What Real-World Video Review Teaches Us
Cricothyrotomy remains the ultimate “can’t intubate, can’t oxygenate” (CICO) procedure. It’s high stakes, rarely performed, and one of the most anxiety-inducing skills in emergency airway management. Despite its importance, most of what we know about cricothyrotomy comes from manikin studies, animal models, or retrospective chart reviews. Until now.
A new study by Merkle and colleagues, published in the Journal of Emergency Medicine (2025), provides one of the most detailed real-world looks at ED cricothyrotomy through video review of actual cases.
The Study at a Glance
- Design: Retrospective, observational study using video review
- Setting: Hennepin County Medical Center (high-volume, Level I trauma center)
- Population: 25 patients who underwent cricothyrotomy in the ED between 2007–2020, out of ~10,000 intubations
- Primary Outcome: Successful ventilation via cricothyrotomy
- Secondary Outcomes: Complications, death, or chronic disability attributable to airway management
What They Found
- Rare but real: Cricothyrotomy occurred in <0.2% of intubations (about 1 in 400).
- Success rate: 22/25 procedures (88%) were ultimately successful.
- Failures: 3 patients had incomplete or failed cric attempts, including one who died without a secured airway.
- Complications:
- Immediate complications occurred in 28%, most commonly right mainstem intubation (20%).
- 12% suffered death or permanent disability directly attributable to airway management.
- Time matters:
- Median time from ED arrival to cricothyrotomy start: 24 minutes.
- Fastest cric: 24 seconds. Slowest: 685 seconds (over 11 minutes).
- The biggest bottleneck: from skin incision to hook/finger placement (median 48 seconds).
- Technique: Almost all were open surgical procedures using a scalpel, hook, and bougie method. Most were performed by EM residents (PGY-3 or higher).
- Hypoxemia: Severe desaturation (SpO₂ <80%) was documented in 40% of cases.
Why This Matters
This study is unique because video review captured details you don’t see in chart reviews: real timing, technique steps, delays, and decision-making. A few key lessons emerge:
- Cricothyrotomy is not always successful. Even in expert centers, some patients cannot be secured surgically, and complications are common.
- The incision-to-tracheal-entry step is critical. This was the slowest and most error-prone phase, suggesting training should focus here.
- Delays kill. Patients often had prolonged hypoxemia before cricothyrotomy, contributing to disability or death. Rapid decision-making is just as important as technical skill.
- Practice is essential. Given its rarity, proficiency can only be maintained through simulation, deliberate practice, and mental rehearsal—not clinical volume.
Strengths & Limitations
Strengths
- First ED study to use video review—providing unprecedented procedural detail.
- Long study period with multiple cases captured.
- Clear outcome measures (success, complications, disability).
Limitations
- Small sample size (25 cases).
- Single-center, academic, airway-focused ED—may not generalize to community settings.
- Most procedures are performed by residents under supervision, which may not reflect attending-level practice.
My Take
As someone who performs and teaches this procedure, I love that Driver and colleagues undertook what feels like an ethnographic study of cricothyrotomy in the wild. Given the rarity of this procedure, their persistence in collecting and analyzing these cases is remarkable.
What stands out most as an educator is how this study exposes the granular mechanics of failure—and how those insights can be translated into better training and preparation. It reinforces that the enemy isn’t just anatomy, it’s time. And time delays often reflect gaps in preparation, planning, and execution, which in turn lead to hypoxia and poor outcomes.
Two critical points about time emerge:
- Recognizing CICO and committing to FONA: The biggest barrier is often making the decision itself. Delays stem from human factors—stress-induced fixation, lack of a shared mental model, and fear of failure.
- Executing eFONA once the decision is made: Logistics matter. Speed depends on preparation, team readiness, equipment setup, and muscle memory. If you haven’t reviewed and practiced this within the past year, you’re probably slower than you think.
Clinical Bottom Line
Cricothyrotomy in the ED remains rare but high-risk, with meaningful rates of failure, complications, and disability. Overcoming fear and hesitation requires focusing on four elements: human factors, preparation, planning, and practice. Together, these form what I call the Fearless FONA Mindset—a deliberate approach to mastering one of the most difficult moments in airway management.
If you manage airways, this study is a reminder: routinely review your individual and team approach to FONA. Work on the specific steps highlighted in this study so that when you face CICO, you can move from decision to incision to trachea before significant hypoxia occurs.
Take the Next Step
Build Your Fearless FONA Mindset
The emergency surgical airway is, at its core, a simple procedure—but one of the hardest to execute under pressure. Fear, hesitation, and human factors often stand in the way. That’s why we created an accessible, easy-to-use pop‑up learning space designed to help you and your team build the habits and mindset that make FONA feel less terrifying and more instinctive.
Through immersive, interactive content, you’ll:
- Explore every critical element of successful FONA.
- Sharpen your technical skills with repeated practice.
- Confront the human factors that cause delay and failure.
- Develop the confidence to act decisively in a CICO crisis.
This is how you dismantle the myth that FONA has to be terrifying.
Master the Four Elements of Fearless FONA
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