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The Element of Language


Clear language is needed to cultivate a fearless FONA mindset. Specific language provides the framework for a shared mental model, so that when someone says “CICO” everyone in the room knows what it means & knows what needs to happen next.

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CICO explained

When intubation fails, and adequate oxygenation cannot be delivered by any of the other upper airway lifelines (FMV&SAD) it’s time to declare CICO and move quickly to address the situation. Watch here.

The reason for this is clear. Time is brain. Poor communication leads to critical delays in the performance of FONA, and bad outcomes related to failed airways are never caused by a failure to intubate, but rather a failure to oxygenate. When CICO is declared by the team a series of well rehearsed actions should occur that will lead to FONA being performed before critical hypoxia occurs.

How many attempts before declaring CICO?

The answer is always BEFORE critical hypoxia occurs. This means you may have time to attempt restoration of adequate oxygenation with all of your three upper airway options, or you may be forced to bypass some or all of them if the situation mandates it. You can still use the time between declaring CICO and the actual incision to try to bridge with a supraglottic or FMV. Work in parallel not in series.

The most important thing to remember is that time is brain. Declare CICO early, and don’t get locked into feeling you have to attempt oxygenation with all your upper airway lifeline options, or that you have to attempt something 3 times. If your best effort(s) fail, or you judge the situation requires immediate transition to FONA then it’s time to moving on and perform rescue FONA.


are we CLEAR?

Now you know the critical language of the failed airway, and how to declare that it’s time for action, and you’ll find further discussion on team communication and language in other elements of this learning space. Because miscommunication should never be the reason that FONA is not performed when the clinical indication for it is “crystal clear.”

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Curated FOAMed & references are here for you when you want more

Spend five minutes to the ABCs of Anaesthesia talking about when to call CICO. This is a great place to spend a little more time thinking about defining your end point during a failed intubation so you can move rapidly to FONA.

CICo part of the vortex approach

CICO is part of the critical language used to identify the need for an emergency surgical airway. No one has thought more about this or is more thorough than Dr Nicolas Chrimes at the Vortex Approach. We highly recommend you add him and his website to your airway learning network.

Effective communication in airway management
Using the power of language to cultivate a fearless fona mindset

“The contribution of human factors to adverse outcomes during emergency airway management is well established. Effective communication is a core non-technical skill that contributes to minimizing such error. The language used must aid rather than hinder communication.” – Nick Chrimes MD

N. Chrimes1,* and T. M. Cook2

1Department of Anaesthesia, Monash Medical Centre, 246 Clayton Rd, Clayton, VIC 3168, Australia, and 2Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Combe Park, Bath BA12 3NG, UK

Next Steps

Congratulations! You are well on your way towards cultivating a Fearless FONA Mindset. To take the next step, visit any of the related posters in this series, or go to the online space below.

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