Table 1

 Crisis management algorithm – memorise and practise: an explanation of each cue in the mnemonic “COVER ABCD”

C1CirculationEstablish adequacy of peripheral circulation (rate, rhythm and character of pulse). If pulseless, institute cardiopulmonary resuscitation (CPR). The core algorithm must still be completed as soon as possible.
C2ColourNote saturation. Examine for evidence of central cyanosis. Pulse oximetry is superior to clinical detection and is recommended. Test probe on own finger, if necessary, whilst proceeding with O1 and O2.
O1OxygenCheck rotameter settings, ensure inspired mixture is not hypoxic.
O2Oxygen analyserAdjust inspired oxygen concentration to 100% and note that only the oxygen flowmeter is operating. Check that the oxygen analyser shows a rising oxygen concentration distal to the common gas outlet.
V1VentilationVentilate the lungs by hand to assess breathing circuit integrity, airway patency, chest compliance and air entry by “feel” and careful observation and auscultation. Also inspect capnography trace.
V2VaporiserNote settings and levels of agents. Check all vaporiser filler ports, seatings and connections for liquid or gas leaks during pressurisation of the system. Consider the possibility of the wrong agent being in the vaporiser.
E1Endotracheal tubeSystematically check the endotracheal tube (if in use). Ensure that it is patent with no leaks or kinks or obstructions (see suggested protocol in Anaesth Intensive Care 1993;21:615). Check capnograph for tracheal placement and oximeter for possible endobronchial position. If necessary, adjust, deflate cuff, pass a catheter, or remove and replace.
E2EliminationEliminate the anaesthetic machine and ventilate with self-inflating (e.g. Air Viva) bag with 100% oxygen (from alternative source if necessary). Retain gas monitor sampling port (but be aware of possible problems).
R1Review monitorsReview all monitors in use (preferably oxygen analyser, capnograph, oximeter, blood pressure, electrocardiograph (ECG), temperature and neuromuscular junction monitor). For proper use, the algorithm requires all monitors to have been correctly sited, checked and calibrated.
R2Review equipmentReview all other equipment in contact with or relevant to the patient (e.g. diathermy, humidifiers, heating blankets, endoscopes, probes, prostheses, retractors and other appliances).
AAirwayCheck patency of the unintubated airway. Consider laryngospasm or presence of foreign body, blood, gastric contents, nasopharyngeal or bronchial secretions.
BBreathingAssess pattern, adequacy and distribution of ventilation. Consider, examine and auscultate for bronchospasm, pulmonary oedema, lobar collapse and pneumo- or haemothorax.
CCirculationRepeat evaluation of peripheral perfusion, pulse, blood pressure, ECG and filling pressures (where possible) and any possible obstruction to venous return, raised intrathoracic pressure (e.g. inadvertent PEEP) or direct interference to (e.g. stimulation by central line) or tamponade of the heart. Note any trends on records.
DDrugsReview intended (and consider possible unintended) drug or substance administration. Consider whether the problem may be due to unexpected effect, a failure of administration or wrong dose, route or manner of administration of an intended or “wrong drug”. Review all possible routes of drug administration.