Table 1

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

C1	Circulation	Establish 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.
C2	Colour	Note 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.
O1	Oxygen	Check rotameter settings, ensure inspired mixture is not hypoxic.
O2	Oxygen analyser	Adjust 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.
V1	Ventilation	Ventilate 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.
V2	Vaporiser	Note 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.
E1	Endotracheal tube	Systematically 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.
E2	Elimination	Eliminate 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).
R1	Review monitors	Review 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.
R2	Review equipment	Review all other equipment in contact with or relevant to the patient (e.g. diathermy, humidifiers, heating blankets, endoscopes, probes, prostheses, retractors and other appliances).
A	Airway	Check patency of the unintubated airway. Consider laryngospasm or presence of foreign body, blood, gastric contents, nasopharyngeal or bronchial secretions.
B	Breathing	Assess pattern, adequacy and distribution of ventilation. Consider, examine and auscultate for bronchospasm, pulmonary oedema, lobar collapse and pneumo- or haemothorax.
C	Circulation	Repeat 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.
D	Drugs	Review 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.