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Thea
tre
Che
cklis
ts -
Rou
tine
& E
mer
genc
yTi
m L
eeuw
enbu
rg F
AC
RR
MK
anga
roo
Isla
nd, S
outh
Aus
tral
ia
Thea
tre
Che
cklis
ts -
Rou
tine
& E
mer
genc
yTi
m L
eeuw
enbu
rg F
AC
RR
MK
anga
roo
Isla
nd, S
outh
Aus
tral
ia
Alth
ough
not
a fa
n of
‘coo
kook
med
icin
e’, t
here
is n
o do
ubt t
hat c
heck
lists
can
hel
p el
imin
ate
sim
ple
erro
rs o
r ove
rsig
ht in
eve
n th
e m
ost e
xper
ienc
ed d
octo
r - p
artic
ular
ly w
hen
task
-lo
aded
in a
n em
erge
ncy.
Thes
e ch
eckl
ists
& a
ide
mem
oire
s ha
ve b
een
com
pile
d fro
m a
var
iety
of s
ourc
es to
be
used
in th
eatre
or E
D b
oth
rout
inel
y an
d in
an
evol
ving
cris
is.
Sour
ces
Aust
ralia
n R
esus
cita
tion
Cou
ncil
- ww
w.re
sus.
org.
auD
ifficu
lt Ai
rway
Soc
iety
UK
- ww
w.da
s.uk
.com
Nat
iona
l Pat
ient
Saf
ety
Foun
datio
n - w
ww.
apsf
.net
.au
EMERGENCY CHECKLISTS
2013 version
Tim LeeuwenburgKangaroo Island
RAPID SEQUENCE INTUBATION
DIFFICULT AIRWAY ALGORITHM
UNEXPLAINED HYPOXIA
ELEVATED or DECREASED ETCO2
ELEVATED AIRWAY PRESSURES
SEVERE HYPO- or HYPERTENSION
MAJOR HAEMORRHAGE
BRADYCARDIA
TACHYCARDIA
CARDIAC ARREST
MYOCARDIAL ISCHAEMIA
ANAPHYLAXIS
OBESE / ASTHMA / DSI
GENERAL PRINCIPLES
MALIGNANT HYPERTHERMIA
TURP SYNDROME
OBSTETRIC ANAESTHESIA
OBSTETRIC CRISIS
INFUSION PROTOCOLS
DRUG FORMULARY
PRIN
CIPL
ES O
F CR
ISIS
MAN
AGEM
ENT
KNO
W, M
ODI
FY a
nd O
PTIM
ISE
THE
ENVI
RONM
ENT
ANTI
CIPA
TE a
ndPL
AN F
OR
A CR
ISIS
ENSU
RE L
EADE
RSHI
P an
dRO
LE C
LARI
TY
COM
MUN
ICAT
EEF
FECT
IVEL
Y
CALL
FO
R HE
LP o
rSE
COND
OPI
NIO
N EA
RLY
ALLO
CATE
ATT
ENTI
ON
and
USE
AVAI
LABL
E IN
FORM
ATIO
N
DIST
RIBU
TE W
ORK
LOAD
and
USE
AVAI
LABL
E RE
SOUR
CES
esta
blis
h pr
otoc
ols
and
proc
edur
esen
sure
room
set
up
is c
ondu
cive
to c
risis
- la
yout
, equ
ipm
ent e
tcho
w c
an th
ings
be
impr
oved
(thi
s in
clud
es e
quip
men
t)
patie
nt -
proc
edur
e - e
quip
men
t - d
rugs
- pe
rson
nel -
retri
eval
- glo
bal p
lans
- spe
cific
pla
ns
assi
gn le
ader
pref
erab
ly n
ot re
spon
sibl
e fo
r tas
ks ie
: has
an
over
view
of t
he s
ituat
ion
lead
er d
ecid
es, p
riorit
ises
and
ass
igns
task
s to
team
lead
ersh
ip a
nd fo
llow
ersh
ip a
ided
by
clea
r com
mun
icat
ion
eye
cont
act,
use
nam
es, c
lear
inst
ruct
ions
, ens
ure
unde
rsta
ndin
g an
d re
port
back
clos
e th
e lo
op -
upst
ream
/dow
nstre
am c
omm
unic
atio
n
call
for h
elp
early
- ev
en if
not
in a
cris
isse
cond
opi
nion
may
be
reas
sura
nce
enou
gh o
r sug
gest
alte
rnat
ives
avoi
d th
erap
eutic
iner
tia
fixat
ion
erro
rs c
omm
onbe
war
e at
tent
iona
l tun
nellin
g / s
ituat
iona
l ove
rload
if yo
u ar
e st
ress
ed y
ou a
re li
kely
to b
e m
issi
ng s
omet
hing
mai
ntai
n si
tuat
iona
l aw
aren
ess
dele
gate
task
s, u
se e
xter
nal r
esou
rces
(tel
emed
icin
e/re
triev
al)
if al
l els
e fa
ils, t
hink
late
rally
- im
prov
ise/
adap
t/ove
rcom
e
COVE
R AB
CD -
A Sw
ift C
heck
SCAN
BP, H
R, R
hyth
m, E
TCO
2Sp
O2,
Col
our
FiO
2, R
otam
eter
,O
2 an
alys
er m
atch
es F
iO2
Vent
ilatio
n - R
R, T
VVa
poris
er &
Mix
ETT
posit
ion
& se
curit
yAb
le to
Elim
inat
e (b
ag)?
Revie
w m
onito
rs, u
pdat
e re
cord
s, re
view
equi
pmen
t
Airw
ay p
ositio
n, p
aten
t?Di
stan
ce in
cm
Brea
thin
g pa
ttern
OK?
Circ
ulat
ion
- tre
nds,
flui
ds
and
bloo
d lo
ss
Drug
s gi
ven
& ap
prop
riate
resp
onse
?
Awar
enes
s - P
atie
nt
Asle
ep, S
elf O
K?
C O V E R A B C D ASW
IFT
CHEC
KPr
ogre
ss o
f Sur
geon
and
of O
pera
tion
CHEC
K
Radi
al p
ulse
, cor
rela
te,
SPO
2 di
slodg
ed?
Incr
ease
FiO
2, w
atch
MAC
Chec
k cir
cuit
& va
poris
er,
vent
ilate
by
hand
Dist
ance
in c
m?
Kink
ed?
Bag
and
O2
avai
labl
e?
Revie
w m
onito
rs, r
evie
w eq
uipm
ent -
any
cha
nges
?
Obs
erve
& p
alpa
te n
eck,
ET
T po
sitio
n, c
uff
Obs
erve
, pal
pate
&
ausc
ulta
te c
hest
. ETC
O2?
Cros
s ch
eck
BP, I
V, lo
sses
&
resp
onse
to R
x/su
rger
y
Chec
k dr
ugs
(erro
r?) a
nd
pate
ncy
IV lin
e. F
lush
ed?
Awar
enes
s, A
ir Em
bolis
m,
Anap
hyla
xis, A
ir in
Ple
ura?
Que
stio
n su
rgeo
n,re
view
old
Note
s
Allo
cate
role
s - I
V ac
cess
Arre
st tr
olle
y
FiO
2 10
0%M
aint
ain
anae
sthe
sia?
Self-
infla
ting
bag,
turn
off
vapo
riser
(use
pro
pofo
l?)
Switc
h ET
T or
use
LM
AEl
imin
ate
circu
it/m
achi
ne
Emer
genc
y Eq
uipm
ent
RETR
IEVA
L?
Bron
chos
pasm
, Oed
ema,
Hypo
xia, H
ypov
entila
tiion
Drug
erro
r? A
ntid
ote?
ANAP
HYLA
XIS?
Awar
enes
s, A
ir Em
bolis
m,
Anap
hyla
xis, A
ir in
Ple
ura?
Notif
y Su
rgeo
n
& M
obilis
e St
aff
EMER
GEN
CY
LARG
E BO
RE IV
s,
FLUI
DS, D
EFIB
, DRU
GS
HIG
H FL
OW
OXY
GEN
AVO
ID A
WAR
ENES
S
VENT
ILAT
E BY
BAG
ENSU
RE E
TT P
LACE
DO
R AL
TERN
ATIV
E
DELE
GAT
E O
PERA
TIO
N O
F EQ
UIPM
ENT
ADDR
ESS
HYPO
XIA,
HY
POVE
NTIL
ATIO
N
ATRO
PINE
10m
cg/k
gAD
RENA
LINE
10m
cg/k
g
MAI
NTAI
N SI
TUAT
IONA
LAW
AREN
ESS
DEFI
NITI
VE S
URG
ERY
OTH
ER C
RISI
S?
ALER
T/RE
ADY
Hypo
/Hyp
erte
nsio
nAr
rhyt
hmia
, Arre
st A
lgor
ithm
Aspi
ratio
n, L
aryn
gosp
asm
Obs
truct
ion,
ETT
/LM
AAI
RWAY
PAT
ENT
& PR
OTE
CTED
CRYS
TALL
OID
, BLO
OD
VASO
PRES
SORS
, CPR
Colo
ur, C
ircul
atio
n, C
apno
grap
hy
Oxy
gen
Supp
ly &
O2
Anal
yser
Vent
ilatio
n &
Vapo
riser
s
ETT
tube
& E
limin
ate
Mac
hine
Revie
w - M
onito
rs &
Equ
ipm
ent
Airw
ay (f
ace
or la
ryng
eal m
ask)
, m
eticu
lous
atte
ntio
n to
ETT
Brea
thin
g (S
V/IP
PV)
Circ
ulat
ion,
IV, B
lood
loss
, ECG
Drug
s - c
onsid
er a
ll give
n &
not
give
n, c
heck
em
erge
ncy
drug
s
Be A
ware
of A
ir an
d Al
lerg
y
Chec
k Pa
tient
, Sur
geon
,Pr
oces
ses
& Re
spon
ses
SCAR
E
Nur
se &
Ana
esth
etis
t!!
!!
N
urse
, Sur
geon
& A
naes
thet
ist!
!!
N
urse
, Sur
geon
& A
naes
thet
ist
SAFE
SUR
GER
Y CH
ECKL
IST
BEFO
RE IN
DUCT
ION
BEFO
RE IN
CISI
ON
BEFO
RE L
EAVE
OT
Has
patie
nt c
onfir
med
iden
tity,
site
, su
rger
y an
d co
nsen
t?
Yes
Is th
e su
rgic
al s
ite m
arke
d?
Yes
Not
app
licab
le
Is th
e an
aest
hetic
mac
hine
& m
edic
atio
n ch
eck
com
plet
e?
Yes
Are
puls
e ox
imet
er, B
P &
ECG
on
the
patie
nt, f
unct
ioni
ng &
acc
epta
ble?
Yes
Snap
shot
take
n?
Does
the
patie
nt h
ave
a kn
own
alle
rgy?
No
Y
es
Diffi
cult
airw
ay o
r asp
iratio
n ris
k?
No
Y
es &
equ
ipm
ent/h
elp
avai
labl
e
Risk
> 5
00m
l blo
od lo
ss (7
ml/k
g ch
ildre
n)?
No
Y
es &
2 IV
s si
ted,
blo
od a
vaila
ble
Confi
rm a
ll te
am m
embe
rs n
ame
& ro
le
Yes
Confi
rm p
atie
nt n
ame
& na
ture
of s
urge
ry
Yes
Not
app
licab
le
Confi
rm a
ntib
iotic
pro
phyl
axis
giv
en
Yes
ANTI
CIPA
TED
CRIT
ICAL
EVE
NTS
To S
urge
on
Wha
t are
crit
ical
or n
on-ro
utin
e st
eps?
H
ow lo
ng w
ill ca
se ta
ke?
Antic
ipat
ed b
lood
loss
?
To A
naes
thet
ist?
Any
patie
nt-s
peci
fic c
once
rns?
Eyes
tape
d, p
ress
ure
poin
ts p
rote
cted
?
To N
ursi
ng T
eam
Has
ste
rility
bee
n co
nfirm
ed?
Any
equi
pmen
t iss
ues
or a
ny c
once
rns?
Is a
ppro
pria
te im
agin
g di
spla
yed?
Nurs
e ve
rbal
ly c
onfir
ms
:
Nam
e of
the
proc
edur
e
Equi
pmen
t, sp
onge
& s
harp
cou
nts
corre
ct
Spec
imen
s la
belle
d?
Any
equi
pmen
t iss
ues
aris
ing?
To s
urge
on, a
naes
thet
ist &
nur
se
Wha
t are
the
key
conc
erns
for t
his
patie
nt in
re
cove
ry a
nd o
ngoi
ng m
anag
emen
t?
Reco
very
sta
ff
Patie
nt a
wak
e &
adeq
uate
ven
tilat
ion?
Dru
g ch
art c
ompl
eted
?
Antib
iotic
s an
d an
alge
sia
addr
esse
d?
DVT
thro
mbo
prop
hyla
xis?
Res
pons
ible
Doc
tor i
dent
ified
& a
vaila
ble?
STAR
T HE
RE
Ask
‘who
will
be
team
lead
er’ &
then
per
form
a s
yste
mat
ic c
heck
of e
ach
of fo
llow
ing
RAPI
D SE
QUE
NCE
INTU
BATI
ON
STAR
T HE
RE
Med
icat
ions!!
Norm
oten
sive
Dos
e!Hy
pote
nsiv
e Do
se
Keta
min
e!!
2 m
g/kg!
!!
0.5m
g/kg
Prop
ofol!
!1-
3 m
g/kg!
!!
0.25
mg/
kg o
r ket
amin
eFe
ntan
yl!!
3 m
cg/k
g!!
!co
nsid
er if
hig
h IC
PSu
ccin
ylcho
line!
1.5-
2 m
g/kg!!
!2
mg/
kgRo
curo
nium
!!1.
2 m
g/kg!
!!
1.6
mg/
kg
Roc
1.2
mg/
kg -
will g
ive s
ame
intu
batin
g co
nditio
ns a
s su
x at
60s
but
no
t rev
ersib
le &
cau
ses
prol
onge
d pa
ralys
is - c
onsid
er R
ISK/
BENE
FIT
ADRE
NALI
NE ‘P
USH
DOSE
’
draw
up
9ml N
/sal
ine
in 1
0 m
l syr
inge
to th
is, a
dd 1
ml o
f 1/1
0,00
0 (c
ardi
ac a
rrest
) adr
enal
ine
shak
e sy
rnge
har
d &
labe
l as
‘ADR
ENAL
INE
10m
cg/m
l’
ADRE
NALI
NE IN
FUSI
ON
6mg
1/10
00 v
ial in
100
ml N
/sal
ine
at 2
-20m
l/hr -
aim
MAP
70
(use
3m
g in
50m
l syr
inge
if u
sing
Niki
T34L
syr
inge
driv
er)
Ask
‘who
will
be
team
lead
er’ &
then
per
form
a s
yste
mat
ic c
heck
of e
ach
of fo
llow
ing
SET
UP!
!!
!!
!!
!!
!IN
TUBA
TIO
N EQ
UIPM
ENT
Mon
itorin
g - B
P, E
CG, S
pO2,
ETC
O2 !!
!Ch
eck! !
!BV
M c
onne
cted
to o
xyge
n!!
!!
!!
!Ch
eck!
Nasa
l Can
nula
e at
15l
/min
PLU
S M
ask
O2!
!Ch
eck! "
"PE
EP v
alve
for B
MV
avai
labl
e!!
!!
!!
Chec
k!
Pre-
oxyg
enat
ion
for F
OUR
min
utes
!!
!Ch
eck! "
"O
roph
aryn
geal
and
2 N
asop
hary
ngea
l Airw
ays
avai
labl
e!!
Chec
k!
Suct
ion
chec
ked
work
ing
& av
aila
ble!
!!
Chec
k! "
"La
ryng
osco
pe b
lade
sel
ecte
d, lig
ht w
orkin
g!!
!!
Chec
k!
Posit
ion
optim
ised
- ear
-to-s
tern
um!
!!
Chec
k! "
"ET
tube
size
cho
sen,
cuf
f tes
ted!
!!
!!
!Ch
eck!
Ram
ping
nee
ded?!!
!!
!!
Chec
k! "
"Al
tern
ate
tube
size
cho
sen
& cu
ff te
sted!!
!!
!Ch
eck!
360
degr
ee a
cces
s to
pat
ient
& m
onito
rs v
isibl
e!!Ch
eck! !
!20
ml S
yrin
ge fo
r cuf
f infl
atio
n !
!!
!!
!Ch
eck!
Crico
thyr
oid
mem
bran
e pa
lpat
ed a
nd m
arke
d!!
Chec
k! !
!St
ylet s
traig
ht-to
-cuf
f and
/or B
ougi
e wi
th R
apiF
it co
nnec
tors!!
Chec
k!
""
""
""
""
""
"G
oose
neck
, filte
r, in
line
ETCO
2 (o
r Eas
yCap
)!!
!!
Chec
k!
""
!!
!!
!!
!!
!Tu
be ti
es &
tape
ava
ilabl
e!!
!!
!!
!Ch
eck!
IV &
DRU
GS!!
!!
!!
!!
!!
Vent
ilato
r set
tings
det
erm
ined
& s
et u
p!!
!!
!Ch
eck!
!!
!!
!IV
Can
nula
con
nect
ed to
flui
d &
runn
ing !!
!Ch
eck! ""
NIBP
on
cont
rala
tera
l arm
and
BP
seen
!!!
Chec
k! "
"TE
AM B
RIEF
Spar
e ca
nnul
a in
situ
!!
!!
!Ch
eck!
INDU
CTIO
N AG
ENT
draw
n up
, dos
e ch
ecke
d !!
Chec
k! "
"Te
am ro
les
allo
cate
d!!
!!
!!
!Ch
eck!
SUX
or R
OC
draw
n up
, dos
e ch
ecke
d !!
!Ch
eck! "
"An
ticip
ated
diffi
cult
airw
ay p
lan’
s A/B
/C/D
disc
usse
d!!
!Ch
eck!
VASO
PRES
SORS
dra
wn u
p, la
belle
d !!
!Ch
eck! "
"Ag
ree
prom
pts
if Sp
O2
< 95
% o
r > 3
intu
batio
n at
tem
pts!
!Ch
eck!
POST
INTU
BATI
ON
drug
s dr
awn
up &
labe
lled !
Chec
k! "
"Di
fficu
lt ai
rway
kit
imm
edia
tely
avai
labl
e &
chec
ked!
!!
Chec
k!
RAPI
D SE
QUE
NCE
INTU
BATI
ON
TRAUMA / CRITICALLY ILL PRE-RSI CHECKLIST(can do this whilst pre-oxygenating)
SET UP
Monitoring - BP, ECG, SpO2, ETCO2 CHECK
Nasal Cannulae at 15l/min PLUS Mask O2 CHECK
Pre-oxygenation for FOUR minutes CHECK
Suction checked working & available CHECK
Position optimised CHECK
Ramping needed? CHECK
IV & DRUGS
IV Cannula connected to fluid & running CHECK
NIBP on contralateral arm and BP seen CHECK
Spare cannula in situ CHECK
INDUCTION AGENT drawn up, dose checked CHECK
SUX or ROC drawn up, dose checked CHECK
VASOPRESSORS drawn up, labelled CHECK
POST INTUBATION drugs drawn up & labelled CHECK
INTUBATION EQUIPMENT
BVM connected to oxygen CHECK
PEEP valve for BMV available CHECK
Guedel airways & two NPO airways available CHECK
Laryngoscope blade chosen, light working CHECK
ET tube size chosen, cuff tested CHECK
Alternate tube size chosen & cuff tested CHECK
Syringe for cuff inflation CHECK
Stylet & Bougie available CHECK
Gooseneck, filter, inline ETCO2 (or EasyCap) CHECK
Tube Tie available CHECK
Ventilator settings determined CHECK
TEAM BRIEF
In-line immobilisation person briefed CHECK
Cricoid pressure person briefed CHECK
Drug giver briefed CHECK
Anticipated difficult airway plan’s A/B/C/D discussed CHECK
Post RSI care brief & maintenance of anaesthesia ready CHECK
Anaesthetic assistant ready CHECK
DIFFICULT AIRWAY KIT AVAILABLE AND PREPARED TO USE IT? CHECK
TRA
UM
A R
SI C
HEC
KLI
ST
VORTEX AIRWAY CHECKLIST
USE AS COGNITIVE AID IN AIRWAY PLANNING AND CRISIS MANAGEMENT
Start with whichever of the three non-surgical airway supports (mask, LMA, ETT) is appropriate.
No more than THREE attempts at each airway support technique (mask, LMA, ETT)! Check!
For each airway support, consider whether changes in the following will help :
Manipulation (head/neck, larynx, device)! ! ! ! ! ! ! Check! Adjuncts (oro/nasopharyngeal airways, stylet/bougie, videolaryngoscope etc) !! Check! Size/Type! ! ! ! ! ! ! ! ! ! ! ! Check! Suction! ! ! ! ! ! ! ! ! ! ! ! Check! Pharyngeal muscle tone! ! ! ! ! ! ! ! ! ! Check!
The aim is to ensure alveolar oxygenation and allow the team to rapidly manage an airway crisis. Move from each of the three non-surgical options (BMV-LMA-ETT) attempting to remain in green zone and avoid deterioration into surgical airway as a rescue for ‘can’t intubate, can’t oxygenate’
BAG & MASK
ETTLMA
SURGICALAIRWAY
STAR
T HE
RE
A
sk ‘w
ho w
ill b
e te
am le
ader
’ & th
en p
erfo
rm a
sys
tem
atic
che
ck o
f eac
h of
follo
win
g
ANAE
STHE
SIA
for O
BESE
BM
I > 3
5 kg
/m2
PREO
PERA
TIVE
EVA
LUAT
ION
- SLE
EP A
PNO
EA &
OTH
ER R
ISKS
?
STO
P-BA
NG >
5!!
Snor
e lo
udly?
!!
!!
Chec
k! !
!!
BMI >
35?!
!!
!Ch
eck!
!!
!!
Tire
d du
ring
dayt
ime?!
!!
Chec
k! !
!!
Age
> 50
?!!
!!
Chec
k!
!!
!!
Obs
erve
d to
sto
p br
eath
ing
in s
leep
?!Ch
eck! !
!!
Neck
circ
umfe
renc
e >
40cm
?!Ch
eck!
!!
!!
Pres
sure
hig
h (B
P)?!
!!
Chec
k! !
!!
Gen
der m
ale?!
!!
Chec
k!
OTH
ER!
!!
poor
func
tiona
l cap
acity
,abn
orm
al E
CG, u
ncon
trolle
d BP
/IHD,
!!
!!
SpO
2<94
% a
ir, p
revio
us D
VT/P
E, p
oorly
con
trolle
d CO
PD o
r ast
hma
!!
!!
Diab
etes
con
trol
OPE
RATI
VE M
ANAG
EMEN
T
CONS
IDER!!
!!
!!
!!
RAM
PING
!!
!!
TECH
NIQ
UE
Anta
cid p
roph
ylaxis
?!!
!Ch
eck! "
"Ea
r-to-
ster
num!
!!
Self-
posit
ion
on ta
ble!
!!
Chec
k!
Pre-
op a
nalg
esia
?!!
!!
Chec
k! "
"Re
duce
s di
fficu
lt ET
T!!
Pre-
oxyg
enat
e RA
MPE
D!!
!Ch
eck!
DVT
prop
hyla
xis?!
!!
!Ch
eck! "
"Im
prov
es v
entila
tion!
!Us
e PE
EP v
alve
on
BMV!!
!Ch
eck!
Care
ful g
luco
se c
ontro
l?!!
!Ch
eck! "
""
""
""
Min
imise
indu
ctio
n-ve
ntila
tion
time!
Chec
k!
!!
!!
!!
!!
!!
!!
!!
Avoi
d sp
onta
neou
s ve
ntila
tion!
!Ch
eck!
EQUI
PMEN
T!!
!!
!!
!!
!!
!!
Desfl
uran
e if
avai
labl
e or
Pro
pofo
l TCI!
Chec
k!
!!
!!
!!
!!
!!
!!
!!
Shor
t-act
ing
opio
ids!!
!!
Chec
k!
Baria
tric
trolle
y/pe
rson
nel t
o lift!!
Chec
k! "
""
""
""
Mul
timod
al a
nalg
esia!
!!
Chec
k!
Gel
pad
ding!!
!!
!Ch
eck! "
""
""
""
PONV
pro
phyla
xis!!
!!
Chec
k!
Larg
e BP
cou
gh!
!!
!Ch
eck! "
""
""
""
Ensu
re fu
ll rev
ersa
l of N
MB!
!Ch
eck!
Ram
ping
of p
atie
nt (p
illows
)!!
Chec
k! "
""
""
""
Extu
bate
& re
cove
r hea
d up!
!Ch
eck!
PEEP
for P
re-O
x an
d BM
V!!
Chec
k!
Pres
sure
sup
port
vent
ilatio
n!!
Chec
k! "
""
""
""
Use
IBW
(exc
ept f
or s
ux)!!
!Ch
eck!
IDEA
L BO
DY W
EIG
HT!
!!
Men!!
!He
ight
(cm
) - 1
00!!
!NB
for P
ropo
fol I
nfus
ion,
use
Ser
vin’s
form
ula
!!
!!
!!
Wom
en!
!He
ight
(cm
) - 1
05!!
!Ad
d 40
% o
f exc
ess
weig
ht to
IBW
!!
!!
!!
!!
!!
!!
!!
ie :
IBW
+ 0
.4(T
BW-IB
W)
STAR
T HE
RE
As
k ‘w
ho w
ill b
e te
am le
ader
’ & th
en p
erfo
rm a
sys
tem
atic
che
ck o
f eac
h of
follo
win
g
OBE
SE IN
TUBA
TIO
N
STAR
T HE
RE
STEP
ONE
Cont
inuo
us n
ebul
ised
salb
utam
ol -
use
O2
not a
ir fo
r neb
sNe
bulis
ed ip
ratro
pium
- 50
0mcg
x3
20 m
inut
ely,
then
hou
rlyHy
droc
ortis
one
100m
g IV
(alte
rnat
ive D
XM 2
0mg
IV o
r IM
)M
gSO
4 2g
(50m
g/kg
max
2g)
IV -
give
n ov
er 2
0 m
inut
es
Cons
ider
diff
eren
tial d
iagn
oses
hear
t fai
lure
, AC
S, a
rrhyt
hmia
pulm
onar
y em
bolis
mPT
X, p
eric
ardi
al ta
mpo
nade
, ob
stru
ctio
n, fo
reig
n bo
dyan
aphy
laxi
s
AVO
ID IN
TUBA
TIO
N IF
PO
SSIB
LE
BUT
IF Y
OU
HAVE
TO
INTU
BATE
Indi
catio
ns -
fatig
ue, r
esp
dist
ress
, det
erio
ratio
n, a
rrest
Max
imise
pre
oxyg
enat
ion
Opt
imise
firs
t pas
s su
cces
sLa
rges
t ETT
pos
sible
Bewa
re b
reat
h st
ackin
g
Keta
min
e 2m
g/kg
IVRo
curo
nium
1.2
mg/
kg o
r Sux
2m
g/kg
IV
Assis
t con
trol /
Vol
ume
cont
rol
RR 8
TV
5-7
ml/k
g IB
WPE
EP 2
cm H
2O IE
1:5
FiO
2 10
0%
perm
issive
hyp
erca
rbia
Ext c
hest
com
pres
sion
Ppla
t < 3
0cm
H2O
Aggr
essiv
e su
ctio
ning
of E
TT, c
heck
KNG
T
A
sk ‘w
ho w
ill b
e te
am le
ader
’ & th
en p
erfo
rm a
sys
tem
atic
che
ck o
f eac
h of
follo
win
g
LIFE
THR
EATE
NING
AST
HMA
STEP
TW
O
Adre
nalin
e 0.
5 m
g IM
(0.0
1mg/
kg) =
0.5
ml o
f 1:1
000
Flui
d bo
lus
20 m
l/kg
CXR,
ECG
, VBG
, Ele
ctro
lytes
, FBC
STEP
THR
EEAG
ITAT
ED P
ATIE
NT
keta
min
e 1.
5 m
g/kg
IV o
ver 3
0 s
then
1 m
g/kg
/hr t
itrat
e to
effe
ct
if no
IV, 5
mg/
kg IM
IF W
ORS
ENIN
G
NIPP
ViP
AP P
S 8c
m H
2OeP
AP P
EEP
3 cm
H2O
cont
inue
neb
s th
roug
h NI
PPV
STEP
THR
EECO
OPE
RATI
VE P
ATIE
NT
NIPP
ViP
AP P
S 8c
m H
2OeP
AP P
EEP
3 cm
H2O
cont
inue
neb
s th
roug
h NI
PPV
IF W
ORS
ENIN
G
keta
min
e 1.
5 m
g/kg
IV o
ver 3
0 s
then
1 m
g/kg
/hr t
itrat
e to
effe
ct
if no
IV, 5
mg/
kg IM
if no
bet
ter,
proc
eed
to N
IPPV
if no
bet
ter,
proc
eed
to
STA
RT
HER
E
A
sk ‘w
ho w
ill b
e te
am le
ader
’ & th
en p
erfo
rm a
sys
tem
atic
che
ck o
f eac
h of
follo
win
g
DIF
FIC
ULT
AIR
WAY
PLA
N
DIFF
ICUL
T AI
RWAY
- KI
T CH
ECKL
IST
Re-P
ositio
n - U
se a
Bou
gie
- Vid
eola
ryng
osco
pe
PLAN
ATR
ACHE
AL IN
TUBA
TIO
N PL
AN
max
3 a
ttem
pts
RSI
max
4 a
ttem
pts
ELEC
TIVE
Ram
p - E
ar to
Ste
rnum
St
ylet ‘
stra
ight
-to-c
uff’
- Fro
va O
xyge
natin
g Bo
ugie
Chan
ge B
lade
Size
Cons
ider
Mille
r or M
cCoy
King
Visio
n VL
PLAN
BSE
COND
ARY
INTU
BATI
ON
PLAN
not i
n RS
Im
aint
ain
oxyg
enat
ion
& ve
ntila
tion
Use
LMA
- Cla
ssic
or S
upre
me
Intu
batin
g LM
A - F
astT
rach
or A
ir Q
IIBl
ind
intu
bate
thro
’ iLM
A or
fibr
eopt
ic as
sist i
f ava
ilabl
eUs
e Pa
rker
tip
ETT
if av
aila
ble
Bag
Mas
k Ve
ntila
teO
roph
aryn
geal
&/o
r Nas
opha
ryng
eal A
irway
LMA
(any
)
Sugg
amad
ex a
t 4-8
mg/
kg if
ava
ilabl
e
PLAN
CAW
AKEN
re-g
roup
post
pone
sur
gery
PLAN
DCI
CO/C
ICV
need
le o
rsu
rgica
l airw
ay
ETT
via iL
MA
blin
d or
fibr
eopt
ic
two
hand
ed B
MV
- Adj
unct
s - L
MA
Cons
ider
USS
to lo
cate
& m
ark
crico
thyr
oid
mem
bran
e14
G je
lco a
nd O
2 co
nnec
tion
with
3-w
ay ta
phi
gh p
ress
ure
O2
devic
eSi
ze 2
2 sc
alpe
l - B
ougi
e - s
ize 6
.0 E
TT
STAR
T HE
RE
Ask
‘who
will
be
team
lead
er’ &
then
per
form
a s
yste
mat
ic c
heck
of e
ach
of fo
llow
ing
UNE
XPLA
INED
HYP
OXI
A - S
pO2
< 90
% o
r dec
reas
e >
5% d
urin
g an
aest
hesi
a
Mal
igna
nt H
yper
ther
mia
che
cklis
t
STAR
T HE
RE
A
sk ‘w
ho w
ill b
e te
am le
ader
’ & th
en p
erfo
rm a
sys
tem
atic
che
ck o
f eac
h of
follo
win
g
ELEV
ATED
ETC
O2!
!!
!!
!!
!!
DECR
EASE
D or
ABS
ENT
ETCO
2
Inha
led
/ Exo
gene
ous
CO2!!
!!
!!
!!
!Ai
rway
Chec
k ca
pnog
raph
for r
etur
n to
bas
elin
e ?!
!!
!!
!Ex
clude
inad
verte
nt o
esop
hage
al in
tuba
tion
?La
paro
scop
ic CO
2 in
suffl
atio
n ?!
!!
!!
!!
NaHC
O3
adm
inist
ratio
n ?!
!!
!!
!!
!!
Circ
uit
Insp
ired
CO2
(sod
a lim
e ex
haus
ted)
?In
com
pete
nt v
alve
s or
Pat
ient
Re-
brea
thin
g ?!!
!!
!!
Air e
ntra
inm
ent (
leak
) ?!
!!
!!
!!
!!
!!
!!
Dilu
tion
of g
as (s
ampl
ing
prob
lem
) ?Hy
pove
ntila
tion!!
!!
!!
!!
!!
!Sa
mpl
ing
line
conn
ecte
d to
circ
uit &
mon
itor ?
Resp
irato
ry d
epre
ssio
n ?!
!!
!!
!!
!!
Vent
ilato
rIn
crea
sed
mec
hani
cal lo
ad o
n lu
ngs
?(d
ecre
ased
com
plia
nce,
incr
ease
d re
sista
nce
in s
yste
m)!!
!!
Chec
k se
tting
s, e
xclu
de ra
ised
RR ?
Inad
equa
te IP
PV -
chec
k TV
/RR/
PEEP
?In
crea
sed
dead
spa
ce -
anat
omica
l/phy
siolo
gica
l ?!!
!!
!G
as E
xcha
nge
Prob
lem
Incr
ease
d Pr
oduc
tion
of C
O2!
!!
!!
!!
!Pr
ofou
nd H
ypot
ensio
n ?
!!
!!
!!
!!
!!
!!
!Pu
lmon
ary
Embo
lism
?Fe
ver ?!
!!
!!
!!
!!
!!
!Ca
rdia
c Arre
st ?
Pare
nter
al n
utrit
ion
?M
alig
nant
hyp
erth
erm
ia ?!
!!
!!
!!
!!
Decr
ease
d Pr
oduc
tion
!!
!!
!!
!!
!!
!!
!Hy
poth
erm
iaNB
: Ap
noea
cau
ses
rise
of P
aCo2
8-1
5mm
Hg fi
rst m
in, t
hen
3mm
Hg/m
in!!
Decr
ease
d m
etab
olism
ELEV
ATED
or D
ECRE
ASED
/ AB
SENT
END
TID
AL C
O2
Hypo
tens
ion,
Myo
card
ial
Isch
aem
ia c
heck
lists
Card
iac A
rrres
t che
ckiis
t
STA
RT
HER
E
Ask
‘who
will
be
team
lead
er’ &
then
per
form
a s
yste
mat
ic c
heck
of e
ach
of fo
llow
ing
ELEV
ATED
AIR
WAY
PR
ESSU
RE
BR
AD
YCA
RD
IA
TAC
HYC
AR
DIA
CA
RD
IAC
AR
RES
T
STAR
T HE
RE
As
k ‘w
ho w
ill b
e te
am le
ader
’ & th
en p
erfo
rm a
sys
tem
atic
che
ck o
f eac
h of
follo
win
g
MYO
CARD
IAL
ISCH
AEM
IA
AT R
ISK
Isch
aem
ic he
art d
iseas
eHy
perte
nsio
nFl
uid
loss
esDi
abet
esSm
oker
, Lip
ids,
FHx
etc
.
OH
CRAP
!O
xyge
n, H
aem
oglo
bin
Cont
ract
ility,
Rate
, Afte
rload
, Pre
load
MIT
IGAT
ION
Perio
pera
tive
Beta
-blo
ckHb
> 1
0g/d
LAd
equa
te O
xyge
natio
nBP
in 3
dig
its,
HR 2
dig
its,
BGL
1 di
git
Regi
onal
Ana
esth
esia
?
SHO
ULD
THIS
AN
AEST
HETI
CBE
GIV
EN H
ERE?
MAN
AGEM
ENT
Are
SpO
2, B
P, H
R, H
b, P
EEP
optim
ised?
!!
Chec
k
ECG
cha
nges
ver
ified
with
ECG
? !!
!Ch
eck
Surg
eon
awar
e of
pro
blem
? !!
!!
Chec
k
Defib
rilla
tor &
Pac
ing
avai
labl
e ? !
!!
Chec
k
RATE
CO
NTRO
L (b
ox) a
ddre
ssed
?!!
!Ch
eck
BLO
OD
PRES
SURE
(box
) add
ress
ed?!
!Ch
eck
CARD
IOLO
GIS
T CO
NSUL
TED?!
!!
Chec
k
Spec
ific th
erap
y ag
reed
ASPI
RIN,
HEPA
RIN,
NIT
RATE
S et
c !!
!Ch
eck
Plan
for E
xtub
atio
n &
Reco
very
? !
!!
Chec
k
Lead
II is
bes
t for
det
ectin
g ar
rhyt
hmia
s.C
M5
dete
cts
89%
of S
T-se
gmen
t is
chae
mic
cha
nges
(righ
t arm
ele
ctro
de o
n m
anub
rium
, lef
t arm
ele
ctro
de o
n V5
and
indi
ffere
nt le
ad o
n le
ft sh
ould
er).
TAKE
A S
NAPS
HOT
BEFO
RE S
TART
Lead
pos
ition
“whi
te is
righ
t; sm
oke
(bla
ck) a
bove
fire
(red
)” on
the
L sid
e
RATE
CO
NTRO
L
EXCL
UDE
hypo
vola
emia
, awa
rene
ss,
or ra
ised
CO2
as c
ause
of t
achy
card
ia!
Chec
k
NEXT
BETA
-BLO
CKAD
E (a
im fo
r HR
< 60
)!Ch
eck
Esm
olol
0.
25-0
.5 m
g.kg
bol
us25
-300
mg/
kg/m
in in
fusio
n
Met
opro
lol
1-1
5 m
g tit
rate
d ov
er 1
5 m
ins!
If b
eta-
bloc
kade
con
tra-in
dica
ted
use
vera
pam
il 2
.5 m
g - r
epea
t if
need
ed FILL
ING
Opt
imise
fillin
g, c
onsid
er n
eed
for P
EEP !
Chec
k
CAUT
ION
USE
OF
VASO
PRES
SORS
!Ch
eck
For h
yper
tens
ion,
con
sider
!!
!Ch
eck
GTN
- su
blin
gual
(0.3
-0.9
mg)
IVI(0
.25
- 4 m
g/kg
/min
tit
rate
to e
ffect
)
Clon
idin
e!!
!!
!Ch
eck
(30
mg
ever
y 5
min
utes
up
to 3
00 m
g)
CARD
IOLO
GY
ADVI
CE 1
3STA
R
STAR
T HE
RE
As
k ‘w
ho w
ill b
e te
am le
ader
’ & th
en p
erfo
rm a
sys
tem
atic
che
ck o
f eac
h of
follo
win
g
!!
HYPE
RTEN
SIO
N!!
!!
!!
!HY
POTE
NSIO
N
Pre-
exis
ting
hype
rtens
ion!
!!
!!
!!
!Hy
povo
laem
ia
treat
ed o
r unt
reat
ed ?!
!!
!!
!C
heck!
"!
bloo
d lo
ss ?!!
!!
!!
!C
heck!
med
icatio
n ta
ken
?!!
!!
!!
!C
heck!
"!
fluid
defi
cit ?!!
!!
!!
!C
heck!
Sym
path
etic
refle
x re
spon
se!!
!!
!!
!!
Card
ioge
nic
light
ana
esth
esia
? Ex
clude
vap
orize
r lea
k, IV
disc
onne
ct!C
heck!
!!
cont
ract
ility,
rate
, dys
thym
ia ?!
!!
!C
heck!
Hypo
xia o
r hyp
erca
rbia
? C
heck
SpO
2, E
TCO
2!!!
Che
ck!
"!
anae
sthe
tic a
gent
?!!
!!
!!
Che
ck!
cere
bral
eve
nt?!
!!
!!
!!
Che
ck!
"!
vaso
dila
tors
?!!!
!!
!!
Che
ck!
raise
d IC
P ?!!
!!
!!
!!
Che
ck!
ischa
emia
?!!
!!
!!
!!
Che
ck!
"!
Dist
ribut
ive
(vas
odila
tion)
vaso
spas
m ?!!
!!
!!
!!
Che
ck!
!!
!!
!!
!!
!!
!!
drug
s ?!
!!
!!
!!
Che
ck!
Sym
path
omim
etic
effe
ct?!
!!
!!
!!
!sy
mpa
thet
ic bl
ock
?!!
!!
!!
Che
ck!
!!
!!
!!
!!
!!
!!
seps
is ? !
!!
!!
!!
Che
ck!
Exog
eneo
us ie
: ad
min
istra
tion
of v
asop
ress
or!!
!C
heck!
"!
anap
hyla
xis ?!
!!
!!
!C
heck!
Endo
gene
ous
eg: p
haeo
chro
moc
ytom
a!!
!!
Che
ck!
!!
!!
!!
!!
!!
!!
Obs
truct
ive
Surg
ical
!!
!!
!!
!!
!!
!!
high
intra
-thor
acic
pres
sure
s ?!
!!
!C
heck!
stim
ulus!
!!
!!
!!
!C
heck!
!!
tam
pona
de ?
Bila
tera
l pne
umot
hora
x?!!
!C
heck!
tour
niqu
et!
!!
!!
!!
!C
heck!
"!
pulm
onar
y em
bolu
s ?!
!!
!!
Che
ck!
posit
ion
eg: T
rend
elen
burg!!
!!
!!
Che
ck!
"!
aorto
cava
l com
pres
sion
from
18/
40 o
nwar
ds !
!C
heck!
Whi
lst v
asop
ress
ors
elev
ate
BP, t
reat
men
t sho
uld
be d
irect
ed to
cau
se
BLO
OD
PRES
SURE
STAR
T HE
RE
As
k ‘w
ho w
ill b
e te
am le
ader
’ & th
en p
erfo
rm a
sys
tem
atic
che
ck o
f eac
h of
follo
win
g
ACCE
SS T
O T
HE C
IRCU
LATI
ON
Two
wide
bor
e IV
s!!
!!
!!
!!
!!
Che
ck!
Co
nsid
er in
traos
seou
s wi
th B
one
Inje
ctio
n G
un!
!!
!!
Che
ck!
Co
nsid
er v
enou
s cu
tdow
n!!
!!
!!
!!
! C
heck!
Co
nsid
er R
apid
Infu
ser C
athe
ter!!
!!
!!
!!
Che
ck !
PARA
MET
ERS
Perm
issive
hyp
oten
sion
MAP
65-
70 m
mHg
may
be
acce
ptab
le!
!!
Chec
k! !
(unl
ess
TBI/s
pina
l inju
ry/e
xsan
guin
atio
n)
t > 3
5, p
H >
7.2,
Lac
tate
< 4
, BE
< -6!
!!
!!
!!
Chec
k! !
Ca >
1.1
, Plt
> 50
, INR
< 1
.5 F
ibrin
ogen
> 1
!!
!!
!!
!!
!!
!!
Che
ck!
FIND
THE
BLE
EDIN
G, S
TOP
THE
BLEE
DING
Min
imise
tim
e to
Sur
gery!!
!!
!!
!!
!Ch
eck!!
Use
tour
niqu
ets
/dire
ct p
ress
ure
to c
ontro
l per
iphe
ral b
leed
ing!
!!
Tam
pona
de b
leed
ing
eg: p
elvic
bin
der,
dire
ct p
ress
ure,
sut
ures!
!!
Chec
k!!
Tran
exam
ic ac
id 1
g lo
ad in
firs
t 4 h
rs!
!!
!!
!!
Chec
k!!
If PP
H - U
terin
e m
assa
ge, o
xyto
cin in
fusio
n, e
rgom
etrin
e, m
isopr
osto
l, TX
A!
Chec
k!!
Tran
sfus
e bl
ood
at a
1:1
ratio
of P
RCs
: FFP!
!!
!!
!Ch
eck!!
Crys
tallo
id 2
50 m
l bol
us ti
trate
to ra
dial
pul
se!!
!!
!!
Chec
k!!
Send
FBE
, X-M
atch
, Ven
ous
Gas
, Cal
cium
, Coa
gs!
!!
!!
Chec
k!!
Arte
rial li
ne, c
onsid
er C
alciu
m (c
itrat
e to
xicity
)!!
!!
!!
Chec
k!!
WAR
M F
LUID
S / W
ARM
THE
RO
OM
/ CA
THET
ERIS
E TH
E BL
ADDE
R!!
Chec
k!!
MAS
SIVE
HAE
MO
RRHA
GE
in R
URAL
HO
SPIT
AL
USEF
UL M
EDIC
ATIO
NS
Hartm
anns
250
ml b
olus
Pack
ed c
alls
or W
hole
Blo
odTr
anex
amic
acid
1g
load
PPH
Oxy
tocin
5 U
IV o
r 10
U IM
Oxy
tocin
Infu
sion
40 U
/ litr
l @ 2
50 m
l/hr
Ergo
met
rine
250
mcg
IV o
r 500
mcg
IMM
isopr
osto
l 200
mcg
x 5
PR
(1m
g)
see
also
PPH
che
cklis
t
STAR
T HE
RE
As
k ‘w
ho w
ill b
e te
am le
ader
’ & th
en p
erfo
rm a
sys
tem
atic
che
ck o
f eac
h of
follo
win
g
ANAP
HYLA
XIS
IMM
EDIA
TE M
ANAG
EMEN
T CH
ECKL
IST
STO
P TR
IGG
ERS
collo
ids/
late
x/an
tibio
tic/b
lood
/NM
B!
!!
!!
!C
heck!
MAI
NTAI
N AN
AEST
HESI
A w
ith IN
HALA
TIO
NAL
AGEN
T if
poss
ible!
Che
ck!
Cal
l for
HEL
P, n
ote
TIM
E!!
!!
!!
!!
Che
ck!
Giv
e 10
0% O
XYG
EN, g
ive
FLUI
DS!
!!
!C
heck!
!C
heck!
ADRE
NALI
NE 5
0-10
0mcg
IV (0
.5m
l-1m
l of 1
/10,
000)
titra
te to
resp
onse
or
0.5m
g IM
(thi
gh) i
f no
IV a
cces
s!!
!!
!!
!C
heck!
ANTI
HIST
AMIN
E, H
YDRO
CORT
ISO
NE 2
00m
g 6/
24!!
!!
Che
ck!
SALB
UTAM
OL
250
mcg
IV o
r 2.5
-5m
g ne
bulis
er in
to c
ircui
t!!!
Che
ck!
EXCL
USIO
NS
Anae
sthe
tic c
ircui
t ob
stru
ctio
n
-fil
ter
-ki
nked
ETT
-cu
ff he
rnia
tion
-tu
be m
igra
tion
Dis
conn
ect c
ircui
t and
ve
ntila
te d
irect
ly w
ith
self-
infla
ting
bag
Che
ck
if pr
essu
re s
till h
igh,
pr
oble
m is
in a
irway
or
ETT
Fore
ign
body
in a
irway
?
Air e
mbo
lism
?
Tens
ion
PTX?
Seve
re b
ronc
hosp
asm
?
PRES
ENTA
TIO
N
Wid
e ra
nge
of
poss
ible
pre
sent
atio
ns M
ost c
omm
on
incl
ude
:
card
iova
scul
ar
colla
pse
or
hypo
tens
ion
(88%
)er
ythe
ma
(48%
)br
onch
ospa
sm (4
0%)
angi
oede
ma
(24%
)cu
tane
ous
rash
(13%
)ur
ticar
ia (8
%)
ADRE
NALI
NE
CONC
ENTR
ATIO
NS
1ml o
f 1/1
000
= 1m
g10
ml o
f 1/1
0,00
0 =
1mg
IV B
OLU
S DO
SE50
- 10
0 m
cg
IM D
OSE
0.5m
g IM
AD
RE
NA
LIN
E I
NF
US
ION
1:1
00
0 A
DR
EN
AL
INE
via
l (1
mg
/ m
l)
Ad
d 3
mg
(3 v
ials
1:1
00
0)
to t
ota
l 5
0 m
ls N
Sal
ine
(6
0 m
cg/m
l)
Ru
n a
t 2
- 2
0 m
l /
hr
aim
MA
P >
70
STAR
T HE
RE
As
k ‘w
ho w
ill b
e te
am le
ader
’ & th
en p
erfo
rm a
sys
tem
atic
che
ck o
f eac
h of
follo
win
g
MAL
IGNA
NT H
YPER
THER
MIA
PRES
ENTA
TIO
N
mas
sete
r spa
smta
chyp
noea
in s
pont
aneo
us b
reat
hing
pat
ient
rise
in E
TCO
2 in
ven
tilate
d pa
tient
unex
plai
ned
tach
ycar
dia,
pro
gres
sing
to h
ypox
aem
iara
ised
tem
pera
ture
arrh
ythm
ias
EXCL
USIO
NS
Inad
equa
te a
naes
thes
ia /
anal
gesia
Infe
ctio
n / S
epsis
Tour
niqu
et Is
chae
mia
Anap
hyla
xis (e
xclu
de h
ypot
ensio
n)Ph
aeoc
hrom
ocyt
oma
or T
hyro
id S
torm
RISK
FAC
TORS
Fam
ily h
istor
yDe
ath
unde
r ana
esth
esia
in fa
mily
Vola
tiles
and
Suxa
met
honi
um
INVE
STIG
ATIO
NS
ABG
, U&E
s, C
K, F
BC, C
lotti
ngM
uscle
bio
psy
IMM
EDIA
TE M
ANAG
EMEN
T
!DI
SCO
NTIN
UE V
OLA
TILE
S!
!!
!!
Chec
k!
!an
d gi
ve
!10
0% O
XYG
EN V
IA H
IGH
FLO
W!
!!
!Ch
eck!
!CA
LL F
OR
HELP
- M
H BO
X!
!!
!!
Chec
k!
!AL
LOCA
TE T
ASK
CARD
S !
!!
!!
Chec
k!
!M
AINT
AIN
ANAE
STHE
SIA
with
PRO
POFO
L an
d O
PIO
ID!
Chec
k!
!EX
PEDI
TE S
URG
ERY!
!!
!!
!Ch
eck!
!DA
NTRO
LENE
2.5
mg/
kg IV
unt
il hyp
erm
etab
olism
reso
lved!
Chec
k!
!CO
OLI
NG -
AXIL
LA /
GRO
IN /
NECK
!!
!!
Chec
k!
!CO
LD F
LUSH
NG
T an
d ID
C!
!!
!!
Chec
k!
MO
BILI
SE A
LL A
VAIL
ABLE
STA
FFNO
TIFY
med
STAR
13S
TAR
MH
EMER
GEN
CY K
IT &
TAS
K CA
RDS
TURP
SYN
DRO
ME
PRES
ENTA
TIO
N
Exce
ss a
bsor
ptio
n of
flui
d du
ring
TUR
P
EARL
Y M
ANIF
ESTA
TIO
NS
CVS
brad
ycar
dia,
hyp
erte
nsio
n
GI
naus
ea &
vom
iting
, abd
omin
al d
iste
nsio
n
CN
San
xiet
y/co
nfus
ion,
hea
dach
e,di
zzin
ess,
slo
w w
akin
g G
A
LATE
MAN
IFES
TATI
ONS
CVS
hypo
tens
ion,
ang
ina,
car
diac
failu
re
RES
Pdy
spno
ea, t
achy
pnoe
a, c
yano
sis
CN
Stw
itchi
ng, v
isua
l cha
nges
, sei
zure
s, c
oma
GU
rena
l tub
ular
aci
dosi
s, re
duce
d ur
ine
outp
ut
EXCL
USIO
NS
Con
gest
ive
card
iac
failu
re
All o
ther
cau
ses
of c
onfu
sion
RISK
FAC
TORS
Abso
rptio
n 1-
2 lit
res
fluid
per
40
min
s op
erat
ing
Larg
e pr
osta
tePr
olon
ged
oper
atio
n >
60 m
ins
Hyp
oton
ic fl
uids
giv
en IV
Volu
me
of ir
rigat
ion
> 30
litre
sIn
expe
rienc
ed s
urge
onH
eigh
t of i
rriga
tion
> 60
cm a
bove
pat
ient
Com
orbi
ditie
s - l
iver
dis
ease
, ren
al s
tone
s, U
TI
Imm
edia
te M
anag
emen
t
Hig
h in
dex
of s
uspi
cion
ABC
- 100
% O
xyge
n
Stop
irrig
atio
n flu
id in
fusi
on, c
athe
teris
e
Che
ck N
a an
d Hb
regu
larly
& c
orre
ct th
em
Frus
emid
e 40
mg
IV
CAES
AREA
N SE
CTIO
N
Emer
genc
y G
A LS
CS C
HECK
LIST
CITR
ATE
GIV
EN?!
!!
!!
!
LARG
E BO
RE IV
ACC
ESS
AND
SECU
RED?
!!
FLUI
DS P
RELO
ADED
?!!
!!
!!
TABL
E IN
LEF
T LA
TERA
L TI
LT?!
!!
!
PREO
XYG
ENAT
ED 1
00%
O2
> 4
MIN
UTES
?!!
ETT
- STY
LET
- BO
UGIE
- TA
PE!
!!
!
SUCT
ION
- ETC
O2
- MO
NITO
RING
!!
!!
FAIL
ED R
SI P
LAN
DISC
USSE
D?
RSI!
!!
!!
!!
!
CRIC
OID!!
!!
!!
!!
PR
OPO
FOL
2mg/
kg!
!!
!!
!
SUXA
MET
HONI
UM 1
mg/
kg!
!!
!!
ETT
PLAC
EMEN
T CO
NFIR
MED
WIT
H ET
CO2!
!
VOLA
TILE!!
!!
!!
!!
O
NGO
ING
NEU
ROM
USCU
LAR
BLO
CKAD
E!!
OXY
TOCI
N av
aila
ble
post
-del
ivery!
!!
!
40 U
NITS
/ 10
00m
l @ 2
50m
l/hr i
f nee
ded!
!!
NEO
NATA
L RE
SUS
ANTI
CIPA
TED?
!!
!!
Emer
genc
y SP
INAL
LSC
S CH
ECKL
IST
CITR
ATE
GIV
EN?!
!!
!!
!
LARG
E BO
RE IV
ACC
ESS
AND
SECU
RED?
!!
FLUI
DS P
RELO
ADED
?!!
!!
!!
TABL
E IN
LEF
T LA
TERA
L TI
LT?!
!!
!
L4-5
INTE
RSPA
CE ID
ENTI
FIED
?!!
!!
PREP
- DR
APE
- GO
WN
- GLO
VES
- MAS
K - H
AT!!
ANTI
SEPT
IC R
EMO
VED
FRO
M S
PINA
L TR
AY!
!
LOCA
L AN
AEST
HETI
C 2%
XYL
OCA
INE/
ADRE
NALI
NE!
2.5M
L BU
PIVA
CAIN
E 0.
5% w
ith O
PIAT
E!!
!
FENT
ANYL
20-
25 m
cg o
r MO
RPHI
NE 1
25 m
cg!
!
SKIN
INFI
LTRA
TIO
N!
!!
!!
!
INTE
RSPI
NOUS
LIG
AMEN
T ID
ENTI
FIED
!!
!
CLEA
R CS
F th
en IN
JECT
& B
ARBO
TAG
E!!
!
OXY
TOCI
N av
aila
ble
post
-del
ivery!
!!
!
40 U
NITS
/ 10
00m
l @ 2
50m
l/hr i
f nee
ded!
!!
NEO
NATA
L RE
SUS
ANTI
CIPA
TED?
!!
!!
STAR
T HE
RE
As
k ‘w
ho w
ill b
e te
am le
ader
’ & th
en p
erfo
rm a
sys
tem
atic
che
ck o
f eac
h of
follo
win
g
LSCS
CHE
CK L
IST
Prep
are
patie
nt &
par
tner
IV a
cces
s 16
G, w
arm
IV fl
uids
on
pum
p se
t!!
So
dium
citr
ate
drin
k!!!
!!
!
Left
late
ral t
ilt to
avo
id a
orto
-cav
al h
ypot
ensio
n!!
Cons
ider
nee
d fo
r ext
ra h
elp
for n
eona
te!
!
Cons
ider
nee
d fo
r ext
ra b
lood!
!!
Posit
ion
of p
lace
nta,
Pre
vious
LSC
S/sc
arrin
g, M
ultip
arou
sG
esta
tiona
l DM
, Sep
sis, T
raum
atic
deliv
ery,
Oth
er!
!
Prop
hyla
ctic
antib
iotic
s 30
min
s be
fore
KTS
!!
Docu
men
tatio
n
Tim
e ca
lled
& tim
e ar
rived!!
!!
!
Cons
ent t
o an
aest
hesia!
!!
!!
Ti
me
anae
sthe
sia in
itiate
d!!
!!
!
GG
MG
, Pre
p, D
rape
, ase
psis!
!!
!
Posit
ioni
ng!!
!!
!!
!
Tim
e of
KTS
!!!
!!
!!
Ti
me
of d
elive
ry!
!!
!!
!
Tim
e of
dru
gs!
!!
!!
!
If co
nver
sion
to G
A of
fere
d, d
ocum
ent r
isks,
time
and
spec
ify if
dec
lined!
!!
!
Any
com
plica
tions
?!!
!!
!!
Post
-op
DVT
prop
hyla
xis a
nd a
nalg
esia
cha
rted!
SC
hep
arin
with
held
for 2
4 hr
s af
ter s
pina
l!!
Ep
idur
al c
athe
ter t
ip s
ight
ed &
inta
ct!
!!
GA
SECT
ION
Preo
xyge
nate
- 10
0% o
xyge
nAn
ticip
ate
diffi
cult
airw
ay a
nd ra
pid
desa
tura
tion
Crico
id p
ress
ure
RSI :
Pro
pofo
l - S
uxam
etho
nium
- ET
Tub
e
Onc
e su
x we
ars
off u
se n
onde
pola
risin
g NM
B
NEUR
AXIA
L SE
CTIO
N
Spin
al 2
.5m
l 0.5
% b
upiva
cain
e +
25m
cg fe
ntan
yl (o
r 125
mcg
spi
nal m
orph
ine)
Top
up e
xistin
g ep
idur
al (T
10) t
o T4
for L
SCS
supp
lem
enta
l nitr
ous
if ne
eded
50:
50 N
20/O
2
Give
ant
ibio
tics
unle
ss c
ontra
indi
catio
nO
xyto
cin 3
-5 U
IV o
nce
baby
out
(che
ck n
ot tw
ins!
)O
xyto
cin in
fusio
n - 4
0U/1
000m
l @ 2
50m
l/hr
Post
oper
ative
Ana
lges
ia &
DVT
Pro
phyla
xis
NEO
NATA
L RE
SUS
HR 6
0-10
0 as
siste
d ve
ntila
tion
HR <
60
star
t CPR
3:1
Adre
nalin
e 10
mcg
/kg
IV (u
se th
e 1V
, not
2A)
PPH
Cons
ider
Ton
e - T
raum
a -
Tiss
ues
- Thr
ombi
n
Oxy
tocin
for a
ll - 5
U IV
onc
e ut
erus
em
pty
Oxy
tocin
infu
sion
40U
@ 1
0U/h
r
Chec
k pl
acen
taFu
ndal
rub
to u
teru
sEr
gom
etrin
e 25
0mcg
IVor
500
mcg
IM
Miso
pros
tol 1
000m
cg P
R
Tran
exam
ic ac
id 1
g lo
ad
Chec
k Ch
em 8
, INR
CONS
IDER
SUR
GIC
AL
OPT
IONS
?
Pre-
Ecla
mps
ia
4g M
gSO
4 ov
er 1
5 m
ins,
th
en 1
g/hr
IVI
Labe
talo
l 50m
g IV
+/- H
ydra
lazin
e 5m
g IV
NEUR
AXIA
L BL
OCK
ADE
- Lab
our E
PIDU
RAL
& SP
INAL
for L
SCS
EMER
GEN
CY S
PINA
L LS
CS C
HECK
LIST
ANTI
BIO
TICS
& C
ITRA
TE G
IVEN
?!!
!!
!
IV A
CCES
S, S
ECUR
ED &
FLU
IDS
PREL
OAD
ED?!!
!
CONS
IDER
EPH
EDRI
NE o
r PHE
NYLE
PHRI
NE!
!!
TABL
E PO
SITI
ON,
may
nee
d L
late
ral t
o op
en in
ters
pace!!
L4-5
INTE
RSPA
CE ID
ENTI
FIED
?!!
!!
!
PREP
- DR
APE
- GO
WN
- GLO
VES
- MAS
K - H
AT!!
!
ANTI
SEPT
IC R
EMO
VED
FRO
M S
PINA
L TR
AY!
!!
LOCA
L AN
AEST
HETI
C 2%
XYL
OCA
INE/
ADRE
NALI
NE!!
INTE
RSPI
NOUS
LIG
AMEN
T ID
ENTI
FIED
!!
!!
CLEA
R CS
F, S
WIF
T IN
JECT
ION
with
BAR
BOTA
GE!
!
2.5M
L BU
PIVA
CAIN
E 0.
5% w
ith F
ENTA
NYL
20-2
5MCG
!!
(o
r spi
nal m
orph
ine
125m
cg)
TEST
ADE
QUA
CY O
F BL
OCK
: LT
> C
OLD
!!!
!
CALF
CO
MPR
ESSO
RS a
nd IN
DWEL
LING
CAT
HETE
R!!
OXY
TOCI
N 3-
5 U
post
-del
ivery
(+/-4
0U/L
@ 2
50m
l/hr)!
!
POST
-OP
MUL
TIM
ODA
L AN
ALG
ESIA!
!!
!
CLEX
ANE
40m
g sc
OD
> 4
hrs
post
spi
nal o
r cat
hete
r out!!
EPID
URAL
CHE
CKLI
ST
IV A
CCES
S, S
ECUR
ED &
FLU
IDS
PREL
OAD
ED?!!
!
VALI
D IN
DICA
TIO
N, R
ECEN
T VE
& C
ONS
ENT?!!
!
APPR
OPR
IATE
PO
SITI
ON?
!!
!!
!!
L4-5
INTE
RSPA
CE ID
ENTI
FIED
?!!
!!
!
PREP
- DR
APE
- GO
WN
- GLO
VES
(8) -
MAS
K - H
AT!
!
ANTI
SEPT
IC R
EMO
VED
FRO
M E
PIDU
RAL
TRAY
!!!
SALI
NE A
VAIL
ABLE
if L
ORT
S AP
PRO
ACH!!
!!
EPID
URAL
CAT
HETE
R PR
IMED
with
LA!
!!
!
SKIN
LA
2% X
YLO
CAIN
E wi
th 1
/200
,000
ADR
ENAL
INE!
!
INTE
RSPI
NOUS
LIG
AMEN
T ID
ENTI
FIED
!!
!!
SLO
W A
DVAN
CE W
ITH
TUO
HY N
EEDL
E!!
!!
8c
m, 1
6G/1
8G s
low
adva
nce
to L
ORT
S(A)
in e
pidu
ral s
pace
Note
CAT
HETE
R DE
PTH
adva
nce
CATH
ETER
+5c
m!
!
SECU
RE, T
EST
DOSE
3m
l LA!2
% X
ylo 1
/200
,000
Adr!
!
BUPI
VACA
INE
0.12
5%/1
00m
cg fe
ntan
yl (2
0ml p
rem
ix)!
!
TEST
ADE
QUA
CY O
F BL
OCK
: LT
> C
OLD
, IDC
!!
!
TOP
UP fo
r LSC
S -
2% x
ylo w
ith 1
/200
,000
10-
20m
l!!
STAR
T HE
RE
As
k ‘w
ho w
ill b
e te
am le
ader
’ & th
en p
erfo
rm a
sys
tem
atic
che
ck o
f eac
h of
follo
win
g
POST
PAR
TUM
HAE
MO
RRHA
GE
CONS
IDER
PO
TENT
IAL
CAUS
ES &
SUG
GES
T TO
MID
WIF
E &
OBS
TETR
ICIA
N
Abno
rmal
ities
of u
terin
e co
ntra
ctio
n!!
!!
!!
!!
TONE!!
!!
!!
70%
Reta
ined
pro
duct
s of
con
cept
ion
or in
vasi
ve p
lace
nta!
!!
!!
TISS
UE!
!!
!!
10%
Gen
ital t
ract
trau
ma!
!!
!!
!!
!!
!TR
AUM
A!
!!
!!
10%
Abno
rmal
ities
of c
oagu
latio
n!!
!!
!!
!!
!TH
ROM
BIN!!
!!
!1%
Resu
scita
te A
- B
- CO
xyge
n 15
l/m
in N
RBM
and
IV A
cces
s 16
G x
25
min
utel
y O
bs H
R/BP
/RR/
SpO
2M
obilis
e O
BS D
r - A
NAES
Dr -
MW
- RN
- EN
- Co
nsid
er n
eed
for T
HEAT
RE T
EAM
, BLO
OD,
WAR
MED
FLU
IDS,
INFU
SIO
N PU
MPS
x 2
INIT
IAL
MEA
SURE
SBa
sic re
sus
as a
bove
, also
ens
ure
:
Fund
al p
ress
ure
/ rub
up
cont
ract
ion!
!
Chec
k ut
erus
not
inve
rted!!
!!
Ch
eck
plac
enta
is in
tact!
!!
!
Lay
flat,
reve
rse
Tren
dele
nbur
g!"
"
Set u
p En
Flow
flui
d wa
rmer
""
"
Infu
se H
artm
ann’
s!!
!!
!
Cons
ider
nee
d fo
r BLO
OD
""
"
Synt
ocin
on!
5U IV
/ 10
U IM!
""
Er
gom
etrin
e !2
50m
cg IV
/ 50
0mcg
IM!!
O
xyto
cin IV
I 40u
/L @
250
ml/h!
!!
M
isopr
osto
l 5 x
200
mcg
PR!
!"
BLEE
DING
des
pite
CO
NTRA
CTED
UTE
RUS?
Look
for o
ther
cau
ses
:
Mov
e to
thea
tre!
!!
!!
Ensu
re a
dequ
ate
anae
sthe
sia!
!!
Li
thot
omy
posit
ion,
IDC!
!!
!
Adeq
uate
light
, equ
ipm
ent!!
!!
Insp
ect l
ookin
g fo
r gen
ital t
ract
trau
ma!
!
Exclu
de u
terin
e ru
ptur
e!
""
"
Sutu
re &
repa
ir as
nec
essa
ry!
!!
Cons
ider
nee
d fo
r BLO
OD!"
""
Cons
ider
coa
gulo
path
y &
seps
is (G
BS)!!
Ch
eck
Chem
8, I
NR, H
b, L
acta
te!!
!
War
m O
T, B
air H
ugge
r, En
Flow
war
mer!!
TR
ANEX
AMIC
ACI
D 1g
load
ove
r 10’!
!
STIL
L BL
EEDI
NG?
Cons
ider
ope
ratio
n &
Retri
eval
Bim
anua
l com
pres
sion!
!!
Ex
pert
advic
e 13
STAR
!!
!
RSI G
A!
!!
!!
An
ticip
ate
diffi
cult
airw
ay -
get D
AE k
it!
Pass
a N
GT!!
!!
!
Intra
myo
met
rial p
rost
agla
ndin
-F2a
5mg
dilu
te u
p to
10m
l6m
l in fu
ndus!
!!
!
Cons
ider
nee
d fo
r BLO
OD!!
!
- Bak
ri ba
lloon
tam
pona
de!!
!
- Exp
lore
ute
rine
cavit
y!!
!
- B-ly
nch
sutu
re !
!!
!
- Hys
tere
ctom
y / l
igat
e in
t ilia
cs!!
NEO
NATA
L RE
SUSC
ITAT
ION
STAR
T HE
RE
As
k ‘w
ho w
ill b
e te
am le
ader
’ & th
en p
erfo
rm a
sys
tem
atic
che
ck o
f eac
h of
follo
win
g
NEO
NATA
L RE
SUS
- DRU
GS
ADEN
OSI
NEfir
st d
ose
0.05
mg/
kgse
cond
dos
e 0.
10m
g/kg
then
0.2
0mg/
kgG
IVE
VIA
FAST
FLU
SH
ADRE
NALI
NE
IM : !<
6 y
r 150
mcg
(0.1
5ml)
!6-
12 y
r !30
0mcg
(0.3
ml)
!>
12 y
r!50
0mcg
(0.5
ml)
IV : !C
AUTI
ON
WIT
H DO
SE!
0.01
mg/
kg (1
0mcg
/kg)
!1/
10,0
00 -
0.1
ml/k
g IV
ETT
: 1/1
000
- 0.1
ml/k
g
ADRE
NALI
NE IN
FUSI
ON
0.3m
g/kg
in 1
00m
l N-s
alin
e1m
l/hr =
0.0
5mcg
/kg/
min
Rang
e 1-
20m
l/hr
AMIO
DARO
NE5
mg/
kg lo
adin
fuse
0.5
mg/
kg/h
r
ATRA
CURI
UM0.
5mg/
kg
ATRO
PINE
20m
cg/k
g IV
(max
600
mcg
)di
lute
0.6
mg
to 6
mls
= 10
0 m
cg/5
mls
So g
ive 1
ml p
er 5
kg IV
CODE
INE
1mg/
kg
DEFI
BRIL
LATI
ON
2-4
J/kg
– B
ipha
sic
DEXT
ROSE
0.5
gm/k
g10
% -
5 m
l/kg
IV50
% -
1 m
l/kg
IV
ETT
Leng
th A
ge/2
+ 1
2cm
teet
hDi
amet
er >
1yr -
Age
/4 +
4 m
m
FENT
ANYL
1 m
cg/k
g IV
(0.5
mcg
/kg
IN)
KETA
MIN
E SE
DATI
ON
2-4
mg/
kg IM
0.25
- 0.
5 m
g/kg
IVre
peat
as
need
edIN
TRAN
ASAL
- se
e ov
er
KETA
MIN
E - A
NAES
5-10
mg/
kg IM
1-2
mg/
kg IV
repe
at a
s ne
eded
MET
ARAM
INO
L0.
01 m
g/kg
IV10
mg
in 2
0 m
ls=0.
5 m
g/m
l
MID
AZO
LAM
0.1
- 0.2
mg/
kg IV
MO
RPHI
NE0.
1 m
g/kg
IV
NEO
STIG
MIN
E0.
05 m
g/kg
IV
PARA
CETA
MO
LLo
ad 2
0mcg
/lg fi
rst d
ose
then
15
mg/
kg 6
hrly
PRO
POFO
L1-
3.5
mg/
kg IV
REM
IFEN
TANI
L1m
g/20
ml =
50
mcg
per
ml
Run
at 1
0mcg
/kg/
min
ROCU
RONI
UM0.
6-1.
2 m
g/kg
IV S
TAT
0.1
mg/
kg b
olus
es
SALB
UTAM
OL
Undi
lute
d 5m
g/5m
l5m
cg/k
g ov
er 1
min
IV
SUXA
MET
HONI
UM2
mg/
kg IV
3mg’
kg n
eona
te4
mg/
kg IM
THIO
PENT
ONE
4 m
g/kg
IV
VECU
RONI
UM0.
1 m
g/kg
IV
VOLU
ME
EXPA
NSIO
N20
mls/
kg N
/sal
ine
WEI
GHT
(kg)
Infa
nts
< 12
mon
ths
(age
in m
onth
s +
9) /
2
Child
ren
1-5
year
s2
x (a
ge in
yea
rs +
5)
Child
ren
5-12
yea
rs4
x ag
e in
yea
rs
PAED
IATR
IC E
MER
GEN
CY F
ORM
ULAR
Y
EMER
GEN
CY
Adre
nalin
e 10
mcg
/kg
IVIM
pre
ferre
d in
an
aphy
laxis
Atro
pine
20m
cg/k
g
Met
aram
inol
10m
cg/k
g
Prop
ofol
2m
g/kg
Sux
2mg/
kg
Thio
4m
g/kg
Flui
ds 2
0ml/k
g
2-4J
/kg
Biph
asic
Adre
nalin
e IM
1/1
000
0.01
ml/k
g to
max
0.5
ml
IM la
tera
l thi
gh, r
epea
t 5 m
inut
ely
Adre
nalin
e IV
1,1
0,00
01m
g/10
ml 1
/10,
000
IV10
mcg
(0.1
ml)
per k
g of
1/1
0,00
0
Adre
nalin
e In
fusi
on1/
1,00
0 =
1mg/
ml
3mg
in 5
0ml N
sal
ine
0.3m
g/kg
- 60
mcg
/ml
2mcg
/min
= 2
ml/h
r to
20m
cg/m
in =
20m
l/hr
Amio
daro
ne5m
g/kg
ove
r 20
min
can
push
ove
r 2 m
ins
cent
ral a
cces
s IV
Amio
daro
ne In
fusi
on60
0mg
in 5
0mls
5% d
extro
se0.
5mg/
kg/h
r cen
tral a
cces
s
Atra
curiu
m0.
5 m
g/kg
(0.3
-0.6
mg/
kg) I
V in
duce
,th
en 1
/3rd
dos
e su
bseq
uent
ly
Atro
pine
600m
cg in
6m
l NS
10-2
0mcg
/kg
kids
300-
600m
cg a
dults
Cis-
atra
curiu
m0.
15m
g/kg
IV
Dext
rose
0.5
gm/k
g10
% -
5 m
l/kg
IV50
% -
1 m
l/kg
IV
Ephe
drin
e3-
6mg
bolu
s IV
Esm
olol
0.5m
g/kg
100m
g/m
l dilu
te in
10m
l = 1
0mg/
ml
100k
g=50
mg=
5ml
ETT
Leng
thAg
e/2
+ 12
cm to
teet
h
ETT
Diam
eter
>1yr
- Ag
e/4
+ 4
Fent
anyl
100m
cg/2
ml
2-3
mcg
/kg
IV0.
5-1
mcg
/kg
intra
nasa
l
GTN
Infu
sion
50m
g in
50m
l 5%
dex
trose
1m
g/m
l at 3
-12m
l/hr
Hepa
rin In
fusi
on25
,000
uni
ts in
500
ml (
50U/
ml)
1000
U/hr
= 2
0ml/h
r
Insu
lin IV
I 50
uni
ts in
50m
l5-
10 U
/hr =
5-1
0ml/h
r
Isop
rena
line
1mg
in 5
0ml 5
% d
extro
seG
ive 2
0mcg
(1m
l)th
en in
fuse
at 1
-4m
cg/m
in(3
-12
ml/h
r)
Keta
min
e In
duct
ion
1-2
mg/
kg IV
5-
10m
g/kg
IM
Keta
min
e Se
datio
n0.
2-0.
5 m
g/kg
IV s
edat
ion
2-4m
g/kg
IM s
edat
ion
Keta
min
e In
fusi
on0.
25m
g/kg
/hou
r
Keta
min
e/M
idaz
olam
Infu
sion
200m
g Ke
tam
ine
: 50m
cg fe
ntan
ylin
50m
l run
@ 2
-5m
l/hr
Mag
nesi
um S
ulph
ate
Infu
sion
4 am
poul
es (2
.47g
x 4
= 9
.88g
) to
100m
l N s
alin
e =
120m
l
Load
4g
(50m
) ove
r 20
min
s(1
50m
l/hr o
ver 2
0 m
ins)
then
1g/
hr (1
2ml/h
r)
Met
aram
inol
0.5m
g bo
lus
Mid
azol
am01
.-0.2
mg/
kg IV
Mor
phin
e0.
1 m
g/kg
IV
Mor
phin
e/M
idaz
olam
Infu
sion
50m
g ea
ch in
50m
l NS
1mg/
ml (
1mg/
10m
l)at
10m
cg/k
g/hr
= 2.
5 - 1
5ml/h
r
Nalo
xone
0.1
to 0
.2 m
g IV
2-3
min
utel
y to
de
sired
deg
ree
of re
vers
al
Neos
tigm
ine
005m
g/kg
IV
Para
ceta
mol
20m
g/kg
firs
t dos
eth
en15
mg/
kg P
O
Prop
ofol
2mg/
kg ti
trate
Rem
ifent
anil
1mg/
20m
l = 5
0 m
cg p
er m
lRu
n at
0.1
mcg
/kg/
min
Rocu
roni
um0.
6-1.
2 m
g/kg
IV S
TAT
(get
sam
e in
tuba
ting
cond
itions
as
sux
if us
e ro
c 1.
2mg/
kg)
0.1
mg/
kg b
olus
es th
erea
fter
Salb
utam
ol IV
10m
cg/k
g IV
bol
us o
ver 1
0 m
ins
Sodi
um B
icar
bona
te 8
.4%
1-2
ml/k
g
Suxa
met
honi
um1
mg/
kg a
dult
2 m
g/kg
pae
d
Thio
pent
one
3-5
mg/
kg
Vecu
roni
um0.
1 m
g/kg
load
bolu
s ev
ery
30m
with
5-1
0mg
vec
Vecu
roni
um In
fusi
on0.
1 m
g/kg
/hr
Volu
me
Expa
nsio
n20
mls/
kg N
/sal
ine
FORM
ULAR
Y
ADRE
NALI
NE!
!3m
g in
50m
l N/s
alin
e =
60m
cg/m
l!!!
!ru
n at
2 -
20 m
l/hr
1mg/
1ml a
mp!
!!
!!
!!
!!
!in
cr. t
o ke
ep M
AP >
70
AMIO
DARO
NE!
!di
lute
600
mg
(12m
l) up
to 5
0ml 5
% D
EX!!
!ru
n at
0.5
mg/
kg/h
r15
0mg/
3ml a
mp!
!=
12m
g/m
l!!
!!
!!
!ce
ntra
l acc
ess
ESM
OLO
L!!
!lo
ad 5
00 m
cg/k
g ov
er 6
0sec
s!!
!!
100k
g =
5ml (
100m
g/10
ml)
100m
g/10
ml!!
!m
aint
ain
50m
cg/k
g/m
in!
!!
!!
100k
g =
30m
l/hr
FENT
ANYL!!
!10
0 m
cg/2
ml o
r 500
mcg
/50m
l pre
mix!!
!ru
n at
0 -
100
mcg
/hr
GTN!!
!!
dilu
te 5
0mg
up to
50m
l 5%
DEX
!!
!!
run
at 3
- 12
ml/h
r50
mg/
10m
l am
p!!
= 1m
g/m
l!!
!!
!!
!tit
rate
to B
P/pa
in
HEPA
RIN!
!!
25,0
00 U
in 5
0ml!
!!
!!
!lo
ad 5
000
U IV
!!
!!
500
U/m
l!!
!!
!!
!th
en 2
ml/h
r, tit
rate
APT
T
INSU
LIN
IVI!!
!50
U in
50m
l = 1
U/m
l!!
!!
!lo
ad 1
0U IV
(not
kid
s)!
!!
!!
!!
!!
!!
!th
en ru
n @
5-1
0 m
l/hr!
!
(see
Slid
ing
Scal
e ab
ove)
ISO
PREN
ALIN
E!!
1mg
in 5
0ml 5
% D
EX =
20m
cg/m
l!!!
!1
ml b
olus
to re
spon
se!
!!
!!
!!
!!
!!
!th
en 3
-12
ml/h
r
KET/
MID
AZ!!
!20
0mg
keta
min
e /5
0 m
cg fe
nt in
50m
l!!
!ru
n at
2-5
ml /
hr
MgS
O4
(ecl
amps
ia)!
Add
4 am
ps (2
.47g
) to
100m
l N/s
alin
e!!
!bo
lus
50m
l (4g
) ove
r 20m
ins
ie :
150m
l/hr f
or 2
0 m
ins
!!
!!
= 12
0 m
l tot
al v
olum
e (1
g/12
ml)!
!!
!th
en 1
g/hr
(12
ml/h
r)
MO
RPH/
MID
AZ!
!50
mg
each
to 5
0ml w
ith N
/sal
ine
(1m
g/m
l)!!
run
100
mcg
/kg/
hr (2
.5-1
5 m
l/hr)
PRO
POFO
L!!
!1-
4 m
g/kg
500
mg/
50m
l (10
mg/
ml)!
!!
dose
rang
e 0.
5 m
g/kg
/hr (
use
body
wt =
ml/h
r eg
70kg
= 7
0ml/h
r)
REM
IFEN
TANI
L!!
1mg
in 2
0ml =
50m
cg/m
l!!
!!
!ru
n at
0.1
mcg
/kg/
min
(100
kg =
12m
l/hr)
VECU
RONI
UM!
!1m
g/m
l rec
onst
itute
in w
ater
for i
njec
tion!!
!0.
1 m
g/kg
/hr e
g: 8
mg/
hr in
80k
g pa
tient
INFU
SIO
NS!!
!Id
eally
use
ded
icat
ed s
yrin
ge d
river
(10
- 50m
l cap
acity
) eg
Niki
T34
L
INSU
LIN
SLID
ING
SCA
LE50
U/50
ml =
1U/
ml
B
GL!!
!
RAT
E
mm
ol!!
!U/
hr =
ml/h
r
<
4!!
!0
- STO
P IV
I
4.1
- 9!
!
2
9.1
- 13!
!
3 1
3.1
- 17!
!
4 1
7.1
- 28!
!
6
> 2
8!!
!
8!
!!
chec
k ru
nnin
g
SAFE
PSY
CH S
EDAT
ION
MAT
RIX
LIAI
SE W
ITH
RETR
IEVA
L TE
AM
RAPI
D AS
SESS
MEN
T AC
UTE
AGIT
ATIO
N
AIRW
AY?
BREA
THIN
G?
CIRC
ULAT
ION
DISA
BILI
TY,
DRUG
S?EN
VIRO
NMEN
T, E
CGFU
LL B
LADD
ER?
GLU
COSE
?HE
AD IN
JURY
?
SUG
GES
TED
ALG
ORI
THM
NO IV
ACC
ESS
oral
ola
nzap
ine
10-2
0mg
stat
and/
orIM
I mid
azol
am 5
-10m
gan
d/or
IMI k
etam
ine
4mg/
kg
IV A
CCES
S O
BTAI
NED
IV m
idaz
olam
2-5
mg
and/
orIV
hal
oper
idol
5-1
0mg
and/
orIV
ket
amin
e 1-
1.5m
g/kg
repe
at e
very
5-1
0 m
ins,
targ
et R
ASS
0 to
-3
CONS
IDER
ANAE
STHE
TIC
RISK
ANAE
STHE
TIC
RISK
ANAE
STHE
TIC
RISK
MEN
TAL
HEAL
THSA
FETY
/RIS
K
LOW
thin
, fit,
fast
edM
EDIU
MAS
A II
- III
HIG
Hol
d, s
ick, d
ifficu
lt ai
rway
OSA
etc
LOW
flat,
depr
esse
d, n
o Hx
vio
lenc
e,lo
w ris
k su
icida
l pat
ient
“hap
py” d
runk
thou
ght d
isord
ered
but
com
plia
nt
low
risk
reas
sura
nce
mild
anx
iolyt
ic
rest
rain
tm
onot
hera
pylo
nger
act
ing
agen
ts1:
1 nu
rsin
g
avoi
d dr
ugs
if po
ssib
leor
ient
atio
nre
assu
ranc
e1:
1 nu
rsin
g
MED
IUM
into
xicat
ed /
disin
hibi
ted
unpr
edict
able
delu
siona
l with
poo
r ins
ight
anxio
us +
++
seda
tion
need
edsin
gle
agen
tan
tipsy
chot
ic (+
/- be
nzo)
as a
bove
heav
ier s
edat
ion
airw
ay a
djun
cts
to
hand
airw
ay ri
skno
n-ph
arm
acy
pref
erre
dsh
ort a
ctin
g BD
Ztin
ctur
e of
tim
e
HIG
Hvio
lenc
e /w
eapo
nsph
ysica
l thr
eats
pers
ecut
ory
delu
sions
aro
und
care
“big
guy
” you
who
m c
anno
t res
train
as a
bove
then
keta
min
ese
datio
nor
RSI
/ETT
as o
rang
ebu
t del
ayun
til fa
sted
awai
t ret
rieva
l?
bala
nce
of m
inim
al
seda
tion
& ow
n ai
rway
vsG
A/ET
T
Ola
nzap
ine
- firs
t lin
e or
al a
ntip
sych
otic;
waf
er 1
0-20
mg
oral
, rap
id o
nset
Que
tiapi
ne -
seco
nd lin
e or
al a
ntip
sych
otic;
man
ia, b
ehav
iour
al-b
ased
agi
tatio
n or
pre
vious
use
Halo
perid
ol -
5mg
ORA
L or
10m
g IM
to m
ax 5
0mg;
5-1
0mg
IV u
p to
max
20m
gbe
nztro
pine
1-2
mg
IV s
houl
d be
ava
ilabl
e to
trea
t acu
te d
ysto
nia
Mid
azol
am -
IM 5
-20m
g, IV
0.1
-0.2
mg/
kg in
aliq
uots
, IN
0.2m
g/kg
, ORA
L 0.
5mg/
kgflu
maz
enil 0
.2-0
.5m
g IV
sho
uld
be a
vaila
ble
if ac
ute
reve
rsal
requ
ired
Keta
min
e - P
RE-K
ETAM
INE
SEDA
TIO
N ES
SENT
IAL
to M
INIM
ISE
DELI
RIUM
ie :
BDZ
IM 5
mg/
kg, I
V 0.
5-1.
5mg/
kg s
edat
ion.
Ket
amin
e in
fusio
n ha
s be
en u
sed
for t
rans
port.
Cons
ider
ant
isial
ogog
ue a
djun
ct (a
tropi
ne o
r glyc
opyr
rola
te)
See
also
: M
inh
le C
ong
et a
l. “K
etam
ine
seda
tion
for p
atie
nts
with
acu
te a
gita
tion
and
psyc
hiat
ric il
lnes
s re
quiri
ng a
erom
edic
al
retri
eval
” EM
J M
ay 2
011
- ket
amin
e se
datio
n us
ed to
avo
id R
SI/E
TT o
f red
/bla
ck p
atie
nts
in ri
sk m
atrix
abo
ve
MIN
IMUM
SED
ATIO
N M
ONI
TORI
NG -
SpO
2, E
CG, N
IBP.
Con
sider
ETC
O2
via H
M. S
UPPL
EMEN
TAL
OXY
GEN
AT
ALL
TIM
ESRF
DS re
stra
ints
or n
et, 4
5 de
gree
hea
d up
to m
axim
ise S
V an
d m
inim
ise a
spira
tion
risk.
CHE
CK B
GL!
Proc
edur
e
(i)ob
serv
e pa
tient
- pa
tient
is a
lert,
rest
less
, agi
tate
d or
com
bativ
e (0
to +
4)
(ii)
if no
t ale
rt, s
tate
pat
ient
’s na
me
and
say
to o
pen
eyes
and
look
at s
peak
er-1
if a
wak
ens
with
sus
tain
ed e
ye c
onta
ct to
voi
ce >
10s
to v
oice
-2 if
aw
aken
s w
ith e
ye c
onta
ct to
voi
ce <
10s
-3 if
mov
es o
r ope
ns e
yes
to v
oice
but
no
eye
cont
act
(iii)
if no
resp
onse
to v
oice
, use
phy
sical
stim
ulus
(sho
ulde
r sha
ke, t
rape
zius
sque
eze,
jaw
thru
st)
-4 if
any
mov
emen
t to
phys
ical s
timul
atio
n-5
if n
o re
spon
se to
phy
sica
l stim
ulat
ion
RICH
MO
ND A
GIT
ATIO
N SE
DATI
ON
SCAL
E
RICH
MO
ND A
GIT
ATIO
N SE
DATI
ON
SCAL
ERI
CHM
OND
AG
ITAT
ION
SEDA
TIO
N SC
ALE
RICH
MO
ND A
GIT
ATIO
N SE
DATI
ON
SCAL
ETe
rmDe
scrip
tion
Scor
e
COM
BATI
VEov
ertly
com
bativ
e, v
iole
nt, i
mm
edia
te d
ange
r to
self/
othe
rs+4
VERY
AG
ITAT
EDpu
lls o
r rem
oves
tube
(s),
cath
eter
(s),
aggr
essiv
e+3
AGIT
ATED
frequ
ent n
on-p
urpo
sefu
l mov
emen
t, fig
hts
vent
ilato
r+2
REST
LESS
anxio
us b
ut m
ovem
ents
not
agg
ress
ive o
r vig
orou
s +
1
ALER
T &
CALM
Doct
or o
r Nur
se0
DRO
WSY
Not f
ully
aler
t, bu
t sus
tain
ed a
wake
ning
to v
oice
(eye
s op
en >
10s
)-1
LIG
HT S
EDAT
ION
brie
fly a
wake
ns w
ith e
ye c
onta
ct to
voi
ce <
10s
-2
MO
DERA
TE S
EDAT
ION
mov
emen
t or e
ye o
peni
ng to
voi
ce b
ut n
o ey
e co
ntac
t-3
DEEP
SED
ATIO
Nno
resp
onse
to v
oice
, but
mov
emen
t or e
ye o
peni
ng to
phy
sica
l stim
ulat
ion
-4
UNRO
USAB
LEno
resp
onse
to v
oice
or p
hysi
cal s
timul
atio
n-5
TARG
ET R
ASS
is 0
to -3
AIRW
AY E
QUI
PMEN
T an
d M
ONI
TORI
NG m
ust b
e av
aila
ble
1:1
NURS
ING
, 10
min
utel
y ob
s
LIAI
SE W
ITH
RETR
IEVA
L SE
RVIC
E
TRANSFER INFORMATIONSometimes important details can get forgotten. I use the ABC approach to handover to retrieval team, as follows: “Thank God you’re here! OK, this is John Doe age 21 involved in a motor vehicle accident with prolonged extrication and transferred via ambulance to us. He needs transfer to a trauma centre for a laparotomy for internal bleeding. In terms of summary, here’s his ABC...”
The above would take 90 seconds and is an ordered summary of the patient for handover.
A - Airway Intubated on arrival for GCS M3V1E1 - grade I view.Airway now patent, protected with size 8.5 ETT tube 22cm teeth and tied. Cervical collar in situ.
B - Breathing Paralysed with vecuronium and on volume control TV 600 RR 12R sided HTX and a 34Fr intercostal catheter in place, drained 400ml blood. SpO2 96%
C - Circulation Haemodynamically stable after 750ml crystalloid titrated to radial pulse in 250ml aliquots. HR 90 BP 100/70Bleeding likely from HTX, abdomen and pelvis (binder on)
D - Disability/Drugs M3V1E1 PEARLA initially, now M1V1E1 on propofol/vecuronium infusion.
E - Exposure R HTX drained as above.Abdomen tense and tender in LUQ, suspect splenic injury.No other injuries on log roll, pelvic binder applied.Warm blankets and Bair hugger
F - Fluids 3 x 250ml crystalloid aliquots titrated to radial pulse (SBP 70)IDC in situ and drained 300ml clear urine
G - Gut Last ate 7pm. NG passed and on free drainage.
H - Haematology Hb 114 on iStat, INR 1.1 No ACoTS.
I - Infusions Not needed vasopressorsOn propofol and vecuronium infusions for transport
J - JVP Not elevated - no signs tPTX/tamponade.
K - Kelvin Temp is 36 degrees with active warming
L - Lines 14G IV R wrist8Fr rapid infuser L ACF
M - Micro Has been given ADT
N - Notes/NOK His notes are in this envelope, including copies of plain X-raysNext Of Kin (NOK) are aware and here are their contact details.
