Tactic 1

the readiness is all

The “CricCon” tactic was created by Scott Weingart @emcrit. It borrows language from the military to assign an alert level to FONA. By requiring you to think about the likelihood of the need for FONA before every intubation, it ensures that the signal for FONA is appropriately amplified and escalated based on that assessment.

The graphic below is an adaptation of the original with slight modifications based on our re-interpretations of the levels and what they mean. Each alert level should trigger the appropriate amplification and escalation to ensure that the FONA signal is coming through to you and the team at the right level of urgency.

1. For intubations not predicted to be difficult based on your assessment, FONA should always be verbalized as part of your plan, a quick palpation of neck anatomy should be performed, and the surgical airway equipment should be identified and easy to locate.
2. For predicted difficult airways this alert level should trigger the appropriate amplification and escalation. This should include marking the anatomy, and bringing the kit unopened to the bedside.
3. For the airway that is unlikely to be intubated successfully, this “improbable” airway (see below) needs further amplification and escalation. With the number of intubation attempts to be performed discussed beforehand in order to mitigate the number of futile attempts at intubation and ensure a swifter transition to FONA before critical hypoxia can occur.

Tactic 2

The double set up

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The double set-up is a tactic that allows you to be maximally prepared in a situation where time + really scary airway = high likelihood of the need for FONA..

The double set-up means that surgical airway equipment is open and at the bedside, the neck is prepped, and the anatomy is marked. If possible, designate someone to be ready with scalpel in hand at the side of the bed ready for the handoff if intubation fails. Here is this concept as originally presented by Reuben Strayer @EMUpdates.

Tactic 3

the improbable airway

impending hypoxia + low chance of intubation success

Some airways are not simply difficult they are improbable. The “improbable airway” describes the high complexity, low likelihood of success scenario where subsequent intubation attempts after a first failed attempt, are unlikely to lead to a definitive airway. In an improbable airway, you must be able to give yourself permission to break from the usual pattern of multiple intubation attempts, and transition earlier to a surgical airway.

Imagine a patient with severe facial trauma or inhalation burn injury. With your first look no clear path to the trachea is visible, or only such a difficult path that you believe no available optimizations are likely to provide a solution. In this situation, simply transitioning earlier to FONA could be the right call. After all, intubation attempts with only a remote chance of success, only distract and delay you from the necessary actions required to restore oxygen to your patient.

This tactic works best when an “improbable” airway is declared before any attempt at intubation is made. This way, your team can have a shared mental model, and everyone can ensure a swift and smooth transition to FONA in a calm and deliberate fashion before critical hypoxia increases the stress level in the room.

Don’t wait until critical hypoxia occurs and you’re under the gun with time running out. Instead transition to the simpler and more direct option of the surgical airway in a calm and unhurried manner.

don’t just think you’re ready – be ready

a summary of four valuable fona tactics

Like the meaningless phrase “have a high index of suspicion” in medicine, Thinking you’re ready for FONA and being ready are two very different things. These 4 tactics used prior to EVERY intubation will get you one step closer to true FONA readiness.