The Clinical Crisis Protocol

What to do when you don't know what to do

D. John Doyle MD PhD

April 2004

Look, Listen, Feel, Get

The "crisis protocol" is an approach to managing the patient whose life is in danger (eg,from stridor) and when there is limited time to act. More examples are given in the table below. Because response time is so limited, diagnosis of the problem must be accompanied by empirical treatment, i.e. diagnosis and treatment must be carried out concurrently, even when it may be far from clear what is going on. For example, severe bradycardia (heart rate < 40) may or may not be associated with symptoms such as syncope and can be due to many different causes (e.g., third degree heart block, beta blocker overdose, use of an anticholinesterase without sufficient anticholinergic (e.g., neostigmine without atropine) increased ICP, etc.).

Crisis Management in Anesthesiology, by Gaba, Fish, and Howard (Churchill Livingstone, New York) presents a basic protocol for the management of serious problems. While empirical treatment is essential while diagnostic measures are in progress (for example, giving intravenous atropine (0.6- 1 mg) in the case of symptomatic severe bradycardia), there are several other equally important aspects of successful crisis management. These include (1) mobilizing and allocating all available resources (e.g., personnel, supplies and equipment, cognitive aids such as checklists, and external resources such as lab services and consultants), (2) proper allocation of attention during this period of high demands, (3) planning ahead and anticipating (i.e. "staying ahead of the game"), (4) efficient distribution of the workload amongst all available personnel, and (5) frequent reevaluation the situation to avoid fixation errors. Also, the initiation of immediate life-support measures applies to virtually all crises. These measures include (1) discontinuing anesthetics (intraoperative crises), (2) increase the oxygen concentration to 100%, and verify that it approaches 100%, (3) maintain oxygenation at all costs (if in doubt about a ventilation system or oxygen supply, use a backup system or alternate oxygen source, and (4) ensure that the patient has a pulse and that blood pressure is acceptable (if not, commence ACLS protocol).

Examples of Urgent Clinical Problems Requiring Immediate Clinical Intervention

Intraoperative ventricular tachycardia, cardiac arrest

Cyanosis in recovery room

Grand-mal seizures

Severe bradycardia

Stridor

Syncopal attack

Some Forms of Initial Empirical Treatment

Dx: Symptomatic bradycardia

Rx: IV atropine 0.6 - 1 mg

Dx: Sustained apnea

Rx: Positive pressure ventilation

Dx: Pulseless ventricular tachycardia

Rx: Treat as VF with defibrillation and ACLS protocol

Dx: Severe hypoxemia

Rx: 100% oxygen +/- endotracheal intubation

Dx: Ventricular fibrillation

Rx: Defibrillation 200J; ACLS protocol

Approach to the Patient in Crisis: "Look, Listen, Feel, Get"

Look

Color - cyanosis (hypoxia) - pallor - patients ethnicity (eg sicking in Blacks)

Restlessness/Discomfort

Diaphoresis

Wound Sites/ Drains

Neck - Jugular venous pulsations - Trachea - Hematomas (eg post carotid surgery)

Respiration - rate - depth - pattern

Full body exposure/ secondary survey

Listen

Listen to the patient's complaints and observations of bystanders

Stridor and other breathing noises

Heart sounds (?muffled, ?murmur, ?gallop)

Air entry - equal bilaterally? - wheezes? - crackles?

Feel

Pulse - rate - intensity - pattern

Forehead - diaphoresis? - fever?

Grip strength

Get

Help

Crash cart and other equipment/resources, as needed

Vital signs

Old chart

Laboratory tests e.g. ABGs, CXR, electrolytes, etc.

Abbreviations Used

ABG: Arterial Blood Gases (pH and CO2 / O2 tensions)

ACLS:      Advanced Cardiac Life Support (Cardiac Arrest Protocol)

CXR:        Chest X-ray

ECG:        Electrocardiogram (heart elecrtical signal)

ICP:          Intracranial Pressure (brain pressure)

ICU:          Intensive Care Unit

VF:           Ventricular Fibrillation

VT:           Ventricular Tachycardia

Clinical Terms Used

Apnea: Failure to breathe (a clinical emergency)

Cardioversion: Electrical conversion of VT or atrial fibrillation to sinus rhythm

Cyanosis: Blue color resulting from very severe hypoxemia (emergency)

Defibrillation: Electrical conversion of VF to (hopefully) a sinus rhythm

Endotracheal Intubation: Insertion of a "breathing tube" into the trachea to protect the airway from soiling and to allow artifical breathing

Hypoxemia: Low tissue oxygen levels (eg art oxyen tension < 60 mmHg)

Grand Mal Seizure: Classic epileptic seizure with clonic / tonic movements usually associated with unconsciousness (emergency)

Stridor: Noisy inspiration from airway obstruction (emergency)

Syncope: Fainting: (emergency if recovery is delayed)

VF, VT: Lethal ventricular rhythms requiring instant treatment(ACLS)

Bradycardia: Slow heart rate (<60) Not all bradycardias are emergencies

Heart Block: Interruption of one of more cardiac conduction pathways