Procedures, Airway Management and Resuscitation
This domain is examined as a series of decision points: can you predict the difficult airway, drug it safely, rescue it when it fails, and run a compliant resuscitation? Doses, energies and confirmation methods are all fair game.
Airway assessment and rapid sequence intubation
Predict difficulty with LEMON (look, evaluate 3-3-2, Mallampati, obstruction, neck mobility). Preoxygenate for 3 minutes to end-tidal oxygen above 90%. Haemodynamically unstable patients tolerate ketamine 1-2 mg/kg better than propofol; etomidate 0.3 mg/kg is cardiovascularly neutral. Rocuronium 1.2 mg/kg gives intubating conditions in about 60 seconds; succinylcholine 1.5 mg/kg is faster but contraindicated in hyperkalaemia, burns beyond 24-48 hours, crush injury, denervation and malignant hyperthermia susceptibility. Confirm placement with continuous waveform capnography, not auscultation alone.
When it fails
Place a supraglottic device, then perform scalpel-bougie cricothyrotomy. DOPES explains a deteriorating intubated patient: displacement, obstruction, pneumothorax, equipment failure, stacked breaths. Post-intubation hypotension is usually sedation, hypovolaemia or auto-PEEP - treat the cause.
Vascular access and drains
Central lines by Seldinger technique under ultrasound; internal jugular for most ICU patients, femoral in arrest. Complications include arterial puncture, pneumothorax, haematoma and catheter-related bloodstream infection. Insert chest drains in the safe triangle - fifth intercostal space, mid-axillary line - and never use the trocar against the lung. Use ultrasound for paracentesis, thoracocentesis and pericardiocentesis. Intraosseous access when intravenous access fails in resuscitation.
Resuscitation quality
Compression rate 100-120/min, depth 5-6 cm, full recoil, interruptions under 10 seconds, chest compression fraction above 60-80%, and a team leader who closes the loop. Defibrillate VF and pulseless VT at 200 J biphasic. After return of spontaneous circulation: saturation 94-98%, PaCO2 35-45 mmHg, MAP at least 65 mmHg, and active avoidance of fever.
Worked example
An 80 kg patient with potassium 6.8 and GCS 8 needs intubation. Ketamine 1.5 mg/kg (120 mg) and rocuronium 1.2 mg/kg (96 mg) are appropriate; succinylcholine is not, because of the hyperkalaemia. Prepare for post-intubation hypotension: fluid, reduce sedation, and check the ventilator graphics for auto-PEEP.
Traps
Accepting auscultation instead of capnography. Skipping preoxygenation. Treating cricoid pressure as a failed-airway plan. Sedating a hypotensive patient with propofol and calling the arrest intubation-related.