Airway and respiratory

Can't Intubate, Can't Oxygenate Algorithm

Failed intubation to front-of-neck access

Reviewed by Alex G, BSN, RN, CEN, CCRN, CMC, NREMT-P · From the Reference tab of the app

Each step lists what to do, then the choices that lead on. In the app the algorithm is tapped through one decision at a time.

1 Intubation failed

Call for help; declare a difficult airway
Maximum 3 attempts at laryngoscopy (4th by an expert)
Oxygenate between attempts

Next: supraglottic airway → step 2

2 Supraglottic airway

Second-generation SGA (i-gel, LMA ProSeal), up to 3 attempts
Oxygenation adequate: stop and think (wake, intubate through the SGA, or proceed)

SGA works → step 3 SGA fails → step 4

3 Stop and think

Wake the patient if possible
Intubate through the SGA with a fiberoptic scope
Proceed with the SGA only if necessary
Tracheostomy or cricothyroidotomy if the airway must be secured

End of this path.

4 Final face-mask attempt

Two-person, two-handed mask with oral and nasal airways
Ensure full paralysis

Mask works → step 3 Fails: CICO → step 5

5 Front-of-neck access

Declare CICO
Extend the neck; identify the cricothyroid membrane (laryngeal handshake)
Scalpel-bougie-tube: horizontal stab, rotate blade, bougie, 6.0 cuffed tube
Impalpable membrane: 8–10 cm vertical skin incision, then blunt dissection

End of this path.

Related one-pagers

Airway and RSIRSI: the 7 Ps: Failed airway: limit attempts (2–3) and oxygenate with an SGA or bag-mask. Can't intubate, can't oxygenate: cricothyrotomy per protocol.

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