UNASSIGNED: Airway management is a core component of the treatment of cardiac arrest. Where a rescuer cannot establish a patent airway to provide oxygenation and ventilation using standard basic and advanced airway techniques, there may be a need to consider emergency front-of-neck airway access (eFONA, e.g., cricothyroidotomy), but there is limited evidence to inform this approach.
UNASSIGNED: This scoping review aims to identify the evidence for the use of eFONA techniques in patients with cardiac arrest.
UNASSIGNED: In November 2023, we searched Medline, Embase, and Cochrane Central to identify studies on eFONA in adults. We included randomised controlled trials, non-randomised studies, and case series with at least five cases that described any use of eFONA. We extracted data, including study setting, population characteristics, intervention characteristics, and outcomes. Our analysis focused on four key areas: incidence of eFONA, eFONA success rates, clinical outcomes, and complications.
UNASSIGNED: The search identified 21,565 papers, of which 18,934 remained after de-duplication. After screening, we included 69 studies (53 reported incidence, 40 reported success rate, 38 reported clinical outcomes; 36 studies reported complications). We identified only one randomised controlled trial. Across studies, there was a total of 4,457 eFONA attempts, with a median of 31 attempts (interquartile range 16-56.5) per study. There was marked heterogeneity across studies that precluded any pooling of data. There were no studies that included only patients in cardiac arrest.
UNASSIGNED: The available evidence for eFONA is extremely heterogeneous, with no studies specifically focusing on its use in adults with cardiac arrest.

OBJECTIVE: The preferential use of a scalpel (SCT) or puncture techniques (PCT) for cricothyrotomy remains a controversial topic.
OBJECTIVE: We performed a systematic review and meta-analysis comparing puncture cricothyrotomy with scalpel cricothyrotomy using overall success rate, first-time success rate, and time taken to perform the procedure as the primary outcome together with complications as a secondary outcome.
METHODS: Pubmed databases, EMBASE databases, MEDLINE, Google Scholar, and Cochrane Central Register of Controlled Trials, from 1980 to October 2022.
RESULTS: A total of 32 studies were included in the systematic review and meta-analysis. It also showed that PCT was close to SCT in terms of overall success rate (82.2% vs. 82.6%, Odd Ratios OR = 0.91, [95%CI: 0.52-1.58], p = 0.74) as well as first-performance success rate (62.9% vs. 65.3%, OR = 0.52, [0.22-1.25], p = 0.15). PCT does not compare favorably with SCT in terms of required time for the procedure (the mean time required for PCT versus SCT incision in the intervention groups was 0.34 standard deviations higher (Mean Difference MD = 17.12, [3.37-30.87], p = 0.01) as well as complications (21.4% vs. 15.1%, Relative Risk RR = 1.49, [0.80-2.77], p = 0.21).
CONCLUSIONS: The results show that SCT has an advantage over PCT in terms of time required for the procedure, while there is no difference in overall success rate, first-time success rate after training, and complications. The superiority of SCT may be the result of fewer and more reliable procedural steps. However, the level of evidence is low (GRADE).

Live animal models can be used to train anaesthetists to perform emergency front-of-neck-access. Cannula cricothyroidotomy success reported in previous wet lab studies contradicts human clinical data. This prospective, observational study reports success of a cannula-first \'can\'t intubate, can\'t oxygenate\' algorithm for impalpable anatomy during high fidelity team simulations using live, anaesthetised pigs.Forty-two trained anaesthesia teams were instructed to follow the Royal Perth Hospital can\'t intubate, can\'t oxygenate algorithm to re-oxygenate a desaturating pig with impalpable neck anatomy (mean (standard deviation, SD) 16.2 (3.5) kg); mean (SD) tracheal internal diameter 11 (1.4) mm. Teams were informed that failure would prompt veterinary-led euthanasia.All teams performed percutaneous cannula cricothyroidotomy as the initial technique, with a median (interquartile range, IQR (range)) start time of 42 (35-50 (24-93)) s. First-pass percutaneous cannula success was 29% to both insufflate tracheal oxygen and re-oxygenate. Insufflation success improved with repeated percutaneous attempts (up to three), but prolonged hypoxia time increasingly necessitated euthanasia (insufflation 57%; re-oxygenation 48%). First, second and third percutaneous attempts achieved insufflation at median (IQR (range)) 74 (64-91 (46-110)) s, 111 (95-136 (79-150)) s and 141 (127-159 (122-179)) s, respectively. Eighteen teams failed with percutaneous cannulae and performed scalpel techniques, predominantly dissection cannulation (n = 17) which achieved insufflation in all cases (insufflation 100%; re-oxygenation 47%). Scalpel attempts were started at median (IQR (range)) 142 (133-218 (97-293)) s and achieved insufflation at 232 (205-303 (152-344)) s.While percutaneous cannula cricothyroidotomy could rapidly re-oxygenate, the success rate was low and teams repeated attempts beyond the recommended 60 s time frame, delaying transition to the more successful dissection cannula technique. We recommend this \'cannula-first\' can\'t intubate, can\'t oxygenate algorithm adopts a \'single best effort\' strategy for percutaneous cannula, with failure prompting a scalpel technique.

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BACKGROUND: An emergency front-of-neck access (eFONA), also called can\'t intubate, can\'t oxygenate (CICO) rescue, is a rare event. Little is known about the performance of surgical or percutaneous airways in EDs across Australia and New Zealand.
OBJECTIVE: To describe the management of cases resulting in an eFONA, and recorded in The Australian and New Zealand Emergency Department Airway Registry (ANZEDAR).
METHODS: A retrospective case series and review of ED patients undergoing surgical or percutaneous airways. Data were collected prospectively over 60 months between 2010 and 2015 from 44 participating EDs.
RESULTS: An eFONA/CICO rescue airway was performed on 15 adult patients: 14 cricothyroidotomies (0.3% of registry intubations) and one tracheostomy. The indication for intubation was 60% trauma and 40% medical aetiologies. The intubator specialty was emergency medicine in eight (53.3%) episodes. Thirteen (86.7%) cricothyroidotomies and the sole tracheostomy (6.7%) were performed at major referral hospitals with 12 (80%) surgical airways out of hours. In four (26.7%) cases, cricothyroidotomy was performed as the primary intubation method. Pre-oxygenation techniques were used in 14 (93.3%) episodes; apnoeic oxygenation in four (26.7%).
CONCLUSIONS: Most cases demonstrated deviations from standard difficult airway practice, which may have increased the likelihood of performance of a surgical airway, and its increased likelihood out of hours. Our findings may inform training strategies to improve care for ED patients requiring this critical intervention. We recommend further discussion of proposed standard terminology for emergency surgical or percutaneous airways, to facilitate clear crisis communication.