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OXFORD MEDICAL PUBLICATIONS

Anaesthesia for
Emergency Care
Oxford Specialist Handbooks published and forthcoming
General Oxford Specialist Oxford Specialist Handbooks
Handbooks in Neurology
A Resuscitation Room Guide Epilepsy
Addiction Medicine Parkinson’s Disease and
Day Case Surgery Other Movement Disorders
Hypertension Stroke Medicine
Perioperative Medicine,
Second Edition Oxford Specialist Handbooks
Postoperative Complications, in Paediatrics
Second Edition Paediatric Dermatology
Renal Transplantation Paediatric Endocrinology
and Diabetes
Oxford Specialist Handbooks Paediatric Gastroenterology,
in Anaesthesia Hepatology, and Nutrition
Anaesthesia for Emergency Care Paediatric Haematology and
Cardiac Anaesthesia Oncology
Neuroanaethesia Paediatric Intensive Care
Obstetric Anaesthesia Paediatric Nephrology, Second
Ophthalmic Anaesthesia Edition
Paediatric Anaesthesia Paediatric Neurology, Second Edition
Regional Anaesthesia, Stimulation and Paediatric Radiology
Ultrasound Techniques Paediatric Respiratory Medicine
Thoracic Anaesthesia
Oxford Specialist Handbooks
Oxford Specialist Handbooks in Pain
in Cardiology Spinal Interventions in Pain
Adult Congenital Heart Disease Management
Cardiac Catheterization and
Coronary Intervention Oxford Specialist Handbooks
Cardiac Electrophysiology and in Psychiatry
Catheter Ablation Child and Adolescent Psychiatry
Cardiovascular Computed Forensic Psychiatry
Tomography Old Age Psychiatry
Cardiovascular Magnetic Resonance Oxford Specialist Handbooks
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Inherited Cardiac Disease Pulmonary Imaging
Nuclear Cardiology Thoracic Imaging
Pulmonary Hypertension Oxford Specialist Handbooks
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Oxford Specialist Handbooks Cardiothoracic Surgery
in Critical Care Colorectal Surgery
Advanced Respiratory Hand Surgery
Critical Care Hepatopancreatobiliary Surgery
Neurosurgery
Oxford Specialist Handbooks Operative Surgery, Second Edition
in End of Life Care Oral Maxillofacial Surgery
End of Life Care in Cardiology Otolaryngology and Head and
End of Life Care in Dementia Neck Surgery
End of Life Care in Nephrology Paediatric Surgery
End of Life Care in Respiratory Plastic and Reconstructive Surgery
Disease Surgical Oncology
End of Life in the Intensive Urological Surgery
Care Unit Vascular Surgery
Oxford Specialist
Handbooks in
Anaesthesia
Anaesthesia
for Emergency
Care
Edited by

Jerry Nolan
Consultant in Anaesthesia and Intensive Care Medicine
Royal United Hospital NHS Trust,
Bath, UK

Jasmeet Soar
Consultant in Anaesthesia and Intensive Care Medicine
Southmead Hospital, North Bristol NHS Trust,
Bristol, UK

1
1
Great Clarendon Street, Oxford OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
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© Oxford University Press 2012
The moral rights of the authors have been asserted
First Edition published in 2012
Impression: 1
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
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rights organization. Enquiries concerning reproduction outside the scope of the
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address above
You must not circulate this work in any other form
and you must impose this same condition on any acquirer
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Library of Congress Control Number: 2012933283
ISBN 978–0–19–958897–8
Printed in China by
C & C Offset Printing Co, Ltd
Oxford University Press makes no representation, express or implied, that the
drug dosages in this book are correct. Readers must therefore always check
the product information and clinical procedures with the most up-to-date
published product information and data sheets provided by the manufacturers
and the most recent codes of conduct and safety regulations. The authors and
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 v

Preface

Anaesthetizing patients for surgical and medical emergencies can be chal-

lenging. The time critical nature of the intervention may mean proceeding
with a limited medical history and only a brief assessment with minimal
investigations. Ideally, these patients should be fully resuscitated, but in
some circumstances (e.g. after major trauma) anaesthetizing the patient
can be an essential component of the initial resuscitation.
When planning this book, we aimed to include most of procedures
encountered by the ‘on-call’ anaesthetist, both during the day and out-of-
hours. In keeping with the Oxford Handbook series, the style is concise but
we have tried to include the essential information needed to anaesthetize
these patients safely. The first section comprises a series of topics that
are generic to many emergencies and the remaining sections cover
a full range of conditions that may require anaesthesia in the operating
room, emergency department, critical care unit, and radiology suite. In
recognition of the increasing role of doctors in prehospital emergency
medicine, we have included a section on prehospital anaesthesia and
transport. Clearly, every possible scenario cannot be covered in this book.
If there is any doubt about the best way to proceed in an emergency, seek
expert help early.
Although aimed principally at the anaesthetic trainee, this book should
be of value to consultants in anaesthesia and critical care and to trainees
and consultants in emergency medicine.
We would appreciate feedback (to the e mail address below) about this
book, particularly in relation to topics that we have omitted or any errors
that we have missed. Finally, we thank all the authors for their high quality
contributions in the face of pressing deadlines and our wives and children
who now struggle to remember what we look like.

Jerry and Jasmeet

[email protected]
2012
This page intentionally left blank
 vii

Contents

Contributors ix
Symbols and Abbreviations xiii

1 General Principles 1
2 Prehospital 53
3 The Injured Patient 63
4 Anaesthesia for the Critically Ill Patient 109
5 General Surgical Emergencies 137
6 Ear, Nose, and Throat Emergencies 155
7 Maxillofacial Emergencies 171
8 Cardiovascular Emergencies 179
9 Neurological Emergencies 215
10 Plastic Surgery 249
11 Obstetric Emergencies 261
12 Urological Emergencies 289
13 Paediatric Emergencies 297
14 Ophthalmic Emergencies 337
15 Anaesthesia for Emergency Radiological
Procedures 343
16 Anaesthetic Emergencies 355

Index 393
This page intentionally left blank
 ix

Contributors

Anne-Marie Amphlett Charles Deakin

Specialist Trainee Consultant in Cardiac Anaesthesia
Bristol School of Anaesthesia and Intensive Care Medicine
University Hospital Southampton
Monica Baird
Consultant in Anaesthesia Simon Finney
Royal United Hospital NHS Trust Consultant in Anaesthesia and
Bath Intensive Care Medicine
Guy Bayley Royal Brompton Hospital, London
Consultant in Paediatric Andrew Georgiou
Anaesthesia, Specialist Trainee
Bristol Royal Hospital for Children
Bristol School of Anaesthesia
Jonathan Benger
Professor of Emergency Care,
Ben Gibbison
University of the West of England, Specialist Trainee
Bristol and Consultant in Bristol School of Anaesthesia
Emergency Medicine,
University Hospitals Bristol Amit Goswami
NHS Foundation Trust Specialist Trainee
Bristol School of Anaesthesia
Craig Carroll
Consultant in Anaesthesia Richard Griffiths
Salford Royal Hospital NHS Consultant in Anaesthesia
Foundation Trust Peterborough and Stamford
Hospitals NHS Trust
Emma Clow
Specialist Trainee Kim J. Gupta
Bristol School of Anaesthesia Consultant in Anaesthesia and
Intensive Care Medicine,
Tim Cook
Royal United Hospital NHS Trust,
Consultant in Anaesthesia Bath
and Intensive Care,
Royal United Hospital NHS Carl Gwinnutt
Trust, Bath Formerly Consultant in
Anaesthesia
Jules Cranshaw
Salford Royal Hospital NHS
Consultant in Anaesthesia and Foundation Trust
Intensive Care Medicine
Royal Bournemouth Hospital, Clare Hommers
Bournemouth Specialist Trainee
Rhys Davies Bristol School of Anaesthesia
Consultant in Anaesthesia
North Bristol NHS Trust, Bristol
x CONTRIBUTORS

Tim Hooper Henry Murdoch

Specialist Trainee Specialist Trainee
Bristol School of Anaesthesia Bristol School of Anaesthesia
Dom Hurford Jerry Nolan
Specialist Trainee Consultant in Anaesthesia and
Bristol School of Anaesthesia Intensive Care Medicine,
Royal United Hospital NHS Trust,
Rob Jackson Bath
Specialist Trainee
Bristol School of Anaesthesia Judith Nolan
Consultant in Paediatric
Chris Johnson Anaesthesia,
Consultant in Anaesthesia Bristol Royal Hospital for Children
North Bristol NHS Trust, Bristol
Sonja Payne
Alistair Johnstone Specialist Trainee
Specialist Trainee Bristol School of Anaesthesia
Bristol School of Anaesthesia
Carol J. Peden
Rebecca Leslie Consultant in Anaesthesia and
Specialist Trainee Intensive Care Medicine,
Bristol School of Anaesthesia Royal United Hospital NHS Trust,
Bath
David Lockey
Consultant in Anaesthesia and Susanna Ritchie-McLean
Intensive Care Medicine, North Specialist Traineee in Anaesthesia,
Bristol NHS Trust and London Peterborough & Stamford
Helicopter Emergency Hospitals NHS Foundation Trust
Medical Service,
Royal London Hospital Edward Scarth
Specialist Trainee
Melanie McDonald Bristol School of Anaesthesia
Specialist Trainee
Bristol School of Anaesthesia Joe Sebastian
Consultant in Anaesthesia
Patrick Magee Salford Royal Hospital NHS
Consultant in Anaesthesia Foundation Trust
Royal United Hospital NHS Trust,
Bath Jasmeet Soar
Consultant in Anaesthesia
Thomas Martin and Intensive Care Medicine,
Specialist Trainee North Bristol NHS Trust,
Bristol School of Anaesthesia Bristol
Lucy Miller Matt Thomas
Specialist Trainee Consultant in Anaesthesia and
Bristol School of Anaesthesia Intensive Care Medicine,
University Hospitals Bristol NHS
Ronelle Mouton Foundation Trust
Consultant in Anaesthesia
Royal United Hospital NHS Trust,
Bath
 CONTRIBUTORS xi
Julian Thompson Andy Weale
Specialist Registrar in Prehospital Consultant Vascular Surgeon
Care, London Helicopter North Bristol NHS Trust, Bristol
Emergency Medical Service,
Royal London Hospital Nicola Weale
Consultant in Anaesthesia
Jenny Tuckey North Bristol NHS Trust, Bristol
Consultant in Anaesthesia
Royal United Hospital NHS Trust, David Windsor
Bath Specialist Trainee
Bristol School of Anaesthesia
Medha Vanarase
Consultant in Anaesthesia Helen Wise
John Radcliffe Hospital, Oxford Consultant in Anaesthesia, Poole
Hospital NHS Foundation Trust
Michelle White
Consultant in Anaesthesia,
Mercy Ships, formerly Consultant
in Paediatric Anaesthesia,
Bristol Royal Hospital for Children
This page intentionally left blank
 xiii

Symbols and Abbreviations

b cross reference
i increased
d decreased
~ approximately
l leading to
± plus/minus
2 important
# fracture
#NOF fractured neck of femur
M website
A–a alveolar–arterial
AAA abdominal aortic aneurysm
AAGBI Association of Anaesthetists of Great Britain and Ireland
ABCDE airway, breathing, circulation, disability, exposure
ABG arterial blood gas
ACEI angiotensin converting enzyme inhibitor
ADH anti-diuretic hormone
AKI acute kidney injury
ALI acute lung injury
ALS advanced life support
APTT activated partial thromboplastin time
ARDS acute respiratory distress syndrome
ASA American Society of Anesthesiologists
AV atrioventricular
BP blood pressure
Ca calcium
CABG coronary artery bypass grafting
CBF cerebral blood flow
CDH Congenital diaphragmatic hernia
CEA carotid endarterectomy
CICV can’t intubate, can’t ventilate’
cLMA classic laryngeal mask airway
CMRO2 cerebral metabolic rate of O2
CNB central neuraxial block
CNS central nervous system
xiv SYMBOLS AND ABBREVIATIONS

CO2 carbon dioxide

COPD chronic obstructive pulmonary disease
CP cricoid pressure
CPAP continuous positive airway pressure
CPB cardiopulmonary bypass
CPP cerebral perfusion pressure
CPR cardiopulmonary resuscitation
Cr creatinine
CS Caesarean section
CSF cerebrospinal fluid
CSI cervical spine injury
CT computed tomography
CTPA computed tomography pulmonary angiography
CV central venous
CVC central venous catheter
CVP central venous pressure
DBD donation after brain death
DBP diastolic blood pressure
DCD donation after circulatory death
DI diabetes insipidus
DIC disseminated intravascular coagulation
DND delayed neurological deficit
DVT deep venous thrombosis
ECG electrocardiogram
ED emergency department
EDH extradural haematoma
EEG electroencephalogram
EMG electromyograph
ENT ear, nose, and throat
ET end-tidal
ETO2 end-tidal oxygen concentration
EVAR endovascular aneurysm repair
EVD external ventricular drain
FAST focused assessment by sonography in trauma
FBC full blood count
FETO2 fraction of end-tidal oxygen
FFP fresh frozen plasma
FiO2 fraction of inspired oxygen
FOI fibreoptic intubation
FRC functional residual capacity
 SYMBOLS AND ABBREVIATIONS xv
GA general anaesthesia/anaesthetic
GCS Glasgow Coma Scale
GI gastrointestinal
h hour/s
H+ hydrogen ion
HAS human albumin solution
Hb haemoglobin
HDU high-dependency unit
HELLP haemolysis, elevated liver enzymes, low platelets
HFOV high-frequency oscillatory ventilation
HIV human immunodeficiency virus
HLA human leucocyte antigen
HME heat and moisture exchanger
HTLV human T-lymphotropic virus
ICD implantable cardioverter-defibrillator
ICH intracerebral haematoma
ICP intracranial pressure
ICS Intensive Care Society
ICU intensive care unit
Ig immunoglobulin
ILM intubating laryngeal mask
IM intramuscular
INR international normalized ratio
IO intraosseous
IOP intraocular pressure
IPPV intermittent positive pressure ventilation
IVC intravenous
IVC inferior vena cava
K+ potassium ion
LA local anaesthesia/anaesthetic
LFT liver function test
LMA laryngeal mask airway
LMWH low-molecular-weight heparin
LV left ventricular
MAC minimum alveolar concentration
MAP mean arterial pressure
mg milligram/s
MH malignant hyperthermia
MI myocardial infarction
MILS manual in-line stabilization
xvi SYMBOLS AND ABBREVIATIONS

min minute/s
mL millilitre/s
MRI magnetic resonance imaging
Na+ sodium ion
NICE National Institute for Health and Clinical Excellence
NIV non-invasive ventilation
NMBA neuromuscular blocking agent
NSAID non-steroidal anti-inflammatory drug
O2 oxygen
PA pulmonary artery
PaCO2 partial pressure of arterial carbon dioxide
PCA patient-controlled analgesia
PCC prothrombin complex concentrate
PCI percutaneous coronary intervention
PCO2 partial pressure of carbon dioxide
PE pulmonary embolism
PEA pulseless electrical activity
PEEP positive end-expiratory pressure
PET pre-eclamptic toxaemia
PICU paediatric intensive care unit
PIP peak inspiratory pressure
PNB peripheral nerve block
PO orally (per os)
PO2 partial pressure of oxygen
PONV postoperative nausea and vomiting
PPH postpartum haemorrhage
PR rectally (per rectum)
PRN as needed (pro re nata)
PT prothrombin time
RA regional anaesthesia/anaesthetic
RBC red blood cell
rFVIIa recombinant Factor VIIa
RNA ribonucleic acid
RRT renal replacement therapy
RSI rapid sequence induction
RV right ventricular
s second/s
SAD supraglottic airway device
SAH subarachnoid haemorrhage
SaO2 arterial oxygen saturation
 SYMBOLS AND ABBREVIATIONS xvii
SBP systolic blood pressure
SC subcutaneous
ScvO2 oxygen saturation of central venous blood
SIGN Scottish Intercollegiate Guidelines Network
SIRS systemic inflammatory response syndrome
SSEP somatosensory evoked potential
STEMI ST-elevation myocardial infarction
SVC superior vena cava
SVR systemic vascular resistance
TAP transversus abdominis plane
TBI traumatic brain injury
TEG thromboelastogram
TIA transient ischaemic attack
TIPSS transjugular intrahepatic portosystemic shunt
TIVA total intravenous anaesthesia
TOF tracheo-oesophageal fistula
TRALI transfusion-related acute lung injury
TT tracheal tube
U&Es urea and electrolytes
US ultrasound
VF ventricular fibrillation
VP ventriculoperitoneal
VT ventricular tachycardia
VTE venous thromboembolism
WFNS World Federation of Neurological Surgeons
This page intentionally left blank
 Chapter 1 1

General Principles

Preoperative assessment 2
Rob Jackson
Rapid sequence induction and tracheal intubation 6
Rob Jackson
Drugs for emergency anaesthesia 10
Rob Jackson
Vascular access 16
Jerry Nolan
Transfusion 20
Jerry Nolan
Fluid therapy 26
Jerry Nolan
Electrolytes 30
Jerry Nolan
Acute pain management 40
Tim Cook
Monitoring 46
Patrick Magee
Regional versus general anaesthesia 50
Tim Cook
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