A 58-year-old man with type 2 diabetes mellitus is admitted for emergency open reduction and internal fixation of a fractured femur. He consumed a heavy meal (biryani with ghee) at 18:00 hours. Admission to the hospital is at 22:30 hours, and emergency surgery is planned for 23:30 hours (1 hour after admission). On examination, he is obese (BMI 32 kg/m²), has a history of GERD, and his blood glucose is 280 mg/dL. What is the most appropriate airway management strategy for this patient?

Explanation

## Emergency Surgery with Full Stomach: Airway Management ### Risk Stratification | Risk Factor | Present | Significance | |---|---|---| | Time since food intake | 4.5 hours (18:00–22:30) | <6 hours = full stomach | | Meal type | Heavy (biryani with ghee) | High fat content delays gastric emptying | | Obesity | BMI 32 kg/m² | Increases aspiration risk, difficult airway | | GERD history | Yes | Increased gastric acid reflux risk | | Diabetes mellitus | Yes | Gastroparesis may impair emptying | | Emergency surgery | Yes | Cannot delay for fasting | **Key Point:** This patient has MULTIPLE high-risk features for aspiration pneumonitis and requires rapid sequence intubation (RSI) despite inadequate fasting time. ### Rapid Sequence Intubation Protocol **Mnemonic:** **CRASH-C** = Cricoid pressure, Rapid sequence, Avoid bag-mask ventilation, Succinylcholine (or rocuronium), Head-up position, Confirm tube placement 1. **Pre-oxygenation:** 3–5 minutes with 100% O₂ (or 8 vital capacity breaths) 2. **Induction agent:** Etomidate or ketamine (avoid propofol—hypotension risk in emergency) 3. **Neuromuscular blocker:** - **Succinylcholine 1–1.5 mg/kg IV** (onset 30–60 sec) — preferred for RSI due to rapid onset - OR **Rocuronium 1.2 mg/kg IV** (onset 60–90 sec) — alternative if succinylcholine contraindicated 4. **Cricoid pressure (Sellick maneuver):** Applied at 10 N before loss of consciousness, increased to 30 N after induction 5. **Minimize bag-mask ventilation:** Reduces gastric insufflation and aspiration risk 6. **Intubation:** Confirm with capnography **High-Yield:** In emergency settings with full stomach, RSI is the standard of care. The risk of aspiration pneumonitis (Mendelson syndrome) outweighs the risk of anesthetic induction. **Clinical Pearl:** Succinylcholine is preferred over rocuronium in RSI because of its faster onset (30–60 sec vs. 60–90 sec), allowing quicker airway control. However, rocuronium is acceptable if succinylcholine is contraindicated (e.g., malignant hyperthermia susceptibility, severe hyperkalemia risk). ### Why Delay Is Not an Option - Emergency fracture fixation cannot be postponed 6 hours - Prolonged immobilization increases thromboembolism and infection risk - Patient is hemodynamically stable enough for immediate surgery ```mermaid flowchart TD A[Emergency surgery with full stomach]:::outcome --> B{Time since food?}:::decision B -->|< 6 hours| C[High aspiration risk]:::urgent C --> D[Rapid Sequence Intubation]:::action D --> E[Pre-oxygenation 3-5 min]:::action E --> F[Induction: Etomidate/Ketamine]:::action F --> G[Succinylcholine 1-1.5 mg/kg]:::action G --> H[Cricoid pressure applied]:::action H --> I[Intubate + confirm]:::action I --> J[Proceed with surgery]:::outcome ```