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CRISIS MANAGEMENT

(comparison of the various components of the SCARE Algorithm)

- place the cursor on each "Note" for more information -

SCARE

SCAN CHECK ALERT/READY EMERGENCY

C Circulation

Note the rate, rhythm and volume of the pulse and note the end tidal carbon dioxide concentration (ETCO2).
Note Palpate a pulse. Correlate rate, rhythm and volume with the oximeter and ECG. Check capillary refill and ETCO2 trace.
Note Circulation: If there is an impending arrest allocate the circulation" task and ask for the arrest trolley to be fetched If the pulse or ETCO2 fails, feel for a major pulse and start external cardiac massage

Colour

Note the colour of the patient's mucous membranes and blood and note the saturation reading of the oximeter (SaO2). If suspicious try the pulse oximeter on yourself. Take arterial blood for a lab check on saturation or blood gases. If the oximeter is suspect, resite or replace it and/or do an arterial blood gas. Consider inserting an arterial line.. If there is any question of cardiac, circulatory or respiratory compromise, give 100% O2 regardless of the saturation

O Oxygen Supply

Note the rotameter settings and that the bobbins are spinning and calculate the inspired oxygen fraction (FIO₂).
Note Briefly increase the oxygen flow rate and calculate the new expected FIO2 in the breathing circuit. If adequate saturation cannot be confirmed, administer 100% oxygen. Plan how to provide analgesia and anaesthesia Supply 100% oxygen at a very high flow rate if necessary

Oxygen Analyser

Note that the
readout matches that expected in the inspiratory limb of the breathing
circuit. Calibrate if necessary Check that the changes in the FIO2 are in line with the calculated changes in FIO2 in the breathing circuit. Confirm that the gas in the inspired limb of the breathing circuit is 100% oxygen. Confirm the inspired gas in the breathing circuit is 100% oxygen.

V Ventilation

Note the patient's chest movements. Correlate these with the capnograph, breathing circuit pressures and tidal volumes. Ventilate by hand and repeat SCAN. Check circuit, scavenging, valves and visible moving ventilator parts. Allocate the "airway and breathing" task. Ventilate with a self-inflating bag. See breathing below. Ventilate by hand - use a self-inflating bag. Obtain appropriate chest movement, airway pressures and ETCO2 (see breathing below).

Vaporisers

Note the vaporiser settings on all vaporisers and the volatile agent liquid level on the vaporiser in use Check the vaporiser(s) are correctly seated and set, "locked in" and connected and that there are no gas or liquid leaks. Turn the vaporiser off if there is cardio-respiratory compromise. Plan how to provide analgesia and anaesthesia Turn off all vaporisers unless the problem is clearly unrelated or is hypertension or awareness.

E Endotracheal Tube

or laryngeal mask airway: Note its position (distance marker at the lips), its orientation and its security
Note or laryngeal mask airway: Check position, orientation and patency. If ET tube is in use exclude endobronchial intubation.
Note or laryngeal mask airway: Allocate the "equipment" task. If suspicious, prepare to remove and change the tube or LMA. or laryngeal mask airway: Remove and replace if there is any doubt whatsoever about its position or patency.

Eliminate Circuit

Note that, in a crisis, you may need to remove machine, circuit, filter, ETT and its connections, eg. the "catheter mount". Check that an independent means of ventilating the patient (eg. self-inflating bag) and an alternate supply of oxygen are available Prepare & check the correct function of an alternate breathing system and separate oxygen source. The machine, circuit, filter and connections unless the problem is clearly unrelated.

R Review Monitors

Note monitors in use and review all readings, waveforms and alarm settings. Update the anaesthetic record.
Note Check all monitors in use and compare current monitor values with those on the anaesthetic record.
Note . Recheck, correlate and record all readouts and trends. Call for additional monitors as necessary Frequently scan. Allocate someone to review trends and keep notes and ensure sensor integrity.

Review Equipment

Note all equipment in use, especially items in contact with the patient. Review its safety and function.
Note Check that all equipment in contact with or relevant to the patient is safe and functioning correctly Remove or replace suspect equipment. Bring in additional emergency equipment as appropriate Check, and remove all non-essential equipment in contact with patient (retractors, diathermy, etc.).

A Airway

Note the position of the head and neck, and the position, patency and security of any artificial airways or masks.
Note . Observe, palpate and auscultate the neck. If suspicious of airway obstruction, plan direct pharyngoscopy Adjust head and neck, attempt gentle chin lift. Prepare for pharyngoscopy; if suspicious, go to airway obstruction. Go to laryngospasm, airway obstruction, or aspiration algorithms as indicated. Consider intubation. See Bacon page 4.

B Breathing

Note chest and abdominal movements and correlate these with the respiratory rate and pattern of spontaneous ventilation. Palpate and auscultate the chest whilst repeating SCAN. Review the ETCO2 if a capnograph is in use. Expose the chest and abdomen. Repeat SCAN and CHECK whilst comparing L & R sides. Consider causes Go to bronchospasm, pulmonary oedema, ARDS, ventilation, desaturation algorithms as indicated. Consider ventilation.

C Circulation

Note trends in all cardiovascular parameters and correlate these with estimated blood or other fluid losses.
Note Cross check any abnormal BP readings where possible. Check the zero and scales of transducers Check IV access. Secure additional access (venous & arterial) as necessary. Prepare to transfuse Go to tachycardia, bradycardia, hypotension, hypertension, myocardial ischaemia, or cardiac arrest

D Drugs

Note drugs that have been given and correlate doses with effects. Note correct function of all IV lines and infusions.
Note Check all ampoules, syringes, labels, infusion apparatus, connections & cannulae from fluid source to vein.
Note Allocate the "drugs" task. Check all drugs & infusions & the entire IV apparatus. Draw up, check & label drugs that may be needed. Has there been an error? Ensure all drugs are labelled and keep a record of doses and times.

A

"Be Aware of Air and Allergy". Be Aware yourself, think of possible Awareness in the patient, and of Air (or other) embolism, Air in the pleura (pneumothorax), Allergy or Anaphylaxis.
Note Specifically consider the possibility of Awareness. Note
Air (or other) embolism. Note
Air in pleura (pneumothorax): Note
Allergy or Anaphylaxis: Note
See the relevant sub-algorithms for signs and high risk situations. Decide whether Awareness, Air (or other) embolism, Air in pleura (pneumothorax), Allergy and Anaphylaxis are possible causes of the problem, and act accordingly (see algorithms). Go to awareness, air (and other) embolism, air in pleura (pneumothorax) and anaphylaxis algorithms as indicated.

SWIFT CHECK

Note what the surgeon and other personnel are doing, check the patient's position on the table and that the physiological responses match the circumstances. Correlate the monitored parameters with the clinical situation and risk factors. Specifically question the surgeon about what is being done, and check the pre-operative assessment, medical record and ward drug chart. Make another assessment of the general situation, of the patient, of the activities of the surgeon and other personnel, and of the possible effects of the operation and/or any drugs or infusions Go through as indicated when there is time.

Ý Top

		SCAN	CHECK	ALERT/READY	EMERGENCY
C	Circulation
		Note the rate, rhythm and volume of the pulse and note the end tidal carbon dioxide concentration (ETCO2). Note	Palpate a pulse. Correlate rate, rhythm and volume with the oximeter and ECG. Check capillary refill and ETCO2 trace. Note	Circulation: If there is an impending arrest allocate the circulation" task and ask for the arrest trolley to be fetched	If the pulse or ETCO2 fails, feel for a major pulse and start external cardiac massage
	Colour
		Note the colour of the patient's mucous membranes and blood and note the saturation reading of the oximeter (SaO2).	If suspicious try the pulse oximeter on yourself. Take arterial blood for a lab check on saturation or blood gases.	If the oximeter is suspect, resite or replace it and/or do an arterial blood gas. Consider inserting an arterial line..	If there is any question of cardiac, circulatory or respiratory compromise, give 100% O2 regardless of the saturation
O	Oxygen Supply
		Note the rotameter settings and that the bobbins are spinning and calculate the inspired oxygen fraction (FIO₂). Note	Briefly increase the oxygen flow rate and calculate the new expected FIO2 in the breathing circuit.	If adequate saturation cannot be confirmed, administer 100% oxygen. Plan how to provide analgesia and anaesthesia	Supply 100% oxygen at a very high flow rate if necessary
	Oxygen Analyser
		Note that the readout matches that expected in the inspiratory limb of the breathing circuit. Calibrate if necessary	Check that the changes in the FIO2 are in line with the calculated changes in FIO2 in the breathing circuit.	Confirm that the gas in the inspired limb of the breathing circuit is 100% oxygen.	Confirm the inspired gas in the breathing circuit is 100% oxygen.
V	Ventilation
		Note the patient's chest movements. Correlate these with the capnograph, breathing circuit pressures and tidal volumes.	Ventilate by hand and repeat SCAN. Check circuit, scavenging, valves and visible moving ventilator parts.	Allocate the "airway and breathing" task. Ventilate with a self-inflating bag. See breathing below.	Ventilate by hand - use a self-inflating bag. Obtain appropriate chest movement, airway pressures and ETCO2 (see breathing below).
	Vaporisers
		Note the vaporiser settings on all vaporisers and the volatile agent liquid level on the vaporiser in use	Check the vaporiser(s) are correctly seated and set, "locked in" and connected and that there are no gas or liquid leaks.	Turn the vaporiser off if there is cardio-respiratory compromise. Plan how to provide analgesia and anaesthesia	Turn off all vaporisers unless the problem is clearly unrelated or is hypertension or awareness.
E	Endotracheal Tube
		or laryngeal mask airway: Note its position (distance marker at the lips), its orientation and its security Note	or laryngeal mask airway: Check position, orientation and patency. If ET tube is in use exclude endobronchial intubation. Note	or laryngeal mask airway: Allocate the "equipment" task. If suspicious, prepare to remove and change the tube or LMA.	or laryngeal mask airway: Remove and replace if there is any doubt whatsoever about its position or patency.
	Eliminate Circuit
		Note that, in a crisis, you may need to remove machine, circuit, filter, ETT and its connections, eg. the "catheter mount".	Check that an independent means of ventilating the patient (eg. self-inflating bag) and an alternate supply of oxygen are available	Prepare & check the correct function of an alternate breathing system and separate oxygen source.	The machine, circuit, filter and connections unless the problem is clearly unrelated.
R	Review Monitors
		Note monitors in use and review all readings, waveforms and alarm settings. Update the anaesthetic record. Note	Check all monitors in use and compare current monitor values with those on the anaesthetic record. Note .	Recheck, correlate and record all readouts and trends. Call for additional monitors as necessary	Frequently scan. Allocate someone to review trends and keep notes and ensure sensor integrity.
	Review Equipment
		Note all equipment in use, especially items in contact with the patient. Review its safety and function. Note	Check that all equipment in contact with or relevant to the patient is safe and functioning correctly	Remove or replace suspect equipment. Bring in additional emergency equipment as appropriate	Check, and remove all non-essential equipment in contact with patient (retractors, diathermy, etc.).
A	Airway
		Note the position of the head and neck, and the position, patency and security of any artificial airways or masks. Note .	Observe, palpate and auscultate the neck. If suspicious of airway obstruction, plan direct pharyngoscopy	Adjust head and neck, attempt gentle chin lift. Prepare for pharyngoscopy; if suspicious, go to airway obstruction.	Go to laryngospasm, airway obstruction, or aspiration algorithms as indicated. Consider intubation. See Bacon page 4.
B	Breathing
		Note chest and abdominal movements and correlate these with the respiratory rate and pattern of spontaneous ventilation.	Palpate and auscultate the chest whilst repeating SCAN. Review the ETCO2 if a capnograph is in use.	Expose the chest and abdomen. Repeat SCAN and CHECK whilst comparing L & R sides. Consider causes	Go to bronchospasm, pulmonary oedema, ARDS, ventilation, desaturation algorithms as indicated. Consider ventilation.
C	Circulation
		Note trends in all cardiovascular parameters and correlate these with estimated blood or other fluid losses. Note	Cross check any abnormal BP readings where possible. Check the zero and scales of transducers	Check IV access. Secure additional access (venous & arterial) as necessary. Prepare to transfuse	Go to tachycardia, bradycardia, hypotension, hypertension, myocardial ischaemia, or cardiac arrest
D	Drugs
		Note drugs that have been given and correlate doses with effects. Note correct function of all IV lines and infusions. Note	Check all ampoules, syringes, labels, infusion apparatus, connections & cannulae from fluid source to vein. *Note*	Allocate the "drugs" task. Check all drugs & infusions & the entire IV apparatus. Draw up, check & label drugs that may be needed.	Has there been an error? Ensure all drugs are labelled and keep a record of doses and times.
A
		"Be Aware of Air and Allergy". Be Aware yourself, think of possible Awareness in the patient, and of Air (or other) embolism, Air in the pleura (pneumothorax), Allergy or Anaphylaxis. Note	Specifically consider the possibility of Awareness. Note Air (or other) embolism. Note Air in pleura (pneumothorax): Note Allergy or Anaphylaxis: *Note* See the relevant sub-algorithms for signs and high risk situations.	Decide whether Awareness, Air (or other) embolism, Air in pleura (pneumothorax), Allergy and Anaphylaxis are possible causes of the problem, and act accordingly (see algorithms).	Go to awareness, air (and other) embolism, air in pleura (pneumothorax) and anaphylaxis algorithms as indicated.
SWIFT CHECK
		Note what the surgeon and other personnel are doing, check the patient's position on the table and that the physiological responses match the circumstances.	Correlate the monitored parameters with the clinical situation and risk factors. Specifically question the surgeon about what is being done, and check the pre-operative assessment, medical record and ward drug chart.	Make another assessment of the general situation, of the patient, of the activities of the surgeon and other personnel, and of the possible effects of the operation and/or any drugs or infusions	Go through as indicated when there is time.