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Lesson

Front-of-Neck Access

12 min Airway & Breathing Skip to quiz

Objective: Recognize cannot-intubate-cannot-oxygenate early and say it out loud. Treat front-of-neck access as a trained last step to get oxygen in. Do not cut the neck if you have not trained that procedure.

Why this matters

Patients die in the minutes you spend hoping the next look will be clearer. When you cannot intubate and cannot oxygenate, stop taking more laryngoscope looks and get oxygen in.

Use a supraglottic airway (SGA) and a two-person bag-valve-mask (BVM). If those fail, and you are trained and authorized, move to front-of-neck access.

This lesson is about when to go to the neck. It is not a surgical manual, and it is not permission to improvise. Your protocol, training, and medical direction decide whether you carry a cricothyrotomy kit and which technique you use.

Verbalize
  • Plan A, Plan B, and Plan C are already spoken, including a plan to give oxygen.
  • I am saying, “This is CICO.” CICO means cannot intubate, cannot oxygenate.
  • We have already tried an SGA and our best BVM, or those are not possible.
  • If I am trained and authorized, I am going to the front of the neck now. I am not waiting for a fourth look.

Clinical sequence

  1. Give oxygen now with a two-person BVM, an SGA, or both. Count the looks out loud.
  2. If you still cannot get oxygen in, say “CICO” so the team stops handing you the same blade.
  3. Go to the front of the neck only if you are trained and authorized. Use the kit and the landmark you practiced. Do not try a procedure you only read about.
  4. Put a carbon dioxide waveform on whatever you place in the neck. If you are not authorized, keep giving oxygen and get the patient to someone who is.

What CICO means in practice

  • You cannot place an endotracheal tube, or the tube you placed is not in the trachea.
  • You cannot get oxygen in with a BVM, adjuncts, or an SGA. The oxygen saturation (SpO2) is falling or never rose. The waveform is unreadable or absent.
  • This is not a hard view. A hard view still gets oxygen between looks. See preoxygenation and difficult airway.

What Front-of-Neck Is — and Is Not

  • For adult cannot-intubate-cannot-oxygenate teaching, scalpel, then bougie, then tube is the usual hospital pathway. EMS systems that authorize a surgical airway train one kit and one landmark. That landmark is the cricothyroid membrane. This site does not teach the incision.
  • Needle or cannula cricothyrotomy is more often a pediatric option, or a short bridge. In adults, a needle-only airway fails more often than crews expect. It kinks, it misses, or it does not move enough air. Do not treat a 14-gauge needle in the neck as the adult surgical airway.
  • Put continuous waveform end-tidal carbon dioxide (EtCO2, the carbon dioxide trace on the monitor) on whatever you place in the neck. That is the same rule as any other advanced airway.

Teaching points

  • Say CICO out loud so the team stops handing you the same laryngoscope.
  • Give the best oxygen first. Use a two-person BVM, an adjunct, and an SGA. Front-of-neck access is for when those cannot get oxygen in.
  • If you are not trained or not authorized, your job is still to give oxygen with what you have and get to a clinician who is. Do not invent a procedure you have not trained.
  • A destroyed face or a burned neck belongs in the anticipation lesson. Say Plan C before the first look.

Common errors

  • Taking a fourth and fifth look while the SpO2 is 40%.
  • Calling CICO when you have not tried a two-person seal or an SGA.
  • Placing a neck airway and never putting a waveform on it.

Practice

One-minute check

Talk through a burned, obese patient. Plan A is video or direct laryngoscopy. Plan B is an SGA. Plan C is trained front-of-neck access. Your partner stops you if you say “one more look” after you have already said CICO.

Related: Difficult Airway Anticipation, Supraglottic Airways, DOPE-S.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.

1. CICO (cannot intubate, cannot oxygenate) means:
2. Before front-of-neck access, you still need to have:
3. Adult needle-only cricothyrotomy is:
4. If you are not trained or authorized for FONA (front-of-neck access) and the patient is CICO:
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