Crisis management — MH, anaphylaxis, LAST, MTP

Watch out

Malignant hyperthermia — first 5 minutes

Triggers: succinylcholine + ALL volatile (sevo/des/iso). Triad: ↑ ETCO2 refractory to ↑ MV → masseter spasm or rigidity → hyperthermia (LATE). Stop volatile/succ, hyperventilate 100% O2 at 10 L/min, switch to TIVA. CALL MH HOTLINE 1-800-MH-HYPER. Dantrolene 2.5 mg/kg IV (Ryanodex 250mg/5mL). Cool to 38°C. Treat hyperK.

Mnemonic — Stop · Call · Cool · Dantrolene

MH treatment — call, cool, dantrolene

Stop · Call · Cool · Dantrolene

• StopStop volatile + succinylcholine. Switch to TIVA. Hyperventilate 100% O2 at 10 L/min.
• CallCall MH hotline 1-800-MH-HYPER (1-800-644-9737). Get extra hands. Have someone bring the MH cart.
• CoolCold IV NS, ice packs to groin/axilla, cold gastric/bladder lavage. Stop cooling at 38°C — avoid overshoot.
• DantroleneDantrolene 2.5 mg/kg IV bolus, repeat q5 min until symptoms resolve. Max ~10 mg/kg. Reconstitute Ryanodex (250 mg/vial) faster than original (200 mL → 5 mL).

Treat hyperK with calcium + insulin/glucose + bicarb. Treat arrhythmia (avoid CCBs — interact with dantrolene). Continue dantrolene 1 mg/kg q6h × 24 h post-event. ICU monitoring 24-48 h.

Watch out

Anaphylaxis — first 90 seconds

Triggers: NMBs (esp roc — most common), antibiotics (cefazolin, vanc), latex, chlorhexidine, sugammadex (rare), contrast. Off trigger → legs up → adrenaline. EPI IM 0.5 mg or IV 10-100 mcg titrated. Tryptase ×3 (immediate, 1h, 24h). Refer to allergist.

Mnemonic — OLA

Anaphylaxis — Off · Lift · Adrenaline

Off · Lift · Adrenaline

• OOFF — stop the trigger (stop antibiotic, stop sugammadex/rocuronium infusion, remove latex source)
• LLIFT — legs to 30° (autotransfusion); turn FiO2 to 1.0; call for help
• AADRENALINE — epinephrine IM 0.5 mg or IV 10-100 mcg titrated; q1-2 min if needed; infusion 0.05-0.5 mcg/kg/min for refractory

Send tryptase × 3 (immediate, 1 hr, 24 hr — supports diagnosis). Adjuncts: H1 (diphenhydramine 50 mg), H2 (famotidine 20 mg), steroid (hydrocortisone 200 mg, dex 8 mg) — these are SECONDARY, never delay epi for them. Refer to allergist for skin testing.

Watch out

Local anesthetic systemic toxicity (LAST)

Tinnitus → metallic taste → twitching → seizure → arrhythmia → arrest. Stop injecting at first symptom. Airway + 100% O2, benzo for seizure, INTRALIPID 20% 1.5 mL/kg bolus then 0.25 mL/kg/min × 10 min minimum. Avoid lidocaine, vasopressin, β-blockers, CCBs. SMALL-dose epi only (≤1 mcg/kg).

Mnemonic — Tinnitus → Twitching → Tonic-clonic → Tachy/brady → flatline

LAST — recognize early, treat with lipid

LAST recognition + lipid

• EarlyTinnitus, metallic taste, perioral tingling, lightheadedness — STOP injecting
• MidMuscle twitching, dysarthria, agitation — escalating CNS
• LateTonic-clonic seizure → coma → arrhythmia (wide-complex) → cardiac arrest
• TxAirway + 100% O2; benzo for seizure; INTRALIPID 20% 1.5 mL/kg bolus then 0.25 mL/kg/min × 10 min minimum (or until stable + 10 min after)
• AvoidAVOID lidocaine, vasopressin, beta-blockers, CCBs. Use SMALL-dose epi (≤1 mcg/kg). Bupivacaine — most cardiotoxic; bind to lipid sink.

Ratio for lipid: 1.5 mL/kg lean body wt bolus, then 0.25 mL/kg/min infusion. Max ~12 mL/kg total. Have lipid available wherever neuraxial/peripheral blocks are performed.

Watch out

Massive transfusion protocol

Activate when: anticipated >10 units PRBC in 24h OR >4 units/hr OR hemodynamic instability with bleeding. Ratio 1:1:1 (PRBC : FFP : platelets). TXA 1g IV within 3h of trauma. Calcium gluconate 1g per 4-6 units (citrate). Warm fluids/blood; viscoelastic (TEG/ROTEM) guides component therapy. Watch hyperK + hypoCa + acidosis + hypothermia (lethal triad).

Rule

Lethal triad — keep them out of it

Hypothermia + acidosis + coagulopathy reinforce each other: cold blood doesn't clot, lactate rises, INR/aPTT prolong. Active warming, keep core ≥35°C, keep pH ≥7.2, keep INR <1.5. Permissive hypotension OK until bleeding controlled.