The Critical Importance of Immediate Access to FONA Equipment in All Anesthetic Locations

In a CICV emergency, minutes count! In the absence of ventilation and following the onset of hypoxia, brain damage can occur within 4-8 minutes if not reversed. Almost uniformly, it is both the delay in recognizing a CICV emergency as well as the delay in taking action to obtain a surgical airway that contribute most significantly to patient injury and death. Therefore, when other measures to ventilate and oxygenate a patient have failed, every effort to expedite the creation of an airway through the "front of the neck” is warranted.

This includes performance of the procedure by the most experienced provider who is immediately available. At times, this may be the surgeon, and at others it will be the anesthesiologist. Though many ORs will have a scalpel available in the room for the planned procedure, there are many cases where this won’t be so. Waiting for the arrival of a surgical airway kit or scalpel can take more time than is available in these emergencies. Thus, the immediate availability of basic FONA equipment is intended to minimize such delays and improve patient outcomes.

Equipping Healthcare Providers for Success

To address the urgency of CICV emergencies, FONA kits are now available within arm's reach of anesthesia providers. Each kit contains skin prep, a 10-0 broad blade scalpel, a bougie, and a 6-0 endotracheal tube and is located in every anesthesia machine drawer and adult code bag. Reliable availability of cost-effective (less than $30) and expert endorsed FONA kits will eliminate delays in performing an emergent surgical airway and improve patient safety in time critical situations.

Our anesthesia technicians will work to ensure reliable kit availability. As always, it is also recommended that FONA kit and other patient safety equipment availability be routinely confirmed prior to providing anesthesia.

Please note that the Melker – Emergency Cricothyroidotomy Kits (approximately $400 each) will continue to be stocked in ample numbers in the anesthesia supply rooms at HC, JMC and the VAMC. Should a provider prefer easy access to this kit, it is recommended that it be brought to the room as part of the basic room setup, prior to initiating any anesthetic.

Scalpel-Bougie-Tube FONA Technique

FONA through the cricothyroid membrane can be performed with very minimal equipment, such as described below. Several slight variations of this technique exist (largely distinguished by how the scalpel is utilized).

Ultimately, the equipment and technique of choice is up to each individual provider.

This is ONE suggested approach, endorsed by several airway societies.

Scalpel-Bougie-Tube FONA "How To" Video

Scalpel-Bougie-Tube FONA "How To": A Step-by-step Guide

1.    CALL FOR HELP and ANNOUNCE to the room this is a Cannot Intubate-Cannot Ventilate (CICV) Emergency

2.    Continue 100% OXYGENATATION attempts (face mask, Hi-flow, LMA etc.)

3.    PARALYZE the patient (rules out laryngospasm & eases attempts at ventilation)

4.    POSITION PATIENT (extend head and neck with shoulder roll & remove any head pillows or towels)

**Palpation of relevant anterior neck anatomy is difficult or impossible without head and neck extension

5. POSITION YOURSELF

Þ   Are you right-handed? Stand at the patient's left shoulder.

Þ   Are you left-handed? Stand at the patient’s right shoulder.

** The non-dominant hand palpates and identifies the cricothyroid membrane while the dominant hand uses the scalpel.

6.    PREPARE EQUIPMENT

** FONA Kit (available in anesthesia machine drawer and adult code bags) and contains:

1) Skin prep

2) 10-0 scalpel (a broad blade scalpel such as this is ideal)

3) Bougie

4) 6-0 cuffed ETT

7. PALPATE cricothyroid membrane (CTM)

1)    Palpate with your non-dominant hand, starting at the sternal notch (which is reliably palpable and midline even in cases of obesity, neck pathology or tracheal deviation)

2)    With your thumb and index finger, move upwards along the tracheal rings until the large cricoid cartilage is palpated

3)    The 'dip' immediately above the cricoid cartilage is the cricothyroid membrane (CTM), It's about the size of the pad of your index finger and is immediately caudad to the thyroid cartilage (Adam’s apple)

4)    Stabilize the larynx in the midline

5)    Maintain hand positioning for next steps

8. Horizontal STAB incision through the cricothyroid membrane (CTM)

1)    PREP skin (May omit if not immediately available)

2)    Horizontal STAB incision through CTM

3) Then TWIST blade vertically and MAINTAIN TRACTION within incision - Keeping the blade inserted into your incision, rotate blade vertically and maintain traction within incision by pulling blade towards you.

9. INSERT Bougie & Railroad ETT

1)    Insert the bougie while abutting coude tip against the blade

2)    Advance to 10 cm

3)    'Railroad' the ETT over the bougie. Rotation of tube while railroading will ease insertion as will holding skin traction. Consider lubrication if available.

Tip: Avoiding False Passage - If the bougie gets “hung up” at a depth of less the 5cm, you have created a false passage and the bougie IS NOT in the trachea. Proceed back to Step 5 and start over.

10. OXYGENATE

1)    Remove bougie, inflate cuff and connect machine circuit, Mapleson, etc.

11. CONFIRM ETCO2

1)    Confirm ETCO2 with capnography (EZ cap is prone to false positives yet can be used first while awaiting capnography). Once ETCO2 confirmed, check ETT depth as main-stemming can occur. (The carina is approximately 9-11 cm below your insicion, thus an ETT depth of 5-8 cm is about right)

2)    No ETCO2?

a.    Quickly rule out mucous plug by passing soft suction catheter and check circuit connections and monitor

b.     Rule out false passage by direct visualization of tracheal rings with bronchoscope.

c.    Avoid creating subcutaneous emphysema with large volume/high pressure tidal volumes until you’ve confirmed your ETT is in the trachea

d. Remember a FLAT (ETCO2) TRACE = WRONG PLACE until proven otherwise (i.e. This may appear obvious, but it bears repeating that though the hesitation to remove a suspicious ETT is common, the risk of leaving an incorrectly placed ETT in the wrong place (not in the trachea) is absolute and will most certainly lead to severe injury and death.)

e.    Even in the setting of cardiac arrest, small “bumps” on the ETCO2 waveform tracing will be observed, even in the absence of chest compressions! A flat ETCO2 tracing must ALWAYS prompt actions to rule out a misplaced ETT.

f.      If chest compressions are currently in progress, your ETCO2 will reach levels of 10-20 mmHg with quality compressions and again, the waveform tracing will NOT be flat (even with less than quality compressions)

12. Formalize/stabilize the airway

1)    A surgical specialty team should be consulted stat (if not already called) to help evaluate the next best course of action.

2)    Suture the ETT or formalize airway with assistance of surgical team

For NONPALPABLE airway structures (due to obesity, overlying pathology, etc.) 

The goal in these instances is to dissect through the thick tissue overlying and obscuring the thyroid cartilage, CTM, and cricoid cartilage so that these structures become palpable to the provider.

1.     Skin incision & blunt tissue dissection down to CTM

1) Make a generous vertical skin incision of at least 5 cm (possibly more) through overlying adipose tissue and over the CTM.  Make sure the incision is deep enough to extend all the way down to the laryngeal structures.

2) Finger dissection down to the CTM

3) “Stab twist bougie tube” as already described above