Emergency front-of-neck access: scalpel or cannula—and the parable of Buridan’s ass †

Maintaining oxygenation is the principal purpose of airway management. Oxygen delivery in airway crises is aimed at preventing cardiac arrest and limiting hypoxic consequences before quickly moving on to secure the airway or wake the patient up if appropriate. Currently, there is debate¹² concerning the most appropriate method to facilitate oxygenation during a 'can't intubate, can't oxygenate' (CICO) scenario while a definitive airway is secured. Emergency front-of-neck access (FONA) courses include a critical analysis of cannula cricothyroidotomy as part of their curricula. This has been driven by widespread acceptance and teaching of Heard's algorithm.³ However, concerns^124–6 have been raised over the high failure rate of cannula cricothyroidotomy in CICO management when compared with surgical access, and its future omission has been advocated. The Canadian Airway Focus Group⁷ excludes cannula cricothyroidotomy from their recommendations unless the clinician is very experienced with jet ventilation. They state that options should be limited to either the percutaneous needle-guided wide-bore cannula or an open surgical technique.

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