Immediate management approach

Core principle: treat first, diagnose in parallel

• Use a structured approach every time (ABCDE) to avoid missing life-threatening problems.
• Do the basics well: oxygen, ventilation, circulation support, and monitoring often fix the immediate danger.
• Reassess after every intervention (loop back to A) and escalate early if not improving.
• Think: “What will kill the patient in the next few minutes?” then act.

First 30 seconds: safety, help, and overview

• Check scene safety (theatre/ICU/ward): sharps, diathermy, gases, suction, electrical hazards.
• Call for help early: senior anaesthetist/ODP, resus team/ICU outreach as appropriate; be specific (“I need airway help now”).
• Quick look: conscious level, work of breathing, colour, bleeding, monitors, airway device position.
• Ask for key info while you act: what happened, what drugs given (especially opioids, muscle relaxant, local anaesthetic), allergies, baseline status.

ABCDE: Airway

• Look/listen/feel for obstruction: snoring, gurgling, stridor, silence, paradoxical chest movement.
• Simple manoeuvres: head tilt–chin lift or jaw thrust; remove visible obstruction; suction secretions/vomit.
• Airway adjuncts: oropharyngeal airway (OPA) if unconscious; nasopharyngeal airway (NPA) if tolerated and no contraindication (e.g., suspected base of skull fracture).
• If airway not protected or ventilation inadequate: prepare for bag-mask ventilation and consider supraglottic airway; call for senior help early.
• If tracheal tube present: check depth/markings, capnography trace, cuff pressure, and tube patency (suction/catheter pass).

ABCDE: Breathing

• Give high-flow oxygen immediately if unwell (unless known risk of CO2 retention—still treat hypoxia first).
• Assess: respiratory rate, chest movement, auscultation, SpO2, end-tidal CO2 (ETCO2) if available.
• Support ventilation if needed: bag-mask ventilation; ensure good seal, two-person technique if possible.
• Common immediate causes to consider: airway obstruction, bronchospasm, pneumothorax, pulmonary oedema, aspiration, equipment/ventilator problem.
• If sudden deterioration on ventilator: disconnect and hand-ventilate with a self-inflating bag to separate patient vs machine problem.

ABCDE: Circulation

• Check pulse, blood pressure, capillary refill, ECG rhythm, bleeding, urine output (if catheter).
• Get IV access (at least one working cannula; two if unstable). Take bloods early if indicated (FBC, U&E, VBG/ABG, coagulation, group & save/crossmatch).
• Treat hypotension: fluids (balanced crystalloid bolus) if likely hypovolaemia; stop/adjust anaesthetic agents; consider vasopressor (e.g., metaraminol/phenylephrine per local policy) and call senior help.
• Treat bradycardia with compromise: check for reversible causes; consider atropine per local guidance; prepare for ALS if deteriorating.
• If major haemorrhage suspected: activate major haemorrhage protocol early, give tranexamic acid if appropriate, warm patient and fluids, correct coagulopathy.

ABCDE: Disability (neurology) and glucose

• Assess conscious level (AVPU or GCS), pupils, and check for seizures.
• Check blood glucose early—hypoglycaemia is common and treatable.
• Consider drug effects: residual anaesthetic/sedation, opioids, local anaesthetic toxicity, neuromuscular blockade.
• If opioid-induced ventilatory depression suspected: support ventilation first; then consider naloxone titrated in small doses per local policy.

ABCDE: Exposure, temperature, and “don’t miss” checks

• Look for rash/urticaria, swelling, bleeding, surgical site issues, hidden haemorrhage, line disconnections.
• Check temperature; actively warm if hypothermic (worsens coagulopathy and delays drug clearance).
• Review drugs and infusions: correct patient, correct line, correct rate; stop potential culprit if reaction suspected.
• Ensure adequate analgesia but avoid oversedation; reassess regularly.

Monitoring and immediate investigations

• Minimum monitoring in an unwell patient: ECG, non-invasive BP, SpO2, capnography if ventilated, temperature; consider arterial line if unstable.
• Use capnography whenever ventilating a patient (mask, supraglottic airway, or tracheal tube).
• ABG/VBG helps quickly: oxygenation, ventilation (CO2), acid-base, lactate, haemoglobin, potassium.
• 12-lead ECG if chest pain, arrhythmia, or unexplained hypotension.
• Portable CXR/ultrasound (if available) can help with pneumothorax, pulmonary oedema, line position—do not delay life-saving treatment.

Common “first time” scenarios: quick actions

• Desaturation after induction: call for help; 100% O2; check chest rise and capnography; jaw thrust + OPA; two-person bag-mask; consider laryngospasm/bronchospasm; consider supraglottic airway; follow failed intubation plan if needed.
• Hypotension after spinal/induction: left uterine displacement if pregnant; fluids; vasopressor per local policy; reduce anaesthetic depth; check for bleeding and anaphylaxis.
• Sudden high airway pressure on ventilator: disconnect and hand-ventilate; check tube kink/biting/secretions; auscultate; consider bronchospasm or pneumothorax; check circuit/filters.
• Bradycardia: check oxygenation and depth of anaesthesia; treat reversible causes (vagal stimulus, high spinal, hypoxia); atropine if compromised per local policy; prepare for ALS if deteriorating.
• Anaphylaxis (suspected): stop trigger; call for help; high-flow O2; lie flat with legs raised; give IM/IV adrenaline per local guideline; fluids; antihistamine/steroid as adjuncts; measure tryptase and document clearly.

Communication, escalation, and documentation

• Use closed-loop communication: allocate tasks (“You get suction and airway trolley”; “You call the consultant”).
• Escalate early if: persistent hypoxia, ongoing hypotension, reduced consciousness, difficult airway, or uncertainty.
• Handover using SBAR (Situation, Background, Assessment, Recommendation).
• Document: timeline, observations, drugs (dose/time/route), response to treatment, senior involvement, and plan; complete incident reporting if appropriate.