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EHPLE Anesthesia study materials
EHPLE Anesthesia study resources

EHPLE Anesthesia: Intraoperative Management and Critical Events

EHPLE Anesthesia · Work through your exam, one topic at a time.

All guide sections

Intraoperative Management and Critical Events

What this domain tests

Critical-event items test recognition and first actions under uncertainty: anaphylaxis, malignant hyperthermia, hemorrhage, laryngospasm, bronchospasm, and sudden hypotension.

Core rules

  • Anaphylaxis: hypotension, bronchospasm, rash, and GI symptoms. Stop the trigger, give 100% oxygen, epinephrine 10-100 mcg IV boluses (0.5-1 mg IM if no IV), fluids, and adjuncts.
  • Malignant hyperthermia: rising ETCO2 despite hyperventilation, rigidity, tachycardia, and hyperthermia. Stop volatile agents and succinylcholine, give 100% oxygen at high flow, dantrolene 2.5 mg/kg repeated to 10 mg/kg, cool, and treat hyperkalemia and arrhythmias; avoid calcium channel blockers.
  • Hemorrhage: activate massive transfusion, use balanced 1:1:1 resuscitation, give tranexamic acid 1 g, allow permissive hypotension until control, and keep the patient warm.
  • Laryngospasm: 100% oxygen with CPAP, jaw thrust, propofol 0.5 mg/kg, and succinylcholine 0.5-1 mg/kg if severe.
  • Bronchospasm: deepen anesthesia, give beta-agonist, use epinephrine if severe, and check the tube.
  • Sudden hypotension: use POCUS, check rhythm, and consider bleeding, anaphylaxis, tension pneumothorax, and auto-PEEP.

Worked example

Ten minutes into sevoflurane, ETCO2 rises to 65 mmHg despite doubled minute ventilation, heart rate is 130, and the jaw is rigid. Temperature is 38.2°C. The diagnosis is malignant hyperthermia, not light anesthesia. Stop sevoflurane and succinylcholine, hyperventilate with 100% oxygen at high flows, give dantrolene 2.5 mg/kg (175 mg for 70 kg), cool, and monitor potassium, CK, and urine. The reasoning is that hypercarbia precedes hyperthermia and dantrolene is the only disease-specific treatment.

Traps

Waiting for hyperthermia before treating MH; giving calcium channel blockers with dantrolene; treating anaphylaxis with antihistamines first; missing tension pneumothorax because the patient is only hypotensive; using large-volume crystalloid instead of blood in massive hemorrhage.

Key points

  • MH: rising ETCO2, rigidity, tachycardia; give dantrolene 2.5 mg/kg.
  • Anaphylaxis: epinephrine is first-line, not antihistamines.
  • Massive hemorrhage: balanced transfusion, TXA 1 g, warming.
  • Severe laryngospasm: propofol and succinylcholine.
  • Sudden hypotension requires POCUS and a structured differential.