A Primary FRCA OSCE station on MedMock, start to finish

During laser microlaryngoscopy the surgeon reports a flash and smoke in the airway. What are your immediate actions?

I would declare an airway fire emergency, call for senior anaesthetic help and the difficult airway trolley, and simultaneously remove all three components of the fire triangle. First, ignition source: tell the surgeon to stop lasering immediately, turn the laser to standby and remove the laser and any burning swabs or drapes from the airway. Second, oxidiser: stop ventilation immediately, disconnect the breathing circuit at the tracheal tube, and turn off oxygen and nitrous oxide fresh gas flows. Third, fuel: flood the pharynx with sterile saline from the prepared syringe on the surgical trolley to extinguish flames and cool tissues, deflate the tracheal tube cuffs and remove the tracheal tube immediately.

Once the flames are out and the burning tracheal tube has been removed, what do you do next?

First, inspect the removed tracheal tube closely to ensure no melted or charred fragments have broken off and remained in the trachea or bronchi. Second, re-establish ventilation using room air—twenty-one per cent oxygen—via a bag-valve-mask, avoiding high inspired oxygen until we are certain there are no smouldering embers, then re-intubate early with a fresh tracheal tube before progressive thermal airway oedema makes intubation impossible. Third, with the ENT surgeon, perform rigid and flexible bronchoscopy and oesophagoscopy to assess the extent of thermal and smoke injury to the larynx, trachea and bronchi, remove any foreign debris or soot, and lavage gently.

How would you manage the patient after the airway has been secured and examined?

If there is any laryngeal or tracheobronchial thermal injury, I would keep the patient sedated, intubated and ventilated and transfer them to Intensive Care rather than extubating in theatre, because mucosal oedema peaks over the first 12 to 24 hours. I would give intravenous dexamethasone to reduce airway oedema, perform a chest radiograph and arterial blood gas looking for pneumothorax, atelectasis or inhalational lung injury, nurse the patient head-up, and plan a cuff-leak check and repeat endoscopic airway inspection before any trial of extubation. Afterwards I would complete an incident report, preserve the damaged equipment for investigation, debrief the theatre team and fulfil our statutory Duty of Candour with the patient and family.

Finally, what precautions should be in place before starting laser airway surgery to prevent this from happening?

Precautions address the environment, the patient, the airway device and the gas mixture. In theatre, warning signs are posted on locked doors, windows are covered, a designated Laser Safety Officer is present, all staff wear wavelength-specific protective goggles, and a 50-millilitre syringe of sterile saline is drawn up ready on the trolley. For the patient, the eyes are taped and covered with wet saline swabs, and the surrounding face and neck are draped with wet surgical swabs using non-reflective matt black instruments. For the airway, we use a dedicated laser-resistant flexible metallic tracheal tube, inflating the proximal cuff with saline tinted with methylene blue so any cuff puncture is immediately visible and self-dousing, and using the lowest possible inspired oxygen concentration—ideally 25 to 30 per cent oxygen in air or helium, with no nitrous oxide and no volatile agents.

Thank you. That is the end of the station.