2024.2 Day 2 VIVA 17

Airway Management

A 65-year-old man is brought by ambulance to your rural emergency department after injuring the right side of his face with heavy spring-loaded equipment. He reports no loss of consciousness or vomiting.

On examination, there is extensive swelling from the lateral canthus of the right eye to the right submandibular region, causing facial distortion, as well as swelling in the right neck leading to drooling.

The on-call locum surgeon is ready to drain the right facial hematoma in the local operating theatre

  • Patient Factors:

    • OSA + Obesity (BMI 45):

      • Elevated risk of airway collapse and postoperative respiratory failure.

      • Consider CPAP compliance, recent sleep study data, and baseline SpO₂.

      • No HDU/ICU on site: limited ability to manage expected complications like CO₂ retention or post-op obstruction.

    • Cardiac History – Stents + Clopidogrel:

      • Dual antiplatelet therapy essential to prevent stent thrombosis.

      • High perioperative bleeding risk.

      • No access to interventional cardiology or PCI; time-critical transfers not guaranteed.

      • Discuss timing of surgery post-stent placement (ideally >6 months).

    • Anticipated Difficult Airway:

      • Mallampati IV, limited neck mobility, and large neck circumference.

      • No VL or experienced fibreoptic operator available.

  • Resource Limitations:

    • Airway Management: Limited adjuncts and operator experience.

    • Post-op Support: No advanced respiratory or cardiac support; no HDU/ICU.

    • Retrieval Logistics: Transfer time >2 hrs; weather/availability may delay access to definitive care.

  • Risk-Benefit Considerations:

    • Elective case should be postponed and redirected to tertiary care.

    • If emergent, escalate risk and implement mitigation plans early, including retrieval coordination pre-op.

How would you modify plans if this were an emergency laparotomy?

  • Emergency takes precedence over transfer.

  • Airway Plan: Awake fibreoptic if time permits; otherwise RSI with ketamine + rocuronium and surgical backup.

  • Prepare scalpel-bougie FONA with neck marked pre-induction.

  • Activate retrieval and blood bank protocols early.

  • Accept higher intraoperative risk but prioritise oxygenation, haemostasis, and pain control.

The surgeon insists on proceeding. How do you mitigate airway risks?

  • Ramped positioning + HFNO during preoxygenation to prolong safe apnoea.

  • Anticipate difficult mask seal: use two-person technique and adjuncts (nasal/oral airways).

  • Ready i-gel or second-gen SGA if intubation fails.

  • Minimise sedation; avoid agents that compromise respiratory drive excessively pre-induction.

How does Scenarioville’s lack of ICU affect your planning?

  • Pre-alert retrieval teams before surgery begins.

  • Choose anaesthetic with rapid offset (e.g., TIVA) and titrate carefully.

  • Prepare contingency for overnight CPAP/NIV if tolerable; consider earlier extubation and awake management to avoid need for re-intubation.

  • Monitor ABGs for CO₂ retention.

What preoperative tests would you request?

  • FBC, EUC, LFTs.

  • ECG + baseline troponin.

  • ABG for hypercapnia baseline (esp. in OSA/obesity hypoventilation).

  • Platelet count + TEG/ROTEM if available, particularly if surgery can't be delayed.

How would you counsel the patient about risks?

  • Document conversation thoroughly.

  • Use visual aids or written explanation if language/literacy is a barrier.

  • Discuss: increased perioperative risk, higher chance of unplanned ICU transfer or complications due to local resource limits.

  • If possible, involve family/support person and obtain signed informed consent.

Describe your airway plan for this patient.

  • Anticipation and Planning:

    • Declare this as an anticipated difficult airway.

    • Team briefing with clear roles.

    • Pre-induction neck marking and FONA prep.

    • Avoid paralysis unless ready for surgical airway.

  • Plan A:

    • RSI using ketamine + rocuronium.

    • Two-person mask technique + ramped position.

    • If VL unavailable: Macintosh blade with Frova bougie.

  • Plan B:

    • Insert i-gel; confirm placement with EtCO₂ and chest rise.

  • Plan C:

    • FONA using scalpel-bougie technique.

    • Consider ultrasound pre-induction if landmarks uncertain.

You encounter Grade 4 view on laryngoscopy. Next steps?

  • No further attempts; move to Plan B (SGA).

  • Confirm i-gel placement; if ventilation fails, progress to Plan C.

  • Maintain oxygenation; avoid prolonged apnoea.

  • Ensure entire team is informed and prepared for surgical airway.

The i-gel fails. How do you proceed to FONA?

  • Scalpel-bougie technique:

    • Vertical skin incision over CTM.

    • Horizontal stab through membrane.

    • Bougie in, railroad 6.0mm ETT.

    • Confirm with EtCO₂ and chest rise.

  • Maintain cricoid pressure only if not distorting anatomy.

How would you modify FONA for his obesity?

  • Use ultrasound to mark anatomy pre-induction.

  • Use longer ETT (6.0 reinforced tube).

  • Anticipate more bleeding and soft tissue resistance.

  • Ensure assistant is trained to provide optimal retraction.

The surgeon asks you to ‘just try again’ with laryngoscopy. Your response?

  • "We’ve reached the safe limit for attempts. ANZCA guidelines support immediate progression to surgical airway."

  • Explain risks of further attempts: airway trauma, worsening view, delay.

  • Reiterate that oxygenation, not intubation, is the goal.

Post-FONA, the SpO2 remains 85%. Why?

  • Misplacement of tube or inadequate ventilation.

  • Check EtCO₂ and re-suction tube.

  • Consider bilateral tension pneumothoraces or pulmonary oedema.

  • Ultrasound to assess lung sliding; needle decompression if needed.

Outline your postoperative plan in Scenarioville.

Immediate Monitoring:

  • HDU-equivalent care: 1:1 nursing, EtCO₂, continuous SpO₂, hourly vitals.

  • ABG at 1 and 4 hours to monitor ventilation.

OSA Considerations:

  • Lateral and semi-upright positioning.

  • Resume CPAP if compliant and device available.

  • Avoid sedating analgesics. Use multimodal pain relief.

Cardiac Monitoring:

  • ECG q4–6h x 24h.

  • Troponin if symptomatic or ECG changes.

  • Resume antiplatelets within 24h if haemostasis secure.

Triggers for Retrieval:

  • SpO₂ <90% despite oxygen.

  • Chest pain with ECG changes.

  • Neurological decline or haemodynamic instability.

He develops chest pain post-op. How would you manage?

  • 12-lead ECG + troponin.

  • Aspirin 300mg PO, GTN infusion if hypertensive.

  • If STEMI: heparin + urgent retrieval.

  • Inform retrieval early even if awaiting confirmation.

The SpO₂ drops to 88% overnight. Your actions?

  • Elevate head of bed. Administer HFNO or CPAP if tolerated.

  • Rule out fluid overload, atelectasis, and respiratory fatigue.

  • Consider rescue re-intubation using known difficult airway plan.

How would you manage his clopidogrel post-op?

  • Resume within 24h if surgical field hemostatic.

  • If delay needed, consult cardiology.

  • Consider cangrelor infusion if very high thrombotic risk.

The retrieval team is 6 hours away. How do you stabilise?

  • HFNO or CPAP to support oxygenation.

  • Use IV GTN and morphine for chest pain.

  • Maintain MAP >65 mmHg with noradrenaline if hypotensive.

  • Document limitations and involve family in decisions.

What discharge criteria would you set?

  • No events for >24h.

  • Ambulatory on room air.

  • ECG and cardiac markers normal.

  • Surgical wound healing, able to manage CPAP at home.

Key Phrases:

  1. "This scenario meets ANZCA PS55 criteria for high-risk transfer."

  2. "Oxygenation, not intubation, is the primary goal in airway crises."

  3. "Every airway attempt must be deliberate, coordinated, and capped at two before progressing to FONA."

  4. "Early retrieval activation is critical in resource-limited environments."

  5. "Pre-induction marking and ultrasound localisation are essential in obese or distorted neck anatomy."

Key Learning Objectives:

  1. Assess surgical risk in the context of limited rural resources, incorporating comorbidities like OSA, obesity, and cardiac stents.

  2. Formulate a stepwise difficult airway plan using Plan A–C framework with escalation to FONA and preoperative preparation.

  3. Implement perioperative strategies for high-risk patients without HDU/ICU, including monitoring thresholds and early retrieval triggers.

  4. Perform and adapt scalpel-bougie FONA in obese patients, including anatomical landmarking with ultrasound.

  5. Recognise and manage postoperative complications (e.g., STEMI, desaturation) within the limits of a rural district hospital.

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