CICO
— can't intubate, can't oxygenate.

Steven McGaughey, MD MCI · OHSU Department of Emergency Medicine, Pediatric EM

A two-fork algorithm for can't-intubate-can't-oxygenate in children, sized for the kit you actually have, and honest about what the literature can and can't say.

Print CICO reference (PDF)
Part 1 · The decision

CICO decision pathway.

The first decision is anatomic, not by age. The second is which technique your kit and training actually support — name it as a choice and have the other ready as Plan B.

Trigger CICO in a child = failed intubation and failed BVM / LMA.
Both must be true. Declare it aloud; the clock starts.
↓
Decision Is the cricothyroid membrane palpable and large enough to accept a 4.0+ ETT?
Anatomy, not age. Roughly school-age (~ 8 yr) and larger; varies by build, neck size, and the kit you have.
↓
Yes — adult CTM Scalpel-finger-bougie cricothyroidotomy through the CTM.
Adult algorithm, same gear, same technique.
No — smaller child Literature unresolved. Pick the pathway your kit and training support; have the other ready as Plan B.
See fork below.
Three anchors for either fork

What's true regardless of which pathway you pick.

  1. A second provider keeps oxygenating from above (BVM / LMA) the entire time.
  2. Capnography confirms placement. Non-negotiable, both procedures.
  3. Brief, time-limited attempt — ~45 sec is a useful heuristic, not a validated threshold. If oxygenation isn't establishing, convert.
Part 2 · The fork

Two pathways. Pick by your kit and training.

Both pathways have proponents and shortcomings; neither has high-quality pediatric outcome data. The question to answer in your department before the case: which one are we trained for, and what do we actually have on the wall?

Traditional pathway

Needle cric + jet ventilation

DAS-Paediatric 2015 · textbook

14–16G angiocath through the CTM (largest practical) → connect to a manual jet ventilator (regulated wall O₂) or BVM via a 3.0 ETT adapter (Cole technique). Watch chest rise. Convert if no rise or barotrauma develops. Scalpel reserved for needle failure.

Emerging pathway

Surgical tracheotomy

Berger-Estilita 2021 · Morgenstern 2025

Driven by ~50% needle-cric failure in simulation. Vertical midline skin incision below the cricoid → expose trachea → vertical cut through 2 (max 3) tracheal rings → bougie → small ETT. Avoid the lower 25% of the neck (innominate vessels).

A note on the evidence The pediatric CICO literature is small, mostly simulation, and not consistent. Disma 2024 (ESAIC/BJA) and DAS-Paediatric 2015 list the needle-first pathway. Berger-Estilita 2021 and Morgenstern's 2025 First10EM review argue for surgical-first based on needle failure rates in simulation. Both are defensible. What isn't defensible is choosing under time pressure — pick a pathway in advance, drill it, stock for it.

Diagram showing the branch point between needle/jet ventilation and surgical tracheotomy in pediatric eFONA, with anatomic decision criteria.
The eFONA fork. Branching by anatomy, not by age. Annotation: surgical tracheotomy is technically a tracheotomy below the cricoid in young children, not a cricothyroidotomy through the CTM.
Part 3 · Oxygenating through the cannula

Most ED clinicians don't have a manual jet ventilator.

Cole — BVM via a 3.0 ETT adapter — is the realistic default. Knowing what each method actually delivers (and what it doesn't) changes how you set it up.

Default · most ED kits

BVM via 3.0 ETT adapter (Cole technique)

Pressure
Limited by BVM peak ~30 cmH₂O (~0.4 PSI)
Flow
100–300 mL delivered per 600 mL squeeze; high resistance through 14–16G
Use when
You have a BVM and an ETT adapter — which is everyone

Safer, less barotrauma. Oxygenates; barely ventilates — accept rising CO₂. Watch chest rise; allow long expiration (I:E ≥ 1:4). Hold the catheter manually — it will kink.

Alternative · regulated wall O₂

Manual jet ventilator (Manujet, ENK, equiv.)

Pressure
<5 yr: 5–10 PSI
5–8 yr: 15–25 PSI
>8 yr: 25–50 PSI*
Flow
High flow per breath; effective tidal delivery
Use when
Manual jet ventilator on the wall, training to match

More effective ventilation but real barotrauma risk in kids. Numbers extrapolated from adult / cadaver — not evidence-anchored. Need a patent upper-airway exit (NPA / OPA, retry SGA) or pneumothorax / arrest.

* Pediatric jet pressures Extrapolated from adult work and cadaver setups; treat as starting points, not targets.

Pediatric transtracheal jet ventilation setup showing wall O2 source, regulator, manual jet ventilator, and angiocatheter connected via a 3.0 ETT adapter.
Jet-vent assembly. The full pathway: regulated wall O₂ → manual jet ventilator → angiocath through the CTM. If your kit lacks a manual jet ventilator, the BVM-via-3.0-ETT-adapter version of this setup is the realistic default.
Part 4 · Delivering breaths

Timing matters more than pressure.

Through a 14–16G catheter, the determining variable isn't pressure or volume — it's whether the chest is fully falling between breaths. Operator-controlled, ~1 sec in, 3–5 sec out.

Step BVM (Cole) Manual jet ventilator
Set n/a — BVM peak ~30 cmH₂O is fixed Dial regulator to age-appropriate PSI before connecting
Inspiration Squeeze gently, ~⅓ of 600 mL bag, ~1 sec Press trigger (Manujet) or occlude side ports (ENK), ~1 sec
Expiration Release. Wait 3–4 sec for passive chest fall Release / unblock ports. Wait 4–5+ sec
I:E ratio ≥ 1:4 ≥ 1:4 (longer in smaller children)
Watch Chest rise on squeeze; full chest fall before next squeeze Chest rise on trigger; full chest fall before next breath
Why 1:4 — and when it relaxes

The 1:4 floor assumes complete upper-airway obstruction — the catheter is the only path in and out. With a patent upper-airway exit (NPA / OPA, retried SGA, jaw-thrust BVM from above), exhalation preferentially follows the native airway and you can ventilate more aggressively — mostly by raising rate, not by squeezing harder. The catheter is flow-limited; harder squeezes mostly raise peak pressure. Chest-fall rule still applies.

⚠ The failure mode

Operator timing is the procedure.

Inadequate expiration through a high-resistance catheter → intrathoracic pressure climbs → pneumothorax / arrest. If the chest is not fully falling between breaths, slow down or stop.

Page 1 · Before things go wrong

First steps — anatomy, physiology, sizing

Why peds airways crash fast, the four physiology facts that drive every decision, and the equipment table.
Sources

Where this comes from.

  1. Berger-Estilita J, et al. A primer for pediatric emergency front-of-the-neck access. A&A Pract 2021;15(4):e01444.
    doi:10.1213/XAA.0000000000001444
  2. Morgenstern J. Pediatric front of neck access. First10EM, Apr 2025.
    Surgical-first argument; reviews failure rates of needle approaches in simulation.
  3. Disma N, et al. Airway management in neonates and infants (ESAIC/BJA). Eur J Anaesthesiol 2024;41:3–23.
    doi:10.1097/EJA.0000000000001928
  4. Black AE, Flynn PER, et al. APA/DAS Paediatric Difficult Airway Guidelines. Paediatr Anaesth 2015;25:346–362.
    doi:10.1111/pan.12615
  5. Doctor JR, et al. AIDAA 2025 — Paediatric unanticipated difficult airway. Indian J Anaesth 2025;69:1167–1186.
    doi:10.4103/ija.ija_1096_25
  6. Frerk C, et al. DAS 2015 guidelines — unanticipated difficult intubation in adults. Br J Anaesth 2015;115:827–848.
    doi:10.1093/bja/aev371
  7. Navsa N, Tossel G, Boon JM. Cricothyroid membrane in neonates. Paediatr Anaesth 2005;15:402–406.
    doi:10.1111/j.1460-9592.2005.01470.x
  8. Fiadjoe JE, et al. PeDI-C registry: pediatric difficult intubation outcomes. Lancet Respir Med 2016;4:37–48.
    doi:10.1016/S2213-2600(15)00508-1
  9. Stacey J, et al. Pediatric CICO simulation. Paediatr Anaesth 2012;23:107–113.
    doi:10.1111/pan.12048
  10. Humphreys S, et al. THRIVE in children (RCT). Br J Anaesth 2017;118:232–238.
    doi:10.1093/bja/aew401
  11. Chrimes N. The Vortex approach to CICO. Br J Anaesth 2016;117(Suppl 1):i20–i27.
    doi:10.1093/bja/aew175
  12. EMCrit 184 — Duggan L. Trans-tracheal jet ventilation.