Episode 19: Surgical Airway

surgical airway


The West Midlands surgical skills course offers cadaveric training for PHEM and EM practitioners on rare life saving procedures. Click here to go straight to their page.


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The Guidelines

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Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. C. Frerk et al. Difficult Airway Society: Intubation guidelines working group. British Journal of Anaesthesia, 115 (6): 827–848 (2015) doi:10.1093/bja/aev371

For more information, have a look at the Difficult Airway Society website.

AAGBI Safer Prehospital Anaesthesia

Click here for the 2017 guidelines

The Kit

Know what your service carries, practice with that equipment, then you will be familiar with the kit you are using in the heat of the moment.


Minimal kit: scalpel, bougie, tube

Tracheal dilators and tracheal hook

The Technique

For a demonstration of the DAS recommended technique for surgical front of neck access, have a look at this video, recorded by colleagues over at openairway.org:

Just a Routine operation

The video we mention in the podcast produced by Martin Bromiley after the death of his wife, Elaine, in a can’t intubate can’t oxygenate scenario is available here:


And have a look at the website for more of Martin’s work with the Clinical Human Factors group.

Other fantastic #FOAM resources regarding airway management are available:

From Nicholas Chrimes  at http://vortexapproach.org

From the fabulous people over at Life in the Fast Lane including a video demo from Scott Weingart from EMCrit: https://lifeinthefastlane.com/ccc/surgical-cricothyroidotomy/


This is Tim’s recent publication we mention in the ‘cast!: Nutbeam, T., Clarke, R., Luff, T., Enki, D. and Gay, D. (2017), The height of the cricothyroid membrane on computed tomography scans in trauma patients. Anaesthesia. doi:10.1111/anae.13905

Aslani, A., Ng, S.-C., Hurley, M., McCarthy, K. F., McNicholas, M., & McCaul, C. L. (2012). Accuracy of identification of the cricothyroid membrane in female subjects using palpation: an observational study. Anesthesia and Analgesia, 114(5), 987–992. http://doi.org/10.1213/ANE.0b013e31824970ba
Bair, A. E., & Chima, R. (2015). The Inaccuracy of Using Landmark Techniques for Cricothyroid Membrane Identification: A Comparison of Three Techniques. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine, 22(8), 908–914. http://doi.org/10.1111/acem.12732
Bennett, J. D., Guha, S. C., & Sankar, A. B. (1996). Cricothyrotomy: the anatomical basis. Journal of the Royal College of Surgeons of Edinburgh, 41(1), 57–60.
Boon, J. M., Abrahams, P. H., Meiring, J. H., & Welch, T. (2004). Cricothyroidotomy: a clinical anatomy review. Clinical Anatomy (New York, NY), 17(6), 478–486. http://doi.org/10.1002/ca.10231
Buonopane, C. E., Pasta, V., Sottile, D., Del Vecchio, L., Maturo, A., Merola, R., et al. (2014). Cricothyrotomy performed with the Melker™ set or the QuickTrach™ kit: procedure times, learning curves and operators’ preference. Il Giornale Di Chirurgia, 35(7-8), 165–170.
Cook, T., Woodall, N., & Frerk, C. (2015). Appendix 4 NAP4 Summary: major complications of airway management in the United Kingdom. British Journal of Anaesthesia (2011) 106 (5): 617-631. https://doi.org/10.1093/bja/aer058
Dover, K., Howdieshell, T. R., & Colborn, G. L. (1996a). The dimensions and vascular anatomy of the cricothyroid membrane: relevance to emergent surgical airway access. Clinical Anatomy (New York, NY), 9(5), 291–295. http://doi.org/10.1002/(SICI)1098-2353(1996)9:5<291::AID-CA1>3.0.CO;2-G
Frerk, C., Mitchell, V. S., & McNarry, A. F. (2015). Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British Journal of Anaesthesia (2015) 115 (6): 827-848. https://doi.org/10.1093/bja/aev371
Hubert, V., Duwat, A., Deransy, R., Mahjoub, Y., & Dupont, H. (2014). Effect of simulation training on compliance with difficult airway management algorithms, technical ability, and skills retention for emergency cricothyrotomy. Anesthesiology, 120(4), 999–1008. http://doi.org/10.1097/ALN.0000000000000138
Langvad, S., Hyldmo, P. K., Nakstad, A. R., Vist, G. E., & Sandberg, M. (2013a). Emergency cricothyrotomy–a systematic review. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 21, 43. http://doi.org/10.1186/1757-7241-21-43
Nakstad, A. R., Bredmose, P. P., & Sandberg, M. (2013). Comparison of a percutaneous device and the bougie-assisted surgical technique for emergency cricothyrotomy: an experimental study on a porcine model performed by air ambulance anaesthesiologists. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 21, 59. http://doi.org/10.1186/1757-7241-21-59
 Navsa, N., Tossel, G., & Boon, J. M. (2005). Dimensions of the neonatal cricothyroid membrane – how feasible is a surgical cricothyroidotomy? Paediatric Anaesthesia, 15(5), 402–406. http://doi.org/10.1111/j.1460-9592.2005.01470.x
 Prithishkumar, I. J., & David, S. S. (2010). Morphometric analysis and clinical application of the working dimensions of cricothyroid membrane in south Indian adults: With special relevance to surgical cricothyroidotomy. Emergency Medicine Australasia, 22(1), 13–20. http://doi.org/10.1111/j.1742-6723.2009.01245.x
 The clinical anatomy of several invasive procedures. American Association of Clinical Anatomists, Educational Affairs Committee. (1999). The clinical anatomy of several invasive procedures. American Association of Clinical Anatomists, Educational Affairs Committee. Clinical Anatomy (New York, NY), 12(1), 43–54. http://doi.org/10.1002/(SICI)1098-2353(1999)12:1<43::AID-CA7>3.0.CO;2-W