PRINCIPLES OF

EMERGENCY ANESTHESIA
Dr Masood Entezari

INTRODUCTION
In elective surgery:
- madding correct diagnosis
- identifying and treating medical disorders
- occurring an appropriate period of starvation
One or more of these conditions are often not met in
emergency work

Further problems :
- dehydration
- electrolyte abnormalities
- hemorrhage
- pain
The components of general anesthesia are the same in
elective and emergency surgery

The key to success in emergency anesthesia is a

thorough preoperative assessment
Particular attention must be given to:
- the search for medical problem
- the occurrence of hypovolemia
- an evaluation of the airway
There are very few patients whose clinical state is so
life threatening that they need immediate surgery
( true emergency)

CLASSIFICATION OF OPERATIONS

The vast majority of patients benefit from :

- the correction of hypovolemia
- the correction of electrolyte abnormality
- stabilization of medical problem
- waiting for the stomach to empty
When to operate is the most important decision that
has to be made in emergency work
Emergency anesthesia general anesthesia
But

Due to the increasing use of regional anesthesia ,

hypovolemia must be corrected pre- operatively
The sedated patient can talk to the anesthetist at
all time
If not ,then airway control may be lost with the
risk of aspiration of gastric contents

FULL STOMACH
Starvation for at least 4-6 hours in emergency
surgery
All emergency patients should be treated as
having a full stomach and so at risk of vomiting
, regurgitation and aspiration
Occurring the vomiting at the induction and
emergence from anesthesia
Entering gastric acid to the lungs and creating a
pneumonitis can be fetal

Silent regurgitation : passive regurgitation of

gastric content up to esophagus
Regurgitation is particularly likely at induction
of anesthesia when several drugs used
Regardless of the period of starvation ,in
emergency anesthesia there is always a risk of
aspiration

The trachea must be intubated as rapidly as

possible after induction
Endoteracheal intubation is performed under
general anesthesia when there is no problem in
preoperative assessment of the airway

Some basic requirements for endoteracheal intubation:

- skilled assistance must be present
- the trolley must tip
- the suction apparatus must work correctly and
be left on
- a rang of sizes of endoteracheal tubes must be
available
- spare laryngoscopes must be available
- ancillary intubation aids, gum elastic bougie
and stillettes must be available

Neither physical nor pharmacological methods should

be relied on to empty the stomach completely
In some specialties (obstetrics) an H receptor blocking
drug and 30 ml sodium citrate used orally 15
minutes before induction of anesthesia
Opiates delay gastric emptying and increase the
likelihood of vomiting

 The only reliable way

to prevent
regurgitation
using the correct anesthetic technique
(rapid sequence induction)

Rapid
sequence
induction

Preoxygenation

Cricoid
pressure

Intubation

PREOXYGENATION
Breathing 100% oxygen for at least 3 minutes before
induction
In breathing oxygen only, the lungs denitrogenate rapidly
and after 3 minutes contains only oxygen and carbon
dioxide
There is a greater reservoir of oxygen in the lunges to
utilize before hypoxia occurs

CRICOID PRESSURE
Identifying the cricoid cartilage on the patient
before induction of anesthesia
Warning the patient that they might feel
pressure on the neck as they go to sleep
Pressing down on the cartilage continuously until
telling the anesthetist to the assistant for
stopping

Object: compressing the esophagus between

the
cricoid cartilage and vertebral column
Pressure is usually undertaken by firm but gentle
pressure on the cartilage by the thumb and
forefinger of the assistant
The cricoid is easily identifiable , forms a complete
tracheal ring , and the trachea is not distorted when
it is compressed
Giving a neuromuscular blocking drug to facilitate
intubation

INTUBATION
The neuromuscular drug must act rapidly and have a
short duration of action
The lungs are not ventilated during a rapid sequence
induction ; this will prevent accidental inflation of
the stomach , which will further predispose the
patient to regurgitation and vomiting
An agent with a short duration of action is valuable
because in cases of failed intubation spontaneous
respiration will return promptly

Suxamethonium has many side effects but remain the

best drug available

Releasing the cricoid pressure only when :

- the trachea is intonated
- the cuff inflated
- the correct position of the tube is
confirmed
The anesthetic is maintained with :
- a volatile agent
- nitrous oxide
- oxygen
- competitive relaxant
- suitable analgesia

The reversal of the relaxant at the end of the procedure is

undertaken with the anticolinesteras (neostigmine)
Atropine or glycopyrrolat is given concomitantly to stop
bradycardia occurring from the neostigmine
Major disadvantage of potential hemodynamic instability
of rapid sequence induction: hypertension and
tachycardia following laryngoscopy and intubation
This is more severe in urgent surgery than elective surgery
because of using opiates at intubation of anesthesia

OTHER INDICATIONS FOR

RAPID SEQUENCE INDUCTION
Every anesthetic ,not just emergency work , should be
considered from the point of view of unexpected
vomiting or regurgitation
Some cases are at high risk and rapid sequence
intubation should be considered carefully as an
option in this group

PULMONARY ASPIRATION
Pulmonary aspiration may be obvious
Silent pulmonary aspiration is presenting as a
postoperating pulmonary complication
Treatment :
suction of airway
oxygenation of the patient(priority)
broncoscopy (may be required)

If the patient is not paralyzed , surgery permitting, he

or she should be allowed to wake up
If paralyzed , intubation and ventilation must occur
and oxygenation maintained
Bronchospasm may be treated with aminophylline
Further treatment may include antibiotics , other
bronchodilators and steroids
Aggressive early management is required

CONCLUSION
Anesthesia for emergency surgery needs careful
preoperative assessment and adequate
resuscitation must be undertaken before surgery