According to the Difficult Airway Society (DAS) 2015 guidelines, after two failed intubation attempts in a 'can't intubate, can't oxygenate' (CICO) scenario with a second-generation supraglottic airway also failing to maintain oxygenation, the immediate next step is:

• A A third intubation attempt with a video-laryngoscope
• B Awake tracheostomy under local anaesthesia
• C Laryngeal mask airway reinsertion at a higher seal pressure
• D Emergency front-of-neck access (scalpel-bougie-tube cricothyroidotomy) ✓

Explanation

The CICO (can't intubate, can't oxygenate) scenario represents an immediately life-threatening emergency. Once declared, the DAS 2015 guidelines mandate immediate front-of-neck access — the scalpel-bougie-tube technique is the preferred method: horizontal 8–10 cm skin incision over the cricothyroid membrane, bougie insertion through the membrane into the trachea, and a size 6.0 cuffed ETT railroaded over the bougie. Continuing intubation attempts wastes critical time. An awake tracheostomy is too slow in an acute CICO. All unnecessary attempts at intubation and ventilation should cease once CICO is declared.

Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.