Introduction to the Quick Reference Handbook (QRH)
The Quick Reference Handbook (QRH) is a collection of guidelines for unexpected or uncommon anaesthesia-related emergencies. It aims to ensure the response to a crisis is as organised and all-encompassing as possible, at a time when the cognitive load can impair performance.
The QRH helps clinicians focus on delivering care, using the skills and knowledge they already have. All clinicians should become familiar with the QRH and be practised in its use, so it's automatically reached for in a crisis.
Keeping your QRH up to date
From time to time individual QRH guidelines will be updated. It's important you replace these in your copy to ensure your QRH is up to date. You can check which edition you have by looking at the Contents page.
If the Contents page says June 2023 this is the latest version. To update from the April 2022 to the June 2023 edition you'll need to replace the following pages:
- 0-1 Cover page (updated footer)
- 0-2 Contents (updated to June 2023 edition; contains updated guideline version number)
- 3-4 Bronchospasm - The principal change is to bring the step excluding conditions which may be misinterpreted as bronchospasm earlier in the list. Minor associated formatting changes.
- 3-10 Local anaesthetic toxicity - Principal changes are to signal need for reduced adrenaline dosage and avoidance of vasopressin in LA toxicity, and slower administration of initial bolus of intralipid. Minor wording and formatting changes to aid clarity. (Note: Adrenaline dose has been modified to bring it into line with the recommendations of this review article, which is also referenced on our local anaesthetic toxicity page. This also brings us into line with the American ASRA guidance, which is itself backed up by this review article.)
If you are familiar with the QRH you can download the 'as is' PDF version, or, if you wish to modify the QRH you can download the editable Word version.
Past updates to the QRH
Previous version: April 2022 update
To update from the October 2021 to the April 2022 edition you'll need to replace the following pages:
- 0-2 Contents (updated to April 2022 edition; contains updated guideline version number)
- 3-1 Anaphylaxis (updated to reflect following changes: Inclusion of the line in point 7: Hydrocortisone and chlorphenamine are no longer part of acute treatment (Box C); Removal of box B: Other drugs; Inclusion of the wording in point 8: Fluid requirements may be significant; Inclusion of the wording in Box D: NAP6 online resource including anaphylaxis follow-up packs.)
Previous version: October 2021 update
To update from the January 2021 to the October 2021 edition you'll need to replace the following pages:
- 0-2 Contents (updated to October 2021 edition; contains updated guideline version number)
- 3-1 Anaphylaxis (updated web link)
Previous version: January 2021 update
To update from the August 2019 to the January 2021 edition you’ll need to replace the following pages:
- 0-1 Cover page (updated footer)
- 0-2 Contents (updated to January 2021 edition; contains updated guideline version number)
- 0-3 Instructions for use (updated web link)
- 3-8 Malignant hyperthermia crisis (updated to reflect Association guideline Malignant hyperthermia 2020)
Previous version: August 2019 update
To update from the January 2019 to the August 2019 edition you’ll need to replace the following pages:
- 0-1 Cover page (updated web address)
- 0-2 Contents (updated to August 2019 edition; contains updated guideline version numbers)
- 3-12 Cardiac ischaemia (removal of incorrect reference to "1%" GTN solution)
Previous version: January 2019 update
To update from the May 2018 to the January 2019 edition you’ll need to replace the following pages:
- 0-1 Cover page (updated logo)
- 0-2 Contents (updated to January 2019 edition; contains updated guideline version numbers)
- 3-1 Anaphylaxis v.3 (further important updates in the light of NAP6)
- 3-4 Bronchospasm v.2 (critical correction to drug dose units)
Previous version: May 2018 update
To update from the January 2018 to the May 2018 edition you’ll need to replace the following pages:
- 0-1 Cover page (contains new wording)
- 0-2 Contents (updated to May 2018 edition; contains updated guideline version numbers)
- 3-1 Anaphylaxis v.2 (updated to reflect conclusions of NAP6)
- 3.-2 Major blood loss v.2 (corrected re: tranexamic acid administration)
Previous version: January 2018 launch
If the Content page says January 2018 this was the launch edition. All guidelines were ‘v.1
What the QRH is not
The QRH is not a substitute for learning and practicing clinical skills. Nor is it a substitute for being familiar with more detailed guidelines and algorithms, such as those for managing cardiac arrest or difficult airway.
It's essential that clinicians learn about these and practice their implementation elsewhere. For example, it's expected that in using the QRH guideline for managing cardiac arrest, clinicians will already have underlying knowledge of conditions causing cardiac arrest and will be competent in providing advanced life support.
The QRH is also not intended to be used as a rule book every single time one of the guideline situations is encountered. For instance, most ordinary occasions of hypotension will have a simple cause and will respond to obvious remedies. The hypotension guideline becomes useful if the situation is out of the ordinary or becomes unremitting. Conversely, for the more immediate and uncommon problems, such as cardiac arrest in theatre, the guideline should be used from the outset to help avoid missing out useful steps in resolving the situation.
The guidelines in the QRH are not intended to be standards of medical care. The ultimate judgement about a particular clinical procedure or treatment plan must be made by the clinician in light of the clinical data presented and the diagnostic and treatment options available.
Using the guidelines
For more information on the guidelines and how to use them in a crisis read Finding your way around the QRH. If you intend to introduce the QRH in your unit, you should read and follow the implementation guide. We also recommend joining the Emergency Manuals Implementation Collaborative for online community-based support in implementation.
You can download the 'as is' PDF version of the QRH, or if you wish to modify it, you can download the editable Word version.
You can also download the Quick Reference Handbook Android app.
If you have any feedback or comments about the QRH, please contact [email protected]
Other QRH guides available
The Obstetric Anaesthetists' Association (OAA) have created a collection of action card guides for medical and resuscitation emergencies in hospitals.
OAA - Quick Reference Handbook for Obstetric emergencies