Endotracheal intubation and emergency airway equipment — branching viva

Branching viva — endotracheal intubation

The examiner releases the stem and then branches into five probes. A strong candidate answers the indication first, defends the anatomy, demonstrates the technique, gives the drug regimen, and names the complications without prompting.

Opening (examiner)

"A four-year-old with bacterial tracheitis arrives drooling, sitting forward, retracting hard, and now drowsy. The saturation is falling despite high-flow oxygen. What is your next move?" ^[9]

Branch 1 — The indication (expected answer)

Secure the definitive airway now — he has a failing airway with impending loss of protection (drooling, drowsy, falling oxygenation). The indications are respiratory failure, a Glasgow Coma Scale of 8 or less, severe shock and cardiac arrest; he meets the first two. Intubate before the arrest, not after it. Assemble the team, preoxygenate, and prepare for rapid sequence intubation.

Probe. "Why a tube and not just a bag-mask?" — A bag-mask is the bridge and keeps most children alive, but it does not protect the lungs from aspiration, fatigues the operator, and cannot reliably deliver high pressures. Only a tube through the cords opens, protects and ventilates. ^[9]

Branch 2 — Sizing and blade (expected answer)

Uncuffed internal diameter equals age over 4 plus 4, giving 5.0 mm; cuffed equals age over 4 plus 3.5, giving 4.5 mm. Depth at the lips equals age over 2 plus 12, giving 14 cm, or about three times the internal diameter. A curved Macintosh size 2 blade is right for this four-year-old; the straight Miller blade is for the infant. ^{[1] [11]}