# 2024.2 Day 1 VIVA 4

It is 1 pm on the weekend at Scenarioville Hospital. A 5-year-old girl presents to the Emergency Department accompanied by her mother with a supracondylar fracture after falling off a trampoline.&#x20;

The surgeon would like to take her to the theatre immediately, as her hand is cold and pulseless. She had lunch 1 hour ago and is very distressed. I

ntravenous access has not been obtained. She has a past history of asthma.

<details>

<summary>What are your main concerns?</summary>

**Immediate threats:**

* **Vascular compromise:**
  * Cold, pulseless hand = limb ischemia risk → **urgent reduction required within 6 hours** to prevent permanent damage.
* **Full stomach aspiration risk:**
  * Ate lunch 1 hour ago → **high risk for regurgitation/aspiration** under GA.
* **Asthma history (PAData confirms mild asthma):**
  * High stress + GA → increased risk of **bronchospasm**.

**Scenarioville resource limitations:**

* **No paediatric ICU or HDU**.
* Retrieval delay (\~2 hours).
* Only basic post-op monitoring available (SpO₂, HR).

**Consent priorities:**

* Discuss **aspiration risk** explicitly with family.
* Explain need for **RSI despite recent food**.
* Explain **possible escalation** to retrieval if respiratory complications arise.

</details>

<details>

<summary>How would you balance the urgency of surgery against aspiration risk?</summary>

* Proceed immediately with **RSI** — **limb salvage > aspiration risk**.
* Risk of permanent disability or amputation if delayed >6 hours.
* Mitigate aspiration risk with RSI, cricoid pressure, and preoxygenation.

**Justification:**

* **NPO guidelines are suspended** in time-critical emergencies.

</details>

<details>

<summary>What preoperative assessments are essential given her asthma?</summary>

* Auscultate chest for wheeze or crackles.
* Confirm recent bronchodilator use (salbutamol MDI or nebuliser).
* Check for recent exacerbations or steroid use (indicates poor control).
* Consider pre-treatment with **salbutamol nebuliser** before GA.

**Justification:**

* Airway reactivity **increases aspiration + bronchospasm risk**.

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<details>

<summary>How does Scenarioville’s lack of ICU affect your decision-making?</summary>

* **Full recovery prior to extubation** is essential → awake extubation only.
* Ensure robust spontaneous ventilation before leaving theatre.
* Plan for overnight monitoring in SCU even if stable.

**Justification:**

* No facility for post-intubation ventilation → must **prevent** complications rather than **rescue**.

</details>

<details>

<summary>What consent points would you prioritise with the mother?</summary>

* Immediate surgery to save the limb.
* Aspiration risk: despite precautions, regurgitation could occur.
* Possibility of prolonged recovery → escalation to retrieval if needed.
* Risks of bronchospasm, pneumonia, re-intubation if complications occur.

**Justification:**

* Informed consent must focus on **emergency-specific risks**.

</details>

<details>

<summary>Would you delay for fasting? If so, how long?</summary>

* **No delay** — urgent limb salvage is the priority.
* RSI minimises risk; cricoid pressure and airway suction readiness further mitigate aspiration risk.

**Justification:**

* Delaying compromises limb viability; aspiration risk can be actively managed.

</details>

<details>

<summary>Outline your induction plan, including drug dosing and airway strategy.</summary>

**Pre-induction preparation:**

* 2x IV cannulas if possible (16–20G based on child's size).
* Preoxygenation:
  * 100% O₂ for 3 minutes if compliant.
  * 8 vital capacity breaths if distressed.
* Salbutamol nebuliser pre-op if wheezy.

**Induction drugs:**

* **Ketamine 1–2 mg/kg IV**:
  * Preserves airway reflexes, causes bronchodilation, maintains haemodynamics.
* **Rocuronium 1.2 mg/kg IV**:
  * Provides rapid muscle relaxation for RSI.
* **Fentanyl 1–2 mcg/kg IV** if no hypovolemia, for blunting response to intubation.
* **Atropine 20 mcg/kg IV** optional if bradycardia concern.

**Airway equipment:**

* Size 5.0 cuffed ETT (age/4 + 3.5 or 4).
* Videolaryngoscope available.
* Size 2 LMA backup ready.
* Bougie, suction prepped.

- **Cricoid pressure:**
  * Apply **gently (10 N)** after LOC; avoid distortion of airway anatomy.

**Positioning:**

* Supine with injured arm supported.
* Avoid over-traction → worsens vascular injury.

</details>

<details>

<summary>Why avoid succinylcholine in this case?</summary>

* Risk of **hyperkalemia** with muscle trauma — theoretical but avoidable.
* Rocuronium 1.2mg/kg achieves RSI conditions safely.

**Justification:**

* Succinylcholine reserved for rare 'can't intubate, can't oxygenate' situations where fastest onset is critical.

</details>

<details>

<summary>How would you modify dosing if she were obese?</summary>

* Use **ideal body weight** for rocuronium dosing.
* Use **lean body weight** for ketamine (high lipophilicity → reduced overdose risk).

**Justification:**

* Overdosing paralytics risks prolonged apnea; underdosing risks failed RSI.

</details>

<details>

<summary>What if you couldn’t secure IV access?</summary>

* IM ketamine 5 mg/kg + IM atropine 20mcg/kg.
* Then inhalation induction with sevoflurane if needed.
* Once sedated → place IV.

**Justification:**

* **Delaying surgery for IV access risks limb loss** → sedation facilitates urgent access.

</details>

<details>

<summary>Would you use cricoid pressure? What are its pitfalls?</summary>

* Yes — high aspiration risk.
* **Pitfalls:**
  * Distortion of airway anatomy → difficult intubation.
  * Overpressure (>20N) collapses airway.

**Justification:**

* Cricoid pressure must be **skillfully applied** and can be **released** if intubation is difficult.

</details>

<details>

<summary>How would you position her given the fracture?</summary>

* Supine with affected arm **padded and supported**, avoiding traction or compression.
* Arm draped carefully to avoid compromise during surgery.

**Justification:**

* Further movement can worsen vascular compromise or cause nerve injury.

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<details>

<summary>The child vomits on induction. What are your next steps?</summary>

**Immediate Management:**

* Place head down and lateral if possible.
* Continuous suction of oropharynx.
* Maintain cricoid pressure if feasible.
* Rapid sequence intubation immediately if not yet intubated.

**Post-Intubation Management:**

* Confirm ETT placement with EtCO₂.
* Suction via ETT if large volumes aspirated.
* Post-op:
  * Chest X-ray (if clinical signs warrant).
  * Start **co-amoxiclav** empirically.
  * Monitor for hypoxia/fever signs of aspiration pneumonitis.

**Escalation/Contingency:**

* SCU admission for close observation.
* Early retrieval activation if SpO₂ persistently <90% or respiratory failure develops.

</details>

<details>

<summary>What clinical signs suggest significant aspiration?</summary>

* Desaturation (<92%).
* New wheeze or crackles on auscultation.
* Increased airway pressures on ventilator.
* Radiographic infiltrates on CXR.

**Justification:**

* Need to identify early to prevent respiratory failure.

</details>

<details>

<summary>How would you ventilate her if she develops bronchospasm?</summary>

* Low tidal volumes (5–6 mL/kg).
* Increase expiratory time (I:E 1:3–1:4).
* Increase PEEP cautiously (5cmH₂O).
* Administer salbutamol puffs via ETT or inline nebuliser.

**Justification:**

* Avoid dynamic hyperinflation and barotrauma.

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<details>

<summary>What if she remains hypoxic despite intubation?</summary>

* Exclude tube obstruction/malposition.
* Rule out tension pneumothorax (unilateral absence of breath sounds → needle decompression).
* Administer adrenaline bolus 1 mcg/kg IV if hypotension and severe bronchospasm.

**Justification:**

* Early identification and treatment of critical complications improves survival.

</details>

<details>

<summary>When would you request retrieval to a tertiary centre?</summary>

* Persistent hypoxia despite optimal ventilation.
* Hemodynamic instability.
* Need for prolonged ventilation >6hr post-op.

**Justification:**

* Scenarioville lacks capacity for advanced ventilation or inotropes.

</details>

<details>

<summary>How would you manage her postoperatively in Scenarioville?</summary>

* SCU admission with continuous SpO₂ and cardiorespiratory monitoring overnight.
* Chest physiotherapy if secretions accumulate.
* Careful fluid management → avoid pulmonary edema.

**Justification:**

* Maximise early detection of deterioration without access to ICU.

</details>

**Critical Phrases:**

* * “Limb salvage outweighs fasting guidelines — RSI is mandatory.”
  * “Ketamine ensures haemodynamic stability and bronchodilation.”
  * “Cricoid pressure must be applied gently — not at the expense of intubation success.”
  * “Persistent hypoxia post-aspiration mandates early retrieval activation.”

#### **Key Learning Points**

1. **Urgency > Fasting Status:**
   * In limb-threatening emergencies, **proceed to surgery immediately** despite NPO violations.
   * **RSI with cricoid pressure** is mandatory to manage aspiration risk.
2. **Ketamine is the Ideal Induction Agent:**
   * Provides **bronchodilation**, **maintains airway reflexes**, and **preserves haemodynamic stability** — perfect for asthmatic, distressed children.
3. **Scenarioville = Prevent Complications, Don’t Rescue Them:**
   * No ICU or advanced ventilation → **awake extubation**, fully reversed, and stable before leaving theatre.
4. **Succinylcholine Should Be Avoided in Acute Trauma:**
   * Risk of **hyperkalaemia** due to upregulated acetylcholine receptors after trauma, even in children.
5. **Positioning Must Protect the Fractured Limb:**
   * **No traction or torsion** during induction/transport → could worsen vascular compromise or cause nerve injury.
6. **Aspiration Requires Immediate Aggressive Management:**
   * **Head down, suction, rapid intubation**, minimal bagging until airway secured.
   * Monitor for **aspiration pneumonitis** post-op with chest X-ray and SpO₂ monitoring.
7. **Early Activation of Retrieval Services if Deterioration:**
   * If persistent hypoxia, bronchospasm, or haemodynamic instability → **contact retrieval early** (retrieval time \~2 hours).
8. **Paediatric-Specific Dosing Principles:**
   * **Ketamine and fentanyl based on lean body weight**,
   * **Rocuronium based on ideal body weight**,
   * Always have drug calculations pre-checked before induction.
