This Manual of Algorithms may contain some flaws. If in doubt, use your commonsense and revert to thinking from "first principles".
Constructive criticism is invited - please write with comments to:
Australian Patient Safety Foundation
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WHY USE A CRISIS MANAGEMENT MANUAL?
All anaesthesiologists have to manage complex, rapidly evolving, life-threatening crises with little or no warning.
It has long been shown, however, that human beings can only perceive and process information at a finite rate.
In a crisis, events may unfold at a rate which exceeds our capacity to keep pace.
Several studies have shown that not all crises are managed well, including by experienced anaesthesiologists.
It is best, when all is not going well or in crisis situations, to carry out pre-determined sequences of actions which have been shown to be safe and to cater for rare, dangerous problems as well as for more common, mundane ones.
This Manual provides an approach, via a series of easy-to-access Algorithms and Sub-Algorithms, to any crisis which may occur when a patient is undergoing general or regional anaesthesia.
These Algorithms have been derived from and checked against all relevant incidents amongst the first 4000 reported to the Australian Incident Monitoring Study (AIMS). Correctly used, they will guide the anaesthesiologist to an appropriate set of actions and responses in over 99% of applicable incidents.
The responses outlined here have been developed after thousands of hours of analysis of incidents and after seven one or two day meetings, each attended by 60-100 anaesthesiologists. (See the back cover of the hard copy Crisis Management Manual for a brief account of how this Manual came into existence.)
It must always be remembered that no manual will work in every circumstance and a good outcome cannot be guaranteed. Always use your common sense, and revert, if necessary, to working from first principles.
The Manual is based on the mnemonic "COVER ABCD - A
SWIFT CHECK", and is designed for use when any patient is undergoing
general or regional anaesthesia. It applies whether the patient is
ventilated or spontaneously breathing.
The mnemonic serves as a reminder always to cycle systematically through a basic series of thoughts and actions, the intensity of which will depend on the circumstances. This series of thoughts and actions is:
The four levels of intensity for each of these components are represented by another, supplementary mnemonic - "SCARE" (SCAN, CHECK, ALERT/READY, EMERGENCY)..
The SCAN sequence should be followed every 5 minutes of any anaesthetic procedure, or more often if necessary. This overcomes the need for special training sessions, as the sequence rapidly becomes second nature and can usually be completed in 40-60 seconds. The CHECK sequence should be used whenever all is not going according to plan, and should also be practised regularly.
Do not hesitate to move on to the ALERT/READY and
EMERGENCY sequences if you are worried, if events are moving quickly, or if it seems that
an adverse outcome is possible. These should also be practised from time to
On the other hand, if, for example, it is suddenly noticed that the patient is pulseless and blue, the full EMERGENCY sequence of COVER should be carried out immediately with progression to any appropriate Sub-Algorithms.
It is important that the basic COVER ABCD sequence is followed before becoming focused on any particular Sub-Algorithm; a major problem is "locking mentally onto" a diagnosis which may not be correct. When assistance is called for, one person should repeatedly cycle through the COVER ABCD sequence and consider other possibilities, whilst the steps in any relevant Sub-Algorithms are followed. Some Sub-Algorithms repeat components of COVER (eg "give 100% oxygen"), usually when the entire sequence does not necessarily have to be followed in full at the outset, whereas others start by instructing anaesthesiologists to ensure that the full COVER sequence has been completed before starting the Sub-Algorithm (eg. that for persistent desaturation, or air embolism).
Although the standard COVER ABCD - A SWIFT CHECK sequence should always be followed, some components become less important or redundant under particular circumstances: for intubated, ventilated patients the A and B after COVER become redundant; for patients breathing spontaneously via any mask, A and B precede COVER, as indicated at the start of this section, and V for Ventilation in COVER becomes redundant. For a patient being ventilated via a laryngeal mask, B becomes redundant; and for a patient breathing spontaneously and receiving oxygen from a source independent of an anaesthetic machine (eg from a wall-mounted flowmeter during regional or intravenous anaesthesia), the V of COVER again becomes redundant.
REMEMBER: Always go through COVER ABCD for ventilated patients and AB COVER CD for patients breathing spontaneously via any mask - followed in each instance by - A SWIFT CHECK. It will be obvious in any particular circumstance which components become redundant.
REMEMBER: Request assistance early on, allocate tasks and calmly coordinate activities, repeatedly cycling through COVER as well as any sub-algorithm/s thought to be appropriate.
ETT - Endotracheal tube