Can't Intubate, Can't Oxygenate

About this case

An elective laparoscopic Nissen becomes an unanticipated failed airway after rapid sequence induction in a 45-year-old with a BMI of 47. Three laryngoscopy attempts have failed, bag-mask ventilation is impossible, and a supraglottic device has not rescued it. Saturation is 68% and falling, which puts the entire case under a hard time limit.

Key clinical features

• CICO Declared

  3 failed laryngoscopy attempts, BMV impossible, LMA failed — must declare CICO now

• Hypoxic Spiral

  SpO₂ 68% and falling, EtCO₂ 0 (no ventilation), 140 kg/BMI 47

• Time-Critical

  3–5 min to irreversible brain injury at current SpO₂

• Surgical Airway

  Scalpel-finger-bougie cricothyrotomy — the only correct next step

What the examiner is testing

• Whether you declare CICO out loud and act, instead of continuing to attempt intubation as saturation falls.
• Your command of a failed-airway algorithm under interruption, including when escalation stops being optional.
• How you articulate the time pressure — the examiner is assessing whether you understand that deliberation itself is the error here.
• Team direction: who you task with what, and whether you call for help early enough to matter.

Where candidates lose points

• Cycling through additional laryngoscopy attempts or device swaps well past the point where they can succeed.
• Naming the surgical airway as a theoretical option without committing to performing it now.
• Losing marks on the pre-induction assessment — the examiner will ask what should have been anticipated in this patient.

How it is scored

Every BoardSim case is scored across the same five phases — pre-operative evaluation, anaesthetic plan, intra-operative management, crisis management, and emergence — for a total of 100 points, with a pass set at 70 and no missed critical action. You receive a written report against each phase rather than a single number. Read the scoring methodology.