Immediate management

What “immediate management” means (in anaesthesia)

• The first minutes of responding to acute deterioration: prioritise oxygenation, ventilation, circulation, and brain protection.
• Use a structured approach (ABCDE) to avoid missing reversible problems.
• Treat life-threatening issues as you find them; don’t wait for a full diagnosis before starting basic stabilisation.
• Escalate early: call for senior help and additional hands if you are worried.

First actions: stay safe, get help, get organised

• Stop and assess the scene: is the patient, staff, and environment safe (e.g., diathermy, sharps, oxygen, spills)?
• Call for help early: theatre coordinator/ODP, anaesthetic registrar/consultant, resus team if needed.
• Allocate roles: airway, drugs, monitoring, documentation/timekeeper, runner for equipment/blood.
• Bring the emergency equipment to the bedside: airway trolley, suction, bag-valve-mask, defib, emergency drug box.

ABCDE approach (what to do, not just what to think)

• A – Airway: look/listen/feel for obstruction; open airway (head tilt–chin lift or jaw thrust), suction, consider airway adjuncts (oropharyngeal/nasopharyngeal) if tolerated.
• B – Breathing: give high-flow oxygen; check chest movement, respiratory rate, SpO2, auscultation; assist ventilation with bag-mask if inadequate; consider pneumothorax/bronchospasm/aspiration.
• C – Circulation: check pulse, BP, capillary refill, ECG rhythm; control obvious bleeding; ensure IV access (2 large-bore cannulae if shocked); give fluid bolus if hypotensive; start vasopressors early if needed (with senior support).
• D – Disability: assess consciousness (AVPU/GCS), pupils, glucose; treat hypoglycaemia; consider seizures, stroke, drug effects, hypercarbia/hypoxia.
• E – Exposure: look for rash/urticaria (anaphylaxis), bleeding, surgical causes; check temperature; prevent heat loss.

Monitoring and immediate data to gather

• Ensure minimum monitoring: ECG, non-invasive BP cycling frequently, SpO2, capnography if ventilating, temperature when relevant.
• If intubated/ventilated: capnography is essential; sudden loss of ETCO2 is an emergency until proven otherwise.
• Get a rapid set of observations and trends (what changed, when, and after what intervention).
• Consider urgent tests early: blood gas (ABG/VBG), glucose, Hb, lactate, electrolytes; group & save/crossmatch if bleeding.

Common immediate scenarios and first-line responses

• Hypoxia (low SpO2): increase FiO2 to 1.0, check airway patency, check chest rise, listen for wheeze, confirm capnography, consider disconnection/obstruction/pneumothorax/aspiration; call for senior help early.
• Hypotension: check pulse/rhythm, depth of anaesthesia, bleeding, anaphylaxis; give fluid bolus, reduce volatile/propofol if appropriate, start vasopressor (e.g., metaraminol/phenylephrine) per local practice; consider arterial line if ongoing.
• Bradycardia: assess perfusion and cause (vagal, hypoxia, high spinal, drugs); treat hypoxia, stop stimulus, consider atropine; prepare for pacing if unstable.
• Tachycardia: pain/light anaesthesia, hypovolaemia, sepsis, arrhythmia; treat cause, check ECG rhythm, consider fluids/analgesia; escalate if unstable.
• Bronchospasm: high-flow oxygen, deepen anaesthesia, check tube position/kinking, give inhaled bronchodilator (salbutamol), consider adrenaline if severe or anaphylaxis suspected.
• Anaphylaxis: stop suspected trigger, call for help, high-flow oxygen, lay flat with legs raised, give IM/IV adrenaline as per severity and local guideline, rapid IV fluids, antihistamine/steroid as adjuncts, take tryptase samples and document clearly.
• Laryngospasm (often on emergence): remove stimulus, jaw thrust, CPAP with 100% oxygen; deepen anaesthesia; consider small dose suxamethonium if persistent (senior support).
• Cardiac arrest: start CPR immediately, call resus team, follow ALS algorithm; in theatre, consider reversible causes (hypoxia, bleeding, anaphylaxis, local anaesthetic toxicity).

Airway: immediate basics for new starters

• If ventilation is failing, prioritise bag-mask ventilation; a well-sealed mask and two-person technique often fixes the problem.
• Use simple adjuncts early (oropharyngeal airway) and suction for secretions/vomit.
• If intubated and deteriorating: think “DOPE” (Displacement, Obstruction, Pneumothorax, Equipment failure) and act quickly.
• If you cannot oxygenate: call for senior help immediately and follow the local difficult airway plan; prepare for front-of-neck access only with appropriate support.

Circulation: fluids, blood, and vasopressors (safe principles)

• Treat shock early: oxygen, IV access, fluids, vasopressors, and identify the cause (bleeding, sepsis, anaphylaxis, cardiogenic).
• Give small, reassessed boluses (e.g., 250–500 mL crystalloid) while monitoring response; avoid repeated blind boluses without reassessment.
• If bleeding suspected: activate local major haemorrhage protocol early; warm the patient and fluids; request blood products promptly.
• Vasopressors are often needed in anaesthesia-related hypotension; use per local policy and seek senior input early.

Communication and documentation (often forgotten, always important)

• Use closed-loop communication: say who you are addressing, what you want, and confirm it is done.
• Give a clear summary to seniors: what happened, key vitals, what you’ve done, response to treatment, what you need next.
• Document times, drugs (dose/route), fluids/blood, observations, and suspected cause; this matters for handover and incident review.
• After stabilisation: debrief briefly, restock equipment/drugs, and complete required reporting (e.g., DATIX) with senior support.