Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.


CardioPulmonary Resuscitation in the Operating Room


The Stanford Emergency Manual has become an essential reference for anesthesiologists. The manual lists diagnostic and therapeutic steps to follow in 26 different emergency scenarios. When a Code Blue or a dire change in vital signs occurs in an operating room, the Manual directs the resuscitation team to the correct order of action at a time when minds are racing, thoughts have become jumbled, and near-perfect intervention is required.

The Stanford Emergency Manual is now available in a 4¼ X 5-inch pocket version, suitable for carrying in one’s briefcase or backpack as you move from one anesthetizing location to another. The Stanford Emergency Manual has been used in all Stanford Hospital anesthetizing locations since 2012, and Stanford has printed and shipped thousands of Manuals to institutions around the United States and the world. One can also order a laminated 8½ x 11½-inch version of the Manual to hang in each operating room. A printable version of the Stanford Emergency Manual is available online for free.

In addition to Advanced Cardiac Life Support (ACLS) algorithms, the Stanford Manual lists specific instructions on the management of:

  • Anaphylaxis
  • Bronchospasm
  • Delayed Emergence
  • Difficult Airway/Cricothyrotomy
  • Embolism – Pulmonary
  • Fire – Airway
  • Fire – Non-Airway
  • Hemorrhage
  • High Airway Pressure
  • High Spinal
  • Hypertension
  • Hypotension
  • Hypoxemia
  • Local Anesthesia Toxicity
  • Malignant Hyperthermia
  • Myocardial Ischemia
  • Oxygen Failure
  • Pneumothorax
  • Power Failure
  • Right Heart Failure
  • Transfusion Reaction
  • Trauma

Why implement an Emergency Manual?  Supported by published literature, the Stanford group cites these reasons on their webpage:

“Medical simulation studies show that integrating an emergency manual into the operating room results in better management during crises events.

  • Pilots and nuclear power plant operators use similar cognitive aids for emergencies and rare events.
  • During a crisis event, the stacks of relevant literature are rarely accessible.
  • Memory worsens under stress and distractions interrupt our planned actions.
  • Expertise requires significant repetitive practice, so none of us are experts in every emergency.”
The Emergency Manual was created by the same team which pioneered simulator training for anesthesiologists, headed by Stanford faculty members Drs. David Gaba, Steven Howard, and Sara Goldhaber-Fiebert. The term “cognitive aid” is an academic term referring to resources which help people to remember or apply relevant knowledge appropriately, but since “cognitive aid” is not a familiar term to most anesthesia professionals, the Stanford authors call the book an Emergency Manual, a term which has developed broad acceptance. The Stanford group published the academic article “Emergency Manual Uses During Actual Critical Events and Changes in Safety Culture From the Perspective of Anesthesia Residents: A Pilot Study” in 2016,  and “Clinical Uses and Impacts of Emergency Manuals During Perioperative Crises” in 2020. Both articles describe the successful implementation of the Emergency Manual. Both were published in the journal Anesthesia and Analgesia.

This example illustrates the utility of the Stanford Emergency Manual:

An anesthesiologist is working at a freestanding outpatient surgery center, and is scheduled to anesthetize a patient for an arthroscopic rotator cuff repair. Prior to the surgery, the anesthesiologist is performing an ultrasound-guided interscalene nerve block when the patient suddenly loses consciousness and then develops cardiovascular collapse following the injection of the local anesthetic bupivacaine. The attending anesthesiologist remembers that the treatment for Local Anesthesia Toxicity involves injecting Intralipid intravenously, but he/she doesn’t remember the dose. The patient is turning blue and lacks pulses.  

The anesthesiologist calls out to the circulating nurse to bring in the Code Blue cart, hands his pocket copy of the Stanford Emergency Manual to a second nurse, and tells her to turn to the page on Local Anesthetic Toxicity and read the treatment instructions out loud. The nurse does so, and begins reading from these following pages from the Manual:


The anesthesiologist calls for Intralipid stat, while the nurse reads each line from the Emergency Manual treatment. The anesthesiologist follows the algorithm, intubates the trachea, and begins ventilating 100% oxygen into the patient’s lungs. CPR is started because there are no palpable pulses. The anesthesiologist then begins administering doses of Intralipid per the Manual. The patient is stabilized and eventually survives without any adverse outcome.

At the Palo Alto multi-specialty surgery center where I am the Medical Director, one Manual is available for the operating rooms and a second Manual hangs on the Code Blue Cart. We  teach a Mock Code or a Malignant Hyperthermia drill every six months, and we rehearse the use of the Stanford Emergency Manual during each drill.

If the facilities you work at don’t have copies of the Stanford Emergency Manual, get yourself a Pocket Emergency Manual.

You won’t regret it.




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