This sphincter relax during oesophageal peristalsis to allow food into stomach but remain contracted other time. It can not define anatomically but may be detected using intraluminal pressure manometry. LOS is main barrier preventing reflex of gastric contents .

Lower oesophagel sphincter (contd)

Drugs that decrease LOS pressure and increase tendency to gastro oesophageal reflex1. Anticholinergic drugs 2. Ethanol 3. Ganglion blocker 4. Tricyclic anti depressent 5. Opioids 6. TPS

LOS(contd)
Factors which delayed gastric emptying 1. Shock 2. Pain, fear , anxiety 3. Late pregnency 4. Deep sedation 5. Solid foods

Situation in which vomiting and regurgitation may occur

Full stomach:
With absence or abnormal peristalsis Peritonitis of any cause Post operative ileus Metabolic ileus -Hypokalimia -Uraemia - Diabetic ketoacidosis Drug induced ileus -Anticholenargic With obstruction of peristalsis Gastric carcinoma Pyloric stenosis With delayed gastric emptying Shock Fear, pain, anxiety Late pregnency Deep sedation Recent solid and fluid intake

Other cause: Hiatus hernia Oesophageal stricture(benign or maliglant) Pharyngeal pouch

Techniques of anaesthesia
It is important to recognize the pt. who may have significant gastric residue and who is in danger of aspiration. The anaesthetic management of such pt. may be described in 5 phases1. Preparation 2. Induction 3. Maintanance 4. Reversal and emergence 5. Post operative management

Techniques of anaesthesia(contd)
Phase-I
Preparation: a) Insertion of N-G tube b) Clear oral antacides(Na-citrate) to raise the pH of gastric contents c) Pre operative administration of H2 receptor

antagonist

Techniques of anaesthesia
Phase-II
Induction: Rapid sequence induction: Indications: 1. Full stomach 2. Pregnant pt. 3. Bowel obstruction 4. Morbid obesity

Techniques of Rapid sequence induction:

1. Pre oxygenation with 100% o2 for 3-5 min. 2. Pt. to be sniffing position(nack flexed on shoulder and head extend). 3. Skilled assistant on right side to perform cricoid pressure(sellicks manoeuvre) 4. Sleeping dose of induction agent given 5. Cricoid pressure should be given as soon as consciousness is lost. (some prefer to inform pt. and apply it just before induction and maintained untill the cuff of ETT is inflated- cricoid pressure 1-3 kg wt or 40N) 6. Without waiting to the effect of induction agent paralysis dose of succinylcholine is administrated immediately 7. As soon as the jaw being to relax, laryngoscopy is performed and trachea is intubated, cuff is inflated and cricoid pressure is removed.

Phase-III
Maintanance of anaesthesia: 1. N2O 50-66% with O2 depending on patients condition; 2. Volatile anaesthetic agent with appropriate concentration. 3. NMBA: Rocuronium and atracuronium is drugs for routine use. Pancuronium is usefull in pt. with hypovolumia as it increases arterial pressure.

Phase-IV
Reversal and emergence:
After insertion of last skin suture1. Discontinuation of anaesthetic drugs 2. Ventilation manually 3. Neostigmine and atropine are given in one bolus. 4. Extubation of trachea done after protective airway reflex become because chance of aspiration is great. 5. Level of consciousness should be assessed.

Phase- V
Post operative management: 1. Proper analgesia (eg. Morphine 0.2 mg/kg) 2. Fluid balance : maintanance and abnormal loss. 3. Monitoring of vital signs

The anaesthesist and major trauma:

Management of a pt. with major trauma requires a multidisciplinary team effort. In many hospitals the anaesthesist/ICU trainee is a integral member of trauma team. Trauma management is based on Advanced trauma life support (ATLS) protocols.

The anaesthesist and major trauma(contd)

The suggested scheme for trauma management is as follows: 1. Rapid primary survey: Recognition and treatment of any immediate life threatening complications like Airway obstruction Tension/ open pneumothorax Massive haemothorax Fail chest Cardiac temponade 2. Resuscitation of vital functions: Control of maemorrage Intravenous accesss Volume resuscitation

The anaesathesist and major trauma(contnd)

Suggested scheme for trauma management 3. Detailed secondary surveyRecognition of any potentially life threatening injury. Example Ruptured aorta pulmonary/ cardiac construction Diaphragmatic rupture Haemoretroperitoneum 4. Definite care Steps 1 and 2 are performed simultaneously.

The anaesthesist and major trauma(contd)

Airway/ breathing:
Airway assessment reveals one of the three clinical scenarios1. pt. is conscious, alert, talking High flow of o2 via face mask No need for immediate airway intervention A full clinical evaluation can be done 2. pt. has a reduced conscious level but some degree of airway control gag reflex still present. If pt. is maintaining airway and breathing adequately then no need for immediate intervention. Further evaluation can be done 3. pt. has reduced conscious level. Gag reflex absent. Tracheal intubation and artificial ventilation should be carried out at once.

Circulation:
Haemorrhage is the most common cause of shock in the injured pt. Pt. with major trauma often require urgent restoration of circulatory blood volume. Isotonic electrolyte are used for initial resuscitation and 1-2 litre Hartmann.s solution is given rapidly and pt. response is assessed. Whole blood is ideal fluid for restoration of blood volume in the haemorrhage shock. If cross matched blood is not yet available a synthetic colloid solution may be given.

On arrival in the theatre, the pt. is placed on operation table. 100% O2 is given. Anaesthesia should be induced so that surgery can start as soon as possible. Induction: Rapid sequence induction using Ketamin (0.3-0.7 mg/kg) Ketamin should not be used in pt. with significant head injury. Etomidate 0.1-0.3 mg/kg is an alternative for Normovolumic pt. Pancuronium and Rocuronium is given in small incremental dose to maintain relaxation. In shock state MAC value is approached more rapidly so volatile agent should be reduced.

Definitive care

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