12.4 Anaphylaxis, Hemorrhage, Age-Specific Arrest & Disaster Response

Anaphylaxis, Hemorrhage, Age-Specific Arrest & Disaster Response

Core principle: In an ambulatory facility, recognition and simultaneous action must occur before a definitive diagnosis is complete. Stabilize the patient, stop the likely cause, mobilize the emergency team, and arrange transfer early when the patient may exceed the center’s rescue capability.

Perioperative Anaphylaxis

An anesthetized patient cannot report itching, throat tightness, or dizziness, and skin findings may be hidden. Suspect anaphylaxis when abrupt hypotension, bronchospasm, increased airway pressure, difficult ventilation, desaturation, edema, urticaria, or cardiovascular collapse follows exposure to an antibiotic, neuromuscular blocker, latex, chlorhexidine, dye, blood product, or other agent. A rash may be absent.

Stop the suspected trigger and infusion, announce the emergency, bring the resuscitation cart, and provide 100% oxygen and airway support. Epinephrine is first-line; the anesthesia professional titrates intravenous doses in a monitored anesthetized patient, while intramuscular epinephrine in the anterolateral thigh is the standard initial route for a patient without established monitored IV management. Begin rapid isotonic fluid resuscitation because profound vasodilation and capillary leak can sharply reduce circulating volume. Bronchodilators, antihistamines, and corticosteroids are adjuncts and must never delay epinephrine.

Document exposure times, medications, hemodynamics, interventions, and response. Preserve relevant product identifiers and arrange hospital observation because symptoms may recur. Provide the patient with event information and specialist follow-up for investigation rather than assigning an unconfirmed allergy to every perioperative drug.

Uncontrolled Hemorrhage

Recognize blood loss from the field, suction, sponges, dressings, drains, swelling, vital-sign trends, capnography, mental status, and urine output. Visual estimates are unreliable; use measured suction minus irrigation, weighed materials when feasible, and serial clinical data. Concealed bleeding can occur in the abdomen, retroperitoneum, joint, or soft tissue even when external loss appears small.

Call for surgical source control, activate the facility hemorrhage and transfer plan, obtain large-bore access, warm the patient, and send ordered testing without delaying life-saving care. Administer fluids, blood products, reversal agents, or antifibrinolytic therapy only under the authorized protocol and orders. Avoid the lethal spiral of hypothermia, acidosis, dilution, and coagulopathy. Maintain specimen and blood-product checks, record all intake and estimated loss, and give the receiving hospital an exact SBAR report.

Cardiac and Respiratory Arrest

Begin high-quality CPR for pulselessness, minimize interruptions, attach a defibrillator, and distinguish shockable from nonshockable rhythms. Address reversible causes such as hypoxia, hypovolemia, electrolyte disturbance, tension pneumothorax, tamponade, thrombosis, toxins, and anesthetic complications. In respiratory deterioration with a pulse, prioritize airway positioning, ventilation, oxygenation, reversal when indicated, and treatment of laryngospasm or bronchospasm before arrest occurs.

Use the cause-specific checklist when standard algorithms require modification. LAST calls for lipid emulsion and smaller epinephrine doses; MH calls for dantrolene and trigger removal; anaphylaxis calls for epinephrine and fluids. Assign roles for compressions, airway, defibrillation, medications, documentation, family communication, emergency medical services access, and transfer.

Pediatric Adaptation

Record pediatric weight in kilograms and use a length- or weight-based reference for equipment, defibrillation energy, fluids, and medication doses. Respiratory failure and bradycardia often precede pediatric cardiac arrest, so effective ventilation and oxygenation are critical. Use correctly sized masks, airways, suction catheters, cuffs, and defibrillator pads. Independent read-back of decimal dose and concentration reduces tenfold errors. When a caregiver is present, designate a team member to communicate without interfering with resuscitation.

Disaster, Utility Failure and Evacuation

The emergency plan uses an incident-command structure with a clear leader, internal and external communication methods, accountability for patients and staff, and criteria for evacuation versus shelter in place. Scenarios include fire, severe weather, earthquake, active threat, mass casualty, medical-gas interruption, power or water loss, information-system outage, and hazardous-material release.

During evacuation, maintain patient identification, airway and medication support, clinical records, and destination tracking. Prioritize patients according to mobility, anesthesia status, physiologic instability, and immediate life-support needs. Know primary and alternate exits, assembly locations, utility shutoffs, emergency supplies, generator limitations, and how emergency responders gain access. Drills must test actual communication and movement, not merely attendance. After an event or exercise, conduct a structured debrief, document gaps, assign corrective actions and deadlines, and verify that changes work in a later drill.

Recovery After an Emergency

After transfer or stabilization, preserve the record, medication containers, device identifiers, and timeline needed for clinical review. Notify leadership and required agencies under policy, disclose the event through the authorized process, and support involved patients, families, and staff. A hot debrief captures immediate operational facts; a later multidisciplinary review separates active errors from system conditions, assigns corrective actions, and verifies sustained improvement. Restock and inspect emergency supplies before service resumes.