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81. DROWNING AND NEAR DROWNING 577
Alison M. Jeziorski
88. BETA BLOCKER/ CALCIUM CHANNEL BLOCKER OVERDOSE 635
Christopher L. Cropsey and Patrick B. Knight
SECTION C. NEUROLOGIC CRISES 583
82. SEIZURES AND STATUS EPILEPTICUS 585
Pravin Taneja
SECTION D. OTHER CRISES 597
83. PYLORIC STENOSIS 599
John J. Freely Jr. and Michel Sabbagh
84. SICKLE CELL DISEASE 606
Andrew Franklin
85. HEMOPHILIA (PRESENTATION IN EMERGENCY
SURGERY) 615
J. Matthew Kynes
PART IX. TOXINS
86. INTRODUCTION TO PERIOPERATIVE CRISIS
MANAGEMENT: TOXINS 623
William R. Hand
89. COCAINE INTOXICATION AND HYPERTENSIVE EMERGENCY 642
Jagan Ramamoorthy and Noreen E. Murphy
90. COAGULATION SYSTEM: EMERGENCY SURGERY IN THE PATIENT TAKING WARFARIN OR LOW MOLECULAR WEIGHT HEPARIN 650
Shannon Kilkelly
91. COAGULATION SYSTEM: DIRECT ORAL ANTICOAGULANTS 655
Christina F. Burger, Melissa L. Bellomy and Joseph J. Schlesinger
92. OPIOID AND BENZODIAZEPINE OVERDOSE 661
Brad Eastman and Larry Field
93. ALCOHOL WITHDRAWAL 667
Tracy McGrane
94. SEROTONIN TOXICITY 674
Patrick E. Britell and Charles M. Andrews
95. ANTICHOLINERGIC OVERDOSE 679
Philip Fanapour, Peggy White and Brenda G. Fahy
SECTION A. SPECIFIC TOXICITIES 625
87. LOCAL ANESTHESIA SYSTEMIC TOXICITY 627
96. INSULIN OVERDOSE 687
Richard J. Novak
Joel Barton and Gavin Martin
Index 693
X CONTENTS
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PREFACE
is book has grown out of decades of experience by the overall group of authors in practicing simulation and teach­ing concepts of perioperative crisis resource management at our institutions, at national meetings, and in our residency and fellowship training programs. e purpose of this book is to ll a gap between two areas of valuable work that exist in the perioperative emergency space; namely, between the books that consist largely of steps of diagnosing a problem followed by a list of immediate and subsequent treatment steps and those reference books or review articles that form the compendium works, including a review of all of the basic science behind a topic. As such, the goal of this volume is to be an up- to- date, high- yield, clinically relevant resource for understanding the epidemiology, pathophysiology, and proper assessment and management of a wide variety of peri­operative emergencies. Our target audience is anesthesiolo­gists, nurse anesthetists, surgeons, recovery and critical care nurses, and anyone else practicing within the perioperative arena. Additionally, the case vignettes and discussion ques­tions (all of which are able to be answered from the chapter text) are intended to be used by educators both in the clini­cal teaching setting and in a ipped classroom model.
But why is such a book needed? It is becoming increas­ingly recognized that perioperative emergencies, including full cardiac arrest, are dierent from out- of- hospital cardiac arrest and even dierent from in- hospital cardiac and res­piratory arrest in medical patients. e problems that one encounters and rates of survival to discharge are signi­cantly dierent in surgical and obstetrical patients. Part of this is likely explained by the simple dierences between traditional advanced cardiac life support (ACLS) and what has recently been called anesthesia advanced circulatory life support (A- ACLS).4 In traditional ACLS, there is little to nothing known about the patient and their past medical history by the team of rst responders, the event is normally not witnessed, the cause is typically a rhythm disturbance
and oen due to coronary ischemia, and the focus is on restoring circulation and oxygenation that may have been absent for a long period of time. Conversely, in periopera­tive advanced life support, or A- ACLS, the event is almost always witnessed, the rst responders almost always know an extensive amount about the patient, their medical his­tory, and the events leading to the unstable or pulseless state, the causes are quite variable, and while the focus is also on restoring circulation and oxygenation, the interrup­tion in either of these is frequently very brief.
However, what is similar between perioperative emer­gencies and all others is that all care teams struggle with poor adherence to management guidelines. As such, much work remains to be done in training teams in crisis resource management principles, including the use of cognitive aids, which have been shown to greatly increase adherence to published guidelines during urgent and emergent events. Accordingly, while the bulk of this book concerns under­standing the pathophysiology and management of spe­cic diagnoses, there are three introductory chapters that review (1) a critical thinking approach to the unstable or pulseless patient, (2) crisis resource management principles to improve team performance, and (3) the importance of cognitive aids in adhering to guidelines during periopera­tive emergencies.
e remainder of the book is structured based on the critical thinking approach detailed in chapter 1. It is divided into six major areas of instability: cardiac, pulmonary, neu­rologic disorders, metabolic/ endocrine, and toxin- related disorders, as well as a section dedicated to shock states. As the discussion in these sections focuses on the general adult patient, we have also included sections related to specic emergencies for obstetrical and pediatric patients, as well as changes to any management algorithms specic to these patient populations.
Matthew D. McEvoy and Cory M. Furse
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xiii
CONTRIBUTORS
Arnoley S. Abcejo, MD
Resident in Anesthesiology Department of Anesthesiology Mayo Clinic College of Medicine Rochester, MN
Neha Aggarwala, B.Med, FANZCA
Department of Anesthesia Toronto Western Hospital, University Health Network University of Toronto Toronto, Canada
Shamsuddin Akhtar, MD
Associate Professor Department of Anesthesiology and Pharmacology Yale University School of Medicine New Haven, CT
Brian F. S. Allen, MD
Assistant Professor of Anesthesiology Department of Anesthesiology Vanderbilt University Medical Center Nashville, TN
Jacquelyn E. Allison, MD
Associate Professor of Clinical Anesthesia Indiana University School of Medicine Indianapolis, IN
Charles M. Andrews, MD, FACEP
Assistant Professor Department of Neurosurgery Department of Medicine, Division of Emergency Medicine Medical University of South Carolina Charleston, SC
Emily J. Baird, MD, PhD
Assistant Professor Assistant Program Director Department of Anesthesiology and Perioperative Medicine Oregon Health and Science University Portland, OR
Arna Banerjee, MD
Associate Professor of Anesthesiology Assistant Dean for Simulation in Medical Education Department of Anesthesiology Vanderbilt University Medical Center Nashville, TN
Joel Barton, MD
Assistant Professor Department of Anesthesia and Perioperative Medicine Medical University of South Carolina Charleston, SC
Bret D. Alvis, MD
Assistant Professor of Anesthesiology and Critical Care Medicine Department of Anesthesiology Division of Critical Care Medicine Vanderbilt University School of Medicine Nashville, TN
John Barwise, MB, ChB
Associate Professor of Clinical Anesthesiology and Neurological Surgery Division of Anesthesiology Critical Care Medicine Vanderbilt University Medical Center Nashville, TN
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Melissa L. Bellomy, MD
Resident Physician Department of Anesthesiology Vanderbilt University Nashville, TN
Jeremy Bennett, MD
Assistant Professor Cardiothoracic Anesthesia Vanderbilt University Medical Center Nashville, TN
Michelle Y. Braunfeld, MD
Clinical Professor of Anesthesiology University of California, Los Angeles David Geen School of Medicine Los Angeles, CA
Tricia E. Brentjens, MD
Associate Professor of Anesthesiology Columbia University Medical Center Division of Critical Care Anesthesia Director of Liver Transplant Anesthesia Columbia University College of Physicians and Surgeons New York, NY
Patrick E. Britell, MD
Department of Anesthesiology Department of Neurosurgery Medical University of South Carolina Charleston, SC
Marek Brzezinski, MD, PhD
Professor Department of Anesthesia and Perioperative Care University of California, San Francisco San Francisco, CA
Anthony T. Chau, BSc (Pharm), ACPR, MD, FRCPC
Department of Anesthesiology, Perioperative and Pain Medicine Division of Obstetric Anesthesia Brigham and Women’s Hospital Harvard Medical School Boston, MA Department of Anesthesiology, Pharmacology, and erapeutics University of British Columbia Vancouver, Canada
Martin Chen, MD, MPH
Assistant Professor of Anesthesiology Department of Anesthesiology Columbia University Medical Center New York, NY
Benjamin Cobb, MD
Fellow Department of Anesthesia Stanford University School of Medicine Stanford, CA
Christopher L. Cropsey, MD
Assistant Professor of Anesthesiology Department of Anesthesiology Division of Critical Care Medicine Vanderbilt University Medical Center Nashville, TN
Robert J. Deegan, MB, PhD, FFARCSI
Professor of Anesthesiology Director of Intraoperative Echocardiography Department of Anesthesiology Vanderbilt University Medical Center Nashville, TN
Christina F. Burger, PharmD, BCPS
Clinical Pharmacist VA Tennessee Valley Healthcare System Assistant Professor of Clinical Pharmacy University of Tennessee College of Pharmacy Nashville, TN
Shobana Chandrasekhar, MD
Associate Professor Department of Anesthesiology Division of Obstetric and Gynecologic Anesthesiology Baylor College of Medicine Houston, TX
XIV CONTRIBUTORS
Stephen F. Dierdorf, MD
Professor of Clinical Anesthesiology Medical University of South Carolina Charleston, SC
Julie D. Dunlap, MD
Assistant Professor of Clinical Anesthesia Indiana University School of Medicine Indianapolis, IN
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L. Jane Easdown, MD, MHPE
Associate Professor Division of Neuroanesthesiology Vanderbilt University Medical Center Nashville, TN
Brad Eastman, DO
Assistant Professor Department of Anesthesia and Perioperative Medicine Medical University of South Carolina Charleston, SC
Brian N. Egan, MD
Assistant Professor of Anesthesia Indiana University School of Medicine Indianapolis, IN
Rania Elkhateb, MD
Lecturer of Anesthesia Cairo University Giza, Egypt
Brenda G. Fahy, MD, MCCM
Professor of Anesthesiology Department of Anesthesiology University of Florida Gainesville, FL
Philip Fanapour, DO
Critical Care Medicine Fellow Department of Anesthesiology University of Florida Gainesville, FL
Larry Field, MD
Associate Professor Department of Anesthesia and Perioperative Medicine Medical University of South Carolina Charleston, SC
Babar Fiza
Clinical Lecturer Department of Anesthesiology University of Michigan Ann Arbor, MI
Andrew Franklin, MD, MBA
Monroe Carell Jr. Children’s Hospital at Vanderbilt Nashville, TN
John J. Freely Jr., MD
Department of Anesthesiology Greenville Hospital System Greenville, SC
Michael Gropper, MD
Professor and Chair Department of Anesthesiology University of California San Francisco San Francisco, CA
Maribeth Guletz, MD
Clinical Fellow in Anesthesia Harvard Medical School Anesthesia Resident Department of Anesthesia, Critical Care, and Pain Medicine Massachusetts General Hospital Boston, MA
Rajnish K. Gupta, MD
Associate Professor of Anesthesiology Division of Multispecialty Adult Anesthesiology Vanderbilt University Medical Center Nashville, TN
William R. Hand, MD
Associate Professor Department of Anesthesia and Perioperative Medicine Medical University of South Carolina Charleston, SC
Doris M. Hardacker, MD
Associate Professor of Clinical Anesthesia Indiana University School of Medicine Indianapolis, IN
James Hardy, MBBS, BSc
Sta Anesthesiologist Northern California Anesthesia Physicians California Pacic Medical Center San Francisco, CA
Marc Hassid, MD
Assistant Professor Department of Anesthesia and Perioperative Medicine Medical University of South Carolina Charleston, SC
CONTRIBUTORS XV
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Joy L. Hawkins, MD
Professor of Anesthesiology Director of Obstetric Anesthesia University of Colorado School of Medicine Aurora, CO
Christopher L. Heine, MD
Assistant Professor of Anesthesia and Perioperative Medicine Medical University of South Carolina Charleston, SC
Mark Henry, MD
Cardiothoracic Anesthesiology Fellow Department of Anesthesiology Vanderbilt University Medical Center Nashville, TN
Mark A. Henry, MD
Fellow in Critical Care Medicine Department of Anesthesiology Division of Critical Care Vanderbilt University Nashville, TN
Nichole D. Horn, MD
Assistant Professor of Anesthesia Indiana University School of Medicine Indianapolis, IN
Leslie Jameson, MD
Associate Professor Department of Anesthesiology University of Colorado School of Medicine Aurora, CO
Alison M. Jeziorski, MD, MBA
Assistant Professor Department of Anesthesia and Perioperative Medicine Medical University of South Carolina Charleston, SC
Rachel M. Kacmar, MD
Assistant Professor Department of Anesthesiology University of Colorado School of Medicine Aurora, CO
Nayema Khan, MD
Department of Anesthesia Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Boston, MA
Shannon Kilkelly, DO
Assistant Professor Department of Anesthesiology Vanderbilt University Medical Center Nashville, TN
Nathaniel N. Hsu, MD
Department of Anesthesiology and Critical Care University of Pennsylvania Philadelphia, PA
Christopher G. Hughes, MD
Associate Professor of Anesthesiology and Critical Care Medicine Department of Anesthesiology Division of Critical Care Medicine Vanderbilt University School of Medicine Nashville, TN
Romina G. Ilic, MD
Sta Anesthesiologist Beth Israel Deaconess Medical Center Clinical Instructor Harvard Medical School Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Boston, MA
Adam J. Kingeter, MD
Department of Anesthesiology Vanderbilt University Medical Center Nashville, TN
Ko Kla, MD
Assistant Professor of Clinical Anesthesiology Department of Anesthesiology Vanderbilt University Medical Center Nashville, TN
Patrick B. Knight, MD
Department of Anesthesiology Vanderbilt University Medical Center Nashville, TN
Eleni Kotsis, DO
Obstetric Anesthesiology Fellow Department of Anesthesiology University of Pittsburgh School of Medicine Magee- Womens Hospital of the University of Pittsburgh Medical Center Pittsburgh, PA
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Avinash B. Kumar, MD, FCCM, FCCP
Associate Professor Associate Fellowship Director Department of Anesthesiology Division of Critical Care Vanderbilt University Nashville, TN
James M. Kynes, MD
Assistant Professor of Anesthesiology Department of Anesthesiology Vanderbilt University Medical Center Nashville, TN
Elizabeth M. S. Lange, MD
Department of Anesthesiology Northwestern University, Feinberg School of Medicine Chicago, IL
Angela Lee, MD
Fellow Department of Anesthesiology Columbia University College of Physicians and Surgeons New York, NY
Jack Louro, MD
Assistant Professor of Clinical Anesthesiology University of Miami Health System Miami, FL
Grant C. Lynde, MD, MBA
Associate Professor of Anesthesiology Chief, Division of Practice and Process Improvement Department of Anesthesiology Emory University Atlanta, GA
Pirjo H. Manninen, MD, FRCPC
Department of Anesthesia Toronto Western Hospital Toronto, Canada
Gavin Martin, MB, ChB
Professor of Anesthesiology and Division Chief Division of Orthopaedics, Plastics, and Regional Anesthesiology Department of Anesthesiology Duke University Medical Center Durham, NC
Lorri A. Lee, MD
Professor Departments of Anesthesiology and Neurological Surgery Vanderbilt University Medical Center Nashville, TN
Yafen Liang, MD
Assistant Professor of Anesthesiology Division of Cardiothoracic Anesthesiology Vanderbilt University Medical Center Nashville, TN
Grace Lim, MD
Assistant Professor Department of Anesthesiology University of Pittsburgh School of Medicine Magee- Womens Hospital of the University of Pittsburgh Medical Center Pittsburgh, PA
Steven Lipman, MD
Clinical Associate Professor Department of Anesthesia Stanford University School of Medicine Stanford, CA
C. LaToya Mason, MD
Associate Professor Department of Anesthesiology Division of Obstetric and Gynecologic Anesthesiology Baylor College of Medicine Houston, TX
Letha Matthews, MBBS
Associate Professor of Clinical Anesthesiology Division of Multispecialty Anesthesiology Clinical Director Division of Neuroanesthesiology Vanderbilt University Medical Center Nashville, TN
Tracy McGrane, MD, MPH
Assistant Professor Vanderbilt University Medical Center Nashville, TN
Emily McQuaid- Hanson
Obstetric Anesthesiology Fellow Department of Anesthesiology Massachusetts General Hospital Boston, MA
CONTRIBUTORS XVII
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Julia Metzner, MD
Departments of Anesthesiology and Pain Medicine and Neurological Surgery University of Washington Seattle, WA
Jill M. Mhyre, MD
Associate Professor Department of Anesthesiology University of Arkansas for Medical Sciences Fayetteville, AR
Rebecca Minehart, MD, MSHPEd
Assistant Professor in Anesthesia Harvard Medical School Assistant Residency Program Director Obstetric Anesthesia Fellowship Program Director Department of Anesthesia, Critical Care, and Pain Medicine Massachusetts General Hospital Boston, MA
John D. Mitchell, MD
Residency Program Director Department of Anesthesia, Critical Care, and Pain Medicine Beth Israel Deaconess Medical Center Associate Professor of Anesthesia Harvard Medical School Boston, MA
Vivek Moitra, MD, FCCM
Associate Professor Department of Anesthesiology Columbia University College of Physicians and Surgeons New York, NY
Richard C. Month, MD
Assistant Professor of Clinical Anesthesiology Department of Anesthesiology and Critical Care University of Pennsylvania Philadelphia, PA
Laurel E. Moore, MD
Associate Professor Department of Anesthesiology University of Michigan Health System Ann Arbor, MI
Noreen E. Murphy, MD
Anesthesiology Resident University of Wisconsin Hospital and Clinics Madison, WI
Anne Newcomer, MD
Clinical Fellow Department of Anesthesiology University of California San Francisco San Francisco, CA
Aaron Mittel, MD
Clinical Fellow in Anesthesia Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA
K. Annette Mizuguchi, MD, PhD, MMSc
Associate Clinical Professor Department of Anesthesiology University of California San Diego, California
Daria M. Moaveni, MD
Assistant Professor of Clinical Anesthesiology Department of Anesthesiology, Perioperative Medicine, and Pain Management University of Miami, Miller School of Medicine Jackson Memorial Hospital Miami, FL
Ju- Mei Ng, FANZCA
Assistant Professor Harvard Medical School Sta Anesthesiologist Department of Anesthesiology, Perioperative and Pain Medicine Brigham Women’s Hospital Boston, MA
Alexandria N. Nickless, DO
Sta Anesthesiologist Allegheny Health Network Pittsburgh, PA
Heather C. Nixon, MD
Department of Anesthesiology University of Illinois Hospital and Health Sciences System Chicago, IL
XVIII CONTRIBUTORS
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Richard J. Novak, MD
Adjunct Clinical Associate Professor of Anesthesia Department of Anesthesia, Perioperative and Pain Medicine Stanford University Stanford, CA
Mark E. Nunnally, MD
Director, Adult Critical Care Services Department of Anesthesiology, Perioperative Care, and Pain Medicine NYU Langone Medical Center New York, NY
Jason B. O’Neal, MD
Cardiothoracic Anesthesiology Fellow Department of Anesthesiology Vanderbilt University Medical Center Nashville, TN
Jennifer Oliver, DO, MPH
Brigham and Women’s Hospital Boston, MA
Jerey J. Pasternak, MD
Associate Professor of Anesthesiology Mayo Clinic College of Medicine Rochester, MN
John Pawlowski, MD, PhD
Director Department of Anesthesia, Critical Care, and Pain Medicine Division of oracic Anesthesia Beth Israel Deaconess Medical Center Assistant Professor Harvard Medical School Boston, MA
Feyce Peralta, MD
Assistant Professor of Anesthesiology Northwestern University Chicago, IL
Jagan Ramamoorthy, MD
Assistant Professor of Anesthesiology University of Wisconsin Hospital and Clinics Madison, WI
Amanda T. Redding, MD
Assistant Professor Department of Anesthesia and Perioperative Medicine Medical University of South Carolina Charleston, SC
Michael G. Richardson, MD
Associate Professor of Anesthesiology Vanderbilt University School of Medicine Nashville, TN
Amy Robertson, MD
Assistant Professor of Anesthesiology Vanderbilt University School of Medicine Nashville, TN
Michelle Sher Rovner, MD
Assistant Professor Department of Anesthesia and Perioperative Medicine Medical University of South Carolina Charleston, SC
Philip Rubin, MD
Assistant Professor of Anesthesiology Yale School of Medicine New Haven, CT
Michael Sabbagh, MD, MBA, FAAP
Assistant Professor Department of Anesthesia and Perioperative Medicine Medical University of South Carolina Charleston, SC
Uma Sasso, MD
Assistant Professor Department of Anesthesiology Ohio State University Columbus, OH
Joseph J. Schlesinger, MD
Assistant Professor of Anesthesiology Critical Care Medicine Vanderbilt University Medical Center Sta Physician Anesthesiology Service— Surgical Critical Care VA Tennessee Valley Healthcare System Nashville, TN
CONTRIBUTORS XIX
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