EM · Procedural & diagnostic ED skills
Front-of-neck access and the emergency surgical airway
Also known as Emergency surgical airway · Cricothyroidotomy · Scalpel-bougie-tube cricothyroidotomy · Surgical cricothyroidotomy · Front-of-neck access · FONA · CICO rescue
Front-of-neck access in the ED — the scalpel-bougie-tube cricothyroidotomy for the cannot-intubate, cannot-oxygenate (CICO) event. The indication is the declared CICO state after every non-surgical lifeline (face mask, supraglottic airway, endotracheal tube) has failed. The anatomy is the cricothyroid membrane between the thyroid cartilage above and the cricoid ring below. The technique is the six-step sequence — laryngeal handshake, transverse stab incision through skin and membrane with a scalpel, turn the blade 90 degrees, pass the bougie caudally, railroad a size 6.0 mm cuffed endotracheal tube, confirm with sustained waveform capnography. The complications are bleeding, posterior tracheal wall injury, oesophageal injury, false passage and delayed tube displacement. The differential is the rescue oxygenation lifelines (face mask ventilation, supraglottic airway) and the alternative FONA technique (narrow-bore needle cricothyroidotomy with jet ventilation) — each distinguished by its place in the algorithm and its failure modes. ACEM Fellowship, globally tagged.
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- Upper airway obstruction in the emergency department
- The primary survey (ABCDE) — the trauma assessment framework
- Procedural sedation in the emergency department
- Local anaesthesia and topical agents
- Paediatric trauma — the modified approach
- Major trauma resuscitation — the team-based systematic approach
- Trauma team leadership
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- CICO is the one airway emergency that cannot wait — declare it aloud, call for help, and perform the scalpel-bougie-tube cricothyroidotomy without delay. Hesitation and a last hopeless laryngoscopy are how an airway crisis becomes an airway death; the recurring NAP4 failure was performing the cut too late.
- Needle cricothyroidotomy is not the adult rescue. NAP4 documented repeated needle failure in the obese (kinking, dislodgement, a cannula too short to reach the trachea, barotrauma from jet ventilation against an obstructed upper airway). The scalpel-bougie-tube is the DAS-specified adult default.
- If the cricothyroid membrane cannot be felt, make a vertical midline skin incision to explore, then a transverse cut through the membrane — a blind transverse skin cut in the obese neck risks the anterior jugular veins and the wrong level.
- Withdraw the scalpel and you lose the tract before the bougie is placed — keep the blade in, turn it 90 degrees, and railroad the bougie alongside it.
- Confirm tracheal placement with sustained waveform capnography from the first breath — chest movement alone is not confirmation; a flat trace means a false passage and mandates re-siting the tube.
Meet the patient
A 55-year-old obese man is brought from a high-speed motorcycle crash with shattered maxillofacial trauma, bleeding from the mouth and nose. Two senior laryngoscopists have each had three best attempts — blood and distorted anatomy, no view. A size 4 i-gel and two-person face-mask ventilation have failed: the chest does not move, SpO2 72 per cent and falling, the heart rate bradying to 42.[2]
One question decides the next sixty seconds: has every non-surgical lifeline been exhausted? If yes — and only then — declare CICO aloud and cut. Hesitation and a last hopeless laryngoscopy are how an airway crisis becomes an airway death.[3]
References12ShowHide
- [1]Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults Br J Anaesth, 2015.PMID 26556848
- [2]Cook TM, Woodall N, Harper J, et al. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments Br J Anaesth, 2011.PMID 21447489
- [3]Chrimes N, Higgs A, Rehak A Lost in transition: the challenges of getting airway clinicians to move from the upper airway to the neck during an airway crisis Br J Anaesth, 2020.PMID 32475685
- [4]Groombridge C, Maini A, Helsloot D, et al. Emergency surgical airway experience from an Australian major trauma centre emergency department Scand J Trauma Resusc Emerg Med, 2025.PMID 40506752
- [5]McCaul CL, Bick E, Vanner R Equipment for cricothyroidotomy: optimum tube size needs a compatible bougie. Comment on Br J Anaesth 2021; 127: 479-86 Br J Anaesth, 2021.PMID 34565521
- [6]Mabry RL, Nichols MC, Shiner DC, et al. A comparison of two open surgical cricothyroidotomy techniques by military medics using a cadaver model Ann Emerg Med, 2014.PMID 24094476
- [7]Fennessy P, Greco E, Gelber N, et al. Emergency Front-of-Neck Airway Rescue Via the Cricothyroid Membrane: A High-Resolution Computed Tomography Study of Airway Anatomy in Adults Anesth Analg, 2021.PMID 33989226
- [8]Cook TM, Woodall N, Frerk C Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia Br J Anaesth, 2011.PMID 21447488
- [9]Roback MG, Wathen JE, MacKenzie T, et al. A randomized, controlled trial of i.v. versus i.m. ketamine for sedation of pediatric patients receiving emergency department orthopedic procedures Ann Emerg Med, 2006.PMID 17052563
- [10]Gharavifard M, Boroumand Reza Zadeh B, et al. A Randomized Clinical Trial of Intravenous and Intramuscular Ketamine for Pediatric Procedural Sedation and Analgesia Emerg (Tehran), 2015.PMID 26495383
- [11]Rosenberg PH, Veering BT, Urmey WF Maximum recommended doses of local anesthetics: a multifactorial concept Reg Anesth Pain Med, 2004.PMID 15635516
- [12]Torp KD, Metheny E, Simon LV Lidocaine Toxicity StatPearls, 2025.PMID 29494086