Emergency Response and Patient Safety
This domain tests recognition and the first correct action in an emergency, plus the systems that prevent never-events. Stems typically present a deteriorating patient or a safety breach and ask what you do first. The first action is almost always: recognize, call for help, and remove the cause.
Wrong-site prevention
The Universal Protocol has three parts: preoperative verification of patient, procedure, site and side against documents and imaging; marking the site by the surgeon with the patient involved when possible; and a time-out in the room with the whole team immediately before incision, confirming patient, procedure, site, position, implants, imaging, and antibiotics. Everyone on the team can stop the line.
Malignant hyperthermia
Triggered by volatile anesthetics and succinylcholine in susceptible patients. Early signs are unexplained tachycardia, rising end-tidal CO2 despite adequate ventilation, masseter spasm, and generalized rigidity; hyperthermia is a late sign. Action: stop triggers, call for help, hyperventilate with 100% oxygen at high flow, give dantrolene 2.5 mg/kg IV and repeat as needed, cool the patient, treat acidosis and arrhythmias, and monitor urine output.
Other emergencies
Anaphylaxis: epinephrine, airway, fluids. Cardiac arrest: start compressions, defibrillator, follow ACLS. Massive hemorrhage: direct pressure, large-bore access, blood products, warming. Local anesthetic systemic toxicity: stop injection, airway, lipid emulsion per protocol.
Fire
The fire triangle is oxidizer, fuel, and ignition. In an airway fire: stop the gas flow, remove the burning material, extinguish with saline, then reestablish the airway. For a general fire, use RACE for evacuation and PASS for extinguisher use.
Worked example
Twenty minutes into a sevoflurane case, end-tidal CO2 climbs and the patient's heart rate rises despite increased minute ventilation, then the jaw tightens. This is malignant hyperthermia until proven otherwise. The team stops the anesthetic, calls for the MH cart, gives dantrolene 2.5 mg/kg, switches to 100% oxygen at high flow, and begins active cooling - they do not wait for the temperature to rise.
Traps that cost marks
Waiting for hyperthermia before treating MH; using room air ventilation during a fire; skipping the time-out for a 'obviously correct' case; not designating someone to call for help.