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Airway·CA-3 / Fellow

Airway: The CICO Disaster

Morbidly obese patient for emergency surgery. Navigate the failed intubation and failed LMA transition to a surgical airway.

The stem

A 45 y.o. morbidly obese male (BMI 55) with OSA is brought for emergency exploratory laparotomy for a perforated bowel. After a standard RSI, you are unable to intubate with direct laryngoscopy or a GlideScope. You attempt to place an LMA, but it does not provide any ventilation. The patient's O2 saturation is now 60% and his heart rate is falling to 40 bpm. PHYS: BP 80/40, HR 40, O2 Sat 60%.

Focus

Emergency surgical airway transition, situational leadership, and management of the 'Cannot Intubate, Cannot Oxygenate' (CICO) scenario.

Examination relevance

The 'Board Failure' scenario: Do you keep trying to intubate or do you cut the neck? This is the ultimate test of clinical courage.

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Expert sample response

This is a 'Cannot Intubate, Cannot Oxygenate' (CICO) emergency. My first priority is recognizing that non-invasive airway management has failed and declaring a CICO crisis to the entire team.

I will immediately perform an emergency surgical airway. While I will call for a surgeon to assist, I am prepared to perform a scalpel-bougie cricothyroidotomy myself without delay, as the patient is suffering from profound hypoxia and bradycardia. Simultaneously, I will administer 0.5-1.0 mg of Atropine to treat his bradycardia and continue attempts at bag-mask ventilation as a 'bridge' while the neck is being prepped. I will not attempt another intubation or LMA placement, as these have already failed and further attempts only waste time while the patient sustains irreversible brain injury.

Full walkthrough

What the Examiner Is Testing

This is the ultimate airway test. The examiner wants to see that you can recognize CICO, stop attempting failed techniques, and commit to a surgical airway without additional hesitation. Clinical courage — the willingness to cut the neck rather than keep inserting devices that have already failed — is the core skill being evaluated.

The Board Trap

The trap is trying another intubation attempt or another LMA size while the saturation is at 60% and falling. Every second spent on a failed non-invasive airway is a second of ongoing hypoxic brain injury. The second trap is waiting for a surgeon to arrive before starting the cricothyroidotomy — in CICO, you cannot wait.

Walk-Through: How This Case Plays Out

Examiner: You've tried direct laryngoscopy and a GlideScope. The LMA is in but not ventilating. The sat is now 60%. What do you do?

Me: I am declaring a CICO emergency to the entire room, right now, out loud. I need everyone to hear it. I am not attempting another intubation or repositioning another LMA — those have failed. I'm moving to a surgical airway. I'm grabbing a scalpel and performing a scalpel-bougie cricothyroidotomy. While I'm doing that, I want someone pushing atropine 0.5 to 1 mg for the bradycardia, and someone continuing bag-mask attempts as a bridge — not stopping, just continuing while I prep the neck.

Examiner: How do you perform the scalpel-bougie technique?

Me: I'd palpate the cricothyroid membrane — it's between the thyroid cartilage and the cricoid ring. Make a transverse stab incision through skin and membrane, hook the trachea caudally with my finger, insert the bougie caudally into the trachea, railroad a 6.0 ETT over the bougie. Inflate the cuff, ventilate, confirm with ETCO2. The entire sequence should take under 60 seconds.

Examiner: A surgeon runs in and says "I'll do the tracheostomy." Do you wait for them?

Me: No. I would say "I'm already starting — please assist." At SpO2 of 60% and falling with bradycardia, the time to a formal tracheostomy is too long. The scalpel-bougie cricothyroidotomy is faster and something I can perform right now. The surgeon can take over control of the airway after I've established ventilation and the patient is stable.

Examiner: You've secured the surgical airway and the SpO2 is recovering. What's your next concern?

Me: I'm worried about hypoxic brain injury. I need to determine how long the sat was critically low and for how long. I'd get an arterial blood gas to check for acidosis and assess the degree of oxygen debt. I'd look at the pupils for signs of herniation. The patient goes to the ICU regardless — I need to have an honest conversation with the surgeon about post-hypoxic neurological prognosis and document the timeline of the airway emergency carefully.

Key Phrases That Score Points

  • "Declare CICO out loud to the entire room — the team needs to know we are now doing a surgical airway."
  • "No more LMA attempts — that technique has failed, I'm going to the neck."
  • "Scalpel-bougie cricothyroidotomy: palpate the cricothyroid membrane, stab, hook, bougie, ETT, inflate, confirm ETCO2."
  • "I cannot wait for the surgeon — at SpO2 60%, brain injury is happening now."
  • "Post-CICO: ABG, pupil exam, ICU admission, and honest family discussion about neurological risk."

Why This Case Appears on the Boards

CICO is the exam's highest-stakes scenario because it tests clinical courage and action under existential time pressure. The examiner is not primarily testing technique — they're testing whether you will stop trying failed approaches and commit to a definitive action before irreversible harm occurs.