Manage a child with a difficult airway in the emergency department — OSCE

Candidate brief

You have this station to assess an anticipated-difficult airway, prepare the team and equipment, and outline the recognise-oxygenate-escalate-rescue plan including how you would respond to failure. Identify this as an anticipated-difficult airway, assemble the right help and rescue equipment, and never let it become a cannot-oxygenate airway. [2] [1]

Key teaching and management objectives

Begin by recognising this as an anticipated-difficult airway: Goldenhar syndrome distorts the craniofacial anatomy and mandible, and the documented previous difficult intubation is the single strongest predictor of future difficulty. Treat it as a senior-led planned event — call an experienced anaesthetist and ENT surgeon to the bedside, bring the difficult-airway trolley, a videolaryngoscope and a correctly sized supraglottic airway open and ready — and consider an awake or carefully judged inhalational technique rather than a full rapid-sequence induction that abolishes the tone holding the airway open, because a syndromic child may obstruct completely once sedated. [2] [3]

Outline the recognise-oxygenate-escalate-rescue plan. Position her in the sniffing position, preoxygenate fully with high-flow oxygen, and keep oxygen on at every step because a child desaturates within a minute. Give one optimised best attempt with the right blade, external laryngeal manipulation, a skilled assistant and, where available and familiar, a videolaryngoscope, which improves the view in children who are difficult to intubate. At the first failure, call for the most senior help, avoid repeating more than a small number of best attempts, and insert a supraglottic airway to oxygenate. [4] [1]

Demonstrate that you can recognise deterioration: a worsening view, falling saturations despite oxygen, and bradycardia are stop signals, not nuisances, and repeated laryngoscopy traumatises and swells the cricoid — the narrowest point of the child's airway. If the supraglottic airway oxygenates, use the time it buys to wake an elective child or proceed with the resuscitation; if it fails to oxygenate, declare cannot-intubate-cannot-oxygenate and prepare for emergency front-of-neck access with the scalpel-bougie technique while running resuscitation in parallel. [1] [3]

Close with prevention and documentation. The best emergency front-of-neck access is the one prevented by anticipation, a single best attempt, early help and supraglottic rescue before the child reaches cannot-oxygenate. After the event, document the view, the devices that worked and failed, the drugs, and an explicit plan for the next anaesthetist, and arrange the appropriate monitored disposition — paediatric intensive care for the critically ill child — because the next team will rely on that record. [2] [1]