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United States military personnel often proceed directly to surgical airway placement due to complex facial injuries or the need to expedite care during various tactical scenarios [23]. A study of 72 battlefield prehospital cricothyroidotomies noted a success rate of 68%, with a 21% rate of miscannulating the trachea [24]. Combat medics performed most of these procedures. Patients undergoing cricothyroidotomy had a high mortality rate of 66%. The authors recommend that tactical EMS clinicians should be well versed in surgical airway techniques before attempting them [25].

A study of Israeli defense forces revealed that intubation success rates fall with each subsequent attempt [26]. Therefore, rescuers should determine thresholds for abandoning initial intubation efforts in favor of surgical airway placement.

Otolaryngologic airway emergencies

Any condition that results in airway edema and bleeding may create significant challenges. Post‐tonsillectomy bleeding is an example. Brisk bleeding may threaten to obstruct the airway. Effective measures to control bleeding include direct pressure with gauze, which may be moistened with 1:1000 epinephrine. Exceptional care must be taken not to precipitate airway obstruction with the gauze. For example, it may be held with a hemostat so that it doesn’t fall into the airway. If definitive airway control is necessary because of profuse bleeding, difficulties should be anticipated and appropriate contingency plans ready. Surgical airway may be necessary, but again, should only be attempted by experienced clinicians.