What is the emergency procedure when endotracheal (ET) intubation cannot be performed?

Emergency Front-of-Neck Airway Access (Cricothyroidotomy)

When endotracheal intubation cannot be performed and ventilation fails (a "can't intubate, can't oxygenate" or CICO situation), emergency surgical cricothyroidotomy using the scalpel-bougie-tube technique is the definitive life-saving procedure. 1, 2

The Standard Technique: Scalpel-Bougie-Tube Cricothyroidotomy

This is a 4-step open surgical approach through the cricothyroid membrane that has replaced older needle-based techniques due to superior success rates and fewer complications. 1, 2

Why This Technique is Preferred

• Provides a definitive airway with cuff protection against aspiration, unlike needle cricothyroidotomy which has high failure rates and always requires conversion to surgical technique 2
• Enables confirmation of success via waveform capnography, which is essential in emergency situations 1, 2
• Allows adequate ventilation with low-pressure sources, facilitates exhalation, and permits PEEP application 1, 2
• Uses familiar standard equipment (scalpel, bougie, small cuffed tube) that should be immediately available 2
• Can be performed rapidly when properly trained, which is critical as profound hypoxemia and cardiac arrest are inevitable without intervention 1

Critical Timing: The "Priming for FONA" Approach

The British Journal of Anaesthesia guidelines emphasize staged preparation to avoid the common problem of delayed intervention: 1

• After ONE failed intubation attempt: Get the front-of-neck airway set to the bedside 1, 2
• After ONE failed attempt at facemask or supraglottic airway ventilation: Open the FONA set 1, 2
• At CICO declaration: Use the set immediately—transition should occur within 60 seconds 1

The 4-Step Scalpel-Bougie-Tube Procedure

1. Identify the cricothyroid membrane by palpation between the thyroid and cricoid cartilages 2
2. Make a horizontal incision through skin and membrane using a scalpel with short, rounded blade 2
3. Apply caudal traction on the cricoid cartilage using a tracheal hook for retraction 2
4. Insert a bougie as a guide, then railroad a small cuffed tracheal tube over it 2

After placement, confirm position with waveform capnography and ventilate with a low-pressure source. 2

Alternative Techniques (Historical Context)

While the Difficult Airway Society 2004 guidelines listed both cannula (needle) cricothyroidotomy and surgical cricothyroidotomy as options 1, current evidence strongly favors the open surgical approach:

• Needle cricothyroidotomy has been relegated to an alternative option only, with high complication and failure rates, inability to provide adequate exhalation, and risk of barotrauma 2
• The American Society of Anesthesiologists now recommends surgical cricothyroidotomy as the preferred technique, with needle cricothyroidotomy only as an alternative with pressure-regulated devices 2
• Cannula techniques require high-pressure ventilation sources (standard anesthesia machine oxygen flush is insufficient), have low success rates, and risk of kinking 1

Common Pitfalls to Avoid

• Delaying the procedure while attempting multiple failed intubation or ventilation attempts is the greatest cause of morbidity—procedural reluctance kills more patients than complications of the procedure itself 1, 2
• Choosing needle cricothyroidotomy as first-line approach due to perceived simplicity—this has unacceptably high failure rates in true emergencies 2
• Attempting emergency tracheostomy instead of cricothyroidotomy—this is more difficult, takes longer, and has higher complication rates in emergency situations 2, 3
• Failing to ensure adequate neuromuscular blockade before attempting FONA, which decreases success rates 1
• Not having equipment immediately available—the FONA set must be at bedside with scalpel, bougie, small cuffed tube, tracheal hook, and capnography capability 2

Special Considerations

• Ongoing bleeding is NOT a contraindication to performing emergency front-of-neck airway access 2, 4
• Emergency cricothyroidotomy is a temporary measure to restore oxygenation—definitive airway management (formal tracheostomy or fiberoptic intubation) should follow once the patient is stabilized 1
• Late complications are significantly less frequent with cricothyroidotomy compared to emergency tracheostomy, supporting its use as the technique of choice 3
• Emergency cricothyroidotomies should be converted to tracheostomies in a timely fashion as there is insufficient evidence they are safe as long-term airways 5, 3