Indications
- Can't intubate, can't oxygenate (CICO) — the final rescue step of the DAS 2025 failed-airway algorithm (Plan D), when tracheal intubation, supraglottic airway device, and facemask ventilation have all failed and the patient cannot be oxygenated.
- Complete upper airway obstruction above the cricothyroid membrane where oral/nasal access is impossible (massive facial trauma, airway burns, angioedema, upper airway tumour/bleeding) and no other route to oxygenation exists.
Contraindications & cautions
Relative cautions (not reasons to delay)
- Distorted neck anatomy (haematoma, surgical scarring, tumour) — landmarks may need to be identified by palpation or ultrasound if time allows, but proceed on best judgement if oxygenation is failing.
- Coagulopathy — bleeding risk is accepted given the immediate threat to life.
- Scalpel cricothyroidotomy is taught for adults and older children/adolescents. In young children the cricothyroid membrane is small and compliant — paediatric airway guidance (APLS/DAS-aligned) generally prefers needle/cannula techniques, with surgical FONA reserved for older children; follow paediatric-specific guidance and senior/ENT input.
There is no absolute contraindication
- In true CICO, the alternative is hypoxic death — proceed even with imperfect landmarks or a coagulopathic patient.
Preparation
- Declare CICO loudly and assign the front-of-neck airway to a designated operator immediately — do not wait for a "final" facemask attempt to fail before opening the kit.
- Have the cricothyroidotomy kit opened and visible from the start of every anticipated difficult RSI, not fetched only once CICO is declared.
- Continue attempts at oxygenation by any other means (facemask, SAD) while the surgical airway is being prepared, without delaying the incision.
- Position: neck extended if no C-spine concern; patient supine.
- No time for full aseptic technique or formal consent in true CICO — this is an emergency life-saving intervention.
Equipment — scalpel-bougie-tube
Landmarks — the laryngeal handshake
Identify the cricothyroid membrane using the laryngeal handshake: place the thumb and middle finger on the superior cornua of the thyroid cartilage, and the index finger drops naturally into the cricothyroid membrane between the thyroid and cricoid cartilages.
Step-by-step technique — scalpel-bougie-tube
Palpate and stabilise
Perform the laryngeal handshake with the non-dominant hand to identify and stabilise the larynx. Once the membrane has been located within the wound, that hand stays on the larynx and does not move until the tube is in.
Long vertical midline incision
Using the size 10 scalpel, make a single long midline vertical skin incision (up to around 8 cm), cutting caudad to cephalad. DAS 2025 recommends the vertical incision for all cases and removes the older palpable/impalpable decision point — one technique, whether or not you can feel the membrane.
Blunt dissect and re-identify
Separate the tissues bluntly with the fingers of both hands, then re-identify and stabilise the larynx by palpation within the wound to locate the cricothyroid membrane. The vertical incision gives a longer field, which is what makes this possible in obesity, distorted anatomy or a bleeding neck.
Incise the membrane
Stab through the cricothyroid membrane with the scalpel and turn the blade to open the hole, keeping it in place as a marker of the trajectory until the bougie is in.
Bougie
Slide the coudé-tipped bougie along the blade, through the membrane, into the trachea, aiming caudally; feel for tracheal hold-up/clicks confirming tracheal placement.
Railroad the tube
Remove the scalpel, thread a size 6.0 cuffed tracheal tube over the bougie into the trachea, advancing to a normal depth, then remove the bougie.
Inflate and confirm
Inflate the cuff, connect the bag, and confirm tracheal placement with waveform capnography and bilateral chest rise/air entry — exactly as for an oral tracheal tube.
Secure
Secure the tube robustly (tie, not just tape) — accidental displacement of a surgical airway is a further life-threatening event.
Complications
Early
- Failure to identify the correct plane / false passage — commonest cause of technique failure.
- Bleeding from anterior neck vessels or thyroid isthmus.
- Surgical emphysema if the tube is misplaced pretracheally.
- Oesophageal or posterior tracheal wall injury with an overly deep stab.
Late
- Subglottic stenosis.
- Voice change / laryngeal injury.
- Infection at the stoma site.
- Need for later formal tracheostomy and airway reconstruction.
Pitfalls & pearls
- The single biggest failure mode is delay — declare CICO and cut early rather than repeating failed intubation/SAD attempts.
- Keep the stabilising hand on the larynx throughout the entire sequence; losing landmarks mid-procedure is a major cause of failure.
- One confident, generous vertical incision beats multiple tentative cuts — a short incision is a common cause of failure, and hesitancy costs time and worsens bleeding.
- This is a low-frequency, high-stakes skill — regular simulation/manikin rehearsal is essential, as real cases are rare.
- Keep the kit identical across resus bays and prehospital settings so muscle memory transfers directly.
DOPS pointers
RCEM curriculum: Intermediate/Higher Procedural Skill. Given true CICO is rare, sign-off is often achieved via simulation. What assessors look for:
| 1 | Observed only (or simulated) — can describe indications, landmarks and the scalpel-bougie-tube sequence. |
| 2a | Performs on a manikin/simulation with a supervisor present: correct laryngeal handshake, confident single incision. |
| 2b | Performs the full sequence fluently under time pressure in simulation, including tube confirmation and securing. |
| 3 | Recognises CICO promptly in a simulated scenario and leads the team through declaration and escalation to Plan D without hesitation. |
| 4 | Independent; can teach, supervise, and lead departmental simulation training for this skill. |
References
- Ahmad I, El-Boghdadly K, Ahmed A, et al. Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults. Br J Anaesth 2026;136(2):283–307. (Standardised vertical-incision scalpel–bougie–tube eFONA.)
- Difficult Airway Society. DAS emergency front-of-neck airway guidelines and eFONA teaching resources — das.uk.com.
- RCEM Curriculum 2021 — Emergency Medicine Specialty Learning Outcomes: intermediate/higher procedural skills (DOPS), airway management.