Failed intubation — difficult-airway algorithm viva

This is an unanticipated difficult intubation with developing hypoxaemia, and the response is the structured difficult-airway algorithm, not a series of repeated identical attempts — repeated attempts are strongly associated with complications including hypoxaemia and cardiac arrest.^[2]

Call for help immediately. Optimise Plan A: reposition, reduce or release cricoid pressure, use the best available device (a video laryngoscope), and use a bougie to assist tube placement. If a second optimised attempt fails, do not persist — move to Plan B and place a supraglottic airway, which both oxygenates and can be a conduit for intubation. If the supraglottic airway fails, move to Plan C: optimise face-mask ventilation with a two-person technique, an oropharyngeal airway and full paralysis. If mask ventilation fails — the can't-intubate, can't-oxygenate situation — move without delay to Plan D, the front-of-neck access: a scalpel-bougie-tube cricothyroidotomy through the cricothyroid membrane.^[1]

The decision point is defined and the escalation is rehearsed: the operator who fails twice optimised attempts steps up the ladder, and the surgical airway is performed decisively when oxygenation cannot be maintained, rather than after a series of diminishing returns.^[1][2]