# 2024.2 Day 2 VIVA 20

You are called by the duty ED Medical Officer for assistance. The ED Medical Officer and Junior Doctor have attempted to remove a nasal foreign body under IV ketamine sedation from a 5-year-old girl who weighs 20kg.

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The ED MO has been unsuccessful in removing it.<br>

The child remains sedated, with stridor and SaO2 88% on Hudson mask on 10L/minute.

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<summary>What are your immediate considerations and approach towards assisting?</summary>

**Immediate danger assessment:**

* Risk of complete airway obstruction from dislodged FB
* Laryngeal oedema or bronchospasm secondary to manipulation or FB irritation

**Positioning and oxygenation:**

* Keep child upright or in comfortable position
* Apply high-flow nasal cannula oxygen at 2 L/kg/min
* Escalate to CPAP/BiPAP if available and tolerated

**Avoid interventions that may worsen situation:**

* Avoid suction or positive pressure unless child becomes apnoeic

**Team mobilisation:**

* Call for help: second anaesthetist, surgical airway team
* ENT review if available; prepare difficult airway cart

**Prepare for deterioration:**

* Set up for emergency cricothyroidotomy or tracheostomy
* Ensure retrieval team activation (2-hour delay anticipated)

**Scenarioville constraints:**

* Limited ENT and no on-site bronchoscopy

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<summary>How would you differentiate laryngeal from nasal obstruction?</summary>

* *Nasal obstruction:* Inspiratory and expiratory snoring, possibly unilateral, improves with mouth breathing.
* *Laryngeal obstruction:* Inspiratory stridor, voice hoarseness, retractions, drooling, and inability to phonate.
* *Dual pathology:* Evaluate airflow through each nostril; assess voice, work of breathing, and auscultate for upper airway sounds.

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<summary>What if the child becomes apnoeic?</summary>

* *Initial actions:* Immediate jaw thrust, insert appropriately sized Guedel airway.
* *Avoid bag-mask ventilation* unless desaturation is severe due to risk of dislodging FB into larynx.
* *Call for immediate assistance:* Surgical airway must be prepared.
* *Use capnography and precordial stethoscope* to detect ventilation.

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<summary>Would you attempt to visualise the airway now?</summary>

* *Not unless critical:* Risk of dislodging FB into lower airway or worsening obstruction.
* If child is apnoeic or deteriorating:
  * *Proceed with direct laryngoscopy* only if retrieval, ENT, and difficult airway support are available.
  * *Prepare rigid bronchoscope and backup surgical airway.*

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<summary>How does ketamine sedation affect your approach?</summary>

* *Benefits:* Preserves airway reflexes, maintains spontaneous ventilation, provides sedation.
* *Cautions:* May mask signs of worsening obstruction, respiratory depression still possible.
* *Prepare:* Preoxygenate thoroughly, ensure skilled airway hands available.

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<summary>What monitoring is essential?</summary>

* *Continuous SpO2, ECG, capnography (preferably waveform)*
* *Precordial stethoscope* to assess for equal breath sounds.
* Blood pressure cycling every 2–3 minutes

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<summary>Describe your induction plan for securing the airway</summary>

**Setup:**

* Two senior clinicians: airway and drugs
* ENT and surgical airway team alerted
* Rigid bronchoscope and tracheostomy tray ready

**Pharmacological approach:**

* *Ketamine 1 mg/kg IV:* Maintains airway tone and haemodynamics
* *Rocuronium 1.2 mg/kg:* Fast onset, avoids sux (risk of myopathy/undetected NM disease)
* *Glycopyrrolate 5 mcg/kg:* Reduces secretions, improves view

**Induction plan:**

* Modified RSI with gentle mask ventilation if saturating poorly
* Avoid cricoid pressure unless aspiration is imminent
* *Videolaryngoscopy first-line* with straight blade as backup

**ETT planning:**

* Use cuffed tube (start at 4.5 mm ID), +/- 0.5 mm either side
* Have suction and rigid bronchoscopy tray at bedside

**Adaptations for Scenarioville:**

* Ensure all size tubes and bougies available
* Pre-load ETT on bronchoscope if equipment allows

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<summary>Why not use propofol (or what is the issue with propofol)?</summary>

* *Rapid loss of airway tone* → airway collapse and total obstruction
* *Hypotension risk* in young or volume-depleted patients
* Ketamine preferred for safety margin in airway control

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<summary>How would you modify if you suspect laryngeal FB?</summary>

* *Avoid paralysis:* maintain spontaneous ventilation
* Inhalational induction with sevoflurane
* ENT must be ready with rigid scope to extract FB immediately
* Avoid positive pressure ventilation pre-intubation

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<summary>What’s your tube size strategy?</summary>

* Estimate by age or formula: (Age/4 + 3.5) = \~4.5 cuffed for 3–5 y.o.
* Cuffed tube allows better control of ventilation and bronchoscopy
* Have size range 4.0–5.0 ready; uncuffed only if no alternative

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<summary>Would you use cricoid pressure?</summary>

* *Controversial in FB cases*
* Only if high aspiration risk
* May worsen laryngoscopy view or displace FB; release if obscures view

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<summary>How would you confirm tube placement?</summary>

* *Visual confirmation of passage through cords*
* Capnography with square waveform
* Auscultation (equal breath sounds, especially important if FB migration)
* Consider fibreoptic check if available

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<summary>The child is now intubated. Outline your next steps</summary>

**Immediate actions:**

* Secure ETT firmly (tape + ties)
* Confirm placement (CXR, ETCO₂, auscultation)
* Insert arterial line for ABGs, especially if prolonged transfer expected

**Ventilation strategy:**

* Pressure-controlled ventilation
* Tidal volume 6–8 mL/kg
* Maintain mild hypercapnia if needed to prevent barotrauma

**Sedation:**

* Ketamine infusion 5–20 mcg/kg/min
* Add dexmedetomidine if available for smooth sedation and airway reflex suppression

**Retrieval planning:**

* Notify retrieval team early; document all events and timelines
* Prepare transport ventilator, infusion pumps
* Ensure access to resus drugs, suction, and spare ETTs

**Scenarioville limitations:**

* Limited paeds support overnight → pre-emptive planning essential
* Discuss patient with tertiary ENT centre to coordinate care

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<summary>What ventilation strategy would you use?</summary>

* Pressure control to minimise barotrauma
* Vt 6–8 mL/kg, RR titrated to normocapnia
* Adjust PEEP to maintain oxygenation, mindful of FB location

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<summary>How would you manage rising peak pressures?</summary>

* Suction tube to rule out obstruction
* Check for pneumothorax (clinical + transillumination or ultrasound)
* Bronchospasm: administer bronchodilators or steroids
* Reassess tube position and patency

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<summary>What antibiotics would you start?</summary>

* *IV Co-amoxiclav 30 mg/kg TDS* to cover aspiration organisms
* Add metronidazole if suspected anaerobic contamination or FB perforation

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<summary><strong>When would you consider extubation?</strong></summary>

* In tertiary hospital *after FB confirmed removed and airway oedema settled*
* Leak test before extubation
* Ensure ENT team and theatre available for reintubation if failed

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<summary>What safety-netting would you provide the retrieval team?</summary>

* Written handover: meds given, airway grade, any difficulties
* Precise sedation regime and backup plans
* Discuss anticipated problems (airway reobstruction, bronchospasm, desaturation)
* Pack extra airway equipment

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#### **Key Concepts Covered**

1. Recognition of dual airway obstruction risk (nasal and laryngeal)
2. Scenarioville limitations and proactive team mobilisation
3. Safe induction technique in children with airway foreign bodies
4. Paediatric pharmacological choices and sedation safety
5. Preparation for retrieval with comprehensive planning and documentation
