The COVER ABCD algorithm detected (82%), diagnosed (68%) and corrected (66%)
a high proportion of the 38 relevant incidents in the first 4000 AIMS
anaesthesia incidents.
(1) Commonest modes of presentation were,
hypoxia/desaturation - 53%, airway obstruction/laryngospasm - 8%, aspiration -
8%, cardiac arrest - 8%, air embolus - 6% and hypotension - 3%
(2) 39% of incidents were sequelae of "cutting corners" in an effort
to save time. Retrospectively, in 73% of these incidents the urgency was judged
to be perceived rather than real. Failure to check the machine resulted in
equipment related problems in 5% of cases.
(3) EMST* - Emergency Management of Severe Trauma protocol (Australia -
Figure 1). USA/UK
equivalent is ATLS (Acute Trauma Life Support) protocol.
Figure 1
ACUTE TRAUMA SUB-ALGORITHM (*EMST protocol)
As many incidents in trauma patients involve "corner cutting",
such as failure to check due to perceived urgency, it is essential the
recheck everything carefully. The best way to do this is to start again with
COVER ABCD. If not successful consider possible missed diagnoses - follow
the
EMST system - repeat the primary survey, review results to date
and look for missed injuries.
A airway injury
look for
failure to secure airway
failure to ventilate with tube in airway
manage
failed intubation drill
consider surgical cricothyrotomy early with facial injury
cervical spine injury
look for
priapism, areflexia, trauma above clavicles
history of neck pain or tenderness
manage
immobilise neck, review cervical spine X-ray
(radiologist if possible), further films as required
B
tension pneumothorax
look for
distended neck veins, decreased air entry on ipsilateral side,
hyperresonance on ipsilateral side, mediastinal shift away
manage
immediate needle thoracotomy, formal UWSD insertion
relevant
algorithm
pneumothorax algorithm
massive haemothorax
look for
distended or flat neck veins, decreased air entry on ipsilateral side
dullness to percussion on ipsilateral side, mediastinal shift away
manage
volume load ++, formal UWSD insertion, beware of increased bleeding
on UWSD insertion, consider early involvement of thoracic surgeon
relevant
algorithms
hypotension (hypovolaemia) / pneumothorax
algorithms
pulmonary contusion
look for
desaturation in presence of chest injury
manage
desaturation algorithm
bronchopulmonary fistula
look for
continuous air leak via UWSD
manage
consider UWSD piercing lung, consider inserting additional large UWSD,
consider isolating lung with ETT down other bronchus or double-lumen tube
relevant
algorithm
desaturation
algorithm
C unexplained blood loss/hypovolaemia
look for
sites of concealed bleeding: chest/abdomen/pelvis,
sites of visible bleeding
manage
consider chest X-ray, consider pelvis X-ray,
consider diagnostic peritoneal lavage or if severe, urgent laparotomy
view operative site, examine known wounds
if MAST suit in use:
ensure correct inflation
consider removal using standard method
relevant
algorithm
hypotension algorithm
cardiac tamponade
look for
distended neck veins, decreased heart sounds
unexplained hypotension, equalisation of cardiac pressures
manage
consider pericardial tap/may need open drainage
myocardial contusion
look for
unexplained dysrhythmias, ST.T wave changes on ECG
hypotension with adequate filling
manage
dysrhythmia (bradycardia &
tachycardia) / hypotension
algorithms
hyperkalaemia after suxamethonium ("Scoline", "Anectine")
look for
patient after head injury, spinal injury or burns,
widened QRS, cardiac arrest
manage
consider taking blood for K estimation, CPR as required,
give glucose and insulin, consider giving calcium, consider giving NaHCO3,
do not discontinue CPR continue for at least 30 minutes
relevant
algorithm
cardiac arrest / hyperkalaemia
algorithms
D
undiagnosed intracranial collection
look for
dilating pupil under GA, unexplained bradycardia
and hypertension in presence of known or suspected head injury,
raised ICP if monitored, failure to waken
manage
urgent CT scan if available, urgent neurological consultation
E hypothermia
look for
temperature fall during long cases
manage
cover as much of patient as possible,
active warming and heating methods, warm theatre
Top
Back
