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Airway and respiratory · Core10 / 12

Rheumatoid neck for emergency surgery: failed intubation at RSI73-year-old woman, 58 kg, for emergency laparoscopic appendicectomy; vomiting

Unanticipated failed intubation at RSI: the full DAS plan A to D

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Know this first

  • Atlanto-axial subluxation in long-standing RA can be silent or cause occipital pain and myelopathy.
  • Hoarseness or stridor suggests cricoarytenoid arthritis (30–50% of severe RA).
  • DAS: 3 + 1 intubation attempts, up to 3 SAD attempts, then a final facemask attempt.
  • With a working SAD, the default is to wake the patient.
  • Prednisone 7.5 mg or more for over 3 weeks: risk of adrenal suppression.

The patient

73-year-old woman, 58 kg, for emergency laparoscopic appendicectomy; vomiting, temperature 38.4 °C. Rheumatoid arthritis for 25 years: neck pain spreading to the back of the head; hoarse for months; mouth opening 3.5 cm, limited neck movement. Drugs: methotrexate weekly, prednisolone 7.5 mg daily for 2 years, folic acid. Vitals: BP 132/78, HR 108, SpO2 95% on air, RR 20. Hb 10.4 g/dL.

The examiner asks

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  1. Consider

    What are the key issues?

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    • A 73-year-old with long-standing RA and a full stomach, for emergency appendicectomy. Patient
    • At 73, febrile and on steroids, she needs reduced propofol; over 1.5 mg/kg drops BP badly.
    • Her occipital neck pain suggests atlanto-axial subluxation, which can also be silent. Disease
    • Months of hoarseness point to cricoarytenoid arthritis, common in severe RA. Airway
    • Methotrexate can damage her liver, lungs and marrow. Disease
    • Two years of prednisolone 7.5 mg means her adrenals may not respond to stress.

  2. Prepare

    What will you check and give before induction?

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    • Neurological exam for myelopathy, documented before anything is done. Disease
    • Flexion–extension films are often poor quality; I treat her neck as unstable regardless.
    • Her fever puts her in the moderate stress band: 50–75 mg hydrocortisone IV today.
    • Methotrexate continues; the evidence supports keeping it going.
    • Awake tracheal intubation weighed: any expected difficulty in plans A to D makes it worth considering. Airway
    • She is cooperative but vomiting; I choose RSI with videolaryngoscopy and inline stabilisation, awake as backup.

  3. Plan

    Talk me through your induction.

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    • Head-up; I pre-oxygenate until expired oxygen reaches 0.9; nasogastric tube aspirated. Airway
    • Manual inline stabilisation with a videolaryngoscope to limit her neck movement.
    • Reduced propofol, rocuronium 1.2 mg/kg, with no gap between them. Stem trigger
    • A smaller tube for her cricoarytenoids; second-generation SAD ready. Airway
    • Plans A to D briefed; front-of-neck kit in the room.

  4. Crisis

    Two videolaryngoscope attempts give only a grade 4 view. SpO2 91% and falling, BP 110/70, HR 112. What do you do?

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    • DAS Plan A failing in a rheumatoid neck: oxygenate by facemask between attempts. (Crisis)
    • A third attempt only with a real change; no more neck movement to get a view.
    • Declare failed intubation; Plan B, second-generation SAD, up to three attempts; eFONA kit primed.
    • SAD works: stop, think, communicate.
    • Her appendix can wait, so I wake her: sugammadex dosed to train-of-four, 16 mg/kg only if still profoundly blocked.
    • Controlled emergence on the SAD, then awake bronchoscopic intubation, neck neutral.

  5. Crisis

    Instead, the SAD fails after three attempts, and two-person mask ventilation fails. SpO2 72%, HR 50. What do you do?

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    • DAS Plan D: CICO is declared aloud and each team member gets a role. Crisis
    • Full dose of relaxant; oxygen kept on her upper airway.
    • In CICO, oxygen beats her cervical spine: full neck extension for eFONA.
    • Vertical incision, then scalpel–bougie–size 6.0 cuffed tube.
    • Ventilate with 100% oxygen, confirm with capnography.
    • Her bradycardia is hypoxic; oxygen through the new airway treats it. Pulse lost: CPR, adult arrest algorithm.
    • Afterwards: neurology rechecked, ICU, and a written airway alert to her and her doctor. After surgery

Fatal mistakes

  • Repeated laryngoscopy attempts with no change.
  • Forcing her neck into flexion or extension for a view.
  • Hesitating over the scalpel once she is CICO.
  • No steroid cover in a woman on long-term prednisolone.

Checked against: Miller 10e · DAS 2025

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