Cannot intubate, cannot oxygenate is an emergency: call for help, declare CICO, proceed to front-of-neck access per local training.
Assessment
- LEMON or local checklist: Look, Evaluate, Mallampati, Obstruction, Neck
- Previous anaesthetic and airway documentation
- Full airway trolley and second anaesthetist early
Optimise first attempt
- Position: head-up, ramped if obese
- Preoxygenation, apnoeic oxygenation if appropriate
- Video laryngoscopy if trained; bougie ready
Plan A
- Mask ventilation and intubation
- Optimise: position, video laryngoscopy, bougie
- Limit attempts (3 plus 1)
Plan B / C
- Second-generation supraglottic airway
- Stop and think, oxygenate
- Wake up if feasible
Plan D (CICO)
- Cannot intubate, cannot oxygenate
- Declare, call for help
- Scalpel front-of-neck access
DAS intubation plan summary
1
Plan A
Face mask ventilation and maximal attempt intubation (up to 3 adjustments). Maintain oxygenation throughout.
Face mask ventilation and maximal attempt intubation (up to 3 adjustments). Maintain oxygenation throughout.
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2
Plan B
Insert supraglottic airway (e.g. second-generation LMA). Ventilate and consider fibreoptic intubation through device if stable.
Insert supraglottic airway (e.g. second-generation LMA). Ventilate and consider fibreoptic intubation through device if stable.
↓
3
Plan C
Wake patient up if surgery not immediately life-threatening and airway unsafe.
Wake patient up if surgery not immediately life-threatening and airway unsafe.
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4
Plan D
CICO: emergency front-of-neck access (scalpel cricothyroidotomy in adults per DAS).
CICO: emergency front-of-neck access (scalpel cricothyroidotomy in adults per DAS).
After failed intubation
- Declare events clearly to team
- Document and inform patient
- Refer to airway clinic if appropriate
Pitfalls
- Repeated blind attempts without SGA
- Paralysis before confirmable mask ventilation
- No CICO kit in room
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026