Transcript Emergency_Procedures

Emergency Procedures
The Surgical Technologist’s
Responsibilities During Emergencies
in the O.R. Setting.
Blood Loss
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Blood loss is monitored intra-operatively to
aid in determining the need for the patient
to receive a blood transfusion
Suction canisters have measurements on
them so that an estimated blood loss (EBL)
can be determined
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The surgical technologist should keep close
track of the amount of irrigation fluid being
used
This information is used to calculate the
amount of blood the patient has lost
The irrigation used is subtracted from the
total amount in the canister and this gives a
more accurate amount of blood loss
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In some cases the circulator may weigh the
sponges that have been removed from the sterile
field to give another blood loss estimate
This method is rarely used and would be
calculated by the circulator
Average blood loss can be estimated for a
saturated lap sponge at 100ml per lap
Saturated laps should be squeezed out into a bowl
or over the suction tip and fluid suctioned into the
cell saver if one is available or off table suction
canister
Blood Replacement
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When blood loss is to great to be controlled
by intra-operative hemostatic control alone,
blood replacement therapies are in order,
but blood loss must still be controlled
Blood replacement involves the
administration of whole blood or blood
components such as plasma, packed red
blood cells, or platelets via an IV
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This is used to increase the circulating
blood volume, to increase the number of
red blood cells, and to provide plasma and
platelet clotting factors that have been
depleted during surgery as a result of blood
loss
Blood Products
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Blood product may be either homologous (donated by
another person) or autologous (donated previously by the
patient and stored for surgical use)
Autotransfusion is the use of the patients own blood,
which has been processed for reinfusion
Cell Savers used intraoperatively are another method
employed in major surgeries where a large amount of
blood loss is anticipated
Cell savers suction like a traditional suction, anticoagulate
the blood (Heparin drip employed as part of suction
tubing), filter the blood being suctioned into a reservoir,
and it is readministered to the patient at the anesthesia
person’s or surgeon’s discretion
Cell Saver Contraindications
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Cell savers should not have the following fluids
suctioned into the reservoir as the solutions are
damaging to red blood cells:
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Bacitracin (lyses cells) and topical hemostatic agents
such as Thrombin (coagulates cells)
Or deadly to the patient if infused intravenously
into their system:
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Amniotic fluid, presence of malignant cells, fecal
material present from a perforated bowel, presence of
infection
Hemolytic Transfusion Reactions
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If blood is not properly matched prior to
transfusion a hemolytic transfusion
reaction or hemolytic anemia, may develop
This may result from Rh incompatibility
from mismatched blood transfusions
Severe hemolytic reactions can be fatal and
must be treated immediately
The Conscious Patient
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May exhibit fatigue and complain of lack of
energy
The patient may experience rapid pulse, shortness
of breath, and pounding of the heart
The skin may appear jaundiced and pallor may be
exhibited, especially in the palms of the hands
Pallor- an unnatural paleness or absence of color
in the skin
The Patient Under General
Anesthesia
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Will not show these signs, and the only
signs noted may be a generalized diffuse
loss of blood and a lowered blood oxygen
saturation level due to the inability of the
red blood cells to carry oxygen
If a hemolytic transfusion
reaction is suspected,
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The transfusion should be immediately
stopped and a blood sample sent to the
blood bank to rule out a mismatch
Appropriate drug therapies will be started
by anesthesia persons
Cardiopulmonary Resuscitation
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Every healthcare professional should be
familiar with the technique of CPR, that is,
manually providing chest compressions
and ventilations to patients in cardiac arrest
in an effort to provide oxygenated blood to
the brain and vital organs
As a CST you will certify in CPR every
year or two
ABC’s of CPR
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Airway- open and free of foreign bodies
Breathing- artificial breathing is done until
natural breathing is restored
Circulation- chest compressions are given
in place of natural pulse (80 to 100 beats
per minute for adult)
Cardiac Arrest in the O.R.
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The primary responsibility of the CST is to
protect the sterile field
The CST should remain sterile and should keep
the tables and the operative area sterile
The surgical wound should be packed & covered
with a sterile drape
It is also the CST’s responsibility to keep track of
all instruments, sponges, & needles
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Pay careful attention to the needs of the
surgeon
When CPR must be performed through the
sterile field, sterile team members should
perform whatever procedures are necessary
(e.g., open chest heart massage)
Sterility may become secondary to
lifesaving procedures
Malignant Hyperthermia (MH)
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Is a life threatening, acute pharmacogenetic
disorder, that occurs during or after anesthesia
Characterized by a rapid increase in body
temperature, unexplained tachycardia, unstable
blood pressure, muscle rigidity, tachypnea, &
cyanosis
Body temperature may rise to over 46C or 114F
MH
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Is usually triggered by an anesthetic gas such as
Halothane, Enflurane, or Isoflurane
It may also may be triggered by a muscle relaxant
such as Succinylcholine (Anectine)
Succinlycholine (“succs” for short) short is the
only depolarizing muscle relaxant in use today
The rapid increase in body temperature is due to
an increase in the metabolic state, caused by an
inherited defect in the muscles of the skeletal
system of some patients
MH
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The most obvious sign to the CST will be
total body rigidity
Treatment of MH
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At the first sign of masseter spasm, or jaw
muscle tightness, the anesthesia provider
will stop the administration of triggering
anesthetic agents & deepen the anesthesia
using opioids, barbiturates, or propofol
Every hospital has its own protocol for
dealing with the crisis
The CST should be familiar with the
protocol in order to anticipate emergency
needs of the surgeon
MH
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In the case of a sudden, intense, &
unanticipated attack, the surgery may need
to be stopped as soon as possible
Treatment includes packing the patient in
ice, circulating ice water through a
nasogastric tube, & irrigating the open
abdominal wound with chilled irrigation
fluids
MH treatment
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DANTROLENE is the drug of choice in
treating the hypermetabolism
Steroids & diuretics may also be
administered
Ventilation will be adjusted to compensate
for the increased end tidal CO2
100% oxygen will be administered
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Since surgery may need to be stopped as
soon as possible in order to focus attention
on dealing with the MH crisis, the CST
must be prepared to anticipate the needs of
the surgeon for quick closure and/ or
actions within the sterile field to assist in
cooling the patient
Emergency medical services
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In the emergency department of the
hospital, nurses triage, or sort and classify
patients in order of need for immediate
medical attention
Emergency physicians then assess which
patients may be treated in the E.R. or on
the medical wards of the hospital and
which need emergency surgery
Indications of emergency
situations
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The CST is frequently called on to work in
emergency surgery situations or to react
appropriately when the elective surgery
becomes an emergency
The CST must be able to anticipate
emergency situations & to prepare for them
in advance
This skill comes with experience
The entry level CST
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Should be able to recognize an emergency
situation when it occurs
Indicators such as - rapidly dropping blood
pressure, cardiac dysrhythmia, & any vital
signs out of normal range provide the
surgical team with information about
impending emergent situations
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Some emergencies occur suddenly, with
little or no warning, such as rapid
hemorrhaging (hypovolemia)
It is important that the entire surgical team
react in a calm & quick fashion
Prior to surgery, the surgeon or anesthesia
provider should be notified immediately if
any of these indicators occur
Indicators of emergency
situations
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Difficulty breathing
Chest pain
Changes in skin color or
temperature
Changes in vital signs
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Open bleeding wounds or
visible punctures not
indicated on the patients
chart
Inability to move an
extremity
Misshapen / misaligned
body part
Disorientation or
confusion
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The surgeon and anesthesia provider will
assess the situation & will provide
instruction on how the team should proceed
Objectives & priorities in
emergency situations
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The objective of emergency care &
emergency & trauma surgery is to preserve
life, to prevent further deterioration of the
patient’s condition, and to provide
whatever care necessary to restore the
patient to his or her previous lifestyle
Most commonly seen
emergencies in the O.R.
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Syncope- sudden loss of consciousness
Convulsions/ seizures- disturbances of
nervous system function resulting from
abnormal electrical activity of the brain
The primary duty of the surgical team,
including the CST, is to protect the patient
from injury
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Anaphylactic reactions- An exaggerated
allergic reaction to a substance or protein
Substances most likely to cause a reaction
are drugs such as local anesthetics,
codeine, antibiotics, animal derived drugs
such as insulin, contrast media & in some
cases the latex found in surgical gloves &
foley catheters
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A patient suffering a reaction generally
first shows only mild inflammatory
symptoms such as itching, swelling, & in
some cases, difficulty breathing
As the reaction progresses, the patient
experiences further difficulty breathing due
to bronchospasm & laryngeal edema
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During an anaphylactic reaction, the
surgical team must maintain the airway and
provide supplemental oxygen or the patient
may die of respiratory failure
The symptoms of vascular collapse must
also be treated to prevent death from
cardiovascular failure
EPI
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Epinephrine is the first line drug in the treatment
of a severe anaphylactic reaction
Epi causes bronchodilation, therby reducing
laryngeal spasm
It also raises heart rate and raises blood pressure
Because an anaphylactic reaction occurs so
quickly & can so often lead to death, it is
important that it be avoided altogether by
identifying patient allergies
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Allergy information must be available to
the entire surgical team
This lowers the risk of provoking an
anaphylactic reaction
Allergies should be marked on the chart &
on patients ID bracelet
Any history of previous reactions should be
noted in the chart
Impending cardiac arrest
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Warning signs a CST should be able to recognize
in order to anticipate emergent needs
Chest pain(in awake pt.)
Unstable blood pressure
Tachycardia
Cardiac dysrhythmia
Respiratory changes
Hypovolemia
Laryngospasm (anesthesia having difficulty
ventilating the patient)
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Remember:
The primary responsibility of the STSR
in any emergency is to:
MAINTAIN THE STERILE FIELD