Anaesthetic Crisis Manual

Book Review: The Anaesthetic Crisis Manual, David C Borshoff

The Anaesthetic Crisis Manual (The ACM), was first published in 2011 and is a collection of 22 life threatening crises that anaesthetists manage in everyday practice. Based on the cockpit QRH (quick reference handbook) used in the airline industry, and using CRM (crew resource management) principles developed for aviation safety, the ACM brings tried and tested checklist instruction to the field of Patient Safety. LITFL reviewed the book as a potential resource in the setting of the emergency resuscitation area and at the ICU bedside.

The ACM utilises accepted national and international resuscitation guidelines, with input from anaesthetic special interest groups and has been on our radar for use in the Emergency Department since it was ‘highly commended‘ at the BMA Medical Book Awards 2012.
The ACM is presented in highly functional, robust and fluid resistant material, ideal for the emergency room environment and is endorsed by the ESA (European Society of Anaesthesiology) and ASA (Australasian Society of Anaesthetists).

Consisting of both a Crisis Protocol section, which provides a checklist of tasks to complete when the diagnosis is known, and a Crisis Prevention section for troubleshooting before a crisis develops, the ACM provides concise, clear and simply worded instructions for use by any health professional leading or assisting in crisis management.

Even the most experienced clinicians can forget important steps in treatment pathways and, like the quick reference handbook in an aircraft cockpit, its placement in all anaesthetising locations may improve performance, provide welcome support and promote crew resource management principles

Appearance:

The cover of the book is so nice it makes you want to stroke touch it. It fits comfortably in one hand, has a sturdy ring binder with a device to allow the book to hang from any RESUS trolley. The pages, like the Australian Dollar, feel like they are made of plastic and are resistant to spills in the trauma environment. The pages are clearly indexed, tabulated and colour coded, with large writing and a simple, intuitive presentation. The ACM will be made available in iOS and Android versions very soon…

The book exists as an International text and a specific North American edition (The Anesthetic Crisis Manual…), where in the latter they spell adrenaline incorrectly as ‘e-p-i-n-e-p-h-r-i-n-e’, drop most unnecessary vowels and throw in the occasional ‘Y’all’ for good measure.

Crisis Management and Crisis Prevention.

The Crisis Management section presents 2 pages on each topic. The left page provides a concise prioritized list on how to manage the crisis. The right page elaborates and defines key issues pertinent to the crisis such as differential diagnoses, target physiological parameters, drug dose preparations or a brief description on how to perform procedures. Topics covered include:

• Cardiovascular: VF / VT, Asystole / PEA, PALS- Paediatric Advanced Life Support, Severe Intraoperative, Haemorrhage, Anaphylaxis…
• Respiratory: Difficult Mask Ventilation, Unanticipated Difficult Intubation, Can’t Intubate Can’t, Ventilate, Laryngospasm…
• Obstetric: PPH- Post Partum Haemorrhage, Maternal Collapse, Neonatal Resuscitation
• Miscellaneous: Hyperkalaemia, Malignancy Hyperthermia…

The Crisis prevention section deals mostly with the approach to an isolated abnormal physiological parameter and adds a nice touch to the manual. The layout is similar to the preceding section with the left page this time dedicated to a list of causes for the abnormality, and the right side describing a diagnostic pathway to isolate and fix the problem.

What we liked

• The checklist approach on the left page works well as an alternative to an algorithm; a checklist being both clearer and even easier to follow
• Definitions and descriptions on the right page are highly relevant. For example in the section on Severe Intraoperative Haemorrhage biochemical targets are defined along with options on haemostatic therapy, their precise indication and initial dosages
• The checklists are evidenced based, referencing international guidelines: Resuscitation Council UK Guidelines (2010), American Heart Association Guidelines for CPR (2010), Australia and New Zealand Anaesthetic and Allergy Group anaphylaxis management guidelines (2013), and papers
• The Crisis Prevention section covers extremely common problems in a very clear and methodical way. This section would also be extremely valuable to ICU and ED doctors, particularly in the rapid assessment of deteriorating intubated patients during transfer
• Advocates a team-based approach to the management of an anaesthetic crisis
• Excellent SCE type exam practice for junior doctors training for their fellowship exams, or alternatively as an aide-memoire for staff grade or consultant level

Things to consider

• ACM occasionally sacrifices fine detail for clarity, but any omissions have been very carefully considered
• A concise crisis manual cannot take into account variations in local guidelines nor does it provide an exhaustive list of options on management. It does however describe in detail a single safe approach
• Whilst many of the scenarios are applicable to other areas of critical care, some are not. For example the management of bronchospasm intra-operatively is quite different to that in the Emergency Department, where management is geared around the prevention of intubation through the aggressive use of NIPPV

Overall

They say you should not judge a book by its cover, but in this case it meets those high expectations and does exactly what it says on the tin. The structure and purpose of the book also lends itself to other areas of critical care and the Anaesthetic Crisis Manual is just screaming out for a sequel. Would be great to see the author produce a specific Emergency Medicine version of the book with chapters including; ‘Delayed Sequence Intubation’, ‘Procedural Sedation’, ‘Acute Agitation and Arousal’, ‘Status Epilepticus’ and ‘Massive GI Haemorrhage’, just to mention a few…