Trauma & Toxicology & Airway – Full Test

You are transporting Landon Bell, a patient by air from Thunder Bay, with closed head injury, hemo-pneumothorax and chest tube in place with no ongoing blood loss or bubbling, subclavian venous catheter.  They are intubated with 8 ETT.

List six emergencies you need to be prepared for (6 marks)

Darnell Byers is a 28-year-old traumatically injured patient admitted to the intensive care unit.  He was initially intubated at the time of admission then underwent resuscitative laparotomy with splenectomy for ruptured spleen and hemoperitoneum.  He is now stable and meets criteria for extubation. When propofol is discontinued he becomes agitated, bites into the endotracheal tube occluding the lumen.  The ventilator alarms low volume therefore bag-ventilation is trialed but unsuccessful. Vitals:  Blood pressure 186/88mm Hg, heart rate 149bpm, SpO₂ 73%.

Outline your management (2 marks)

Immediately after instituting your management, endotracheal suction reveals the presence of copious frothy pulmonary edema.  Ventilator settings Assist-Control Volume Control:  Frequency 28 VC 350mL PEEP 15 FiO₂ 1.0.  P/F is 72.  Chest X-ray demonstrates bilateral patchy infiltrates.

Provide the most likely diagnosis (1 mark)

Describe the underlying physiology for this diagnosis (1 mark)

Describe one specific intervention this patient requires prior to hospital discharge (1 mark)

You are consulted by telephone from a doctor in a peripheral hospital requesting assistance and transfer for Andrew Sharples, a patient with severe burns. Burn locations include head, face, chest and arms with estimated 15% total body surface area involvement.  The patient has SpO₂ 92% on room air, is expectorating soot, is mentating and endorsing pain.  There are facial burns.

Prior to transfer, outline one immediate management priority (1 mark)

Provide five criteria for severe burns (5 marks)

You are on New Years’ day in the ICU and admit Kiefer Rollins,  a 35-year-old male to your intensive care unit.  He was found belted in his vehicle which had skidded off the road into a water-filled ditch.  When he was found by EMS water had entered the vehicle and he was submerged up to his mid-chest.  He was unconscious but breathing when at 4 breaths per minute when he was extricated.  His core temperature was measured at 29^oC.

Describe ONE cardiac, respiratory, neurologic and renal physiologic change as a result of hypothermia (4 marks)

Outline two mechanisms for treatment of severe hypothermia in this context (2 marks)

On arrival to your ICU the patient suffers a cardiac arrest.  Articulate two thresholds related to the injury and aside from end-tidal CO2 or frailty that would justify termination of resuscitation (2 mark)

Ben Tyson, a 27-year old male was driving a borrowed car at high speed, resulting in a collision with a tree.  This is the initial radiograph.

Provide the most likely diagnosis: (1 mark)

Describe four radiologic findings on a supine portable CXR that may be seen in this condition (4 marks)

Andrej Guzman is a 20-year-old male admitted to the trauma resuscitation bay with complications from a diving trauma.  Compare and contrast spinal shock and neurogenic shock (4 marks)

Willy Steel is a 27-year-old male presenting to the ER with hypotension and positive FAST after car crash. Tranexamic acid is considered to help achieve hemostasis.

a) State the pharmacologic action of tranexamic acid. (1 mark)

b) State the loading dose of TXA. (1 mark)

Bertrand Khatami is a 38-year-old man, weight 80 kg, rescued from a house fire with 40% TBSA partial and full-thickness burns. He has soot in his oropharynx, singed nasal hair, and a hoarse voice. SpO2 is 99% on room air. Lactate is 6.8 mmol/L. Carboxyhemoglobin is 28%. He is intubated for airway protection.

a) Calculate the Parkland formula fluid requirement for the first 24 hours. (2 marks)

b) State why SpO2 of 99% does not reflect adequate oxygen delivery in this patient. (1 mark)

c) State the treatment for the carboxyhemoglobin level described. (1 mark)

d) State the additional toxin that must be considered given the elevated lactate and name its antidote. (2 marks)

Kwabena Lacroix is a 29-year-old man who contacted a high-voltage power line (estimated 11,000 V). On examination he has small entry and exit wounds on his hand and foot, each less than 2 cm, with surrounding erythema. He is alert, GCS 15, and vital signs are normal. He complains of severe pain in his forearm, which is tense and exquisitely tender to palpation, with reduced sensation in the fingers. Urine is dark red-brown. ECG shows occasional ventricular ectopics.

a) State why the surface appearance of the wounds underestimates the severity of this injury. (1 mark)

b) State the diagnosis suggested by the forearm findings and identify the confirmatory bedside measurement. (2 marks)

c) State the cause of the dark urine and the renal complication it risks. (2 marks)

d) State the minimum duration of cardiac monitoring required for this patient given the ECG finding. (1 mark)

Freda Abrahamson is a 44-year-old female admitted to the intensive care unit following intentional ingestion of several anti-psychotics and anti-epileptic drugs.

Explain the difference between zero and first order elimination with respect to pharmacokinetics (2 marks)

List one drug with zero order kinetics (1 mark)

Phenytoin elimination changes from first to zero order with increasing therapeutic drug levels.  Describe the clinical relevance of this phenomenon (1 mark)

Calculate the number of half-lives required to eliminate 90% of a medication with first order or linear kinetics (2 marks)

Adrianna Kasumi is a 67-year-old wheelchair-bound woman with adrenal leukodystrophy who is rescued from a house fire. In the ED she is alert with GCS 15 and soot in her nares. Vital signs and oropharyngeal examination are initially unremarkable. She is placed on supplemental oxygen pending further assessment for inhalation injury and carbon monoxide poisoning.

a) List FOUR indications for intubation in a patient with smoke inhalation injury. (4 marks)

b) List THREE clinical manifestations of carbon monoxide poisoning. (3 marks)

c) List FOUR indications for hyperbaric oxygen therapy in carbon monoxide poisoning. (4 marks)

Harvey Masters is a 29-year-old man who presents to the ICU following intentional overdose with an unknown substance. He has severe metabolic acidosis and acute kidney injury. The toxicology team is asked whether emergent hemodialysis should be considered for enhanced drug elimination.

a) List SIX drugs or toxins for which hemodialysis should be considered to enhance elimination. (6 marks)

Everett Kane is a 37-year-old male admitted with anion gap metabolic acidosis, decreased level of consciousness requiring endotracheal intubation and multiorgan failure from suspected intoxication.  Dialysis in indicated for some intoxications.

List five overdoses that, when severe, have dialysis as the recommended therapy (5 marks)

Yolanda Leonard is a 26-year-old woman with a history of injection drug abuse and suspected endocarditis undergoes routine transesophageal echocardiography.  She receives 5 mg of midazolam and 100μg of fentanyl, as well as benzocaine topical spray, for the procedure.  During the procedure she is noted to have a falling oxygen saturation that remains in the mid 80% range despite increasing supplemental oxygen.  On physical examination, her blood pressure is 95/70 mm Hg, heart rate 125/min, and respirations 30/min.  Her skin and mucous membranes have a cyanotic appearance.  Her lungs are clear on auscultation and her cardiac examination reveals a grade III/VI systolic murmur that varies with respiration and is unchanged from earlier in the day.  An arterial blood sample obtained with pulse oximetry at 86% is brown-blue in colour.  Blood gas measurements show: PO₂ 200 mmHg, PCO₂ 30 mmHg, and pH 7.40.

Provide the most likely etiology for cyanosis (1 mark)

Describe one investigation to confirm the diagnosis (1 mark)

Describe one treatment you would recommend (1 mark)

There has been a terrorist attack in the Metropolitan subway with multiple people exposed.  The toxin is the nerve gas sarin.

Describe the expected toxidrome (4 marks)

List four principles of management, including at least two pharmacologic strategies (4 marks)

Explain how sympathomimetic and muscarinic receptor blocker toxidromes are distinguished clinically (2 marks

Lisa Bruce is a 50-year-old female admitted with decreased level of consciousness requiring endotracheal intubation and shock of unclear etiology.  You are asked to review the following blood gas by your junior resident.

PO₂ 80, pH 7.46, PCO₂, HCO₃ 16. Anion gap 22

Describe the blood gas abnormality (2 marks)

List two conditions that produce this abnormality (2 marks)

Ahmed Khalil is a 19-year-old male admitted to the emergency department from home with decreased level of consciousness. He was at work earlier in the day (auto repair shop), and came home early complaining of feeling unwell, he was vomiting and complaining of flank pain.  An hour later he was found by his mother unresponsive.  On exam he is moaning to pain, but otherwise unresponsive.  With stimulation he withdraws his arms and legs. Vitals: HR 124, regular RR 36 SpO2 100% on oxygen by mask BP  88/62. Labs reveal the following:

1. Hematology Hb 154 g/L WBC 16.2 Plt: 368 INR:  1
2. Chemistry Na 146 K 4 Cl 108 HCO3 8 Lactate 3.4 Urea 13.1 Cr 168 Glc 8.9 Osmolality: 346
3. Venous Blood gases: pO₂: 248 on oxygen by mask pCO₂: 10 HCO₃:  4 pH:  98
4. Urinalysis: Crystals seen

Provide the most likely diagnosis with justification (4 marks)

List two therapies specific for this diagnosis that you would recommend (2 marks)

You are assessing Malik Ghasim, a 23-year-old male university student suspected of polypharmacy ingestion.  Complete the following antidote/therapy table (16 marks)

You are caring for Marin Thompson, a 48 year old woman post renal transplant for diabetic nephropathy. She has a long history of chronic pain due to diabetic neuropathy.  She recovered uneventfully from her transplant and was discharged day 5 with normal renal function.  Discharge medications were: tacrolimus 5 mg q 12h, prednisone 5 mg daily, escitalopram 20 mg daily, lansoprazole 30 mg daily, furosemide 40 mg q 12h, fentanyl patch 50 mcg/hour, duloxetine 30 mg daily, ondansetron 8 mg po PRN, metoclopramide 10 mg q 6h PRN, insulin lantus 24 units daily with a sliding scale for insulin regular

She is admitted 1 month after transplant with signs of urosepsis.  Urine culture shows enterococcus faecium (vancomycin resistant).  In addition, PCR shows high titres of CMV.  She is started on ganciclovir and linezolid.   Two days later the outreach team is called because of tachycardia (HR 146) , fever (40.9), diaphoresis and shivering.  Blood pressure is 168/92 (usual BP ~ 140/80). She had three very loose stools during the night.  Pupils are slightly dilated ~5 and reactive.  She is agitated requiring 4-point restraints and tremulous.  Chest is clear to auscultation, and chest radiograph shows mild bibasilar atelectasis.  Abdomen is mildly distended with hyperactive bowel sounds.  There is no peripheral edema.

Provide the most likely diagnosis (1 mark)

Outline your management plan (2 marks)

Bartholomew Burress is a 48-year-old man is admitted following an intentional ingestion of an unknown quantity of sustained-release verapamil approximately 6 hours prior. He is progressively deteriorating. Initial vitals are: HR 42 bpm, BP 78/42 mmHg (MAP 54), urine output 10 mL/hr over 3 hours. He is on norepinephrine 0.25 mcg/kg/min and epinephrine 0.15 mcg/kg/min. He is intubated on volume control: Vt 450 mL, RR 22, PEEP 8, FiO₂ 0.5. Plateau pressure 22 cmH₂O.

Investigations reveal: ABG: pH 7.21, PaCO₂ 38 mmHg, PaO₂ 90 mmHg. Lactate 6.2mmol/L. Glucose 18mmol/L, K⁺ 5.6 mmol/L, creatinine 160 µmol/L.

He has received 3L crystalloid and 2 grams calcium chloride with minimal response. LVOT VTI is estimated at 10 and cardiac index is calculated at 2.4.

Describe the key pathophysiology mechanism underlying shock (2 marks)

List two specific therapies indicated now to improve hemodynamics aside from calcium (2 marks)

Identify the MOST APPROPRIATE mechanical circulatory support option in the event of continued deterioration (1 mark)

Transvenous pacing is attempted, however, despite maximum pacemaker output, the heart rate remains at 42bpm. Assuming the pacemaker is functional, assembled correctly and inserted into the correct location, list TWO explanations for failure to capture in this situation (2 marks)

You are called to assess Hector Chavez a 47-year-old gentleman with quadriplegia from posterior circulation stroke for hypotension. He was admitted 24 days ago. Tracheostomy was performed 10 days ago via Ciaglia technique. Over the past 3 days he has been doing tracheal mask trials for 4, 6 and then 8 hours, tolerating speaking valve without difficulty. On examination Hector appears in extremis with accessory muscle use, minimal breath sounds and the chest appears barrel shaped. Blood pressure is 60/30mm Hg HR 140bpm SpO₂ 89% FiO₂ 1.0 RR 40. Tracheostomy stoma is clean and dry, speaking valve was applied five minutes ago.

POCUS demonstrates no lung sliding bilaterally.

Outline the MOST IMPORTANT next step in management (1 mark)

One month later you are called to the Hector’s bedside for cough. He has improved clinically with advancement of diet to thickened liquids based on absence of aspiration during functional endoscopic evaluation of swallowing. Cough is noticed during and after eating. History from bedside nursing highlights belching and abdominal distention soon after initiation of nocturnal invasive ventilation. Chest x-ray reveals air-filled esophagus.

Provide the MOST LIKELY diagnosis and THREE risk factors (4 marks)

Yulia Amalaberg is a 43-year-old woman who has been intubated for ten days following severe anaphylaxis is being considered for extubation. The team performs a cuff leak test to assess for post-extubation stridor risk.

a) List the FOUR steps for performing a qualitative cuff leak test. (4 marks)

Brenden Etela is a 24-year-old male who underwent craniotomy for closed head injury followed by surgical tracheostomy on day 6 for anticipated prolonged mechanical ventilation. Eighteen hours post-procedure the low-volume alarm sounds. The patient is cyanotic, the tracheostomy tube appears pulled back approximately 2 cm, bag ventilation is not possible due to high resistance, and a suction catheter passes only a few centimetres before encountering resistance.

a) State the most likely explanation for this clinical picture. (1 mark)

b) State the immediate management. (1 mark)

Elvis Adian is a 68-year-old man with hypoxemic respiratory failure who requires urgent endotracheal intubation in the ICU. The team is selecting pre-intubation medications and reviewing the physiologic goals of pharmacologic preparation for intubation.

a) List FOUR general physiologic or pharmacologic goals of using medications for intubation. (4 marks)

Pete Henry is a 55-year-old man with a known history of malignant hyperthermia who requires urgent intubation in the ICU for hypoxemic respiratory failure. The team is selecting a neuromuscular blocking agent for rapid sequence intubation.

a) List FIVE contraindications to succinylcholine. (5 marks)

Mark Boucher is a 51-year-old man admitted to the ICU with locked-in syndrome following an embolic posterior circulation stroke 10 days ago. He has consented to tracheostomy. He can trigger the ventilator on a flow trigger of 0.5 L/min but his vital capacity is 50 mL. Sputum production is mild with suctioning required every 4 hours and a very weak cough induced only by passage of an in-line suction catheter. Both cuffed and uncuffed tubes are available as fenestrated, inner-cannula, or single-cannula designs.

a) State EXACTLY TWO reasons why a cuffed tracheostomy tube is required for this patient. (2 marks)

b) State EXACTLY ONE benefit of each of the following tracheostomy tube designs: fenestrated, inner-cannula, and single-cannula. (3 marks)

c) After two weeks of weaning, Mark tolerates a speaking valve placed over the tracheostomy but develops tachypnea and distress when a cap is applied. Briefly explain the cause of distress and state EXACTLY ONE modification to tracheostomy therapy to facilitate capping. (1 mark)

Seun Adebayo is a 64-year-old man with a BMI of 42 kg/m², a full beard, no teeth, obstructive sleep apnea on home CPAP, a history of oral cavity cancer treated with radiation to the neck 3 years ago (no surgery), limited neck extension from cervical spondylosis, a Mallampati class III on assessment, and an inter-incisor gap of 2.5 cm. He requires intubation for worsening hypoxic respiratory failure.

a) List TWO features from this history that independently predict difficult bag-mask ventilation. (2 marks)

b) List TWO features that independently predict difficult direct or video laryngoscopy. (2 marks)

c) State two airway adjuncts that should be immediately available before the first intubation attempt in this patient, given the predicted difficulty. (2 marks)

Pia Lindqvist is a 52-year-old woman brought to the ICU for elective intubation prior to a procedure. Airway assessment is unremarkable. Rocuronium 1.2 mg/kg IV and propofol are given. Direct laryngoscopy yields a Cormack-Lehane grade 4 view. A second attempt with video laryngoscopy and bougie fails; the ETT cannot be passed. Mask ventilation is attempted between attempts with a two-person technique — chest rise is absent, SpO2 is falling from 96% to 84%.

a) State the airway emergency that has been declared and identify the maximum number of intubation attempts recommended before declaring this emergency. (2 marks)

b) Identify the preferred rescue strategy if SpO2 continues to fall below 80%. (1 mark)

c) State the specific clinical indication for sugammadex in this scenario, the dose required, and identify one reason it may not fully resolve the emergency within the required timeframe. (3 marks)

Yusuf Okonkwo-Bello is a 58-year-old man with a known difficult airway (previous Cormack-Lehane grade 3, noted in his chart) presenting with active oropharyngeal bleeding from a posterior pharyngeal mass eroding a tonsillar vessel. He is SpO2 89% on 15L non-rebreather, RR 34, GCS 14, cooperative but anxious. Blood is pooling visibly in the oropharynx with each swallow.

a) State why awake fibreoptic intubation is relatively contraindicated in this patient and identify one additional technique rendered unreliable by the same mechanism. (2 marks)

b) State the preferred pre-oxygenation strategy for this patient before induction. (1 mark)

c) State the recommended primary intubation approach for this patient given the constraints and name the adjunct most likely to improve first-pass success (2 marks)

Birgitta Volkov is a 71-year-old woman with morbid obesity (BMI 44), a short neck, and a non-palpable cricothyroid membrane who has been mechanically ventilated for 16 days. The team proceeds with bedside percutaneous tracheostomy. During the procedure the patient coughs violently, the bronchoscopist loses the airway view, and the tracheostomy tube is placed blindly and secured. SpO2 drops to 81%. Thirty minutes later SpO2 has recovered to 94% on FiO2 0.60 (previously 0.35), peak airway pressure is 38 cmH2O (previously 26), and bilateral breath sounds are equal with the tube in midline position. The RT is concerned about a false passage given the coughing, loss of view, and worsening hypoxaemia.

a) State two anatomical features of this patient representing relative contraindications to percutaneous over open tracheostomy. (2 marks)

b) State the two best methods to confirm endotracheal placement of the tracheostomy tube and name one additional confirmatory modality. (3 marks)

c) State the most likely cause of the post-procedure hypoxaemia and identify two findings that specifically argue against false passage. (3 marks)

Three patients on the chronic ventilator ward each have different tracheostomy tube situations.
Patient A: a 58-year-old man on 16 hours per day of pressure support ventilation with copious thick secretions. His ventilator shows progressively rising peak pressures and reduced tidal volume alarms over 6 hours. Examination confirms the inner cannula is in situ and heavily coated with dried secretions.
Patient B: a 71-year-old woman who is ventilator-independent for 20 hours per day with adequate cough. Her team placed a fenestrated tube to facilitate phonation and decannulation planning. She develops a persistent granuloma at the fenestration site and secretions are difficult to clear as the suction catheter repeatedly diverts through the fenestration.
Patient C: a 44-year-old man who has been fully ventilator-independent for six weeks with strong cough, requiring suctioning only once daily, and is being prepared for decannulation with a size 8 cuffed single-lumen tube in situ.

a) State the cause of Patient A’s ventilator alarms and identify the specific advantage of inner cannula tubes that is relevant to his management. (2 marks)

b) State two complications of fenestrated tracheostomy tubes illustrated by Patient B’s course. (2 marks)

c) State the most appropriate tube change for Patient C at this stage and name one clinical advantage of this change. (2 marks)

Grigor Brandt is a 69-year-old man with a size 6 cuffed tracheostomy following 28 days of mechanical ventilation for ARDS. He has been ventilator-independent for 72 hours. Cuff deflation is attempted and within 10 minutes he becomes tachypnoeic (RR 34), SpO2 drops to 88%, and copious secretions appear at the tracheostomy site. His voice is absent and he is unable to phonate with the cuff deflated.

a) List the four axes that must be systematically assessed when a patient does not tolerate cuff deflation. (2 marks)

b) State the most likely primary cause of cuff deflation failure in this patient and identify the management directed at this specific cause. (2 marks)

c) State what the absent phonation with cuff deflated suggests and name the investigation indicated to evaluate this finding. (1 mark)

d) State what a hemodynamic deterioration during cuff deflation would indicate and name the next step if this is the primary failure mechanism. (1 mark)

Thad Frona is a 75-year-old patient is admitted to the general surgery floor after right hemicolectomy for colorectal cancer ten days prior.  Hospitalization was complicated by paralytic ileus, venous thromboembolism in the right leg and immobility.  You are called to assess for decreased level of consciousness and hypotension.  On arrival the patient appears toxic with elevated work of breathing, diaphoresis and confusion.  They cannot provide a history and are not cooperative with physical examination.

BP 85/40 HR 122 (sinus) SpO₂ 90% 5L O₂ NP RR 30 T 38.5.

Investigations reveal abscess in the right paracolic gutter measuring 10cm x 8cm with evidence of anastomotic leak, WBC 17 (neutrophil 14) Hb 100gL Plt 500.

List five non-reassuring features findings on airway assessment that predict difficulty with bag-mask ventilation or laryngoscopy (5 marks)

Describe non-airway related optimization you would consider prior to intubation (3 marks)

The patient is ideally positioned, receives five minutes of appropriate pre-oxygenation with FiO₂ 1.0 by non-rebreather mask and maintains hemodynamic stability.  Two attempts at tracheal intubation are unsuccessful using an appropriately sized rigid laryngoscope blade.  Ventilation is adequate based on visible chest rise and EtCO₂. Outline your management (4 marks)

Despite your management, endotracheal intubation is unsuccessful.  Bag-mask ventilation with an appropriately sized oropharyngeal airway and two-handed technique is inadequate.  Provide one adjunctive technique or equipment you would implement (1 mark)

Your strategy is unsuccessful.  The patient has decompensated.  SpO₂ 70% BVM FiO₂ 1.0 HR 150 (sinus) BP 90/50.  EtCO₂ is 60mm Hg with minimal chest rise.  Tactile feedback suggests an inability to ventilate.  Outline your management (1 mark)

Rafaela Schulz is a 28-year-old woman who developed acute-onset ascending paralysis over 48 hours, now completely paretic including loss of all cranial nerve motor function. She has a tracheostomy and is fully ventilator-dependent with no spontaneous respiratory efforts. Pupils are 3 mm bilaterally, minimally reactive, requiring pupillometry to confirm reactivity. The neurology team raises the question of neurological death determination.
Over subsequent weeks she shows partial neurological recovery with preserved vertical eye movements and voluntary eyelid closure but no limb or bulbar motor recovery. She is on assist-control ventilation and the ventilator displays 14 total breaths per minute against a set backup rate of 8. The esophageal pressure tracing is shown below. Several weeks later she has further recovery — she is awake, triggering comfortably, and breathing adequately on pressure support. She cannot tolerate a tracheostomy mask trial. The team partially deflates the cuff while maintaining positive pressure ventilation to allow her to phonate.

a) State the primary reason a positive apnea test in this patient cannot be used to diagnose neurological death (1 mark)

b) State two low-technology communication strategies applicable to this patient given her available motor repertoire of vertical eye movements and voluntary eyelid closure. (2 marks)

c) State the ventilator phenomenon demonstrated by the esophageal pressure tracing described and shown, and identify the single Pes finding that confirms this diagnosis. (2 marks)

d) State what P0.1 measures and identify its expected value in this patient (2 marks)

e) State two ventilator parameter adjustments that should be made to address the autotriggering, targeting its most common cause in this clinical context. (2 marks)

f) State two ventilator alarms expected to activate during partial cuff deflation on positive pressure ventilation and name the primary ventilator adjustment required to compensate for the intentional leak. (2 marks)

Jeremy Constance is a 44-year-old male with decreased level of consciousness secondary to intracranial hypertension from subarachnoid hemorrhage.  Airway protection with an endotracheal tube is required.  List three advantages and three disadvantages to rapid sequence induction (6 marks)

William McKenzie is a 59-year-old male admitted to the critical care unit with impending airway collapse from a retropharyngeal tumour.  Awake fiberoptic intubation is planned.

List the two pharmacologic CLASSES of local anesthetic (2 marks)

Provide ONE EXAMPLE from EACH CLASS (2 marks)

Provide the mg per mL concentration in lidocaine 1% (1 mark) 

The patient is treated with lidocaine infusion for post-operative pain management and begins exhibiting tonic-clonic seizure activity.  He is also hypotensive.   Describe your management SPECIFIC to this situation (assume ABC IV O2 Monitor addressed) (4 marks)

You are intubation Julien Sasha, a 21-year-old male using sedation and rocuronium.  The patient is 120 kg.  Identify the following

Ethan Gudelis is a 22-year-old male patient assessed in the emergency department following polypharmacy intoxication.  They ingested alcohol, hydromorphone 20mg, dimenhydrinate 400mg and acetaminophen 4g.  A decision is made to intubate for airway protection using rapid sequence induction with succinylcholine.

Identify the class of medication to which succinylcholine belongs (1 mark)

Describe the mechanism of action of succinylcholine (1 mark)

List three conditions predisposing a patient to hyperkalemia following succinylcholine use (3 marks)

Describe the pathophysiology of hyperkalemia from succinylcholine (2 marks)

Arthur Marks is a 74-year old male in the Emergency Department for whom General Surgery requests your consultation.  Medical history is notable for severe COPD on home oxygen. He presented with nausea and vomiting. Abdominal x-ray shows small bowel obstruction.  During General surgery assessment, he became progressively more tachypneic with marked increased work of breathing. On assessment you determine that clinically he has acute respiratory failure and needs support.  SpO₂ 87% on FiO₂ 0.7 by facemask, RR 36, HR 110bpm BP 147/90. GCS 14. BMI 47.  There is marked intercostal indrawing and scalene use with abdominal paradox.  Lactate is 4.0mmol/L.

Describe the MOST appropriate assistive respiratory technology or oxygen delivery system (1 mark)

During airway assessment you note removable dentures.  Explain the anticipated impact of this information on bag-mask ventilation and laryngoscopy difficulty (2 marks)

Identify TWO SPECIFIC features in Mr. Marks situation that increase the risks during endotracheal intubation (2 marks)

Quill Sattin is a 78-year-old male on the surgery ward two days after total colectomy for cancer. Medical history is significant for COPD with FEV1/FVC ratio of 0.6.  He has developed respiratory distress with a respiratory rate of 35, and SaO₂ of 93% on FiO₂ of 1.0 by high flow mask.  He is rousable but not obeying.  His BP is 160/86.  You determine he needs to be urgently intubated.

His OR record describes a grade three view under video laryngoscopy.  Describe the view (1 mark)

Describe four considerations to intubation UNIQUE to Mr. Sattin (4 marks)

Following endotracheal tube placement and initiation of positive pressure ventilation, Mr. Sattin develops hypotension with BP 65/30. Ventilator parameters are: PCV PC 15cm H2O PEEP 15cm H2O Freq 22 FiO2 1.0.

List FOUR reasons for this hypotension (4 marks)

You are intubating Mark Watson, a patient who is potentially a difficult airway. List EXACTLY FIVE patient factors associated with difficult bag-valve-mask ventilation. (5 marks)