Update: DAS 2025 Makes the Vertical Incision the Standard for FONA.
The DAS 2025 Tracheal Intubation Guidelines have finally changed. They now recommend a new approach to the initial incision for emergency front-of-neck access (eFONA). In my opinion, they’ve moved in the right direction. If you’ve trained using the 2015 algorithm, you’ll remember the fork in the road. It was a stab incision if you can feel the membrane. Make a vertical incision if you can’t.
That decision point is now gone.
The 2025 update eliminates the transverse-vs-vertical debate. It moves decisively toward a single, universal approach. This approach involves a long midline vertical incision, up to 8 cm. The authors make the rationale crystal clear. Palpation of the cricothyroid membrane is often unreliable, even in controlled settings. Making choices under crisis conditions slows operators down. A vertical incision exposes the field better. It works in both palpable and impalpable situations. It increases the likelihood that you’ll actually find the airway when it counts.
“A vertical skin incision is suitable for both palpable and impalpable cricothyroid membranes…” – DAS 2025
This shift reflects a broader evolution. It focuses on recognizing human factors in airway management. The shift also emphasizes reducing cognitive overload and accepting the reality of unpredictable anatomy. FONA training is moving toward one dependable technique, practiced under stress, not a menu of branching options. If you teach airway management, update your materials. If you perform it, retrain your hands.
I’ve done multiple real-world eFONAs and countless cadaver procedures, and the long vertical incision has proven itself every time. It works in chaos, in obesity, and when the landmarks vanish. Consensus is hard with a procedure this rare, but the new DAS update is a step toward clarity. This approach gives clinicians their best chance when everything else has failed.
The message is clear:
In a CICO scenario, cut vertically. Every time.
How to Perform eFONA With a Vertical Incision
Our Essential Elements section of the Scalpel–Finger–Bougie content tackles all of this head-on. We’ve added new visuals, updated guidance, and tools for deliberate practice inside our pop-up learning spaces. We’ve taught a long vertical incision from day one. Now we walk you through precisely how to do it. We also explain why it matters.
For those who want to go deeper, this month’s Deep Cuts provides subscribers with firsthand accounts. These accounts come from clinicians who have performed cricothyroidotomy in true high-stakes crisis. Their tactical insights and hard-earned lessons are raw, practical, and impossible to find anywhere else.
Explore the Entire Fearless FONA Learning Space
Journey through this immersive and interactive learning space. Cultivate a FEARLESS FONA MINDSET where all the key elements to successful FONA are explored. Tackle all the barriers to confident action.
