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Grade 4 Airway Emergency Intubation — FRCA Final MCQ

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HardAirway ManagementGrade 4 Airway Emergency IntubationFRCA Final

A 35-year-old man (ASA I) with a known difficult airway (previous documented Grade 4 Cormack-Lehane view) develops a tension pneumothorax during a mountain biking accident. He has respiratory distress and needs intubation. A needle decompression is performed successfully. What is the safest approach to secure his airway given the known difficult airway?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Awake fibreoptic intubation via nasal route

Even in an emergency, a patient with a documented Grade 4 (no glottic structures visible) difficult airway should have an awake fibreoptic intubation if time and clinical condition allow. After the tension pneumothorax has been decompressed, the patient's condition is stabilised sufficiently to allow an awake technique. The risk of failed intubation leading to CICO is unacceptably high with a Grade 4 view. If the patient is too unstable for an awake technique, surgical tracheostomy under local anaesthesia may be the safest definitive airway.

Reference: DAS – 2025 – Difficult intubation guidelines; DAS – 2020 – Awake tracheal intubation