Emergencies, Complications, and Crisis Management
Crisis recognition and response
The Emergencies, Complications, and Crisis Management domain tests malignant hyperthermia, anaphylaxis, local anesthetic systemic toxicity (LAST), laryngospasm, bronchospasm, aspiration and cardiac arrest. Speed and sequence earn marks.
- Malignant hyperthermia: stop volatile agents and succinylcholine, give 100% O2, hyperventilate, dantrolene 2.5 mg/kg IV and repeat until controlled, cool, treat hyperkalemia, monitor urine output and CK. Do not wait for hyperthermia.
- Anaphylaxis: stop trigger, 100% O2, IV epinephrine 50–100 mcg boluses (or IM 0.5 mg if no IV), fluids, adjunct steroids and antihistamines.
- LAST: stop injection, airway and ventilation, benzodiazepine for seizures, 20% lipid emulsion 1.5 mL/kg bolus, then 0.25 mL/kg/min; avoid vasopressin and calcium channel blockers.
- Laryngospasm: 100% O2 with CPAP, deepen with propofol, suction, and succinylcholine 0.5–1 mg/kg if persistent.
- Bronchospasm: deepen, beta-agonist, epinephrine if severe; check tube position.
Worked example
During sevoflurane anesthesia, ETCO2 rises to 65 mm Hg despite increased minute ventilation, HR 130, and masseter rigidity. The reasoning: suspect malignant hyperthermia before temperature rises. Stop the volatile, give dantrolene 2.5 mg/kg, hyperventilate with 100% O2, cool, and check potassium, CK and urine output. Delay increases mortality.
Traps that cost marks
Do not give dantrolene for isolated tachycardia without considering other causes, but do not delay it in a credible MH crisis. Do not use lidocaine to treat LAST seizures. Do not forget to call for help and assign roles.