Emergency Front-of-Neck Airway Access

Introduction to Emergency Surgical Cricothyroidotomy

• The British Journal of Anaesthesia recommends the scalpel-bougie-tube technique as the preferred method for emergency front-of-neck airway access in cannot intubate, cannot oxygenate (CICO) situations 1

Advantages of Open Surgical Technique

• The open surgical cricothyroidotomy technique provides a definitive airway with cuff protection against aspiration 1
• It enables confirmation of correct placement via waveform capnography 1
• The technique facilitates adequate ventilation, including exhalation and PEEP application 1
• It uses familiar standard equipment, such as a scalpel, bougie, and small cuffed tube 1

Recommended Technique: Scalpel-Bougie-Tube Method

• The scalpel-bougie-tube method is a 4-step approach that should be performed immediately when CICO is declared 2, 3, 4, 5, 6
• The steps include identifying the cricothyroid membrane, making a horizontal incision, applying caudal traction on the cricoid cartilage, and inserting a bougie as a guide for the tracheal tube 1, 2, 3, 4, 5, 6

Equipment Required

• The necessary equipment includes a scalpel with a short, rounded blade, a bougie, a small cuffed tracheal tube, and a tracheal hook 1, 2, 3, 4, 5, 6

Critical Timing Considerations

• The British Journal of Anaesthesia recommends getting the front-of-neck airway set to bedside after one failed intubation attempt, and opening the set after one failed attempt at facemask or supraglottic airway oxygenation 1
• The set should be used immediately at CICO declaration 1

Post-Procedure Verification

• After tube placement, confirmation of position should be done with waveform capnography, and ventilation should be done with a low-pressure source 1, 2, 3, 4, 5, 6
• Pulmonary ventilation should be verified clinically, and the airway should be converted to a definitive one as soon as possible 2, 3, 4, 5, 6

Common Pitfalls to Avoid

• Delaying the procedure while attempting multiple failed intubation or ventilation attempts should be avoided, as rapid hypoxemia with bradycardia mandates immediate action 2, 3, 4, 5, 6
• Choosing needle cricothyroidotomy as the first-line approach is not recommended due to its high failure rates in emergencies 1
• Attempting emergency tracheostomy instead of cricothyroidotomy is also not recommended due to its difficulty and potential complications 2, 3, 4, 5, 6

Cricothyroid Membrane Location and Emergency Access

Anatomical Relationship to Other Structures

• The cricothyroid membrane is positioned superior to the thyroid gland, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 7, 8

Emergency Airway Access Techniques

• The Difficult Airway Society recommends a 4-step surgical cricothyroidotomy approach for emergency front-of-neck airway access in cannot intubate, cannot oxygenate (CICO) situations 9

Special Considerations

• Patients who undergo cricothyroid approximation surgery may have complete loss of the cricothyroid membrane, making emergency cricothyroidotomy impossible, as noted by the Anaesthesia journal 10

Emergency Front-of-Neck Airway Management

Primary Recommendation

• The American Society of Anesthesiologists recommends surgical cricothyroidotomy as the preferred invasive airway technique in cannot intubate, cannot oxygenate (CICO) situations, with needle cricothyroidotomy relegated to an alternative option with a pressure-regulated device 11, 12, 13
• The British guidelines state that scalpel cricothyroidotomy or emergency tracheostomy are preferred to cannula cricothyroidotomy in CICO situations, due to lower complication rates and ability to provide a definitive airway 14

Critical Problems with Needle Cricothyroidotomy

• Needle cricothyroidotomy is associated with high rates of complication and failure, and always requires conversion to standard surgical cricothyroidotomy, with specific limitations including high failure rates, inability to provide adequate exhalation, and risk of barotrauma and gas trapping 14, 15
• The pre-hospital anesthesia guidelines state there is unclear evidence for any role of needle cricothyroidotomy in emergency airway management, and recommend limiting intubation attempts to three maximum to avoid worsening laryngeal edema and trauma 14, 15

Equipment Requirements

• Emergency front-of-neck airway equipment must be immediately available and include a scalpel with short, rounded blade, bougie, small cuffed tracheal tube, tracheal hook for retraction, and capnography capability, according to the Anaesthesia guidelines 14, 13

Special Considerations

• Ongoing bleeding is not a contraindication to performing emergency front-of-neck airway, and the scalpel can be used to both open existing neck wounds and make incisions in the cricothyroid membrane, as recommended by the Anaesthesia guidelines 14
• In thyroid surgery patients with post-operative hematoma causing airway compromise, the wound should be opened and hematoma evacuated before attempting intubation, but if CICO develops, proceed directly to surgical cricothyroidotomy, as recommended by the Anaesthesia guidelines 14

Emergency Front-of-Neck Airway Access (Cricothyroidotomy)

Introduction to Cricothyroidotomy

• The British Journal of Anaesthesia recommends emergency surgical cricothyroidotomy using the scalpel-bougie-tube technique as the definitive life-saving procedure in "can't intubate, can't oxygenate" situations, providing a definitive airway with cuff protection against aspiration 16

The Standard Technique: Scalpel-Bougie-Tube Cricothyroidotomy

• The scalpel-bougie-tube technique enables confirmation of success via waveform capnography, which is essential in emergency situations, and allows adequate ventilation with low-pressure sources 16
• This technique can be performed rapidly when properly trained, which is critical as profound hypoxemia and cardiac arrest are inevitable without intervention, and uses familiar standard equipment (scalpel, bougie, small cuffed tube) 16

Critical Timing: The "Priming for FONA" Approach

• The British Journal of Anaesthesia guidelines emphasize staged preparation to avoid delayed intervention, recommending that the front-of-neck airway set be brought to the bedside after one failed intubation attempt 16
• The guidelines also recommend opening the FONA set after one failed attempt at facemask or supraglottic airway ventilation, and using the set immediately at CICO declaration, with transition occurring within 60 seconds 16

Alternative Techniques (Historical Context)

• The Difficult Airway Society 2004 guidelines listed both cannula (needle) cricothyroidotomy and surgical cricothyroidotomy as options, but current evidence strongly favors the open surgical approach, with the American Society of Anesthesiologists recommending surgical cricothyroidotomy as the preferred technique 17, 18
• Cannula techniques require high-pressure ventilation sources, have low success rates, and risk of kinking, and are no longer recommended as a first-line approach 17, 18

Common Pitfalls to Avoid

• Delaying the procedure while attempting multiple failed intubation or ventilation attempts is the greatest cause of morbidity, and failing to ensure adequate neuromuscular blockade before attempting FONA decreases success rates 16

Special Considerations

• Emergency cricothyroidotomy is a temporary measure to restore oxygenation, and definitive airway management (formal tracheostomy or fiberoptic intubation) should follow once the patient is stabilized, with late complications significantly less frequent with cricothyroidotomy compared to emergency tracheostomy 17, 18