START

❶ Check optimal airway management is in place and maintain anaesthesia: supply 100% oxygen either by tightly fitting facemask, supraglottic airway device or nasal high flow.

❷ Consider ONE final attempt at rescue oxygenation via upper airway if not already done.

❸ Declare CICO and call for help (additional staff and surgical airway expertise e.g. ENT, ICU).

❹ Call for airway rescue trolley and then cardiac arrest trolley.

❺ Give neuromuscular blocking drug now.

❻ Prepare for Front of Neck Access – FoNA (see Box B).

❼ Check that the patient is positioned with full neck extension.

❽ Operator position:

• Right-handed operator stands on patient’s left hand side.
• Left-handed operator stands on patient’s right hand side.

❾ Perform a ‘laryngeal handshake’ to identify the laryngeal anatomy.

❿ Perform FoNA using technique in Box C to intubate trachea via cricothyroid membrane. (If cricothyroid membrane cannot be identified, use technique in Box D).

⓫ Secure tube, continue to oxygenate patient and ensure adequate depth of anaesthesia.

Box A: CRITICAL CHANGES

Cardiac arrest → 2-1

Box B: EQUIPMENT INSTRUCTIONS

Airway rescue trolley, FoNA drawer:

• Scalpel with number 10 blade
• Bougie with coudé (angled) tip
• Tracheal tube, cuffed, 6mm

Box C: (STAB, TWIST, BOUGIE, TUBE TECHNIQUE)

Identify the cricothyroid membrane (If unable, go to Box D) 

• Single transverse incision through skin and membrane 
• Rotate scalpel 90^o with sharp edge facing caudally 
• Slide angled tip of bougie past the scalpel into the trachea 
• Railroad tube over bougie 

Box D: IF BOX C FAILS (SCALPEL, FINGER, BOUGIE TECHNIQUE)

• Make an 8-10 cm vertical incision head to toe orientation 
• Use blunt dissection to retract tissue to identify trachea 
• Stabilise the trachea and proceed as in Box C through the cricothyroid membrane