The readiness is all

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

The graphic below is an adaptation of the original, with slight modifications reflecting our re-interpretations of the levels and their meanings. Each alert level should trigger the appropriate amplification and escalation to ensure the FONA signal reaches 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 the neck anatomy should be performed, and the surgical airway equipment should be identified and easily located.
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 to the bedside unopened.
3. For the airway that is unlikely to be successfully intubated, this “improbable” airway (see below) requires further amplification and escalation. The number of intubation attempts to be performed should be discussed in advance to reduce futile attempts and ensure a swifter transition to FONA before critical hypoxia occurs.

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 a 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.

The double setup is a tactic that maximally prepares you for a situation where time + really scary airway = a high likelihood of needing FONA.

impending hypoxia + low chance of intubation success

Some airways are not simply difficult; they are improbable. The “improbable airway” describes a scenario with high complexity and a low likelihood of success, in which subsequent intubation attempts after a first failed attempt are unlikely to result in 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 distract you from the necessary actions to restore oxygen to your patient.

This tactic works best when an “improbable” airway is declared before any attempt at intubation. This way, your team can share a mental model, and everyone can ensure a swift, smooth transition to FONA in a calm, deliberate manner before critical hypoxia increases stress 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, more direct surgical airway in a calm, unhurried manner.

The Execution Loop

The FONA Playbook is only effective when applied consistently. The execution loop is the mechanism that ensures this happens before every airway, regardless of perceived difficulty.

It begins with assigning the level of risk. Before any intervention, you determine how likely it is that FONA may be required. This initial assessment sets the tone for everything that follows and prevents underestimation of evolving difficulty.

Based on that risk, you then prepare accordingly. Preparation is not uniform; it scales with the situation. In lower-risk cases, it may be limited to awareness and equipment location. In higher-risk scenarios, it becomes physical and immediate, with anatomy marked, equipment opened, and the team positioned for rapid transition.

Next, you define your limits in advance. This includes setting expectations around the number of attempts and recognizing the conditions under which you will move to FONA. By establishing these boundaries early, you reduce the likelihood of repeated, non-productive attempts that delay definitive care.

Finally, you align the team. This means clearly communicating the plan, the level of risk, and the potential need for escalation. Roles are clarified, expectations are shared, and the team operates with a unified mental model.

This loop takes only moments to complete, but it fundamentally shapes performance under pressure. When the situation deteriorates, you are not building a response from scratch—you are executing a plan that has already been established.