Comparison of scalpel sizes for emergency airway access

Scalpel Showdown: Which Blade Makes the Cut for Emergency Airway Access?

Lena Voss monogram
Lena Voss in Health & Wellness November 2026 • 4 min read.

"A pilot study reveals surprising insights into the effectiveness and preference of different scalpel blades for front-of-neck airway procedures."


In emergency medicine, the ability to secure a patient's airway quickly and efficiently is paramount. When faced with a 'can't intubate, can't ventilate' scenario, a front-of-neck access (FONA) procedure, such as a cricothyroidotomy, becomes a life-saving intervention. The Difficult Airway Society recommends a size-10 scalpel blade in their Plan D guidelines, but anecdotal evidence suggests that other sizes, including size-22 blades, are also used.

Recognizing the critical nature of this procedure and the variability in practice, a pilot study was conducted to determine which scalpel blade types are most effective and preferred for emergency FONA techniques. The study aimed to provide data-driven insights that could refine training protocols and improve patient outcomes in these high-pressure situations.

This article delves into the methodology and findings of this pilot study, shedding light on the surprising preferences and performance metrics associated with different scalpel blade sizes. By examining the experiences of trainee anaesthetists, we uncover valuable lessons that could influence future guidelines and practices in emergency airway management.

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Blade Choice in FONA

A 2018 pilot study examined which scalpel blades were effective and preferred for emergency front-of-neck access (FONA) cricothyroidotomy. The Difficult Airway Society recommends a size-10 scalpel blade for Plan D. The source material also identifies #10, #11, #15, and #20 as widely used blade numbers, describing #10 as curved and suited to general incisions.

Emergency Access Methods

Scalpel cricothyroidotomy is used to secure the airway in a “can't intubate, can't oxygenate” (CICO) scenario. The sources state that there is no consensus on the best emergency front-of-neck access method. Conventional approaches include surgical scalpel techniques as well as percutaneous cannula and Seldinger techniques.

From Ancient Knives to Modern Blades

The scalpel’s history is traced from ancient obsidian tools to modern German-grade stainless steel. One historical overview describes the scalpel as having roots in medical knives used by the Romans, while prehistoric humans occasionally used stone tools for medical purposes. Ancient surgical instruments included dedicated knives, and a 2025 analysis describes ancient scalpels with spatula-shaped handles and blades held at the opposite end.

The Scalpel Size Experiment: Training and Testing

Comparison of scalpel sizes for emergency airway access

The pilot study involved training two Core Trainee year-1 anaesthetists, both with no prior experience or training in FONA techniques. This ensured a level playing field and allowed for unbiased observation of their performance with different scalpel blades. The training protocol consisted of two key components:

First, the trainees watched a training video developed at the Royal Melbourne Hospital, providing them with a standardized visual guide to the FONA procedure. Second, they participated in a 15-minute practice session with an experienced instructor, using an animal larynx specimen to simulate a real-life scenario.

  • Kit 1: Size-11 blade
  • Kit 2: Size-22 blade
  • Kit 3: Size-10 blade
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Current Difficult-Airway Guidance

The Difficult Airway Society provides guidelines for managing unanticipated difficult intubation. The listed guidance is identified as the 2025 update. It includes algorithms and links for downloading the guideline materials.

Limits of Generalization

Evidence from one airway-management study may not apply broadly to other settings. The source highlights differences in education, training requirements, airway-management protocols, availability of paramedic-performed drug-facilitated intubation, and exposure to high-acuity cases. Because of these differences, the study’s results may not be generalizable and may not reflect other studies.

The candidates' attention was deliberately not drawn to the difference in the kits to avoid influencing their performance or preferences. The following parameters were recorded for each attempt: Time to insertion of the tracheal tube, accuracy of insertion, personal preference regarding equipment, and the length of the incisions on the external surface of the specimen.

Implications for Future Practice and Training

The pilot study's findings suggest that while all tested scalpel kits enabled correct tracheal tube placement, the size-22 scalpel was associated with the quickest placement time and was the preferred choice of the trainees. This may be attributed to the larger blade creating a longer skin incision, potentially facilitating easier insertion. However, these results are preliminary and warrant further investigation.

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Why the Size-10 Blade Matters

A pilot study investigated which scalpel blades were effective and preferred for emergency FONA cricothyroidotomy. The source identifies the Difficult Airway Society’s Plan D recommendation of a size-10 scalpel blade. This recommendation provides an established reference point for comparing alternative blade choices.

A Growing Blade Market

One market analysis describes medical scalpel blades as an expanding market worth more than $1.5 billion. It projects strong compound annual growth through 2033. The analysis names Aspen Surgical and Swann-Morton among the market’s top players.

Training for Rare Emergencies

The recommended emergency FONA technique uses a size-10 scalpel, a bougie, and a size-6 cuffed endotracheal tube. CICO scenarios requiring emergency front-of-neck access are rare, making routine day-to-day training difficult for anesthetists. A recent pilot study published in Anaesthesia examined which scalpel blade could provide the quickest and most efficient airway access during such a crisis.

How methods and evidence differ

Across emergency cricothyrotomy studies, timing comparisons are difficult because investigators used different starting and stopping points. Differences in measurement can help explain why results from separate studies do not line up neatly.[1]

What remains uncertain about emergency access

  • Would the relative timing pattern seen on a validated trainer hold under real emergency conditions? The evidence describes feasibility using a standard model, so it does not establish performance in actual emergencies.[2]
  • Could limited visibility during surgical cricothyrotomy affect blade handling or create other risks? A report describes excessive blade bending and breakage as a possible consequence of the restricted field of view.[3]

Terms used in airway access

Seldinger technique
A method involving a needle and guidewire.[1]

Sources

  1. Emergency cricothyrotomy – a systematic review (pmc.ncbi.nlm.nih.gov)
  2. Favour the best in case of emergency cricothyroidotomy–a randomized cross-over trial on manikin focused training and simulation of common devices (pmc.ncbi.nlm.nih.gov)
  3. Broken Scalpel Blade During Emergent Cricothyroidotomy: An Unexpected Complication in a Critical Situation (pmc.ncbi.nlm.nih.gov)

About this Article -

Written with AI assistance from published research, and reviewed by the Mystum team. See our About page for more information.

Everything You Need To Know

1

What is a front-of-neck access (FONA) procedure and why is it important?

A front-of-neck access (FONA) procedure, like a cricothyroidotomy, is a life-saving intervention performed when a patient's airway cannot be secured through traditional methods like intubation or ventilation. Guidelines often suggest using a size-10 scalpel blade for this procedure, but other sizes, such as size-22, are also utilized. Its importance lies in providing an alternative route for oxygen to reach the lungs in emergency situations, potentially preventing death or severe brain damage from lack of oxygen. Selecting the right blade may influence the time it takes to perform the procedure.

2

Can you describe the design of the pilot study that looked at scalpel blade sizes?

The pilot study compared the effectiveness of size-10, size-11, and size-22 scalpel blades in performing FONA procedures. Trainee anaesthetists, with no prior experience in FONA techniques, were trained and then tested using an animal larynx specimen. The time to tracheal tube insertion, accuracy, preference, and incision length were recorded. The goal was to determine if there were measurable differences in performance or preference among the different blade sizes, potentially leading to optimized training protocols.

3

What were the key findings of the pilot study regarding different scalpel blade sizes?

The study revealed that while all tested scalpel kits (size-10, size-11, and size-22) enabled correct tracheal tube placement, the size-22 scalpel was associated with the quickest placement time and was the preferred choice of the trainees. This outcome is significant because it challenges the convention of using a size-10 blade and suggests that a larger blade might offer advantages in terms of speed and ease of use. The quicker placement time with the size-22 blade may be attributed to the larger blade creating a longer skin incision, which could facilitate easier insertion of the tracheal tube.

4

What are the potential implications of the pilot study's findings for future practice and training in emergency airway management?

The study's finding, that the size-22 scalpel was preferred and resulted in quicker placement times, implies that current training protocols and guidelines might need to be re-evaluated. If further research confirms these results, training programs could incorporate the use of size-22 blades for FONA procedures. This shift in practice could potentially lead to faster and more successful airway interventions in emergency situations, improving patient outcomes.

5

Were there any limitations to the pilot study that should be considered when interpreting the results?

While the pilot study provides valuable insights, it is important to note that it involved a small sample size of only two trainee anaesthetists. Additionally, the study was conducted on animal specimens, which may not perfectly replicate the complexities of a human airway. Therefore, the results should be interpreted with caution, and further research with larger sample sizes and human subjects is needed to confirm these findings and establish definitive recommendations for scalpel blade selection in emergency airway access.

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