This Skill Station will cover:
Priming for neck rescue
Cannula, Seldinger and surgical cricothyroidotomy
“Neck rescue” is the contemporary and preferred term for an emergency cricothyroidotomy performed as a definitive, last-resort rescue technique in airway management. It is also referred to in the literature by other designations, including “CICO” (Can’t Intubate, Can’t Oxygenate) rescue, infraglottic rescue, emergency surgical airway, and “eFONA” (emergency front of neck access). This intervention is the final step in a structured airway algorithm, serving as “Plan D” in the linear Difficult Airway Society (DAS) algorithm and as the ultimate technique in the “Vortex approach,” to be employed only after best efforts have failed with other methods.
A “CICO” situation is formally declared when airway obstruction in the upper airway (including the larynx) cannot be alleviated by interventions delivered above the point of obstruction, leading to a complete inability to oxygenate the patient. In such a time-critical scenario, profound hypoxia will rapidly lead to brain injury, cardiac arrest, and death unless oxygenation can be restored via the anterior neck. This module outlines the various techniques and the critical decision-making process involved in this vital procedure
The criteria that need to be fulfilled before a CICO situation is declared are covered in Algorithms and Checklists
The anatomical target for neck rescue is the cricothyroid membrane, a readily accessible, avascular space that allows for the placement of a tube or cannula directly into the trachea, bypassing the upper airway obstruction. The three fundamental methods are categorized by the size of the device used for entry.
1. Small Cannula Techniques
These techniques utilize a narrow cannula (2-3 mm, such as a BD Insyte™ 14G) connected to a high-pressure gas source (e.g., a Meditech Rapid-O2™ device) for oxygen delivery.
BD Insyte™ cannula
BD Insyte™ cannula
- 14G cannula
- Luer lock
- Kink resistant
- Can withstand high pressure O2
Rapid-O2™ device
Rapid-O2™ device
- High-pressure O2 insufflation device
- Occlude port with thumb to insufflate
- Release thumb for exhalation
- Luer lock
These methods rely on a patent airway for exhalation, as the small cannula is only capable of delivering gas under high pressure. Time and care must be taken to allow for passive exhalation and for intrathoracic pressure to return to normal between breaths. In CICO situations, the airway is usually, but not always, patent for exhalation.
The delivery of high-pressure gas carries inherent risks, and complications such as surgical emphysema, pneumothorax, and pneumomediastinum are common.
While the Australian and New Zealand College of Anaesthetists (ANZCA) recommends a needle-first approach, most international guidelines and the limited evidence on success rates favour surgical techniques. As anaesthetists are very often involved in difficult airway cases, all critical care practitioners should be familiar with the equipment used for small cannula techniques.
Small Cannula Insertion Video
This video is copyrighted and cannot be downloaded or reproduced without permission from Dr Andrew Heard
2. Large Cannula Techniques
These techniques employ a larger cannula (4-5 mm), which may be cuffed or uncuffed, and can connect directly to a standard manual resuscitator or a gas circuit.
Melker™ Kit
Melker™ Kit
- Seldinger kit
- Needle, guidewire, dilator
- Cuffed option: size 5.0 ID
- Cuffless options – size 3.5/4.0/6.0 ID
- Can be used to convert small cannula
A Seldinger-type technique, such as the Melker™ system, is often used. This approach is favoured by some intensivists due to its procedural similarity to percutaneous dilatational tracheostomy.
Uncuffed cannulas can provide effective oxygenation but may not generate adequate driving pressure for full ventilation
Large Cannula Insertion Video
This video is copyrighted and cannot be downloaded or reproduced without permission from Dr Andrew Heard
3. Surgical Techniques
These methods result in the placement of a larger, definitive airway with a cuffed tracheal tube (typically 6.0-7.0mm) that allows for full mechanical ventilation. They are generally considered faster and simpler than a formal tracheostomy in an emergency setting.
Scalpel-bougie-tube
Scalpel-bougie-tube
- Size 10 retractable blade scalpel
- Bougie with Coude tip
- Size 6.0-7.0mm ETT
The technique involves a vertical incision through the skin and subcutaneous tissue, followed by a horizontal incision through the cricothyroid membrane. A gloved finger is then inserted to provide controlled dilatation and tactile feedback, feeling for the edges of the thyroid and cricoid cartilages. The tracheal tube can then be inserted either under direct vision or by guiding a bougie along the fingertip.
Scalpel-bougie-tube Video
Given the rare occurrence of cricothyroidotomy in clinical practice, the evidence for the superiority of one technique over another is largely limited to studies on manikins, cadavers, case series, and audits. However, the limited evidence that is available suggests that surgical techniques have better success rates and a lower rate of complications than small cannula techniques.
- International Consensus: As a result, most international guidelines, including those from the Difficult Airway Society (DAS), recommend a surgical neck rescue technique, specifically the “scalpel-bougie-tube” method.
- Regional Variations: The Australian and New Zealand College of Anaesthetists (ANZCA) guidelines, in contrast, recommend a needle-first approach.
The Critical Care Airway Management (CCAM) approach to neck rescue is a systematic, anatomically guided process. It begins with the “laryngeal handshake,” a physical examination to determine if the anatomy of the cricothyroid membrane is palpable.
Palpable Anatomy: If the cricothyroid membrane is clearly palpable, it can be marked at this point.
Non-palpable Anatomy: If the anatomy is not palpable, a long vertical incision should be made. Some experts advocate for a vertical incision in all patients to standardise the technique.
