Paediatric emergency front-of-neck access

In the unpredictable theatre of paediatric emergencies, few events evoke as much urgency and helplessness as a true ‘Cannot Intubate, Cannot Oxygenate’ (CICO) situation.1 In this month's issue of the European Journal of Anaesthesiology, Dr Asgeirsdottir et al. from Reykjavik, Iceland present a devastating case report entitled “The trachea heals but the hypoxia does not: an emergency front-of-neck access in a 4-year-old with foreign body airway obstruction”.2 It is a stark, deeply human narrative that offers rare and invaluable insight into one of anaesthesiology's most harrowing frontiers. The reported case recounts the desperate but technically successful execution of emergency front-of-neck access (eFONA) in a 4-year-old child after complete upper airway obstruction from an embedded inhaled foreign body. Despite the success of establishing a surgical airway and achieving return of spontaneous circulation (ROSC) in the emergency department, the child ultimately succumbed to irreversible hypoxic brain injury. This tragic outcome, while heartbreaking, does not diminish the educational power of the report. Instead, it underscores critical clinical, procedural, and ethical lessons with profound implications for paediatric and emergency care systems.3 Confronting the rare and unforgiving In children, eFONA is a paradoxical intervention; vital but vanishingly rare, technically mostly feasible yet emotionally destabilising, and conceptually clear but nearly impossible to adequately practice. The rarity of paediatric CICO cases means that when they occur, most providers will be facing the situation for the first time, often with limited muscle memory and immense psychological stress. This reported case report makes a meaningful contribution simply by existing; it adds to the scant literature on real-world paediatric eFONA and demystifies the use of the scalpel-(bougie)-tube technique in a child. In this report, the authors offer clarity on the anatomical approach, procedural adaptation in the absence of ideal equipment, and the improvisational decisions dictated by the anatomy of a small child. This transparency is crucial. It reminds us that in real emergencies, algorithms, and potentially rehearsed situations will only serve as guides, but instinctive human judgment eventually drives the outcome. Time as the critical variable The most haunting dimension of this case is that the procedure was successful but the ultimate result was failure. The trachea was accessed, ventilation was restored, and circulation returned. Yet the child's brain had already suffered a catastrophic ischaemic injury. It is this reality that gives the case its emotional and educational resonance. The title's poetic lament, “the trachea heals but the hypoxia does not,” encapsulates the core message: a technical victory is ultimately choked by having run out of time. Importantly, if eFONA was to lead to a good patient outcome in this case, it probably should have been performed at the scene, immediately upon identification of complete airway obstruction. Continued CPR without establishing oxygenation is of limited utility, particularly in children where limited oxygen reserves are quickly depleted. Recognising and acting decisively on this principle remains critical for all frontline providers.3 In their presentation of this case report, the authors made a difficult ethical choice: to omit precise prehospital timelines in deference to the emotional burden on the emergency medical technicians (EMTs) and the child's family. While this choice may be seen as lacking academic accuracy, it reflects a commendable human sensitivity. The report highlights the urgent need for healthcare systems to track and review response times with rigour and without blame. Future similar cases should strive to document timeline data through institutional or anonymised debriefing processes to permit system improvement. It must be emphasised that eFONA is a last-resort, life-saving procedure performed under extreme pressure. Clinicians acting in desperation and good faith within the accepted practice should not be criticised or prosecuted for the likely scenario of an unsuccessful outcome of an eFONA. Team dynamics and decision-making in crisis One of the most compelling elements and descriptions in this case is its attention to nontechnical skills.3 The report emphasises team communication, shared decision-making, and situational awareness, skills commonly neglected in traditional descriptions but critical in high-stakes emergencies. The pivotal moment occurs when a team member verbalises the need for a tracheostomy, catalysing a co-ordinated, decisive response. This single utterance may have saved crucial seconds and empowered the lead clinician to act decisively. Flattened hierarchies may save lives in emergency medicine. When every team member feels authorised to speak up, when roles are clear and rehearsed, outcomes improve. Simulation training that includes such communication cues should be as integral as a procedural rehearsal in paediatric emergency preparedness. The role of prevention, training, and system preparedness (Paediatric) anaesthetists are well honed in the prevention and early recognition and treatment of anatomical and functional airway obstruction.4 Training to prevent CICO situations rather than reliance on a dramatic and commonly futile eFONA is critical. Good basic airway management techniques to allow oxygenation and ventilation remain the key to survival and permit early recognition of the extremely rare situation described in this case report. Paediatric anaesthetists are also fully cognisant of the danger of repeated paediatric airway instrumentation leading to trauma and swelling and aim to prevent a difficult airway from converting into an impossible one, a CICO. Early recognition, calling for help, and adapting different strategies are paramount. Unfortunately, this knowledge is not universally shared between healthcare practitioners across medical specialties exposed to paediatric airways. What emerges most forcefully from this case is the need for better system-wide preparation. Even a perfect technique, leads to poor outcomes if delayed. Thus, any preparation must be multifaceted: simulation of paediatric airway emergencies, availability of appropriately sized equipment, institutional protocols that allow rapid escalation, and psychological readiness for emotionally challenging scenarios. It must also be acknowledged that paediatric CICO scenarios almost always occur outside the controlled environment of the operating room, in emergency departments, intensive care units, ambulances, or prehospital settings. This reality requires all involved providers - not only anaesthetists but also emergency physicians, intensivists, and paramedics – to be both trained and prepared to act rapidly. Delay, hesitation, or unfamiliarity in such settings can critically affect survival. The rabbit eFONA model serves as a useful procedural training tool, but its clinical relevance is limited by significant anatomical differences from children and the absence of physiological realism, such as bleeding and tissue responsiveness. Additionally, standardised, low-stress training conditions and cadaver variability do not reflect the complexity, urgency, and team dynamics of real paediatric CICO scenarios, restricting its generalisability and scalability.5 Simulators and animal models can never fully replicate the real-world stress, unpredictability, and anatomical nuances of paediatric emergencies. It takes everything to cut a child's neck under these circumstances. That cannot be rehearsed. An urgent call for better data and shared experiences has previously been made in this journal and should be re-visited.6 Such data must then be used to design and conduct regular multidisciplinary drills, an embedded culture of team communication, and after-action reviews must be standard practice, especially in low-frequency, high-impact scenarios like paediatric CICO.7 Reflections and takeaways Beyond the technical, this report shines in its ethical and emotional candour. It openly acknowledges the trauma experienced by the medical team and the profound grief of the parents. Yet, through their consent, the child became an organ donor, transforming tragedy into renewed life for others. This detail shared respectfully and powerfully, offers readers a rare look into the holistic arc of critical care, where clinical outcomes and human stories are inseparable. It also permits some form of closure for the affected family, observers, and healthcare providers. Grievance and debriefing in a protected environment is required and takes many forms. This case report is an exemplar of clinical storytelling that balances technical rigour with emotional authenticity offering a complete, structured, and ethically aware account. More importantly, it contributes meaningfully to a field where guidance is sorely needed. In paediatric anaesthesia and emergency medicine, eFONA remains an uncomfortable but essential frontier. This case report, with all its pain and power, reminds us that in medicine, time is breath – and sometimes, the difference between life and death lies not in what we can do, but how quickly we do it. By facing the darkest corners of practice with honesty and precision, this report does more than document a tragedy. It transforms one family's loss into collective knowledge. And in doing so, it brings us all one step closer to being ready for the moment we hope never comes.

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