# 2024.1 Day 1 VIVA 1

You are assessing a patient on your list for the next day. He is a 55-year-old man who is to have an excision of a 3cm x 3cm superficial swelling over the postero-lateral aspect of the neck.&#x20;

The surgical assessment is that this is possibly a lymph node that can be excised in the Supine position with the head tilted away. The expected surgical duration of 30 minutes.&#x20;

The patient has no known allergies, and he is not on any regular medications. He does admit to snoring and has a bushy beard but is otherwise fit and well. He weighs 88 Kgs (BMI = 29).

<details>

<summary>How would you do an airway assessment on this patient?</summary>

**Comprehensive History:**

* **OSA Screening:** STOP-BANG score (snoring, tiredness, observed apnoea, BP >140/90, BMI >35, age >50, neck circumference >40cm, male gender) - this patient scores at least 3 (snoring, male, age)
* **Airway History:** Previous difficult intubation, neck radiation, trauma or surgery
* **GERD symptoms:** Increased aspiration risk during induction
* **Functional capacity:** Assess cardiopulmonary reserve

- **Systematic Physical Exam:**
  * **Mouth opening** (inter-incisor gap <3cm predicts difficult laryngoscopy)
  * **Mallampati classification** (Class III/IV suggests reduced pharyngeal space)
  * **Thyromental distance** (<6cm suggests anterior larynx)
  * **Sternomental distance** (<12.5cm predicts difficulty)
  * **Neck mobility:** Assess extension at atlanto-occipital joint
  * **Dentition:** Loose teeth, prominent incisors, dental appliances
  * **Mandibular protrusion** (inability to advance lower teeth past upper teeth indicates potential difficulty)

**Special Considerations for This Case:**

* **Bushy beard:** Reduces mask seal efficacy; consider:
  * Trimming if acceptable to patient
  * Use of viscous gel to improve mask seal
  * Early transition to two-handed technique
* **Neck mass:** Assess for tracheal deviation, compression symptoms
* **Positioning:** Head tilt may:
  * Improve surgical access but worsen airway obstruction
  * Alter normal airway anatomy for intubation

**Investigations:**

* Consider sleep study if strong OSA suspicion (though not practical pre-op)
* Neck CT if concern about mass compromising airway

**Airway Plan:**

* **Preferred technique:** ETT over SGA because:
  * Surgical field near airway
  * Potential for prolonged procedure
  * Higher security against displacement
* **Induction:**
  * RSI vs modified RSI based on aspiration risk
  * Have double setup ready (plan A/B)
* **Equipment:**
  * Video laryngoscope as first choice
  * Frova introducer available
  * Second generation SGA (e.g. i-gel) as backup
* **Positioning:**
  * Ramped position (head elevated 25°)
  * Optimal sniffing position

</details>

<details>

<summary>Would you consider awake fiberoptic intubation for this patient?</summary>

* Not routinely indicated based on current information
* Would reconsider if:
  * Additional risk factors emerge (e.g. limited neck extension)
  * Mass appears to be compressing airway on further exam
* Benefits vs risks of awake technique must be weighe

</details>

<details>

<summary>How does the beard specifically affect your airway management plan?</summary>

* Primary concern is difficult mask ventilation:
  * Have oral/nasal airways immediately available
  * Consider supraglottic airway early if mask ventilation fails
  * Two-person technique may be required
* Doesn't directly affect intubation success but may delay rescue oxygenation

</details>

<details>

<summary>What pre-oxygenation strategy would you use given his BMI?</summary>

* 3-5 minutes of tidal volume breathing with 100% O2
* Head-up position to prolong safe apnea time
* Consider CPAP/PEEP during pre-oxygenation
* Target EtO2 >90% before induction

</details>

<details>

<summary>How would you modify your plan if the mass was larger (5cm) and fixed?</summary>

* More thorough imaging (CT/MRI) to assess airway compromise
* Consider awake fiberoptic intubation
* Have ENT available for possible tracheostomy
* Discuss possibility of staged procedure

</details>

<details>

<summary>The patient develops respiratory distress in PACU. What are your differentials and management?</summary>

**Immediate Assessment (ABCDE approach):**

* Airway: Stridor, voice changes, secretions
* Breathing: RR, SpO2, chest movement symmetry
* Circulation: HR, BP, capillary refill
* Disability: GCS, pupil response
* Exposure: Check surgical site, temperature

**Differential Diagnosis:**

1. **Surgical Complications:**
   * Neck hematoma (expanding, tense swelling)
   * Recurrent laryngeal nerve injury (hoarse voice, inspiratory stridor)
   * Pneumothorax (unilateral breath sounds)
2. **Airway Issues:**
   * Laryngospasm (sudden onset post-extubation)
   * Edema (from intubation or fluid overload)
   * Secretions/mucous plugging
3. **Other:**
   * Anaphylaxis (rash, wheeze, hypotension)
   * Pulmonary edema (pink frothy sputum)
   * Opioid-induced respiratory depression

**Focused Management:**

* **Call for help** immediately
* **100% oxygen** via non-rebreather mask
* **Inspect neck:**
  * If hematoma:
    * Release sutures/clips at bedside
    * Prepare for reintubation
    * Have FONA equipment ready
* **Auscultate:**
  * Wheeze: Consider bronchodilators
  * Stridor: Consider nebulized adrenaline
* **Drugs:**
  * Consider IV dexamethasone for airway edema
  * Have succinylcholine ready for laryngospasm

- **Investigations:**
  * ABG/VBG (assess oxygenation, ventilation)
  * Bedside ultrasound (hematoma size, pneumothorax)
  * CXR if stable enough

</details>

<details>

<summary>How would you differentiate between laryngospasm and hematoma?</summary>

* **Laryngospasm:**
  * Sudden onset post-extubation
  * No neck swelling
  * Improves with CPAP/succinylcholine
* **Hematoma:**
  * Progressive symptoms
  * Visible swelling
  * Tracheal deviation possible

</details>

<details>

<summary>The surgeon says the hematoma is small. What would you do?</summary>

Still release pressure immediately because:

* Small hematomas can expand rapidly
* Airway compromise may become life-threatening
* Can always re-close if needed

- Prepare for reintubation while releasing

</details>

<details>

<summary>What are your criteria for reintubation?</summary>

* Impending airway obstruction
* SpO2 <90% despite maximal oxygen
* Rising CO2 with respiratory acidosis
* Decreasing GCS
* Fatigue from increased work of breathing

</details>

<details>

<summary>How would you manage suspected anaphylaxis?</summary>

* Immediate IM adrenaline (500mcg)
* IV fluids bolus
* Hydrocortisone 200mg IV
* Chlorphenamine 10mg IV
* Secure airway early if swelling progresse

</details>

<details>

<summary>The patient deteriorates: SpO2 60%, no air entry, and you cannot intubate or ventilate. What next?</summary>

**Declare CICO Emergency:**

* Clear announcement: "This is a CICO situation"
* Mobilize entire team - assign specific roles

**Immediate Actions:**

* Continue 100% oxygen attempts
* Confirm cannot intubate, cannot oxygenate
* Position: Neck extension if possible (unless contraindicated)

**Scalpel-Bougie Technique (ANZCA Guidelines):**

1. **Landmark Identification:**
   * Locate cricothyroid membrane (between thyroid and cricoid cartilage)
   * If unclear, use 3-finger technique (index on thyroid notch)
2. **Stabilization:**
   * Have assistant hold trachea stable
   * Consider local if time allows (1-2ml 1% lidocaine)
3. **Incision:**
   * Vertical 4-5cm skin incision
   * Horizontal stab through cricothyroid membrane
4. **Bougie Insertion:**
   * Insert bougie caudally (30° angle)
   * Feel for tracheal rings confirmation
5. **Tube Placement:**
   * Railroad 6.0 ETT over bougie
   * Inflate cuff, secure tube

* **Confirmation:**
  * **Primary:** Waveform capnography (gold standard)
  * Secondary: Chest rise, misting, SpO2 improvement
  * Tertiary: Auscultation (though less reliable in emergency)
* **Post-Procedure:**
  * Call ENT for formal tracheostomy
  * CXR to confirm position
  * ICU transfer
  * Full documentation
  * Team debrief

</details>

<details>

<summary>Why choose scalpel-bougie over cannula technique?</summary>

* Higher success rates in studies
* More reliable airway diameter
* Less risk of barotrauma
* ANZCA guidelines recommend as first-line

</details>

<details>

<summary>How would you confirm tube placement in this emergency?</summary>

* **EtCO2 is mandatory** - only definitive confirmation
* Secondary signs: Chest rise, SpO2 improvement
* Avoid relying solely on auscultation

</details>

<details>

<summary>What if you can't identify landmarks?</summary>

* Use 3-finger technique as fallback
* Make incision at presumed location (midline, inferior to thyroid cartilage)
* Consider needle decompression if absolutely necessary

</details>

<details>

<summary>When would you consider waking the patient?</summary>

Only if:

* Partial airway maintained
* SpO2 stable >90%
* Patient following commands

Not appropriate in complete CICO scenario

</details>
