This is how I cut the neck by Dr George Kovacs

Performed an eFONA recently. First one in close to 20 yrs in a patient of mine. Lessons from my inexperience coming up.

— AIME Airway (@kovacsgj) June 12, 2018

Case: manual CPR in progress on patient Left. Vascular access with US for potential ECMO on Right. BVM support jaw clenched. Roc 200 mg in low flow state not effective. Non palpable landmarks big neck. 10 pearls/opinion/thoughts when I get back from gym.

— AIME Airway (@kovacsgj) June 12, 2018

1st opinion: we spend far too much time discussing eFONA. Part of this relates to the exposed immediacy of the technical failure (yes I used the f word) of a CICOCV (will explain this later) event. “Did you here about the cric last night”.

— AIME Airway (@kovacsgj) June 12, 2018

1. Continued… Compare this to the far more common and latent physiologic failures of hypotension & hypoxemia during aw mgmt that don’t declare themselves from@a morbidity/mortality point of view until days or weeks later.

— AIME Airway (@kovacsgj) June 12, 2018

2. Many eFONA cases could be avoided. True anatomic/pathologically related CICOCV cases I believe are quite rare and we end up in a FONA scenario because we haven’t optimized physiology and our approach to difficulty.

— AIME Airway (@kovacsgj) June 12, 2018

The true indication for an eFONA is cant intubate can’t oxygenate can’t ventilate. Yes ventilate. Often bc of pulse ox lag of up to a minute (which is eternity in case you failed to intubate/BMV)we abandon what might be effective ventilation because we aren’t using waveform cap.

— AIME Airway (@kovacsgj) June 12, 2018

3. Absolute indication for eFONA. Inability to intubate with falling sats in combination with ineffective optimized supraglottic ventilation (BMV/SGV)

— AIME Airway (@kovacsgj) June 12, 2018

4. eFONA decision inaction /delay and associated fixation error ”just one more go” is a known issue in CICOCV cases. Challenge is knowing when it’s a true failure and indicated vs a failure to optimize. Shit, more “f” bombs.

— AIME Airway (@kovacsgj) June 13, 2018

Ok back 5. Technically commit to approach that can be used on on all cases. Keep it simple and don’t leave options.

— AIME Airway (@kovacsgj) June 13, 2018

6. Position yourself on your dominant side: your RH dom be on patients R side. I didn’t do this as areas occupied

— AIME Airway (@kovacsgj) June 13, 2018

7 Laryngeal handshake stabilize the larynx. It is very mobile.

— AIME Airway (@kovacsgj) June 13, 2018

8. Perform a vertical landmark incision then position index finger in wound and on the the inferior aspect of thyroid cartilage ie upper CTM and leave it there until scalpel enters CTM space

— AIME Airway (@kovacsgj) June 13, 2018

9 enter CTM below index finger extend lateral in both directions then orient #10 bald sharp side down.

— AIME Airway (@kovacsgj) June 13, 2018

10. Here’s where I stray from approach of using the blade as a placelolder. Bleeding is not uncommon and placing the bougie alongside the blade is very difficult with blood.

— AIME Airway (@kovacsgj) June 13, 2018

10 continued: Dipping your index finger that has been riding the top of CTM into the Incised CTM is a very reassuring, protective and I believe sensitive and specific approach to securing access. Then follow up with the bougie along side of finger and then ett.

— AIME Airway (@kovacsgj) June 13, 2018