call for help, and follow your institution's difficult airway algorithm. Since more than 2 passes at intubation is associated with a significant increase in aspiration, hypothermia, and cardiac arrest, attempts should be made to optimize first‐attempt success rate. This includes using an appropriate blade for direct laryngoscopy, providing adequate pre‐oxygenation, optimizing hemodynamics, and choosing appropriate medication. A definitive airway is not always immediately needed – if appropriate oxygenation/ventilation is achieved with a laryngeal mask airway, then it should be used until a definitive airway is needed or ready to be placed.Answer: EEdelman DA, Perkins EJ, Brewster DJ. Difficult airway management algorithms: a directed review. Anaesthesia. 2019; 74(9):1175–1185. doi: 10.1111/anae.14779. Epub 2019 Jul 21. PMID: 31328259.Natt BS, Malo J, Hypes CD, Sakles JC, Mosier JM. Strategies to improve first attempt success at intubation in critically ill patients. Br J Anaesth 2016; 117 Suppl 1:i60–i68. doi: 10.1093/bja/aew061. Epub 2016 May 24. PMID: 27221259.14 In the above patient, after placing an LMA, the patient begins to desaturate, and you notice that there is limited chest wall rise with inspiration. You then attempt another pass at direct laryngoscopy, and while you can see the vocal cords, you cannot pass the endotracheal tube. While attempting to provide adequate bag‐mask ventilation, the patient has an SpO2 of 78% which does not rise. The most appropriate next step is to:Proceed with cricothyroidotomyReplace the LMAProceed with percutaneous tracheostomyProceed with open tracheostomyRe‐dose your paralytic to improve ease of ventilation with bag‐mask ventilationThis difficult airway has now become a failed airway, and prompt action is needed to establish an airway before the patient arrests. A surgical airway is indicated. While tracheostomy could be performed, a cricothyroidotomy is still the procedure of choice given the more easily identifiable anatomy and closer proximity of skin to tracheal lumen.Answer: AEdelman DA, Perkins EJ, Brewster DJ. Difficult airway management algorithms: a directed review. Anaesthesia 2019; 74(9):1175–1185. doi: 10.1111/anae.14779. Epub 2019 Jul 21. PMID: 31328259.Natt BS, Malo J, Hypes CD, Sakles JC, Mosier JM. Strategies to improve first attempt success at intubation in critically ill patients. Br J Anaesth. 2016; 117 Suppl 1:i60–i68. doi: 10.1093/bja/aew061. Epub 2016 May 24. PMID: 27221259.
15 A 65‐year‐old man is in your intensive care unit following a motor vehicle crash in which he sustained pelvic fractures requiring percutaneous fixation, fractures of left ribs 1–7, and associated pulmonary contusions. His pain is well‐controlled, and he is deemed fit to discharge to inpatient rehabilitation. Due to his pelvic fracture pattern, your orthopedic colleague requests that the patient be placed on DVT prophylaxis with warfarin for 6 weeks from the date of operation. Assuming anticoagulation is beneficial in this patient, your response should be:Place the patient on warfarin, and ensure an INR of 2–2.5.Place the patient on a NOAC.Place the patient on dual anti platelet therapy with aspirin and plavix.Place the patient on twice daily lovenox.Place the patient on aspirin alone.Many patients were historically were started on anticoagulation for the prevention of DVTs following orthopedic operations of the lower extremities. Over the past decade or so, there has been a trend to anticoagulate these patients with agents other than warfarin, due to fewer complications from bleeding, as well as decreased incidence of VTE in patients treated with alternate therapy. Aspirin has increasingly been studied as an alternate to low‐molecular weight heparin and NOACs due to increased simplicity of administration, and multiple large‐scale trials have shown aspirin to be non‐inferior to other forms of anticoagulation.Answer: ESimes J, Becattini C, Agnelli G, Eikelboom JW, Kirby AC, Mister R, Prandoni P, Brighton TA ; INSPIRE Study Investigators (International Collaboration of Aspirin Trials for Recurrent Venous Thromboembolism). Aspirin for the prevention of recurrent venous thromboembolism: the INSPIRE collaboration. Circulation. 2014; 130(13):1062–1071. doi: 10.1161/CIRCULATIONAHA.114.008828. Epub 2014 Aug 25. PMID: 25156992.Anderson DR, Dunbar MJ, Bohm ER, Belzile E, Kahn SR, Zukor D, Fisher W, Gofton W, Gross P, Pelet S, Crowther M, MacDonald S, Kim P, Pleasance S, Davis N, Andreou P, Wells P, Kovacs M, Rodger MA, Ramsay T, Carrier M, Vendittoli PA. Aspirin versus low‐molecular‐weight heparin for extended venous thromboembolism prophylaxis after total hip arthroplasty: a randomized trial. Ann Intern Med. 2013; 158(11):800–806. doi: 10.7326/0003‐4819‐158‐11‐201306040‐00004. PMID: 23732713.Azboy I, Groff H, Goswami K, Vahedian M, Parvizi J. Low‐dose aspirin is adequate for venous thromboembolism prevention following total joint arthroplasty: a systematic review. J Arthroplasty. 2020; 35(3):886–892. doi: 10.1016/j.arth.2019.09.043. Epub 2019 Oct 5. PMID: 31733981.
16 You are in the trauma bay during 5 simultaneous trauma activations. In order to most judiciously utilize your blood bank's resources, you are attempting to predict which patients will require a massive transfusion protocol (MTP). Which of the following patients is most likely to require MTP?A 19‐year‐old man with a GSW to the abdomen with negative FAST, SBP of 110 mm Hg, and HR of 100 beats/min.A 23‐year‐old woman involved in an MVC, with a positive FAST, SBP of 110 mm Hg, and HR of 100 beats/min.A 49‐year‐old man with a GSW to the abdomen with a negative FAST, SBP of 94 mm Hg, and HR of 115 beats/min.A 32‐year‐old man who was assaulted, with a positive FAST, SBP of 98 mm Hg, and HR of 130 beats/min.A 44‐year‐old woman with a stab wound to the LUQ with a negative FAST, SBP of 98 mm Hg, and HR of 110 beats/min. Identifying patients who will likely require MTP is essential in the trauma bay. The Assessment of Blood Consumption (ABC) scoring system relies on 4 non‐weighted dichotomous parameters: penetrating mechanism, positive Focused Assessment with Sonography for Trauma (FAST), arrival systolic blood pressure (SBP) of 90 mm Hg or less, and arrival heart rate of 120 bpm or greater. Each positive parameter is given a score of 1, and the total score is evaluated out of 4. A score of 2 or greater predicts the need for MTP with a sensitivity of 75% and a specificity of 86%.Answer: DMaegele M, Brockamp T, Nienaber U, Probst C, Schoechl H, Goerlinger K, Spinella P. Predictive models and algorithms for the need of transfusion including massive transfusion in severely injured patients. Transfus Med Hemother. 2012; 39(2):85–97. doi:10.1159/000337243.Cotton BA, Dossett LA, Haut ER, Shafi S, Nunez TC, Au BK, Zaydfudim V, Johnston M, Arbogast P, Young PP. Multicenter validation of a simplified score to predict massive transfusion in trauma. J Trauma. 2010; 69(Suppl 1):S33–S39. doi: 10.1097/TA.0b013e3181e42411. PMID: 20622617.
17 A 37‐year‐old woman with a history of chronic cholecystitis undergoes a laparoscopic cholecystectomy which requires conversion to an open procedure due to significant inflammatory disease. The case is completed, and the patient is brought to PACU. While reviewing her postoperative labs, you note a blood glucose level of 190 mg/dL, as well as a mild acidosis and leukocytosis. In regard to her hyperglycemia, the following is true:The patient is at increased risk of surgical site infection, as well as overall mortality, but her risk is less than that of a known diabetic.The patient is at increased risk of surgical site infection, as well as overall mortality, but her risk is equal to that of a known diabetic.The patient is at increased risk of surgical site infection, as well as overall mortality, and her risk is higher than that of a known diabetic.The patient has an expected stress response to operation, and since she is not diabetic, no further intervention is required, and her risk of surgical site infection is not significantly increased.There is no clear correlation between isolated episodes of hyperglycemia in non‐diabetic patients, although there is a correlation for diabetic patients.There exists a dose‐dependent relationship between blood glucose levels above 180 mg/dL and postoperative complications, including surgical site infection, length of stay, and overall mortality. Interestingly, this effect is more pronounced in patients who are non‐diabetic than in patients who are diabetic. This is thought to possibly be due to several different causes, including a non‐treatment bias in non‐diabetics (patients with an established diagnosis of DM are more likely to receive insulin), and
