• Acute HypertensionSustained high blood pressure refractory to treating reversible causes Hypertensive Blood Pressure Range Age (yr) · Systolic · Diastolic newborn · > 97 · > 70 1-3 · > 105 · > 61 4-12 · > 113 · > 86
• Air EmbolismClinical diagnosis, may have: ↓ EtCO2 ↓ SaO2 ↓ BP mill-wheel murmur More likely if surgical site above heart or air in IV line
• AnaphylaxisMay have: Hypotension Rash Bronchospasm Common Causative Agents: Neuromuscular blockers Antibiotics Contrast dye Latex Chlorhexidine IV colloids Sugammadex
• Anterior Mediastinal MassHigh Risk Factors Etiology: Hodgkin’s and non-Hodgkin’s lymphoma Clinical signs: Orthopnea, upper body edema, stridor, wheezing Imaging findings: Tracheal, bronchial, carinal, or great vessel compression SVC or RVOT obstruction Ventricular dysfunction Pericardial effusion Anesthetic Plan Perform surgery under local anesthesia, if possible Pre-treat with irradiation or corticosteroids Maintain spontaneous ventilation and avoid paralysis Ensure availability of fiberoptic and rigid bronchoscope Cardiopulmonary bypass or ECMO Type and cross and sternal saw (for surgeons) available
• BradycardiaAge · HR < 30 days · < 100 ≥ 30 days < 1 yr · < 80 ≥ 1 yr · < 60
• BronchospasmMay have: ↓ EtCO2 Upslope stage III EtCO2 ↑ airway pressures ↓ SpO2
• Cardiac ArrestNo pulse or HR < 60 beats per minute with poor perfusion despite effective ventilation with oxygen
• Difficult AirwayDifficult Airway
• Fire: AirwayFire: Airway
• Fire: OR (non-airway)Fire: OR (non-airway)
• HyperkalemiaVerify Hyperkalemia. May have: K+>6 ECG changes: Tall peaked T waves Prolonged PR Wide QRS Heart block Sine wave V fib or asystole Causes of Hyperkalemia: Excessive intake: massive or “old” blood products, TPN, cardioplegia, KCl infusion Shift of K+ from tissues to plasma: crush injury, burns, succinylcholine, malignant hyperthermia, acidosis Inadequate excretion: renal failure Pseudohyperkalemia: hemolyzed sample, thrombocytosis, leukocytosis
• HypotensionSustained low blood pressure with patient at risk for end-organ hypoperfusion, typically > 20% below baseline Age · BP (mmHg)* Infant · MAP 30 or post-conceptual age in weeks 3 mo - 1 yr · 65 - 68 · < 5th% Systolic BP 1 - 3 yr · 68 - 74 4 - 12 yr · 70 - 85 > 12 yr · 85 - 92 * Numbers are only a guide and vary for individual patients and situations
• Hypoxia↓ SpO2
• Increased Intracranial PressureICP > 20 or too high for situation (discuss with neurosurgeon)
• LaryngospasmMay have: Inspiratory Stridor Accessory Muscle Use Sternal Retraction Paradoxical Chest Movement Airway Obstruction ↓ SpO2 ↓ HR Loss of EtCO2
• Local Anesthetic Systemic ToxicityMay have: CNS symptoms (may not occur): Tinnitus Metallic taste Seizures CV collapse: Rhythm disturbance Altered consciousness
• Loss of Evoked PotentialsManagement of signal changes during spine surgery
• Malignant HyperthermiaHypermetabolism: ↑ Temperature ↑ HR ↑ CO2 Acidosis
• Massive HemorrhageOngoing bleeding and/or replacement > half total blood volume (TBV) per hour or TBV < 24 hours
• MATERNAL Postpartum HemorrhageLoss of > 500mL after vaginal birth, or > 1,000mL after cesarean delivery
• Myocardial IschemiaRecognition ST depression >0.5 mm in any lead ST elevation >1 mm (2mm in precordial leads) Flattened or inverted T waves Arrhythmia: VF, VT, ventricular ectopy, heart block Diagnostic studies 12-lead ECG: II, III, aVF for inferior (RCA) V5 for lateral ischemia (LCx) V2, V3 anterior ischemia (LAD) Compare to previous ECGs Request Pediatric Cardiology consult and echocardiogram
• Pulmonary Hypertensive CrisisAcute ↓ BP, ↓ EtCO2, ↑ CVP ↓ O2 saturation, may not be immediate in the absence of an intracardiac communication ↑ airway pressures due to pulmonary artery distension & compression of small intrapulmonary airways ↑ V/Q mismatch & Vd/Vt with subsequent hypoxemia due to ↓ pulmonary blood flow & small airway compression RV diastolic hypertension → reduced LV filling and ↓ cardiac output Bradycardia → Hypotension → Cardiac arrest
• Status EpilepticusPersistent seizures
• Tachycardia, Unstable/SVTTachycardia associated with hypotension. Typically: Infant ≥ 220 bpm Child ≥ 180 bpm
• Tamponade, CardiacBeck’s Triad: muffled heart tones, distended neck veins, decreased systolic blood pressure. Pulsus Paradoxus: cyclic inspiratory decrease in systolic BP of more than 10mmHg Electrical Alternans: cyclic alteration in magnitude of p waves, QRS complex & t-waves Typical presentation of acute tamponade = sudden HYPOTENSION, TACHYCARDIA & tachypnea; patient may be unable to lie flat.
• Tension PneumothoraxMay see: Unilateral breath sounds ↑ HR ↓ SpO2 ↓ BP Tracheal deviation Mediastinal shift
• Transfusion ReactionsReactions may occur with any type of product. Important to determine type of reaction. Types are: Hemolytic Transfusion Reaction Signs: Hemoglobinemia, hemoglobinuria, DIC, ↓ BP, ↑ HR, bronchospasm Non-Hemolytic Transfusion Reaction Signs: ↓ BP, bronchospasm, pulmonary edema, fever, rash Anaphylactic Transfusion Reaction For Treatment steps, click: Tx Signs: Erythema, urticaria, angioedema, bronchospasm, tachycardia, shock
• TraumaInitial management of trauma, follow ATLS