1. Fundamentals of Dynamic Decision Making in Anesthesia 2. Specific Principles of Anesthesia Crisis Resource Management 3. Teaching Anesthesia Crisis Resource Management 4. Debriefing 5. Generic Events Acute Hemorrhage Cardiac Arrest Difficult Tracheal Intubation Emergent (Crash) Induction of Anesthesia Esophageal Intubation High Inspired CO2 High Peak Inspiratory Pressure Hypertension Hypotension Hypoxemia Operating Room Fire ST Segment Change The Septic Patient The Trauma Patient 6. Cardiovascular Events Acute Coronary Syndrome Anaphylactic and Anaphylactoid Reactions Autonomic Dysreflexia Cardiac Tamponade Nonlethal Ventricular Arrhythmias Pulmonary Edema Pulmonary Embolism Sinus Bradycardia Supraventricular Arrhythmias Venous Gas Embolism 7. Pulmonary Events Airway Burn Airway Rupture Anterior Mediastinal Mass Aspiration of Gastric Contents Bronchospasm Endobronchial Intubation Epiglottitis (Supraglottitis) Hypercarbia Hypoxemia During One-Lung Ventilation Massive Hemoptysis Pneumothorax Postoperative Stridor Unplanned Extubation 8.
Metabolic Events Addisonian Crisis (Acute Adrenal Insufficiency) Diabetic Ketoacidosis Hyperkalemia Hypoglycemia Hypokalemia Hyponatremia and Hypo-osmolality Hypothermia Malignant Hyperthermia Metabolic Acidosis Methemoglobinemia Oliguria Thyroid Storm Transfusion Reaction 9. Neurologic Events Central Nervous System Injury Local Anesthetic Systemic Toxicity Perioperative Visual Loss Peripheral Nerve Injury Postoperative Alteration in Mental Status Postoperative Failure to Breathe Seizures 10. Equipment Events Carbon Monoxide in the Anesthesia Circuit Circle System Expiratory Valve Stuck Closed Circle System Inspiratory Valve Stuck Closed Circle System Valve Stuck Open Common Gas Outlet Failure Drug Administration Error Electrical Power Failure Faulty Oxygen Supply Gas Flow Control Malfunction Intravenous Line Failure Loss of Pipeline Oxygen Major Leak in the Anesthesia Breathing Circuit Pop-Off Valve Failure Ventilator Failure Volatile Anesthetic Overdose Waste Anesthesia Gas Disposal System Malfunction 11. Cardiac Anesthesia Events Cardiac Laceration Coagulopathy Following Cardiopulmonary Bypass Emergent "Crash" onto Cardiopulmonary Bypass Hypotension During Cardiopulmonary Bypass Low Cardiac Output State Post-Cardiopulmonary Bypass Massive Systemic Air Embolism Protamine Reaction 12. Obstetric Events Amniotic Fluid Embolism (also termed Anaphylactoid Syndrome of Pregnancy) Cardiac Arrest in the Parturient Difficult Airway in the Parturient Emergency Cesarean Section Hypotension Following Neuraxial Anesthesia Magnesium Toxicity Obstetric Hemorrhage Pre-eclampsia and Eclampsia Total Spinal Anesthesia 13. Pediatric Events Acute Hemorrhage in the Pediatric Patient Anaphylaxis in the Pediatric Patient Aspiration of a Foreign Body Bradycardia in the Pediatric Patient Cardiac Arrest in the Pediatric Patient Difficult Airway Management in the Pediatric Patient Hypotension in the Pediatric Patient Laryngospasm Masseter Muscle Rigidity Sinus Tachycardia in the Pediatric Patient.