2023.1 Day 1 VIVA 2
Last updated
Last updated
A 28 year old man presents to ED at 12 noon, 24 hours post tonsillectomy. He has been bleeding for 2 hours, with 3 vomits of frank blood that filled a small bowl. His vital signs are HR 110, BP 110/70, O2 sats 98% on room air. This morning, he ate some eggs and had coffee at 0700 hrs.
What are your main concerns with this patient?
Airway risk: Blood and clot can cause aspiration & airway soiling, making ventilation difficult.
Difficult laryngoscopy: Ongoing bleeding and swelling can obscure landmarks.
Haemodynamic instability: Hypovolaemia from ongoing blood loss.
Full stomach: Aspiration risk due to recent food intake.
Shared airway: ENT surgeon may need access at the same time as securing the airway.
Yes – Airway protection is critical due to:
Ongoing bleeding & aspiration risk.
Potential deterioration in haemodynamics.
Requirement for surgical control of the bleed under anaesthesia.
Q: What is your approach to RSI in this patient?
MAIDE First
Monitoring/Location
Assistant
Anaesthetist, ENT surgeon/surgeon, second airway team
IV access
Drugs
Ketamine (maintains BP) or Propofol (if haemodynamically stable)
Rocuronium (rapid paralysis)
Equipment
Suction x 2 (Yankauer and flexible)
Video laryngoscope & fibreoptic scope if available
Front-of-neck access (FONA) kit ready
Additional considerations:
Cricoid pressure: Consider but release if difficulties arise.
Pre-oxygenation in head-up position (RSI with NO bag-mask ventilation unless desaturating).
Suction (Yankauer or DuCanto or ETT for pooling, flexible suction for deep blood).
Attempt video laryngoscopy for better visualisation. Risk of camera contamination
Consider ENT assistance (magill forceps, cautery).
If unsuccessful, move to supraglottic airway (SGA) or prepare for FONA
You intubate, but there is no end-tidal CO₂. What are your next steps?
Assess for oesophageal intubation:
Look: Chest rise?
Listen: Bilateral breath sounds?
Feel: Tube depth correct?
Reconfirm with video laryngoscopy if unsure.
If confirmed oesophageal intubation → immediate removal & reintubation.
If tube is in place but no CO₂ & desaturation occurs → CICO pathway.
The patient desaturates further, and you cannot intubate or ventilate. What now?
Declare a Can’t Intubate, Can’t Oxygenate (CICO) emergency.
Call for help and delegate FONA to the most experienced operator.
Perform front-of-neck access (FONA):
Scalpel–bougie–tube technique (scalpel incision, bougie insertion, railroad ETT).
If paediatric-sized patient → consider needle cricothyroidotomy.
Need to avoid excessive tube movement (risk of dislodgement).
Allow access for haemostasis (may need short ETT or reintubation post-procedure).
Close coordination between anaesthetist & surgeon on timing of intervention
Q: How do you assess readiness for extubation in this patient?
Haemostasis confirmed by ENT.
Minimal airway swelling & soiling – suction ETT to ensure clear secretions.
Patient fully awake, strong cough reflex.
Plan for failed extubation:
Have airway equipment ready (SGA, reintubation gear).
Consider trial of SGA before full extubation in high-risk cases.
Intubation exchange catheter.
Q: Would you admit this patient to a higher level of care (or transfer if unavailable)? Why or why not?
Yes, ICU or HDU admission if available or local near transfer for:
Rebleeding risk (common in post-tonsillectomy bleeds).
Potential airway compromise post-extubation.
Need for close observation & potential for reintubation.