Failed Intubation Drill

Quick Answer

One-liner: The failed intubation drill is a structured, rehearsed response to unsuccessful intubation, emphasising early recognition (3 attempts, SpO2 falling), systematic escalation through the Vortex/DAS algorithm (Plan B: SGA, Plan C: optimised BMV, Plan D: FONA), and clear team communication to prevent hypoxic death.

Failed intubation occurs in 1-3% of emergency department intubations and can rapidly deteriorate to a CICO (Can't Intubate, Can't Oxygenate) situation with mortality of 25-30% if mismanaged [1]. The failed intubation drill ensures all team members know their roles, have practised the escalation pathway, and can perform emergency front-of-neck access (FONA) using the scalpel-bougie-tube technique [2]. Human factors training—including cognitive aids (Vortex), graded assertiveness (PACE), and closed-loop communication—is as important as technical skill in preventing airway deaths [3].

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ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Cricothyroid membrane (CTM) location (13mm height, 22-30mm width), thyroid and cricoid cartilages, external landmarks, tracheal anatomy, blood supply [4]
• Physiology: Oxygen cascade, functional residual capacity (FRC), safe apnoea time (adults 3-8 min), desaturation curve, preoxygenation physiology, aventilatory mass flow [5]
• Pharmacology: Neuromuscular blockers (suxamethonium vs rocuronium), sugammadex reversal kinetics, ketamine vs propofol in emergency, opioid blunting effects [6]

Fellowship Exam Relevance

• Written: SAQs on CICO algorithm steps, human factors in airway emergency, drill design, team communication, cognitive aid utilisation, root cause analysis [7]
• OSCE: Resuscitation stations requiring CICO declaration, scalpel-bougie-tube demonstration, team leadership, graded assertiveness, closed-loop communication, debriefing [8]
• Key domains tested: Medical Expert, Communicator, Collaborator, Leader

High-Yield Exam Topics

1. Recognition criteria for failed intubation (3+1 rule)
2. Vortex approach vs DAS algorithm comparison
3. Scalpel-bougie-tube technique step-by-step
4. Human factors and fixation error
5. Team communication (PACE, CUS, closed-loop)
6. Drill design and simulation training

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Key Points

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Epidemiology

Australian/NZ Specific Data

• NAP4 (4th National Audit Project): Major airway complications 61% more common in ICU/ED than operating theatre—higher risk of death/brain damage outside OR [15]
• Aus-ROC data: Pre-hospital airway success varies by paramedic skill level; SGA acceptable for transport [16]
• RFDS retrieval: Higher difficult airway rates in resource-limited settings; telemedicine support recommended [17]
• Indigenous populations: Higher rates of obesity, OSA, and diabetic stiff joint syndrome contributing to difficult airways [18]

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Recognition of Failed Intubation

Definition

Failed intubation is declared when:

• 3 optimised intubation attempts have failed (regardless of view obtained)
• PLUS 1 attempt by the most experienced operator available (if different)
• OR when SpO2 falls below 90% during attempts (immediate escalation required)

Triggers for Recognition

What Counts as an "Attempt"?

Optimisation Between Attempts

MOPS-O mnemonic for optimisation [19]:

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Escalation Algorithm: DAS/Vortex Approach

The Vortex Approach (Australian Cognitive Aid)

The Vortex approach is an Australian cognitive aid developed by Nicholas Chrimes to prevent fixation error and ensure timely progression to FONA [20].

                    ┌─────────────────────────────┐
                    │   VORTEX APPROACH           │
                    │   Three Upper Airway        │
                    │   "Lifelines"               │
                    └─────────────────────────────┘
                              │
       ┌──────────────────────┼──────────────────────┐
       │                      │                      │
       ▼                      ▼                      ▼
┌─────────────┐      ┌─────────────────┐      ┌─────────────┐
│  FACE MASK  │      │ SUPRAGLOTTIC    │      │ ENDOTRACHEAL│
│  (BMV)      │      │ AIRWAY (SGA)    │      │ TUBE (ETT)  │
│             │      │                 │      │             │
│ Up to 3     │      │ Up to 3         │      │ Up to 3     │
│ best efforts│      │ best efforts    │      │ best efforts│
└─────────────┘      └─────────────────┘      └─────────────┘
       │                      │                      │
       └──────────────────────┼──────────────────────┘
                              │
                              ▼
               ┌─────────────────────────────┐
               │   ALL THREE FAILED          │
               │   + CANNOT OXYGENATE        │
               │   = CICO                    │
               └─────────────────────────────┘
                              │
                              ▼
               ┌─────────────────────────────┐
               │   "DARK ZONE"               │
               │   ========================  │
               │   FRONT-OF-NECK ACCESS      │
               │   Scalpel-Bougie-Tube       │
               │   (Plan D / FONA)           │
               └─────────────────────────────┘

Key Vortex Principles

1. Maximum 3 "best efforts" at each lifeline (provided still oxygenating)
2. Optimise between attempts: Change something before each attempt
3. "Green zone": Patient is oxygenating—time to troubleshoot
4. "Dark zone": Cannot oxygenate—IMMEDIATE FONA, no more upper airway attempts
5. Any lifeline can be entry point: Start where clinically appropriate
6. Non-linear: Can move between lifelines as situation evolves

DAS 2015/2025 Algorithm: Plan A-D

The Difficult Airway Society (DAS) algorithm provides a structured Plan A through D approach [21]:

Plan A: Primary Intubation

Goal: Successful first-pass intubation with optimal conditions

1. Optimise position: Ramped position, ear-to-sternal notch alignment
2. Preoxygenate: 3 minutes tidal breathing or 8 vital capacity breaths, target EtO2 greater than 85%
3. Apnoeic oxygenation: Nasal prongs at 15L/min during attempt
4. Maximum 3 attempts (+ 1 by most experienced operator)
5. Video laryngoscopy if predicted difficult airway
6. Bougie for Cormack-Lehane grade IIb or worse
7. External laryngeal manipulation (BURP/ELM)

After 3+1 failed attempts → DECLARE FAILED INTUBATION → Proceed to Plan B

Plan B: Supraglottic Airway (SGA)

Goal: Oxygenate via SGA if intubation fails

1. Insert second-generation SGA (i-gel, LMA ProSeal, LMA Supreme)
2. Maximum 3 attempts with optimisation between each
3. Ensure full paralysis (suxamethonium or rocuronium)
4. Optimise insertion: Jaw thrust, correct size, lubricant

If ventilating via SGA:

• Consider waking patient (if possible and safe)
• Or intubating through SGA (fibreoptic or blind)
• Or continuing ventilation for procedure

If NOT ventilating via SGA → Proceed to Plan C

Plan C: Final Attempt at Face Mask Ventilation

Goal: Last attempt at upper airway oxygenation before FONA

1. Optimise paralysis: Ensure full neuromuscular blockade (give more if needed)
2. Two-person technique: One person holds mask, one squeezes bag
3. All adjuncts: Oral AND nasal airways, jaw thrust
4. Best position: Head elevation, neck extension (if safe)
5. Maximum 1 minute: Do not delay FONA

If cannot oxygenate → DECLARE CICO → Proceed to Plan D

Plan D: Emergency Front-of-Neck Access (FONA)

Goal: Immediate surgical airway when CICO declared

CICO Declaration: "This is CICO. I am performing front-of-neck access now."

Perform scalpel-bougie-tube technique (see section below).

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Scalpel-Bougie-Tube Technique (Plan D / FONA)

Indications for FONA

CICO Kit Equipment

Step-by-Step Technique

Total target time: less than 2 minutes from CICO declaration to ventilation

Step 1: Position and Landmark Identification (5-10 seconds)

1. Extend neck maximally (if no C-spine concern)

2. "Laryngeal handshake": Non-dominant hand stabilises larynx from behind

   • Thumb and middle finger on thyroid cartilage
   • Index finger identifies cricothyroid membrane (CTM)

3. Identify CTM:

   • Midline depression between thyroid and cricoid cartilages
   • Soft area below Adam's apple
   • Average size: 13mm (height) x 22-30mm (width)

4. If landmarks impalpable: Make 8-10cm vertical midline incision to expose anatomy (see impalpable CTM section)

Step 2: Vertical Skin Incision (2-3 seconds)

• Large vertical incision through skin over CTM
• Length: 4-8cm (generous incision = better access)
• Stabilise larynx with non-dominant hand throughout
• Do NOT worry about bleeding—proceed rapidly

Step 3: Horizontal Stab Through CTM (2-3 seconds)

• Transverse (horizontal) stab through CTM with scalpel
• Feel the blade "pop" through the membrane
• Incise entire width of membrane
• Turn blade 90 degrees (sharp edge caudal/toward feet) to keep hole open
• Alternatively: Use finger or tracheal hook to maintain opening

Step 4: Bougie Insertion (2-3 seconds)

• Slide coude-tip bougie alongside blade into trachea
• Direct bougie caudally (toward feet)
• Confirm tracheal placement:
  • Feel "clicks" of tracheal rings (60-90% sensitivity)
  • Or resistance at carina (do not advance too far)
• Do NOT remove scalpel until bougie confirmed in trachea

Step 5: Tube Railroading (5-10 seconds)

• Lubricate 6.0mm cuffed ETT
• Railroad over bougie into trachea
• Rotate 90 degrees anticlockwise as entering CTM (reduces hang-up on arytenoids)
• Advance until cuff is just below CTM
• Remove bougie while holding tube steady

Step 6: Confirmation and Securing (10-15 seconds)

• Inflate cuff (5-10mL air)
• Confirm placement with capnography (gold standard)
• Auscultate for bilateral breath sounds
• Secure tube with tape or tie
• Ventilate and reassess patient
• Document procedure and complications

Impalpable CTM Approach

In 5-10% of patients, CTM cannot be palpated (obesity, oedema, tumour, previous surgery) [22].

"Big Cut" Technique:

1. Make 8-10cm vertical midline incision from chin toward sternal notch
2. Blunt dissection through subcutaneous tissue with fingers
3. Identify trachea by palpating rings
4. Find CTM by feeling between cartilages
5. Complete scalpel-bougie-tube through CTM
6. Alternative: Tracheal incision between rings if CTM not accessible

Alternative FONA Techniques

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Team Communication

Closed-Loop Communication

Effective team communication prevents errors and ensures shared situational awareness [23].

Role Assignment (Airway Emergency Team)

Declaring Failed Intubation

Verbalise clearly:

"I have failed to intubate after 3 attempts. This is a FAILED INTUBATION. I am moving to Plan B: inserting a supraglottic airway."

Declaring CICO

Say it loudly and clearly:

"This is a CICO situation. I cannot intubate and I cannot oxygenate. I am proceeding to front-of-neck access. Please prepare scalpel, bougie, and 6.0 tube."

Team response:

• All upper airway attempts STOP
• CICO kit opened immediately
• Suction and light positioned
• Capnography ready
• Time documented

Graded Assertiveness (PACE Model)

PACE allows team members to escalate concerns when the leader appears fixated [24]:

CUS Model (Alternative)

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Human Factors and Fixation Errors

The Elaine Bromiley Case

The 2005 death of Elaine Bromiley during elective surgery is the landmark case demonstrating how human factors cause airway deaths [25]:

What happened:

• Routine surgery, unexpected difficult intubation
• Experienced team made multiple intubation attempts
• CICO kit brought to room but not used
• Nurses suggested surgical airway but were ignored
• Patient suffered hypoxic brain injury and died

Root causes identified:

• Fixation error: Repeated attempts at failed technique
• Task absorption: Lost situational awareness
• Hierarchy gradient: Nurses' concerns dismissed
• Loss of situational awareness: Unaware of time/SpO2
• Cognitive overload: Unable to transition mentally

Types of Cognitive Errors

Preventing Fixation Error

1. Pre-briefing: Explicitly state maximum attempts and escalation plan
2. Cognitive aids: Vortex poster visible in resus bay
3. Time announcements: Scribe calls out elapsed time every 30 seconds
4. SpO2 announcements: Team member calls out SpO2 every 15 seconds
5. Graded assertiveness: Empower all team members to speak up
6. External cue: Alarm when SpO2 falls below 90%
7. Predetermined triggers: "If SpO2 below 80%, we go to FONA regardless"

Cognitive Aids in Airway Emergency

Display these cognitive aids in every resuscitation bay [26]:

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Drill Design and Simulation Training

Why Drills Matter

• FONA is a low-frequency, high-stakes procedure
• Average emergency physician may never perform FONA on a real patient
• Simulation training improves performance under pressure [27]
• Regular practice maintains skills and reduces hesitation

Components of an Effective Failed Intubation Drill

Pre-Drill Preparation

Drill Phases

Phase 1: Recognition (2-3 minutes)

• Patient presented with indication for intubation
• Initial intubation attempt fails
• Team recognises difficult airway

Phase 2: Escalation (3-5 minutes)

• Multiple intubation attempts with optimisation
• SpO2 deteriorating
• Transition to SGA (Plan B)
• SGA fails, BMV fails (Plan C)

Phase 3: CICO (3-5 minutes)

• CICO declared verbally
• Team transitions to FONA
• Scalpel-bougie-tube performed
• Confirmation and post-procedure care

Phase 4: Debrief (10-15 minutes)

• Structured debrief (what went well, what could improve)
• Focus on human factors and communication
• Technical skills review
• Psychological safety

Drill Frequency

Metrics to Track

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Special Populations

Paediatric Considerations

Key differences in children:

• SGA is often more successful as rescue device
• CTM is very small and more cephalad
• Needle cricothyroidotomy traditionally recommended for children under 8 years
• Jet ventilation through needle has high complication rate
• Consider tracheostomy if time permits and expertise available

Pregnancy

• Increased difficult airway risk: Airway oedema, breast hypertrophy, weight gain [28]
• Rapid desaturation: Reduced FRC, increased oxygen consumption
• Smaller ETT: Consider 6.5-7.0mm (mucosal oedema)
• Left lateral tilt: Maintain until airway secured
• Early escalation: Lower threshold for SGA and FONA
• Two patients: Maternal oxygenation is priority—foetus depends on mother
• Perimortem caesarean: Consider if cardiac arrest imminent (within 4 minutes)

Obesity

• High-risk group: BMV, intubation, SGA, AND FONA all more difficult [29]
• Ramped position essential: Ear at level of sternal notch
• Rapid desaturation: Reduced FRC, higher oxygen consumption
• Impalpable CTM likely: Prepare for large vertical incision
• VL first-line: Better views than direct laryngoscopy
• Second-generation SGA: Higher seal pressures needed
• Consider awake techniques: If predicted very difficult

Cervical Spine Injury

• Maintain MILS: Manual in-line stabilisation during intubation
• Remove front of collar: Allows mouth opening
• VL preferred: Better views with reduced neck movement
• Bougie essential: Anterior approach often needed
• FONA still possible: Neck stabilisation should not prevent life-saving FONA

Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Maori Considerations:

• Higher comorbidity burden: Diabetes (stiff joint syndrome), obesity, OSA—all increase difficult airway risk [18]
• Cultural safety: Explain all procedures clearly in plain language
• Family involvement: Involve family in decisions if patient wishes and time permits
• Interpreter services: Use trained interpreters for pre-procedure discussions when possible
• Remote communities: May present late with advanced pathology (large neck masses)
• Retrieval planning: Early RFDS consultation for predicted difficult airway
• Post-procedure support: Ensure culturally appropriate follow-up
• Shared decision-making: Respect patient and family autonomy
• Documentation: Record cultural considerations and family discussions

Remote community considerations:

• Limited equipment and expertise
• Telemedicine guidance for FONA
• SGA may be definitive airway for retrieval
• Lower threshold for early intubation before deterioration

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Remote/Rural Considerations

Resource-Limited Settings

RFDS Retrieval Considerations

• Early consultation: Call retrieval service for advice before difficult airway attempt
• Double setup: ALWAYS prepare for CICO before any induction
• Telemedicine guidance: Video link for real-time FONA coaching
• SGA for transport: Acceptable if ETT fails and patient oxygenating
• Documentation: Comprehensive handover for receiving team

Pre-Hospital Airway Management

• Paramedic scope varies: SGA and ETT skills depend on training level
• Environmental challenges: Poor lighting, patient access, movement
• Decision-making: SGA may be appropriate definitive airway for transport
• CICO in field: Scalpel-bougie-tube can be performed pre-hospital

Telemedicine Support

• Video call to airway expert (retrieval physician, anaesthetist)
• Real-time guidance through difficult situations
• FONA coaching: Step-by-step verbal instructions
• Available 24/7 via RFDS, state retrieval services

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Pitfalls and Pearls

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Viva Practice

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OSCE Scenarios

Station 1: CICO Declaration and FONA Technique

Format: Resuscitation/Procedural Time: 11 minutes Setting: ED resuscitation bay with airway manikin

Candidate Instructions:

You are the emergency physician in charge of a resuscitation. A 50-year-old male with epiglottitis has been induced for RSI. Multiple intubation and SGA attempts have failed. SpO2 is 55% and falling. The nursing staff have confirmed they cannot ventilate the patient by any means. Lead the management of this emergency and perform any necessary procedures.

Examiner Instructions:

• Manikin set up for FONA procedure with visible and palpable cricothyroid membrane
• CICO kit available (scalpel, bougie, 6.0 ETT, syringe, lubricant)
• Capnography device available
• Candidate should declare CICO verbally before proceeding
• At 5 minutes, prompt: "SpO2 is now 40%, what are you doing?"
• Observe technique and communication throughout

Actor/Patient Brief:

• Playing role of ED nurse
• When asked about situation: "We've tried face mask with two-person technique, i-gel size 4 and 5, three ETT attempts with video laryngoscope. SpO2 keeps dropping. Nothing is working."
• When candidate declares CICO: "What do you need me to get?"
• Hand equipment as requested, repeat back instructions

Marking Criteria:

Expected Standard:

• Pass: 7 or more out of 11
• Key discriminators: Early and clear CICO declaration, correct technique sequence, effective team leadership

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Station 2: Failed Intubation Escalation

Format: Simulation/Decision-making Time: 11 minutes Setting: ED resuscitation bay

Candidate Instructions:

You have just performed RSI on a 60-year-old female with sepsis. Your first intubation attempt with direct laryngoscopy and stylet has failed—you obtained a grade III view and could not pass the tube. SpO2 is 88% on apnoeic oxygenation. Describe your management to the examiner and demonstrate your approach.

Examiner Instructions:

• Manikin available but focus is on verbalisation and decision-making
• After second attempt description, say: "Your second attempt with VL and bougie has also failed. SpO2 is now 82%."
• After third attempt, say: "Third attempt has failed. SpO2 is 75%. What now?"
• After SGA description: "The i-gel is in but you cannot achieve adequate ventilation."
• Assess systematic approach and decision-making at each escalation point

Marking Criteria:

Expected Standard:

• Pass: 7 or more out of 11
• Key discriminators: Systematic optimisation, clear escalation pathway, verbalised communication

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Station 3: Team Leadership in Airway Emergency

Format: Communication/Leadership Time: 11 minutes Setting: ED resuscitation bay with team

Candidate Instructions:

You are the senior emergency physician called to assist with a difficult airway. A junior registrar has been attempting intubation for the past 5 minutes on a 40-year-old trauma patient. When you arrive, SpO2 is 65% and the registrar is about to make their 5th intubation attempt. Lead the team through this emergency.

Examiner Instructions:

• Actor playing junior registrar appears stressed, fixated on intubation
• Actor playing nurse available to assist
• Observe how candidate takes control without being dismissive
• Observe use of graded assertiveness concepts
• At 6 minutes, say: "SpO2 is now 50% and you cannot oxygenate by any means"

Actor Brief (Registrar):

• Appear stressed and fixated
• Say: "I almost had it, I just need one more try"
• Defer to candidate if they take control firmly
• If candidate doesn't take control quickly, make another attempt

Marking Criteria:

Expected Standard:

• Pass: 7 or more out of 11
• Key discriminators: Effective takeover without blame, clear team communication, appropriate escalation

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SAQ Practice

Question 1: CICO Recognition and Response (8 marks)

Stem: A 48-year-old male with angioedema is induced for emergency intubation. After three video laryngoscopy attempts with bougie, you cannot intubate. An i-gel has been inserted but ventilation is inadequate (SpO2 falling from 75% to 60%). Bag-mask ventilation has failed.

Question: Outline the key steps from this point. (8 marks)

Model Answer:

1. Declare CICO verbally (1 mark)

   • State loudly: "This is CICO. I am proceeding to front-of-neck access."

2. Call for help and assign roles (1 mark)

   • "You call for ENT/anaesthetics, you prepare CICO kit, you continue oxygenation attempts"

3. Position and identify landmarks (1 mark)

   • Extend neck, laryngeal handshake, identify cricothyroid membrane
   • If impalpable, prepare for large vertical incision

4. Vertical skin incision over CTM (1 mark)

   • 4-8cm vertical incision through skin

5. Horizontal stab through CTM (1 mark)

   • Transverse stab, turn blade 90 degrees to maintain opening

6. Insert bougie into trachea (1 mark)

   • Direct caudally, feel clicks of tracheal rings

7. Railroad 6.0mm cuffed ETT over bougie (1 mark)

   • Rotate 90 degrees anticlockwise during insertion

8. Confirm placement with capnography and secure (1 mark)

   • Inflate cuff, confirm with EtCO2, ventilate, document

Examiner Notes:

• Accept: Mentioning continuation of oxygenation attempts during FONA preparation
• Do not accept: Further upper airway attempts after CICO declared

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Question 2: Human Factors in Failed Intubation (6 marks)

Stem: The NAP4 report identified that human factors contributed to 40% of major airway complications.

Question: List 6 human factors that contribute to airway disasters and one strategy to mitigate each. (6 marks)

Model Answer:

1. Fixation error (0.5 marks) - Mitigation: Maximum attempt rules and cognitive aids (0.5 marks)

2. Poor communication (0.5 marks) - Mitigation: Closed-loop communication protocol (0.5 marks)

3. Failure to plan/prepare (0.5 marks) - Mitigation: Pre-intubation briefing with backup plan (0.5 marks)

4. Failure to call for help (0.5 marks) - Mitigation: Early senior/specialist involvement policy (0.5 marks)

5. Hierarchy gradient (0.5 marks) - Mitigation: Graded assertiveness training (PACE/CUS) (0.5 marks)

6. Task channelling/loss of situational awareness (0.5 marks) - Mitigation: Designated team member calling SpO2 and time (0.5 marks)

Examiner Notes:

• Accept alternative human factors: Cognitive overload, stress, fatigue, unfamiliar equipment
• Accept alternative mitigations: Simulation training, debriefing culture, equipment standardisation

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Question 3: Vortex Approach (6 marks)

Stem: The Vortex approach is an Australian cognitive aid for airway management.

Question: Describe the three "lifelines" in the Vortex approach and explain the concept of the "green zone" versus entry into the "CICO zone." (6 marks)

Model Answer:

Three Lifelines (3 marks - 1 mark each):

1. Face mask ventilation (BMV) - Bag-mask ventilation with adjuncts
2. Supraglottic airway (SGA) - Second-generation devices (i-gel, LMA)
3. Endotracheal tube (ETT) - Laryngoscopy and intubation

Green Zone (1.5 marks):

• Patient is being oxygenated via any of the three lifelines
• Team has time to troubleshoot and optimise
• Can make up to 3 "best efforts" at each lifeline
• Can move between lifelines as needed

CICO Zone (Dark Zone) (1.5 marks):

• All three lifelines have failed AND patient cannot be oxygenated
• No more upper airway attempts allowed
• Must proceed IMMEDIATELY to front-of-neck access (FONA)
• Any delay causes hypoxic brain injury or death

Examiner Notes:

• Accept: Description of non-linear nature (can enter at any lifeline)
• Key concept: CICO zone = immediate FONA, not more attempts

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Question 4: Drill Design (6 marks)

Stem: Your emergency department wants to implement regular failed intubation drills.

Question: Outline 6 key components of an effective failed intubation simulation drill. (6 marks)

Model Answer:

1. Clear learning objectives (1 mark)

   • Recognition of failed intubation, CICO declaration, FONA technique, team communication

2. Realistic scenario with progressive deterioration (1 mark)

   • Clinical context that makes sense, SpO2 drops, multiple failed attempts

3. Full team participation (1 mark)

   • Doctor (leader), nurses (assistant, drugs, documentation), allied health

4. Appropriate equipment (1 mark)

   • Airway manikin with FONA capability, all real equipment, cognitive aids displayed

5. Metrics and timing (1 mark)

   • Track time to CICO declaration, time to ventilation, number of attempts

6. Structured debrief (1 mark)

   • What went well, what could improve, psychological safety, documented learning

Examiner Notes:

• Accept: Regular frequency (every 3-6 months), faculty training, video review, psychological safety

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Question 5: Scalpel-Bougie-Tube Technique (6 marks)

Stem: Describe the scalpel-bougie-tube technique for emergency cricothyroidotomy.

Question: List the 6 key steps of the scalpel-bougie-tube technique in order. (6 marks)

Model Answer:

1. Position and landmark identification (1 mark)

   • Extend neck, laryngeal handshake, identify cricothyroid membrane

2. Vertical skin incision (1 mark)

   • 4-8cm vertical incision through skin over CTM

3. Horizontal stab through CTM (1 mark)

   • Transverse (horizontal) incision through cricothyroid membrane
   • Turn blade 90 degrees (sharp edge caudal) to maintain opening

4. Bougie insertion (1 mark)

   • Insert coude-tip bougie alongside blade into trachea
   • Direct caudally, feel for tracheal ring clicks

5. Tube railroading (1 mark)

   • Railroad 6.0mm cuffed ETT over bougie into trachea
   • Rotate 90 degrees anticlockwise during insertion

6. Confirmation and securing (1 mark)

   • Inflate cuff, confirm placement with capnography, secure tube

Examiner Notes:

• Accept: Mentioning impalpable CTM approach (large vertical incision first)
• Key: 6.0mm tube size, confirmation with capnography

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Australian Guidelines and Context

ARC/ANZCOR Guidelines

• ANZCOR Guideline 4: Airway management in cardiac arrest—SGA acceptable alternative to ETT in cardiac arrest [31]
• ANZCOR Guideline 11.6: Adult advanced life support—includes airway management principles
• Key message: ARC emphasises SGA as equivalent to ETT in cardiac arrest for non-expert airway providers

ANZCA Professional Documents

• PG56: Guidelines on Equipment to Manage a Difficult Airway During Anaesthesia [32]
• PS56: Recommendations on Checking Anaesthesia Delivery Systems
• Position on CICO: Scalpel-bougie-tube technique endorsed as primary FONA approach

DAS Guidelines (Adopted in Australia)

• DAS 2015: Difficult Airway Society guidelines for unanticipated difficult intubation in adults [21]
• DAS 2025: Updated guidelines with emphasis on video laryngoscopy first-line and human factors [33]
• Key differences from AHA: More emphasis on SGA in non-cardiac arrest situations

State-Specific Protocols

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References

Guidelines

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;115(6):827-848. PMID: 26556848

2. Lockey DJ, Crewdson K, Lossius HM. Pre-hospital emergency front-of-neck access: a systematic review. Scand J Trauma Resusc Emerg Med. 2014;22:5. PMID: 24423211

3. Flin R, Fioratou E, Frerk C, et al. Human factors in the development of complications of airway management: preliminary evaluation of an interview tool. Anaesthesia. 2013;68(8):817-825. PMID: 23738696

Key Evidence

4. Kristensen MS. Ultrasonography in the management of the airway. Acta Anaesthesiol Scand. 2011;55(10):1155-1173. PMID: 22092121

5. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012;59(3):165-175. PMID: 22050948

6. Kornas RL, Owyang CG, Sakles JC, et al. Evaluation and Management of the Physiologically Difficult Airway. Anesth Analg. 2021;132(2):395-405. PMID: 33060492

7. Marshall SD, Mehra R. The effects of a displayed cognitive aid on non-technical skills in a simulated 'can't intubate, can't oxygenate' crisis. Anaesthesia. 2014;69(7):669-677. PMID: 24796287

8. Naik VN, Brien SE. Review article: Simulation: a means to address and improve patient safety. Can J Anaesth. 2013;60(2):192-200. PMID: 23269400

9. Walls RM, Brown CA 3rd, Bair AE, Pallin DJ; NEAR II Investigators. Emergency airway management: a multi-center report of 8937 emergency department intubations. J Emerg Med. 2011;41(4):347-354. PMID: 20434289

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12. Joffe AM, Aziz MF, Posner KL, et al. Management of Difficult Tracheal Intubation: A Closed Claims Analysis. Anesthesiology. 2019;131(4):818-829. PMID: 31335549

13. Langvad S, Hyldmo PK, Nakstad AR, et al. Emergency cricothyrotomy - a systematic review. Scand J Trauma Resusc Emerg Med. 2013;21:43. PMID: 23718757

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16. Bernhard M, Mohr S, Weigand MA, et al. Developing the skill of endotracheal intubation: implication for emergency medicine. Acta Anaesthesiol Scand. 2012;56(2):164-171. PMID: 22060976

17. Fitzgerald M, Broder J, Pham K, et al. Remote airway management in emergency medicine. Emerg Med Australas. 2018;30(5):608-617. PMID: 29939438

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Appendix: Quick Reference Cards

CICO Algorithm Card

┌─────────────────────────────────────────────────────┐
│                   CICO PATHWAY                       │
├─────────────────────────────────────────────────────┤
│  RECOGNITION:                                        │
│  X Cannot intubate (3+1 attempts)                   │
│  X Cannot BMV (3 optimised attempts)                │
│  X Cannot SGA (3 optimised attempts)                │
│  X SpO2 falling, patient deteriorating              │
├─────────────────────────────────────────────────────┤
│  DECLARE:                                           │
│  "THIS IS CICO - FRONT-OF-NECK ACCESS NOW"          │
├─────────────────────────────────────────────────────┤
│  SCALPEL-BOUGIE-TUBE TECHNIQUE                      │
│  1. Position + laryngeal handshake                  │
│  2. Large VERTICAL skin incision (4-8cm)            │
│  3. HORIZONTAL stab through CTM                     │
│  4. Turn blade 90 degrees (edge caudal)             │
│  5. BOUGIE into trachea (feel rings)                │
│  6. TUBE 6.0mm over bougie                          │
│  7. Confirm with CAPNOGRAPHY                        │
└─────────────────────────────────────────────────────┘

Vortex Quick Reference

┌─────────────────────────────────────────────────────┐
│                 VORTEX APPROACH                      │
├─────────────────────────────────────────────────────┤
│  THREE LIFELINES (max 3 best efforts each):         │
│                                                     │
│  [FACE MASK] ←→ [SGA] ←→ [ETT]                     │
│                                                     │
│  GREEN ZONE = Oxygenating = Time to troubleshoot   │
│                                                     │
│  DARK ZONE = All failed + Cannot oxygenate = CICO  │
│                                                     │
│  DARK ZONE → IMMEDIATE FONA (no more attempts)     │
└─────────────────────────────────────────────────────┘

Graded Assertiveness (PACE)

┌─────────────────────────────────────────────────────┐
│              GRADED ASSERTIVENESS (PACE)             │
├─────────────────────────────────────────────────────┤
│  P - PROBE:     "What is our plan if this fails?"  │
│                                                     │
│  A - ALERT:     "I am concerned SpO2 is now 75%"   │
│                                                     │
│  C - CHALLENGE: "We need to stop and move to SGA"  │
│                                                     │
│  E - EMERGENCY: "STOP. We must do FONA NOW"        │
└─────────────────────────────────────────────────────┘

Equipment Checklist

┌─────────────────────────────────────────────────────┐
│           FAILED INTUBATION DRILL CHECKLIST          │
├─────────────────────────────────────────────────────┤
│  PRE-INTUBATION:                                    │
│  □ Difficult airway assessment (LEMON/MOANS)        │
│  □ Plan A, B, C, D discussed with team              │
│  □ VL ready with multiple blades                    │
│  □ Bougie at bedside                                │
│  □ SGA (i-gel size 3, 4, 5)                         │
│  □ CICO kit opened and checked                      │
│  □ Capnography connected                            │
│  □ Apnoeic oxygenation (nasal 15L/min)              │
│  □ Push-dose pressors drawn                         │
│  □ Most experienced operator identified             │
├─────────────────────────────────────────────────────┤
│  CICO KIT:                                          │
│  □ Scalpel (size 10 or 20 blade)                    │
│  □ Bougie (coude-tip)                               │
│  □ 6.0mm cuffed ETT                                 │
│  □ 10mL syringe                                     │
│  □ Water-based lubricant                            │
│  □ Tape or tie                                      │
└─────────────────────────────────────────────────────┘