In Real-World eFONA, Touch, Not Tech, Makes the Difference.

Emergency cricothyroidotomy is among the most time-sensitive and consequential procedures in airway management. Recently, the use of point-of-care ultrasound (POCUS) to identify the cricothyroid membrane (CTM) prior to initiating the procedure has garnered increasing attention. While ultrasound may offer benefits in specific scenarios (particularly in patients with challenging anatomy or during planned high-risk airway interventions), its routine use in emergency front-of-neck access (eFONA) warrants more thoughtful evaluation.

Studies suggest that we are not consistently accurate at identifying the CTM using external palpation. In one study, skilled sonographers located the CTM using ultrasound in approximately 24 seconds, improving accuracy from 58% to 87% compared to palpation.³ However, these findings come from controlled settings.

A key difficulty in assessing ultrasound’s role in this context stems from the limited real-world experience most clinicians have with cricothyroidotomy. Without firsthand exposure, suggested refinements of eFONA with ultrasound may not withstand the intense pressure of a true emergency.

Drawing on personal experience (including three cricothyroidotomies performed, four supervised, and extensive cadaveric and simulation-based training), I offer the following reflections in support of a cautious, context-sensitive approach to POCUS in eFONA. In my experience, beginning with a generous vertical incision (8 cm) and using blunt dissection with digital palpation is faster, more accurate, and associated with fewer complications. Here are the reasons:

1. In Emergencies, Simplicity Saves Lives

In a CICO (can’t intubate, can’t oxygenate) scenario, every second counts. Introducing ultrasound into the sequence (activating the device, obtaining images, interpreting anatomy, and marking the skin) can introduce delays. Though each step may seem minor, the cumulative time lost can be significant. In our Fearless FONA Mindset, learning space, we emphasize that “elegant simplicity” is not merely a stylistic preference—it’s a guiding principle. When seconds determine outcomes, the most direct route to oxygenation in the least number of steps is almost always the best.

2. Cricothyroidotomy Is a Tactile Procedure First

Cricothyroidotomy is typically performed under conditions of poor visualization, due to bleeding, trauma, or distorted anatomy. The procedure is tactile by necessity. While some guidelines suggest a single “stabbing” horizontal incision, in my opinion, success hinges on starting with a vertical incision (usually about 6-8 centimeters) followed by blunt dissection and digital palpation of the CTM. The reason for this is simple: “Some people have fat necks, but everyone has skinny membranes.”

Once you take the few seconds it requires to blunt dissect down to the CTM, identification is easy, and confirmation that you are in the right place is simple.

3. Bleeding Compromises Surface Markings

Bleeding is an expected feature of cricothyroidotomy, not a complication. Once the incision is made, surface markings (whether from palpation or ultrasound) often disappear beneath blood. In such conditions, relying on external references can introduce confusion or delay. A tactile approach, grounded in a deep understanding of airway anatomy, provides a more consistent and dependable method.

“In real-world practice, the ability to identify the membrane by feel becomes essential. An experienced operator should be prepared to perform this procedure without relying on visual cues.“

Confirmation of tracheal access is likewise tactile—much like chest tube placement, the provider never forgets the distinct feel of a CTM and then the tracheal rings under the finger. In our cadaver lab training, we emphasize that these are the two most important tactile sense memories that everyone needs to take away.

4. Context Matters: Lessons from Other Procedures Don’t Always Translate

Support for ultrasound-guided CTM identification often comes from clinicians well-versed in procedural ultrasound, frequently referencing controlled settings, such as central line placement. These environments benefit from time, sterility, and predictable anatomy. Emergency cricothyroidotomy, however, is defined by chaos, urgency, and limited visibility.

Because unanticipated CICO events are rare, it is unlikely that we will ever have high-quality clinical data that definitively supports or refutes the use of ultrasound in this setting. Cadaveric and volunteer-based imaging studies are valuable for training but do not fully replicate the real-world conditions of an airway emergency.

Moreover, not all clinicians have immediate access to ultrasound or the proficiency to use it under pressure. Encouraging POCUS use in these situations could unintentionally complicate a procedure that depends on decisiveness and clarity.

Conclusion: Touch Before Tech

Ultrasound is a valuable tool. It plays a critical role in diagnostic evaluation and procedural planning during a rapidly evolving airway, particularly for the care of critically ill patients with complex physiology. However, in emergency cricothyroidotomy (where every second matters), simplicity, speed, and tactile reproducibility must remain the priority.

We should remain open to innovation, but innovation must be matched with practicality. POCUS may serve a valuable role in select scenarios, but its routine use in eFONA should be approached with caution. In the most critical moments, a tactile-first, streamlined approach remains the most reliable and reproducible method for restoring oxygenation.

Because robust, high-level evidence is unlikely to emerge for such a rare intervention, the insights of clinicians with direct experience in cricothyroidotomy should be given weight. Their perspectives are crucial in shaping best practices for one of the most vital procedures in emergency medicine.

For now, at least,

“Touch, not tech, matters more in eFONA.“

The emergency surgical airway is a simple procedure, but one of the hardest to perform under pressure. Why? Because fear, hesitation, and human factors often stand in the way. In this space, we break down those barriers. We dismantle the myth that FONA has to be terrifying and help you build a FEARLESS FONA MINDSET—one that thrives in the heat of a can’t intubate, can’t oxygenate crisis.

learn more

References

1. Lacy AJ, Kim MJ, Li JL, et al. Prehospital cricothyrotomy: A narrative review of technical, educational, and operational considerations for procedure optimization. J Emerg Med. 2025;70(1):19-34. doi:10.1016/j.jemermed.2024.08.018.
2. Singh N, Rath A, Muduli S, Ponde V. Comment on “Prehospital Cricothyrotomy: A Narrative Review of Technical, Educational, and Operational Considerations for Procedure Optimization” — Ways to explore further. J Emerg Med. Published online May 2025. doi:10.1016/j.jemermed.2025.05.026.
3. Nicholls SE, Sweeney TW, Ferre RM, Strout TD. Bedside sonography by emergency physicians for the rapid identification of landmarks relevant to cricothyrotomy. Am J Emerg Med. 2008;26(8):852-856. doi:10.1016/j.ajem.2007.11.022.
4. Siddiqui N, Yu E, Boulis S, You-Ten KE. Ultrasound is superior to palpation in identifying the cricothyroid membrane in subjects with poorly defined neck landmarks: A randomized clinical trial. Anesthesiology. 2018;129(6):1132-1139. doi:10.1097/ALN.0000000000002454.