Paediatric Emergency Front of Neck Access in the Cannot Intubate Cannot Oxygenate Scenario

Protocols for Paediatric Emergency Front of Neck Access in the Cannot Intubate Cannot Oxygenate Scenario

Clinical Imperatives and the Evolution of Paediatric Airway Management

The management of a paediatric airway in the emergency department (ED) represents one of the most cognitively demanding and high-stakes scenarios in modern emergency medicine. While the incidence of a "Cannot Intubate, Cannot Oxygenate" (CICO) event in children is significantly lower than in the adult population, the physiological margins for error are substantially narrower, necessitating a level of preparedness that transcends standard procedural knowledge.[1, 2] In the United Kingdom, emergency physicians are guided by the Advanced Paediatric Life Support (APLS) framework, which has undergone a paradigm shift in recent years. This shift has increasingly moved away from needle-based interventions toward a primary surgical approach for emergency front of neck access (eFONA).[3, 4] This transition is predicated on a growing body of evidence suggesting that needle cricothyroidotomy, while frequently taught in the past, suffers from high failure rates—particularly in the hands of non-anaesthetists—due to the technical challenges of maintaining a stable airway through a small-bore cannula in a floppy, mobile paediatric larynx.[4, 5]

The fundamental goal of eFONA is the rapid restoration of alveolar oxygenation to prevent hypoxic brain injury and subsequent cardiac arrest.[6, 7] In a CICO scenario, the clinician has already exhausted the primary "lifelines" of airway management: face mask ventilation, supraglottic airway devices (SAD), and tracheal intubation.[1] The transition from these non-invasive or minimally invasive techniques to a surgical intervention is often delayed by complex psychological factors, including fixation on unsuccessful intubation attempts, a reluctance to perform an invasive procedure on a child, and a loss of time perception during high-stress events.[1, 6] Consequently, current UK guidelines emphasize a structured, algorithmic approach that removes the ambiguity of decision-making during the crisis, specifically bifurcating the technique based on whether the neck anatomy is palpable or non-palpable.[5, 8]

Physiological Architecture and Anatomical Development

Effective execution of eFONA requires a nuanced understanding of the developmental anatomy of the child. The paediatric airway is not merely a scaled-down version of the adult airway; it possesses distinct geometric and structural properties that dictate the success or failure of surgical access.[2, 4] These differences are most pronounced in infants and young children, where the larynx is situated more anteriorly and higher in the neck, typically at the level of the $C_2$ to $C_3$ vertebrae, compared to the $C_4$ to $C_5$ position in adults.[4] This cephalad position means the airway is often tucked under the mandible, making the angle for needle insertion nearly impossible to achieve without risking posterior wall perforation or damage to the epiglottis.[4] Furthermore, the cricothyroid membrane (CTM) in an infant is exceptionally small, often measuring less than $2.0\text{ mm}$ in vertical height.[4] This physical constraint renders traditional cricothyroidotomy kits impractical and necessitates a trans-tracheal approach for those with non-palpable landmarks.[4, 8]

Anatomical Feature	Infant / Young Child	Adolescent / Adult	Clinical Implication for eFONA
Laryngeal Position	$C_2-C_3$ (Higher/Anterior)	$C_4-C_5$ (Lower/Posterior)	Interference from mandible and higher risk of false passage.[4]
CTM Dimensions	$<2.0\text{ mm}$ Height	$8-12\text{ mm}$ Height	Surgical tractotomy often required over cricothyroidotomy.[4]
Tracheal Texture	Highly compliant, rubbery	Rigid, often calcified	Trachea may collapse or feel like a vessel under palpation.[5]
Neck Soft Tissue	Significant subcutaneous fat	Minimal relative adipose layer	Landmarks are frequently non-palpable in young children.[1, 5]
Epiglottis	Omega-shaped, long, floppy	U-shaped, shorter, rigid	Obstruction risk and trauma during blind instrumentation.[9]
Narrowest Site	Cricoid cartilage (Non-distensible)	Glottis (Vocal cords)	Resistance often met distal to the cords in small children.[9]

The urgency of eFONA is compounded by the paediatric patient’s physiological predisposition to rapid desaturation. Children have a higher metabolic rate, with oxygen consumption reaching $6-8\text{ mL/kg/min}$, roughly double that of an adult.[9] Conversely, their functional residual capacity (FRC), which acts as the primary oxygen reservoir during apnoea, is smaller relative to their body size.[9] This combination results in a precipitous drop in oxygen saturation ($Sp{O}_2$) once ventilation ceases. In the context of a CICO event, where multiple attempts at ventilation have already failed, the child is likely already on the steep portion of the oxyhaemoglobin dissociation curve, leaving the clinician with mere seconds to establish a surgical airway before irreversible bradycardia and arrest occur.[7, 10] Furthermore, neonates have a short and collapsible trachea of approximately $5\text{ cm}$ in length, meaning that even a successful eFONA carries a significant risk of endobronchial intubation or inadvertent decannulation if not meticulously secured.[9]

The Pathway to the Can't Intubate Can't Oxygenate Declaration

The declaration of a CICO state is the most critical step in the eFONA protocol. Failure to recognize the transition from a difficult airway to a CICO scenario is a leading cause of morbidity in UK emergency departments.[6, 7] To standardise this transition, many institutions adopt the "Vortex Approach" as a cognitive aid. This model visualizes airway management as a whirlpool leading toward a central "CICO" zone, where the clinician must navigate through three non-surgical lifelines: face mask, supraglottic airway, and endotracheal tube.[1]

Optimization of Non-Surgical Lifelines

Before declaring CICO, the clinician must ensure that "best efforts" have been made with each of the three lifelines. Optimization of these lifelines is essential to prevent unnecessary surgical intervention, which itself carries risks of haemorrhage and tracheal trauma.[1, 6] Face mask ventilation requires a two-person technique, the use of oropharyngeal and nasopharyngeal airways, and optimal head positioning.[9] In infants under two years, this involves a shoulder roll to compensate for the large occiput, while in older children, a flat or sniffing position is preferred.[9] The choice of a supraglottic airway device must be age-appropriate, with second-generation devices featuring gastric drainage ports being preferred to reduce the risk of aspiration and allow for higher peak inspiratory pressures.[9] Tracheal intubation attempts should be limited to a maximum of two or three to avoid airway trauma and oedema, with video laryngoscopy recommended early in the sequence to improve first-pass success.[2, 9, 11]

If these three lifelines fail to maintain an $Sp{O}_2$ above $90\%$, or if the child is rapidly bradycardic, the CICO state must be declared loudly and clearly to the entire resuscitation team.[1, 5] This verbal declaration serves as a shared mental model, signaling the immediate transition to the eFONA protocol and the preparation of surgical equipment.[1, 7]

Anatomical Identification and the Laryngeal Handshake

The differentiation between a surgical cricothyroidotomy and a surgical tractotomy depends entirely on the clinician’s ability to palpate the laryngeal landmarks. In many children, particularly those under age eight or those with a high Body Mass Index (BMI), the CTM and tracheal rings are obscured by a thick layer of subcutaneous fat, making traditional palpation unreliable.[5, 12] For children with a BMI in the normal range, actual body weight should be used for calculations, but for those with a high BMI, ideal body weight is often used for drug dosing during resuscitation.[12]

The Three-Step Palpation Technique

The "Laryngeal Handshake" is the gold-standard method for anatomical identification recommended by the Difficult Airway Society (DAS) and integrated into UK paediatric protocols.[6, 13] This technique involves a systematic three-step approach. First, the clinician stabilizes the larynx using the non-dominant hand, grasping it with the thumb and middle finger. This prevents the mobile paediatric airway from rolling during the procedure.[5, 13] Second, the hand moves superiorly from the sternal notch or inferiorly from the hyoid bone to identify the prominent thyroid cartilage "shield".[13] Finally, the index finger slides down into the depression of the CTM. In older children, this is a distinct "dip" between the thyroid and cricoid cartilages.[6, 13] If this handshake does not yield a clear, unambiguous identification of the CTM, the anatomy is deemed non-palpable, and the clinician must proceed to the surgical tractotomy arm of the APLS algorithm.[4, 5, 8]

Surgical Cricothyroidotomy for Palpable Anatomy

For the older child or the child with thin neck habitus where landmarks are easily identified, a scalpel-bougie-tube cricothyroidotomy is the preferred technique.[6, 8] This method leverages the clinician’s familiarity with bougie-assisted intubation and provides a definitive, cuffed airway that allows for conventional positive pressure ventilation.[6, 14]

Equipment and Preparatory Requirements

A standardized eFONA kit should be immediately available in the ED, containing equipment stratified by the child's age and weight.[8] This typically includes a size 10 or 15 scalpel blade, a paediatric-sized bougie ($5\text{ or }10\text{ Fr}$ depending on age), and a cuffed endotracheal tube.[5] For children, the tube size is typically $0.5\text{ to }1.0\text{ mm}$ smaller than the predicted oral ETT size.[4, 8]

Equipment Component	Specification for Paediatric eFONA	Rationale in CICO Scenario
Scalpel Blade	Number 10 or 15.[5]	Provides precision for small anatomical targets.
Bougie	$5\text{ Fr}$ (Infant) / $10\text{ Fr}$ (Child).[8]	Tactile confirmation of tracheal rings ("clicks").[5]
Endotracheal Tube	Cuffed, size $3.0-5.5\text{ mm}$ ID.[8]	Protects against aspiration and allows higher pressures.[14]
Stabilization	Towel clips or heavy silk sutures.[4, 5]	Prevents the trachea from receding into the soft tissue.
Confirmation	Side-stream or in-line capnography.[5]	Gold standard for confirming intratracheal placement.

Procedural Execution

The procedure begins with the neck in maximum extension. While neck extension is generally avoided in trauma, it is mandatory in the CICO state to bring the anterior structures closer to the skin and increase the vertical height of the CTM.[4, 5] A transverse (horizontal) incision is made through the skin and the CTM simultaneously. In the palpable airway, the index finger of the non-dominant hand remains on the CTM to guide the blade, ensuring the incision is centered.[5, 13] The scalpel handle can then be inserted into the incision and rotated $90$ degrees to open the space, or the index finger can be used to maintain the tract.[13] The bougie is passed into the trachea, and the clinician should feel for "clicks" as it moves over the tracheal rings to confirm placement.[5] The ETT is lubricated and passed over the bougie, with care taken not to advance it too far to avoid endobronchial intubation.[4, 9] Cuff inflation is immediately followed by capnography confirmation.[5, 6]

Surgical Tractotomy for Non-Palpable Anatomy

In the younger child or the infant where the CTM is not identifiable—a situation often exacerbated by the "fatty neck" of early childhood—a surgical tractotomy (emergency tracheotomy) is performed.[4, 5] This technique prioritizes finding the trachea via a midline vertical approach rather than attempting to hit a microscopic, non-palpable CTM target.[4] In neonates and infants, a trans-tracheal approach is considered significantly safer than a cricothyroid approach due to the higher position of the larynx and the narrowness of the subglottic space.[4]

The Midline Vertical Approach

The use of a vertical incision is paramount in the non-palpable airway. A horizontal incision in an anatomy-blind scenario carries a significant risk of damaging the carotid arteries or internal jugular veins, which sit laterally to the trachea in children.[5] A vertical incision, conversely, allows the clinician to extend the wound superiorly or inferiorly if the trachea is not immediately located.[5]

Technical Execution of Tractotomy

The procedure involves a long vertical incision ($2-4\text{ cm}$) in the midline, starting from the thyroid cartilage and extending down toward the sternal notch. The clinician must strictly avoid the bottom 25% of the neck, as the innominate vein and artery can rise high in children, often above the sternal notch.[5] Using blunt dissection with fingers or gauze, the clinician clears the pre-tracheal fat and fascia. Although bleeding will be significant, the clinician must rely on touch to feel the "corrugated" texture of the tracheal rings.[4, 5] Because the paediatric trachea is small and mobile, it may disappear into the wound once incised. APLS recommends using towel clips to grasp the tracheal rings and pull them anteriorly, or placing heavy silk stay sutures on either side of the intended incision site to maintain the stoma.[4, 5] A vertical incision is made through two tracheal rings; a horizontal cut is strictly avoided here to prevent complete transection of the small airway.[5] The ETT is then inserted directly into the trachea, often guided by a finger or a bougie.[4, 5]

Critical Appraisal of Needle Cricothyroidotomy

Historically, needle cricothyroidotomy was the primary recommendation for children under age eight due to concerns over permanent laryngeal damage from surgical intervention.[3, 14] However, the current UK perspective has largely relegated needle access to a "bridge" or secondary option.[3, 5] The failure of needle techniques in paediatrics is often attributed to the "kinking" of the cannula as the child moves or during attempts at ventilation.[4] Furthermore, standard syringes and cannulas do not allow for the clearance of secretions or blood, leading to rapid occlusion.[4]

If a needle approach is attempted, it must be performed with a specialized, kink-resistant cannula such as a Ravussin catheter (16 G for babies, 14 G for children).[4] Needle access requires high-pressure jet ventilation to overcome the resistance of the small cannula, which introduces the risk of barotrauma and pneumothorax, especially if the upper airway is completely obstructed.[4, 14] The Manujet III or similar devices must be set to the lowest delivery pressure initially and up-titrated slowly while ensuring enough time for full passive expiration through the upper airway.[4, 14]

Age Group	Cannula Gauge	Jet Pressure (Bar)	Passive Expiration Requirement
Baby / Infant	$16\text{ G}$	$0.5-1.0$	Mandatory upper airway patency.[4, 14]
Young Child	$14\text{ G}$	$1.0-2.5$	Slow titration to achieve chest rise.[4, 14]
Adolescent / Adult	$13\text{ G}$	$2.5-4.0$	High risk of barotrauma if obstructed.[14]

Human Factors and Crisis Resource Management in the ED

The technical ability to perform eFONA is irrelevant if the clinician cannot overcome the psychological barriers to making the "Cannot Intubate, Cannot Oxygenate" declaration. CICO scenarios are characterized by task fixation, where the team continues to attempt intubation while the child's heart rate drops precipitously.[1, 6] Psychological factors such as fear, denial, pride, and a loss of situational awareness can act as significant barriers to performing eFONA.[1]

To mitigate cognitive load, UK emergency departments emphasize clear role definition and the use of cognitive aids.[8, 12] One clinician, the primary airway lead, continues rescue oxygenation attempts from above using a bag-valve mask or supraglottic device, while a second clinician, the surgical lead, prepares the neck and equipment for eFONA.[5] Once the surgical lead begins the incision, a "stop-start" rule is often applied, where all other attempts at intubation must cease to ensure a stable surgical field.[5] The use of displayed algorithms and checklists has been shown to decrease cognitive load and improve the speed of CICO resolution.[8, 12]

Post-Procedural Management and Stabilization

Securing the front-of-neck airway is merely the beginning of the stabilization phase. The surgical airway in a child is inherently unstable and prone to displacement due to the short length of the trachea and the mobility of the neck.[5, 9] Once the airway is secured, the child must be provided with adequate sedation, paralysis, and analgesia to prevent bucking or coughing, which could dislodge the tube.[4, 15]

The "DOPES" mnemonic (Displacement, Obstruction, Pneumothorax, Equipment failure, Stoma/tube size) should be used for systematic assessment if perioperative desaturation occurs after the airway is secured.[9] Because of the high risk of accidental decannulation, stay sutures or maturation sutures (connecting the tracheotomy to the skin) are often utilized in elective paediatric tracheostomies to facilitate rapid re-intubation; in an emergency ED setting, taping these sutures to the chest can provide a "safety line" if the tube is lost.[1, 5] All patients who receive eFONA in the ED require urgent transfer to a theatre setting for a formal tracheostomy or definitive surgical repair by an ENT or paediatric surgeon.[1, 8]

Emerging Technologies and Advanced Airway Mapping

The use of point-of-care ultrasound (POCUS) to map the CTM before an airway crisis occurs is an emerging trend in UK emergency medicine.[6, 13] The "TACA" protocol (Thyroid, Airline, Cricoid, Airline) allows a clinician to identify the CTM even in a neck with difficult-to-palpate landmarks.[6] This involves placing a high-frequency linear probe transverse on the neck to identify the triangular thyroid cartilage, moving caudally to the hyperechoic "airline" of the CTM, and further caudally to the "black lying C" of the cricoid cartilage.[6]

While ultrasound is a powerful tool for predicting difficult airways and confirming tracheal intubation, it should never delay airway access in an emergency CICO scenario.[6, 13] However, in patients with known high-risk features—such as craniofacial syndromes, micrognathia, or a weight less than $10\text{ kg}$—pre-emptively marking the CTM using ultrasound is considered a best practice that can significantly reduce the time to successful eFONA if the airway is lost.[6, 9, 15]

Clinical Synthesis of the UK Approach to Paediatric eFONA

The approach to paediatric eFONA in the UK emergency department has evolved into a highly structured, anatomy-driven protocol. The transition from a needle-first to a surgical-first mindset for children reflects a pragmatic acknowledgment of the technical limitations of cannulas and the absolute necessity of reliable alveolar oxygenation.[3, 4, 5] By categorizing the patient into palpable or non-palpable cohorts, the APLS guidelines provide clear pathways that minimize decision-making delay.

For the older child with palpable landmarks, the scalpel-bougie-tube cricothyroidotomy offers a familiar and definitive airway.[6, 8] For the infant or the child with an indistinct neck, the surgical tractotomy via a vertical midline incision provides a robust method to find the airway when seconds matter.[4, 5] The success of these interventions is ultimately tied to the team’s ability to recognize the CICO state early, utilize cognitive aids like the Vortex approach, and maintain proficiency through regular, high-fidelity simulation.[1, 8, 10] While the surgical airway in a child is a rare requirement, it remains the ultimate fail-safe in the emergency physician's repertoire, a procedure where precision and psychological readiness are the final barriers between the patient and a catastrophic outcome.[5, 7]

Developmental Milestones and Airway Sensitivity

The paediatric airway undergoes significant morphological changes from birth through adolescence, each stage presenting unique challenges for front-of-neck access. In the neonatal period, the trachea is not only short but also highly compliant, meaning that external pressure—such as that from a heavy hand during palpation—can lead to total airway collapse.[5, 9] As the child grows, the larynx moves inferiorly, and the cartilaginous structures become more rigid and identifiable.[4, 13]

Age / Developmental Stage	Laryngeal Level	CTM Height	Primary eFONA Risk
Neonate (0–28 days)	$C_2-C_3$	$<1.5\text{ mm}$	Tracheal collapse and endobronchial intubation.[4, 9]
Infant (1 month – 1 year)	$C_3$	$1.5-2.0\text{ mm}$	Mandibular interference and non-palpable landmarks.[4]
Young Child (1–8 years)	$C_3-C_4$	$2.0-5.0\text{ mm}$	Thick subcutaneous fat layer obscuring the CTM.[1, 5]
Adolescent (> 12 years)	$C_4-C_5$	$>8.0\text{ mm}$	Anatomically similar to adults; risk of calcification.[6, 13]

Understanding these milestones allows the clinician to anticipate the likely arm of the APLS algorithm they will need to follow. For instance, in children under age eight, the consensus increasingly favors formal tracheotomy (surgical tractotomy) if an ENT surgeon is present, but requires the emergency physician to be prepared for the same procedure if ENT is unavailable.[1, 4]

Psychological Barriers and the "Can't" Declaration

One of the most profound challenges in paediatric CICO management is the phenomenon of task fixation and the "human performance" factors that lead to delays.[1, 3] Research indicates that airway practitioners often struggle with the "declaration of failure." This is often rooted in a fear of the surgical procedure itself, which is perceived as more invasive and potentially damaging than repeated intubation attempts.[1, 6] However, in the ICU and ED settings, death secondary to failed oxygenation typically occurs within 45–60 minutes of the first airway intervention, highlighting that the delay in eFONA, rather than the technique itself, is the primary driver of mortality.[6]

The Role of Situational Awareness

Situational awareness (SA) is often the first casualty of a difficult airway event. Clinicians may lose track of time, believing only seconds have passed when minutes have actually elapsed.[1] To combat this, the UK protocol encourages the use of explicit time limits for FONA attempts and the incorporation of extracorporeal membrane oxygenation (ECMO) if available in the tertiary setting, although ECMO remains a rare resource in the acute ED phase.[10] The "Vortex" approach acts as a physical and mental guard against SA loss, providing a visual boundary where "the green zone" of safety ends and the surgical "red zone" begins.[1]

Technical Variations in Surgical Tractotomy

The surgical tractotomy, while conceptually simple, requires high technical precision to avoid the lateral vascular structures and the posterior tracheal wall. The "stab and slide" technique is often discouraged in paediatrics; instead, a more controlled dissection is preferred.[4, 5]

Stay Sutures vs. Towel Clips

A critical debate in paediatric surgical airways involves the stabilization of the trachea once the incision is made. In elective paediatric tracheostomies, stay sutures (long silk threads) are placed through the tracheal wall on either side of the vertical incision.[1] These sutures act like "parachute cords," allowing the clinician to pull the trachea up and open the stoma immediately if the tube is dislodged.[1] In the emergency setting, towel clips are a faster alternative, providing the necessary anterior traction to prevent the small, rubbery trachea from receding into the bloody surgical field.[4]

Managing Hemorrhage

The paediatric neck is highly vascular, and an emergency incision will inevitably lead to significant bleeding. Clinicians are taught to "expect a bloody procedure" and not to be distracted by it.[5] The priority is establishing the airway; once the ETT is in place and the cuff is inflated, the pressure from the tube itself and the restoration of oxygenation will often help slow the bleeding.[5, 6] The use of good lighting, suction, and an assistant to provide horizontal traction on the skin is invaluable, though clinicians must be prepared to proceed by touch if the view is entirely obscured.[5]

Comprehensive Equipment Standardization

In the UK ED, the standardization of the "Difficult Airway Trolley" is a key safety initiative. The eFONA box should be a distinct, easily identifiable part of this trolley, containing age-specific laminated algorithms and the necessary surgical tools.[8]

Age Group	Scalpel Size	Bougie Size	ETT Size (ID)	Secondary Rescue
< 1 Year	15 Blade	$5\text{ Fr}$	$3.0-3.5\text{ mm}$	16 G Ravussin.[4, 8]
1–5 Years	10 Blade	$5\text{ or }10\text{ Fr}$	$4.0-4.5\text{ mm}$	14 G Ravussin.[4, 8]
5–12 Years	10 Blade	$10\text{ Fr}$	$5.0-6.0\text{ mm}$	14 G Ravussin.[4, 8]
> 12 Years	10 Blade	$10\text{ Fr}$	$6.5-7.5\text{ mm}$	13 G Ravussin.[4, 14]

The equipment must be checked daily, and every member of the trauma team should know its location. This physical readiness reduces the "activation energy" required to transition to surgery during a CICO event.[4, 6]

The Role of Specialty-Specific Training

Training in paediatric eFONA is complicated by the rarity of the event. Most clinicians will never perform a paediatric surgical airway in their entire career, yet they must be ready to do so at any moment.[1, 7, 10] Simulation-based medical education (SBME) is the cornerstone of competency maintenance. In the UK, multi-disciplinary practice involving emergency doctors, anaesthetists, and ENT surgeons is highly recommended.[4, 6]

High-fidelity simulation using 3D-printed laryngeal models covered with artificial skin has been shown to improve clinician confidence in navigating the APLS algorithm and performing the technical steps of a tractotomy.[8] These sessions focus not just on the "how" of the procedure, but the "when," emphasizing the cognitive transitions and the verbal declarations required to lead a team through a CICO crisis.[7, 8]

Legal, Ethical, and Family-Centred Considerations

In the UK, the management of a critically ill child in the ED must always consider the presence of parents or persons with parental responsibility.[12] While a CICO scenario is chaotic, APLS guidelines recommend allowing parents to stay with the child if it does not preclude the safety of the child or the personnel.[12] A dedicated staff member should be assigned to support the family during the procedure, explaining the necessity of the surgical airway in simple terms.

Following a CICO event, the clinical team must engage in a structured debriefing. The psychological impact of such a high-stress, rare event on the staff is significant, and the "near-miss" or the successful rescue both offer critical learning opportunities.[2, 12] Prognostication following a period of hypoxia should be withheld for at least 72 hours in comatose children, utilizing a multimodal approach to assess neurological recovery once the airway and cardiovascular system are stabilized.[12]

Summary of Clinical Recommendations for the UK Emergency Department

The approach to paediatric eFONA requires a synthesis of anatomical knowledge, technical skill, and psychological resilience. The following recommendations consolidate the current best practices for UK emergency physicians:

1. Immediate Recognition: Use the Vortex Approach to monitor airway "lifelines" and declare a CICO event as soon as oxygenation cannot be maintained by face mask, SAD, or ETT.[1, 6]
2. Anatomical Assessment: Perform the "Laryngeal Handshake" to determine if the anatomy is palpable or non-palpable.[6, 13]
3. Bifurcated Pathway: If palpable, proceed with a horizontal scalpel-bougie-tube cricothyroidotomy.[6, 8] If non-palpable, perform a vertical midline surgical tractotomy.[4, 5]
4. Surgical Tractotomy Precision: Ensure the incision is in the midline, avoid the lower 25% of the neck, and use towel clips or stay sutures to stabilize the mobile trachea.[4, 5]
5. Confirmation and Stabilization: Confirm intratracheal placement with capnography and secure the tube meticulously, ensuring post-procedural sedation and paralysis.[4, 5, 9]
6. Continuous Training: Engage in regular multi-disciplinary simulation to maintain the technical skills and cognitive readiness for this rare but devastating emergency.[7, 8, 10]

By adhering to these protocols, the emergency physician can transform a chaotic and life-threatening crisis into a controlled, disciplined surgical rescue, ensuring the best possible outcome for the most vulnerable of patients.

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1. A Simplified Approach to Managing the Difficult Airway in Children ..., https://dontforgetthebubbles.com/a-simplified-approach-to-managing-the-difficult-airway-in-children/
2. Management of the difficult airway in the pediatric patient — review of existing scales | Mikolap | Disaster and Emergency Medicine Journal, https://journals.viamedica.pl/disaster_and_emergency_medicine/article/view/DEMJ.a2023.0025/75727
3. Training for Pediatric Cannot Intubate Cannot Oxygenate: Surgical Airway Should Replace Needle Cricothyrotomy - Frontiers, https://www.frontiersin.org/journals/disaster-and-emergency-medicine/articles/10.3389/femer.2026.1772381/full
4. Major Trauma: Emergency Surgical Airway - Paediatric - wymtn, https://www.wymtn.com/uploads/5/1/8/9/51899421/wymtn_paed_surgical_airway_1.2.pdf
5. Pediatric front of neck access (the surgical tracheotomy) - First10EM, https://first10em.com/pediatric-front-of-neck-access/
6. Emergency front of neck access in airway management - PMC - NIH, https://pmc.ncbi.nlm.nih.gov/articles/PMC7807984/
7. Emergency Front of Neck Access - Indian Journal of Respiratory Care, https://www.ijrc.in/abstractArticleContentBrowse/IJRC/31018/JPJ/fullText
8. Impact of a departmental protocol and training on physician confidence in paediatric emergency front of neck access - PMC, https://pmc.ncbi.nlm.nih.gov/articles/PMC11798368/
9. The Paediatric Airway (Chapter 23) - Core Topics in Airway Management, https://www.cambridge.org/core/books/core-topics-in-airway-management/paediatric-airway/09F9DFAE1D603233A629738F1C4EF571
10. Emergency Front-Of-Neck Access in the Pediatric Intensive Care Unit: Development of an Institutional Protocol - PubMed, https://pubmed.ncbi.nlm.nih.gov/41195791/
11. A Primer for Pediatric Emergency Front-of-the-Neck Access - PMC, https://pmc.ncbi.nlm.nih.gov/articles/PMC8083165/
12. Paediatric Life Support (basic and advanced) - View PDF, https://www.resus.org.uk/print/pdf/node/36439
13. Cricothyroidotomy - StatPearls - NCBI Bookshelf - NIH, https://www.ncbi.nlm.nih.gov/books/NBK537350/
14. Front of Neck Airway (FONA) (Chapter 20) - Core Topics in Airway Management, https://www.cambridge.org/core/books/core-topics-in-airway-management/front-of-neck-airway-fona/59EDD0B40C1CC7DFFB11DA054F24F3DB
15. (PDF) An elective Front-of-neck-access as an escape room in a case of tumour obstructing the airway in a child - ResearchGate, https://www.researchgate.net/publication/397844755_An_elective_Front-of-neck-access_as_an_escape_room_in_a_case_of_tumour_obstructing_the_airway_in_a_child_a_case_report

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