Cricothyroidotomy (front-of-neck access, FONA) - CICO scenarios
Cricothyroidotomy is a last‑resort, life‑saving intervention when a patient truly cannot be intubated and cannot be oxygenated despite appropriate optimisation and attempts with bag‑valve‑mask and supraglottic devices. Resuscitation Council UK recommends timely declaration of a CICO (can’t intubate, can’t oxygenate) situation and early use of a surgical FONA by a trained operator rather than prolonged repeated airway attempts (Resuscitation Council UK).
Decision trigger and immediate actions
- Declare CICO early when oxygenation cannot be restored by non‑surgical means after reasonable, time‑limited attempts.
- Call for immediate help (anaesthetics/ENT/surgical teams as available) and announce intent to perform FONA.
- Prepare the FONA kit and allocate roles: team leader, FONA operator (trained), assistant (retraction/stabilisation and handing instruments), oxygen/ventilation manager, and scribe/communicator.
- If a trained operator and equipment are immediately available, proceed to surgical FONA without undue delay.
- If a trained operator or equipment are not immediately available, perform temporising measures while transferring responsibility to a trained clinician (Resuscitation Council UK).
Minimal recommended FONA kit
- Scalpel with handle (size 10 or 11 blade).
- Gum‑elastic bougie.
- Appropriate cuffed tube for adult cricothyroidotomy (e.g., 6.0-6.5 mm endotracheal tube) or a dedicated cricothyroidotomy tube.
- Wide‑bore cannula (14-16G) and connector for temporary cannula oxygenation.
- High‑pressure oxygen delivery or jet ventilator connections (device dependent).