Anesthesia for emergency surgery after cardiac arrest or traumatic cardiac injury
- Nadia Blakemore Hensley, MD
Nadia Blakemore Hensley, MD
- Assistant Professor, Department of Anesthesiology and Critical Care Medicine
- The Johns Hopkins University School of Medicine
- Charles W Hogue, MD
Charles W Hogue, MD
- James E. Eckenhoff Professor of Anesthesiology
- Northwestern University Feinberg School of Medicine
Urgent surgery is sometimes necessary in patients presenting to the emergency department with unstable cardiac status, despite the increased risk of perioperative morbidity or mortality. This topic reviews anesthetic management of patients who have suffered a cardiac arrest with resuscitation, and patients with traumatic cardiac injury. The initial critical interventions in post-cardiac arrest management and the initial management of traumatic cardiac injuries are reviewed elsewhere. (See "Post-cardiac arrest management in adults" and "Evaluation of the survivor of sudden cardiac arrest" and "Cardiac injury from blunt trauma" and "Cardiac tamponade" and "Initial evaluation and management of penetrating thoracic trauma in adults".)
Hemodynamic monitoring — Hemodynamic monitoring in patients with recent cardiac events or injury includes the following general considerations:
●Electrocardiography (ECG) – Continuous electrocardiography (ECG) monitoring is necessary to detect arrhythmias and/or myocardial ischemia.
Computerized ST-segment trending is superior to visual clinical interpretation in the identification of ST-segment changes [1-4] and multiple-lead monitoring is more sensitive than single-lead monitoring, although the ECG is a relatively insensitive method for intraoperative detection of myocardial ischemia [5,6].
●Intra-arterial catheter – Invasive measurement of arterial blood pressure should be used when moment-to-moment blood pressure changes are anticipated and rapid detection is vital. These conditions apply to patients with preexisting hemodynamic instability, as well as those undergoing surgical procedures that are likely to cause rapid blood loss or large fluid shifts. If possible, an intra-arterial catheter is inserted prior to induction of anesthesia.
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- GENERAL CONSIDERATIONS
- Hemodynamic monitoring
- Management of arrhythmias
- Transition to the intensive care unit
- - Transport to the intensive care unit
- - Handover in the intensive care unit
- RECENT CARDIAC ARREST AND RESUSCITATION
- Anesthetic considerations for urgent or emergent surgery
- - Maintenance of hemodynamic stability
- Treatment of hypotension
- - Inotropic and vasopressor agents
- Treatment of arrhythmias
- Fluid management
- - Respiratory management
- - Metabolic issues
- Induction and maintenance of anesthesia
- - Induction of anesthesia
- - Maintenance of anesthesia
- Postoperative management
- TRAUMATIC CARDIAC INJURY
- Preoperative evaluation
- - Hemodynamically stable patients
- - Hemodynamically unstable patients
- Anesthetic considerations
- - Management of hemodynamic instability
- - Management of mechanical ventilation
- - Induction and maintenance of general anesthesia
- - Cardiac tamponade
- Local anesthesia
- General anesthesia
- - Emergence from general anesthesia
- Postoperative management
- SUMMARY AND RECOMMENDATIONS
- General considerations
- Recent cardiac arrest and resuscitation
- Traumatic cardiac injury