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Emergency Front-of-Neck Access — FRCA Final MCQ

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HardAirway ManagementEmergency Front-of-Neck AccessFRCA Final

During rapid sequence induction in an adult, optimised attempts at tracheal intubation, ventilation through a second-generation supraglottic airway device, and two-person facemask ventilation with airway adjuncts have all failed despite complete neuromuscular blockade. The SpO2 is 60% and falling, and a cannot-intubate, cannot-oxygenate situation is declared. According to the Difficult Airway Society 2025 adult guidelines, which Plan D technique should be performed?

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Correct answer: D — Scalpel–bougie–tube cricothyroidotomy with vertical skin and transverse membrane incisions

The correct answer is D. Once tracheal intubation, supraglottic-airway ventilation and optimised facemask ventilation have failed in a fully paralysed patient, Plan D must proceed immediately. DAS 2025 standardises adult eFONA as a scalpel–bougie–tube cricothyroidotomy: make a longitudinal midline skin incision, expose and stabilise the larynx, open the cricothyroid membrane transversely, insert a bougie and railroad a cuffed 6.0-mm tracheal tube. The vertical skin incision improves exposure and permits correction of cricothyroid-membrane localisation error; it is not primarily justified by avoidance of blood vessels. Needle cricothyroidotomy with jet ventilation is not the recommended default adult technique. A transverse skin incision is no longer the standardised approach. Tracheostomy is slower and technically more complex in CICO, while retrograde intubation is inappropriate during critical hypoxaemia.

Reference: Ahmad I, El-Boghdadly K, Iliff H, et al. Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults, Plan D: emergency front-of-neck airway. British Journal of Anaesthesia. Epub 2025;136(1):283–307, 2026. https://pubmed.ncbi.nlm.nih.gov/41203471/