The Formulation of Cognitive Aids and a Systematic Approach to Emergency Front-of-Neck Access, Following a "Can't Intubate, Can't Oxygenate" Crisis in a Patient With Ankylosing Spondylitis.

A patient with ankylosing spondylitis in a "can't intubate, can't oxygenate" situation was rescued with cannula cricothyrotomy and transtracheal jet oxygenation. The case revealed clinical and systematic weaknesses, leading to standardization and reorganization of our equipment. Prepackaged cannula cricothyrotomy sets were placed in standardized locations in the operating rooms in line with our institution's "cannula first" policy. Cognitive aids specific to emergency front-of-neck access (eFONA) were created and placed strategically with the eFONA equipment to prompt and guide operators during airway emergencies. The aids have also been incorporated into our training curriculum to encourage their use.