Immediate treatment

What “immediate treatment” means in anaesthesia

• Start simple, time-critical actions to prevent harm while you get senior help and a fuller diagnosis.
• Prioritise life-threatening problems first: airway, breathing, circulation, then disability (brain), exposure (whole patient).
• Treat what you see (e.g., hypoxia, hypotension) while you search for the cause.
• Reassess after every intervention: “What changed?” and “What’s next?”

First steps: the universal approach (ABCDE)

• A (Airway): look/listen/feel; open airway (jaw thrust/chin lift), suction, consider airway adjuncts (oropharyngeal/nasopharyngeal) if appropriate.
• B (Breathing): give high-flow oxygen; check chest movement, auscultation, respiratory rate, SpO2, capnography if available.
• C (Circulation): check pulse, BP, capillary refill; ensure IV access; start fluids/vasopressors as needed; get ECG monitoring.
• D (Disability): assess consciousness (AVPU/GCS), pupils, glucose; treat hypoglycaemia and seizures promptly.
• E (Exposure): look for bleeding, rash, surgical causes, temperature; keep patient warm.

Call for help early (and say the right words)

• If you are worried: call your senior/consultant early; escalate before you are “stuck”.
• Use clear triggers: “Airway problem”, “SpO2 falling”, “BP 70 systolic”, “No capnography trace”, “Suspected anaphylaxis”.
• Ask for specific help: “Can you come now?”, “Can someone bring the difficult airway trolley?”, “Please call the ODP/ICU outreach”.
• In theatre: stop surgery if needed and tell the team you are treating an emergency.

Immediate treatment in theatre: quick safety checks

• If deterioration occurs: check patient, check monitors, then check the anaesthetic machine/circuit (disconnection, obstruction, empty oxygen).
• Confirm oxygen delivery: 100% O2, high fresh gas flow, manual ventilation if concerned.
• Look at capnography (ETCO2): it is your early warning for airway/circuit problems and cardiac output changes.
• If unsure about ventilation: hand-ventilate, listen to the chest, and check the circuit and endotracheal tube position.

Common first-time emergencies and immediate actions

• Hypoxia (low SpO2): 100% O2, check airway patency, hand-ventilate, check circuit/tube, treat bronchospasm or laryngospasm if present.
• Hypotension: confirm reading, check pulse/ECG, give fluid bolus if appropriate, reduce anaesthetic depth, consider vasopressor (e.g., metaraminol/phenylephrine) and treat cause (bleeding, anaphylaxis, high neuraxial block).
• Bradycardia: assess perfusion; treat causes (vagal stimulus, high spinal, drugs); consider atropine if symptomatic.
• Tachycardia: treat pain, hypovolaemia, hypoxia, hypercarbia; check rhythm; consider sepsis/bleeding.
• Reduced/absent ETCO2 trace: check disconnection/obstruction, tube position, severe bronchospasm, low cardiac output/cardiac arrest.

Airway obstruction and laryngospasm (practical basics)

• Airway obstruction signs: snoring, paradoxical breathing, poor chest rise, falling SpO2, rising ETCO2.
• Immediate actions: jaw thrust, airway adjunct, suction, deepen anaesthesia if appropriate, apply CPAP with 100% O2.
• Laryngospasm (vocal cords shut): stridor or silent airway with no airflow; treat with jaw thrust + CPAP, remove stimulus, deepen anaesthesia; if persistent and desaturating, give a rapid-acting muscle relaxant and ventilate.
• Always call for help early if oxygenation is failing.

Bronchospasm (wheeze, high pressures, slow capnography upstroke)

• Immediate actions: 100% O2, hand-ventilate to feel compliance, deepen anaesthesia (often helps), exclude tube/circuit obstruction and endobronchial intubation.
• Give bronchodilator: salbutamol via inhaler/spacer or nebuliser (or via circuit as per local practice).
• Consider adrenaline if severe or if anaphylaxis suspected; consider steroids and magnesium as per local guidance.
• Reassess: SpO2, airway pressures, ETCO2 waveform, chest auscultation.

Anaphylaxis (time-critical)

• Think anaphylaxis if sudden hypotension, bronchospasm, difficulty ventilating, swelling/urticaria, or cardiovascular collapse after a drug/latex/chlorhexidine exposure.
• Immediate actions: stop suspected trigger, call for help, 100% O2, lay flat with legs raised (if safe), give IV fluids rapidly.
• Give adrenaline early (dose and route per local anaphylaxis guideline); repeat as needed while monitoring response.
• Take bloods for mast cell tryptase at recommended times and document clearly; arrange allergy referral.

Local anaesthetic systemic toxicity (LAST)

• Early signs: tinnitus, metallic taste, agitation, confusion; can progress to seizures, arrhythmias, cardiac arrest.
• Immediate actions: stop local anaesthetic injection, call for help, manage airway and breathing with 100% O2, treat seizures (e.g., benzodiazepine).
• Start lipid emulsion therapy promptly as per local protocol; continue standard resuscitation with modifications for LAST.
• Prevent: incremental dosing, aspiration, ultrasound guidance where appropriate, respect maximum dose, monitor after blocks.

Malignant hyperthermia (rare but critical)

• Clues: unexplained rise in ETCO2, tachycardia, muscle rigidity, acidosis, hyperkalaemia; temperature rise may be late.
• Immediate actions: stop triggering agents, call for help, 100% O2 with high flows, active cooling, treat acidosis/hyperkalaemia.
• Give dantrolene urgently as per local protocol; prepare for ICU care and ongoing monitoring.
• Document and refer to MH service; ensure patient and relatives are informed appropriately.

Cardiac arrest in theatre (first actions)

• Shout for help, start CPR immediately if no pulse/organized output, follow ALS algorithm.
• Ensure 100% O2, secure airway if possible without delaying compressions; use capnography to assess CPR quality and ROSC.
• Treat reversible causes (4 Hs and 4 Ts): hypoxia, hypovolaemia, hypo/hyperkalaemia/metabolic, hypothermia; tension pneumothorax, tamponade, toxins, thrombosis.
• In theatre, consider surgical causes (bleeding, embolism) and communicate clearly with surgeons.

After the immediate crisis: stabilise, communicate, document

• Once stable: reassess ABCDE, review drugs given, check blood gas, Hb, electrolytes, temperature, urine output.
• Plan next steps: continue case vs stop, need for ICU/HDU, ongoing monitoring and investigations.
• Handover using SBAR (Situation, Background, Assessment, Recommendation) with clear timelines and treatments.
• Document events, times, drugs/doses, response, and who was present; complete incident reporting if appropriate.