The febrile trauma patient with a difficult airway

Recognise the combined risks: full stomach (aspiration), cervical immobilisation (reduced laryngoscopic view), obesity and a short thyromental distance (difficult mask ventilation and intubation), and haemodynamic instability (poor tolerance of prolonged hypoxia or hypotension).

Plan A: awake or rapid-sequence video laryngoscopy.

• Preoxygenate aggressively: head-up 25–30°, tight seal, 3 minutes of tidal-volume breathing or 8 vital-capacity breaths; target end-tidal O₂ > 90%.
• Because of the full stomach and instability, I would use a modified rapid-sequence induction with pre-calculated doses (reduced induction agent because of shock) and cricoid pressure applied by the assistant, with the collar left in place but the front removed to allow mouth opening.
• First attempt: video laryngoscope with a bougie preloaded; limit to one optimal attempt (<60 s), maintaining oxygenation with apnoeic oxygenation via nasal cannula at 15 L/min.

Decision points:

• If view is poor, optimise (BURP, remove collar with manual in-line stabilisation, change blade) for a maximum of two attempts.
• If intubation fails but mask ventilation is adequate, insert a second-generation supraglottic airway and either ventilate or intubate through it.
• If 'cannot intubate, cannot oxygenate', proceed immediately to front-of-neck access (scalpel–bougie–tube).
• If the patient desaturates below 85% at any point, abandon the attempt, oxygenate by mask or supraglottic airway, and reassess.

Throughout, keep the surgeon informed and have blood products running before induction.

Fever and possible sepsis raise metabolic demand and oxygen consumption while reducing functional residual capacity, so the safe apnoea time is short. Fever also increases insensible losses and may indicate sepsis with vasodilation and myocardial depression.

Haemodynamic state: BP 92/54 with HR 128 suggests compensated or decompensated shock. Standard induction doses of propofol or thiopentone would cause profound hypotension by removing sympathetic tone.

Practical approach:

• Use a reduced dose of a haemodynamically stable agent - for example, ketamine 1–1.5 mg/kg IV (or etomidate 0.2–0.3 mg/kg) titrated to effect rather than a fixed bolus.
• Give a neuromuscular blocker appropriate for rapid sequence (suxamethonium 1–1.5 mg/kg or rocuronium 1.2 mg/kg) and pre-oxygenate before giving it.
• Start fluid resuscitation and vasopressor support (e.g., a dilute phenylephrine or noradrenaline infusion) before or simultaneously with induction, and have blood ready.
• Avoid agents that worsen hypotension or tachycardia; monitor capnography, invasive arterial pressure if time permits, and temperature.
• Consider that fever may also reflect a drug reaction or malignant hyperthermia only if volatile agents or suxamethonium have been given - so document the timeline.

Urgency never justifies abandoning core safety standards. I would insist on:

1. Continuous waveform capnography before, during, and after intubation - the single most reliable confirmation of tube placement and ventilation.
2. Pulse oximetry with the probe on a reliable site, plus ECG and non-invasive blood pressure cycling every 2–3 minutes until an arterial line is placed.
3. Pre-induction checklist verbalised aloud: suction working, oxygen source checked, airway trolley present, drugs labelled, blood available, assistant briefed on cricoid pressure and front-of-neck access.
4. Temperature monitoring given the fever, and active cooling if indicated.
5. Documentation of the airway plan, number of attempts, and any deviation - this is both a safety and a medico-legal requirement.
6. Team briefing naming roles: who holds the collar, who applies cricoid pressure, who manages the difficult airway trolley.

If any of these cannot be met, that is a reason to pause for the few seconds needed to correct it, not to proceed.