Emergencies in Anaesthesia - 3rd Edition

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OXFORD MEDICAL PUBLICATIONS

Emergencies
in Anaesthesia
THIRD EDITION

edited by
Alastair Martin FRCA
Consultant Anaesthetist,
Royal Devon and Exeter NHS Foundation Trust, UK

Keith G. Allman MD FRCA

Consultant Anaesthetist,
Royal Devon and Exeter NHS Foundation Trust, UK

Andrew K. McIndoe FRCA

Consultant Anaesthetist and Senior Clinical Lecturer,
University Hospitals Bristol NHS Foundation Trust, UK

1
1
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Third Edition published in 2020
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drug dosages in this book are correct. Readers must therefore always check
the product information and clinical procedures with the most up-​to-​date
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otherwise stated, drug dosages and recommendations are for the non-​pregnant
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This edition of Emergencies in Anaesthesia is dedicated to our wives
Sue McIndoe, Fiona Martin, and Cathy Allman.
Thank you so much for your love and support.
 vii

Preface to the
third edition
Welcome to this, the third edition of Emergencies in Anaesthesia and wel-
come also to our new Editor, Alastair Martin, who has taken on the onerous
task of revamping this latest version.
Emergencies in Anaesthesia has been written to help anaesthetists antici-
pate different emergency situations that may arise in the various areas of
anaesthetic practice. We have described topics that may need to be man-
aged immediately or as soon as practicable and these include problems that
may arise preoperatively, in theatre, or in recovery.
The successful management of any emergency arising during anaesthesia
depends on the anaesthetist and their team reacting in a calm and logical
way. Our ability to do this is much improved by experience, training, and
preparation of both the individual and the team. Preparation for emergen-
cies includes gaining the correct knowledge, skills, equipment and help, and
protocols can provide a structure which helps us to focus and treat the
likeliest causes, while remembering to exclude the rare.
We hope that Emergencies in Anaesthesia will stimulate readers to reflect
on their knowledge and readiness to deal with any of the situations dis-
cussed. Additionally, since dealing with emergencies requires all members
of the team to help, and for the theatres to be properly equipped, this book
may serve to remind us what developments we need in our workplace.
Dealing with the unexpected is always made easier by effective planning.
We would especially like to thank all our authors for their excellent work
and, of course, our families for their continued support.
Alastair Martin
Keith G. Allman
Andrew K. McIndoe
February 2020
 ix

Contents

Abbreviations xi
Note on drug dosages xvi
Contributors to the third edition xvii
Contributors to the first edition xix

1 Crisis management and human factors 1

2 Cardiovascular 9
3 Respiratory 57
4 Airway 79
5 Paediatrics 119
6 Obstetrics 155
7 Neurology/​neurosurgery 189
8 Thoracics 215
9 Regional anaesthesia 247
10 Metabolic and endocrine 271
11 Recovery problems 331
12 Emergency department problems 369
13 Equipment problems 401
14 Miscellaneous problems 417
15 Practical procedures 453
Appendix: Drugs 507

Index 533
 xi

Abbreviations

P primary ASAP as soon as possible

S secondary AST aspartate transaminase
A–​A Alveolar–​arterial ATLS advanced trauma life support
AAA abdominal aortic aneurysm ATN acute tubular necrosis
AAGBI Association of Anaesthetists AV atrioventricular/​arteriovenous
of Great Britain and Ireland AVM arteriovenous malformation
ABC Airway, Breathing, Circulation AXR abdominal X-​ray
ABGS arterial blood gases BAL bronchoalveolar lavage
A&E accident and emergency BB bronchial blockers
ACE angiotensin-c​ onverting enzyme BCIS bone cement implantation
ACH acetylcholine syndrome
ACHE acetylcholinesterase BD twice daily
ACS acute coronary syndrome BE base excess
ACTH adrenocorticotrophic BIPAP biphasic positive airway
hormone pressure
ADH antidiuretic hormone BLS basic life support
ADP accidental dural puncture BM ‘blood sugar’
AEC airway exchange catheter BMI body mass index
AEDS automated external BNP b[rain]-​natriuretic peptide
defibrillators BP blood pressure
AF atrial fibrillation BPF bronchopleural fistula
AFE amniotic fluid embolus BPM beats per minute
AHF acute heart failure BSA body surface area
AIDS acquired immune deficiency BTS British Thoracic Society
syndrome
BURP Backwards, Upwards,
ALF acute liver failure Rightwards Pressure
ALI acute lung injury CBF cerebral blood flow
ALS advanced life support CCF congestive cardiac failure
ALT alanine aminotransferase CCU coronary care unit/​critical
APL automatic pressure limiting care unit
APTR activated partial CEA carotid endarterectomy
thromboplastin ratio CI cardiac index
APTT activated partial CICV can’t intubate . . . can’t
thromboplastin time ventilate
ARDS acute respiratory distress CK creatine kinase
syndrome
CK-​MB creatine kinase MB isoenzyme
ARF acute renal failure
CMV cytomegalovirus
ASA American Society of
Anesthesiologists CNS central nervous system
xii Abbreviations

CO cardiac output ECM external cardiac massage

COHB carboxyhaemoglobin ECMO extracorporeal membrane
oxygenation
COPD chronic obstructive pulmonary
disease ECT electroconvulsive therapy
CPAP continuous positive airways ED external diameter; emergency
pressure department
CPB cardiopulmonary bypass EDTA ethylenediamine
tetra-​acetic acid
CPP cerebral perfusion pressure
EEG electroencephalogram
CPR cardiopulmonary resuscitation
EMLA eutectic mixture of local
CRP C-​reactive protein
anaesthetics
CS Caesarean section
ENT ear, nose, throat
CSE combined spinal/​epidural
ERPC evacuation of retained
CSF cerebrospinal fluid products of conception
CSM Committee on Safety of ET endotracheal
Medicines
ETCO2 end-​tidal CO2
CSW cerebral salt-​wasting
ETT endotracheal tube
CSWS cerebral salt-​wasting
EU European Union
syndrome
EUA examination under anaesthetic
CT computed tomography
FAST Focused Assessment with
CTPA computed tomography
Sonography for Trauma
pulmonary angiogram
CV central venous FB foreign body
FBAO foreign body airway
CVC central venous catheter
obstruction
CVE cerebrovascular episode
FBC full blood count
CVP central venous pressure
FEV1 forced expiratory volume in
CVS cardiovascular system 1 second
CXR chest X-​ray FFP fresh frozen plasma
DAS Difficult Airway Society FGF fresh gas flow
DBS double-​burst stimulation FIAA inspired fraction of
DC direct current anaesthetic agent

DDAVP 1-​deamino-​8-​D-​arginine FIO2 inspired fraction of O2

vasopressin FOB fibreoptic bronchoscope
DHI dynamic hyperinflation FOI fibreoptic intubation
DI diabetes insipidus FONA front of neck access
DIC disseminated intravascular FRC functional residual capacity
coagulation
FTC corrected flow time
DKA diabetic ketoacidosis
GA general anaesthesia
DLT double-​lumen tube
G&S group and save
DMV difficult mask ventilation
GCS Glasgow coma scale
DNAR do not attempt resuscitation
GFR glomular filtration rate
DVT deep vein thrombosis
GI gastrointestinal
ECG electrocardiogram
GIT gastrointestinal tract
 Abbreviations xiii

G-​6-​PD glucose-​6-​phosphate IVRA intravenous regional

dehydrogenase anaesthesia
GTN glyceryl trinitrate JVP jugular venous pressure
GU genitourinary KCL potassium chloride
HB haemoglobin LA local anaesthetic/​left atrium
HBV hepatitis B virus LBBB left bundle branch block
HCV hepatitis C virus LFT liver function test
HDU high dependency unit LMA laryngeal mask airway
HIB Haemophilus influenzae b LMWH low molecular weight heparin
(vaccine) LOC loss of consciousness
HIV human immunodeficiency virus LSCS lower segment Caesarean
HME heat and moisture exchanger section
HR heart rate LV left ventricle
IA intra-​arterial LVAD left ventricular assist device
IAP intra-​abdominal pressure LVF left ventricular failure
IBP invasive blood pressure LVH left ventricular hypertrophy
monitoring LVSWI left ventricular stroke
ICD implantable cardioverter work index
defibrillator MA mean acceleration
ICH intracerebral haemorrhage MAC minimum alveolar
ICP intracranial pressure concentration
ICS Intensive Care Society MAOIS monoamine oxidase inhibitors
ICU intensive care unit MAP mean arterial pressure
ID internal diameter MC&S microscopy, culture and
sensitivity
IGE immunoglobulin E
MDI metered dose inhaler
ILCOR International Liaison
Committee on Resuscitation MEN multiple endocrine neoplasia
I:E RATIO inspiratory:expiratory ratio METHB methaemoglobin
IHD ischaemic heart disease MH malignant hyperthermia
ILMA intubating laryngeal MHRA Medicines and Healthcare
mask airway products Regulatory Agency
IM intramuscular(ly) MI myocardial infarction
INR international normalized ratio MRI magnetic resonance imaging
IO intraosseous MSU midstream urine
IPPV intermittent positive pressure NAI non-​accidental injury
ventilation NG nasogastric
ITU intensive therapy unit NHS National Health Service
IU international units NIBP non-​invasive blood pressure
IV intravenous NICE National Institute for Health
IVC inferior vena cava and Care Excellence
IVCT in vitro contracture testing NIDDM non-​insulin-​dependent
diabetes mellitus
IVI intravenous infusion
xiv Abbreviations

NRLS National Reporting and PEP postexposure prophylaxis

Learning System PICC peripherally inserted central
NSAIDS non-​steroidal catheter
anti-​inflammatory drugs PICCO pulse contour cardiac output
NSTEACS non-​ST segment elevation PICU paediatric intensive care unit
acute coronary syndromes
PIH pregnancy-​induced
NSTEMI non-​ST elevation myocardial hypertension
infarction
PLMA ProSeal LMA
OD once daily
PO by mouth
ODP operating department
practitioner PO2 partial pressure O2

OGD oesophago-​ PONV postoperative nausea and

gastroduodenoscopy vomiting

OLV one-​lung ventilation PPI proton pump inhibitor

OMV Oxford Miniature Vaporizer PR per rectum

PA pulmonary artery PRN when required

PABA para-​aminobenzoic acid PT prothrombin

PAC pulmonary artery catheter PTH parathyroid hormone

PACO2 partial pressure arterial CO2 PTT partial thromboplastin time

PACU post-​anaesthetic care unit PUD peptic ulcer disease

PAFC pulmonary artery flotation PV peak velocity

catheter PVR pulmonary vascular resistance
PALS paediatric advanced life QDS four times daily
support
QSOFA quick sepsis-​related organ
PAO2 partial pressure arterial O2 failure assessment
PAP positive airways pressure/​ RA right atrium
pulmonary artery pressure
RAE Ring–​Adair–​Elwyn
Paw airway pressure
RBBB right bundle branch block
PAWP/   pulmonary artery wedge
RBC red blood cell(s)
PAOP     
pressure/​pulmonary artery
occlusion pressure RF recombinant factor
PBLS paediatric basic life support ROSC return of spontaneous
circulation
PCA patient-​controlled analgesia
RS respiratory system
PCI percutaneous coronary
intervention RSI rapid sequence induction
PCV pressure-​controlled ventilation RTA road traffic accident/​motor
vehicle accident
PCWP pulmonary capillary wedge
pressure RUL right upper lobe
PDPH postdural puncture headache RV right ventricle
PE pulmonary embolism/​ SAD supraglottic airway device
phenytoin equivalents SAG-​M saline adenine
PEA pulseless electrical activity glucose–​mannitol
PEEP positive end-​expiratory SAH subarachnoid haemorrhage
pressure SAO2 arterial oxygen saturation
PEFR peak expiratory flow rate SBCU special baby care unit
 Abbreviations xv

SC subcutaneous(ly) TEDS thromboembolism deterrent

stockings
SCD sickle cell disease
TEG thromboelastography
SCI spinal cord injury
TFTS thyroid function tests
ScvO2 central venous O2 saturation
TIA transient ischaemic attack
SD stroke distance
TIVA total intravenous anaesthesia
SHOT Serious Hazards of
Transfusion TMJ temporomandibular joint
SIADH syndrome of inappropriate TOE transoesophageal
antidiuretic hormone echocardiography
secretion TOF train-​of-​four
SIRS systemic inflammatory T-​PA tissue plasminogen activator
response syndrome
TPN total parenteral nutrition
SL sublingual
TRALI transfusion-​related acute
SLE systemic lupus erythematosus lung injury
SLT single-​lumen TSH thyroid stimulating hormone
endotracheal tube
TT tracheal tube
SNP sodium nitroprusside
TURP transurethral resection of the
SOFA sepsis-​related organ failure prostate
assessment
U unit
SPO2 peripheral oxygen saturation
U&ES urea and electrolytes
SSRI selective serotonin-​reuptake
inhibitor URTI urinary tract infection
STEMI ST elevation myocardial US ultrasound
infarction USS ultrasound scan
SV stroke volume UTI urinary tract infection
SVC superior vena cava UV ultraviolet
SVI stroke volume index VATS video-​assisted thoracoscopy
SVR systemic vascular resistance VES ventricular ectopics
SVRI systemic vascular VF ventricular fibrillation
resistance index
VOO ventricular asynchronous
SVT supraventricular tachycardia
VP ventriculoperitoneal (shunt)
T3 tri-​iodothyronine
VSD ventricular septal defect
T4 thyroxine
VT tidal volume
TAVI transcatheter aortic valve
VT ventricular tachycardia
implantation
VTE venous thromboembolism
TB tuberculosis
WFNS World Federation of
TBW total body water
Neurological Surgeons
TCA tricyclic antidepressants
WHO World Health Organization
TCI target controlled infusion
WPW Wolff–​Parkinson–​White
TC/​XE technetium/​xenon (syndrome)
TDS three times daily YAG yttrium–​aluminium–​garnet
(laser)
xvi

Note on drug dosages

Some of the drugs and dosages are suggested outside of those stated in the
British National Formulary (BNF) because the book describes the use of
drugs in specialist situations. Always refer to the BNF and product literature
before using any drug with which you are unfamiliar.
 xvii

Contributors to the
third edition

James Bennett Craig Dunlop

Consultant Anaesthetist, Consultant in Cardiothoracic
Conquest Hospital, East Sussex Anaesthesia and Intensive Care
Healthcare NHS Trust, Hastings, Medicine, University Hospitals
United Kingdom Plymouth NHS Trust, Plymouth,
United Kingdom
Jim Blackburn
Anaesthesia, North Bristol NHS Charles Gibson
Trust, Honorary Associate Consultant in Anaesthesia
Lecturer, University of Bristol, and Intensive Care Medicine,
United Kingdom Royal Devon and Exeter NHS
Foundation Trust, Exeter, United
Hannah Blanshard Kingdom
Consultant in Anaesthesia,
University Hospitals Bristol NHS Gerard Gould
Foundation Trust, Bristol, United Consultant Anaesthetist,
Kingdom Conquest Hospital, East Sussex
NHS Trust, Hastings, United
Tim Cook Kingdom
Consultant in Anaesthesia and
Intensive Care Medicine, Royal Kim J. Gupta
United Hospital, Bath, United Consultant in Anaesthesia
Kingdom and Intensive Care Medicine,
Royal United Hospital NHS
Louise Cossey Trust, Bath, United Kingdom
Anaesthetic Registrar, University
Hospitals Plymouth NHS Trust, Katharine Hunt
Plymouth, United Kingdom Consultant Neuroanaesthetist,
National Hospital for Neurology
Jules Cranshaw and Neurosurgery, University
Consultant in Anaesthesia College London Hospitals,
and Intensive Care Medicine, London, United Kingdom
Royal Bournemouth Hospital,
Bournemouth, United Kingdom John Isaac
Consultant Anaesthetist,
Owen Davies University Hospitals Birmingham
Consultant Anaesthetist, NHS Foundation Trust,
Christchurch Public Hospital, Birmingham, United Kingdom
Christchurch, New Zealand
xviii Contributors to the third edition

Michael Kinsella Mark Scrutton

Consultant Obstetric Consultant Obstetric
Anaesthetist, St. Michael’s Anaesthetist, St. Michael’s
Hospital, University Hospitals Hospital University Hospitals
Bristol NHS Foundation Trust, Bristol NHS Foundation Trust,
Bristol, United Kingdom Bristol, United Kingdom
Daniel Lutman Mark Stoneham
Chief of Heart and Lung, Consultant Anaesthetist and
Children’s Acute Transport Honorary Clinical Senior
Consultant, Great Ormond Lecturer, Nuffield Department
Street Children’s Hospital, of Anaesthetics, Oxford, United
London, United Kingdom Kingdom
Bruce McCormick Kath Sutherland
Consultant Anaesthetist, Specialty Registrar in
Royal Devon and Exeter NHS Anaesthesia, Bristol Royal
Foundation Trust, Exeter, United Children’s Hospital, University
Kingdom Hospitals Bristol NHS
Foundation Trust, Bristol, United
Simon Mercer Kingdom
Director of Medical Education,
Liverpool University Hospitals Benjamin Walton
NHS Foundation Trust, Aintree Consultant in ICM and
University Hospital, Liverpool, Anaesthesia, North Bristol NHS
United Kingdom Trust, Bristol, United Kingdom
Jerry Nolan Manni Waraich
Consultant in Anaesthesia and Consultant in Neurointensive
Intensive Care Medicine, Royal Care & Neuroanaesthetics,
United Hospital, Bath; Professor National Hospital for Neurology
of Resuscitation Medicine, and Neurosurgery, University
University of Warwick, College London Hospitals,
Warwick, United Kingdom London, United Kingdom
Neil Rasburn Nerida Williams
Consultant Anaesthetist, Intensive Care Registrar,
University Hospitals Bristol NHS National Capital Private
Foundation Trust, Bristol, United Hospital, Canberra, Australia
Kingdom
 xix

Contributors to the
first edition

Ciara Ambrose R.D. Evans

Specialist Registrar in Reader, University of Oxford,
Anaesthesia, Southmead Nuffield Department of
Hospital, Bristol, United Anaesthetics, Radcliffe Infirmary,
Kingdom Oxford, United Kingdom
Davinia Bennett Gerard Gould
Fellow in Liver Transplant, Fellow in Thoracic Anaesthesia,
Anaesthesia and Intensive Care, Guy’s and St Thomas’ Hospital,
Queen Elizabeth Hospital, London, United Kingdom
University of Birmingham NHS
Trust, Birmingham, United Kim J. Gupta
Kingdom Consultant Anaesthetist, Bath,
United Kingdom
Colin Berry
Consultant Anaesthetist, Royal Katharine Hunt
Devon and Exeter NHS Trust, Consultant Neuroanaesthetist,
Exeter, United Kingdom National Hospital for Neurology
and Neurosurgery, London,
Hannah Blanshard United Kingdom
Specialist Registrar in
Anaesthesia, Bristol Royal John Isaac
Infirmary, Bristol, United Consultant Anaesthetist,
Kingdom University Hospital, Birmingham,
United Kingdom
Elaine Boyle
Specialist Registrar, Neonatal Michael Kinsella
Unit, Royal Infirmary of Consultant Obstetric
Edinburgh, Edinburgh, United Anaesthetist, United Bristol
Kingdom Healthcare NHS Trust, Bristol,
United Kingdom
Tim Cook
Consultant Anaesthetist, Royal Chris Langrish
United Hospital, Bath, United Specialist Registrar in
Kingdom Anaesthesia, Bristol, United
Kingdom
Jules Cranshaw
Specialist Registrar in Stephen J. Mather
Anaesthesia, Bristol Royal Consultant in Anaesthesia and
Infirmary, Bristol, United Perioperative Medicine, United
Kingdom Bristol Healthcare NHS Trust,
Bristol, United Kingdom