Surgical scalpel hovering over stylized neck, representing emergency airway procedure.

Scalpel Showdown: Which Blade Reigns Supreme for Emergency Airway Access?

Avery Sinclair in Health & Wellness August 2025 • 4 min read.

"A pilot study reveals surprising insights into scalpel blade effectiveness during front-of-neck access procedures, challenging conventional recommendations."

In emergency medicine, securing a patient's airway can be a matter of life and death. When traditional intubation methods fail, a front-of-neck access (FONA) procedure, such as a cricothyroidotomy, becomes necessary. The Difficult Airway Society recommends a size-10 scalpel blade for this procedure, but a recent study has called this into question, suggesting that a different blade size might offer advantages.

A pilot study published in "Anaesthesia" in 2018, conducted by F.J. Lamb, V. Mikkere, M. Mackenzie, and T. Samuels, sought to determine which scalpel blade types were most effective and preferred for emergency FONA techniques. The researchers focused on comparing the commonly recommended size-10 blade with size-11 and size-22 blades.

This study provides a basis for further exploration into optimal scalpel selection for emergency airway procedures, it highlights the importance of continually refining medical techniques to improve patient outcomes. As medical professionals, it’s essential to stay informed about the latest research and adapt our practices based on emerging evidence.

The Blade Battle: Size 10 vs. Size 11 vs. Size 22

Surgical scalpel hovering over stylized neck, representing emergency airway procedure.

The study involved training two novice anaesthetists, who had no prior experience with FONA techniques. These trainees received a 15-minute training session, during which they watched a training video and practiced on an animal larynx specimen under expert supervision. They then performed three sequential FONA-cricothyroidotomies using test kits containing size-10, -11, and -22 scalpel blades.

The researchers measured several key factors during the simulated procedures, including the time taken to insert the tracheal tube, the accuracy of the insertion, the length of the external incision, and the trainees' subjective preferences regarding each blade.

Speed: The size-22 blade was associated with the quickest tracheal tube placement.
Incision Length: The size-22 blade created a longer skin incision compared to the other blades.
Ease of Use: Trainees rated the size-22 blade as easier to use.
Confidence: Trainees reported higher confidence levels when using the size-22 blade in an emergency scenario.
Preference: Both trainees subjectively preferred the size-22 blade.

The study's results indicated that while all three blade sizes enabled correct tracheal tube placement, the size-22 scalpel was associated with the fastest placement time. This was potentially due to the longer skin incision created by the larger blade, which may have facilitated easier insertion.

The Future of FONA: More Research Needed

While the study suggests that a size-22 scalpel blade may offer advantages in emergency FONA procedures, the authors emphasize the need for further research to validate these findings. They are currently undertaking a larger study to investigate their findings in greater depth.

About this Article -

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Everything You Need To Know

What is front-of-neck access (FONA), and why is it important in emergency medicine?

Front-of-neck access (FONA), often involving a cricothyroidotomy, is a critical procedure in emergency medicine used to secure a patient's airway when traditional methods like intubation fail. It involves creating an opening in the neck to insert a tracheal tube, enabling breathing. This procedure is a life-saving intervention in situations where a patient cannot breathe adequately due to obstruction or other airway compromise. The success of FONA directly impacts patient survival and outcomes, highlighting its importance in critical care scenarios.

What were the key findings of the study comparing different scalpel blade sizes for FONA?

The study, which compared size-10, size-11, and size-22 scalpel blades for FONA, revealed several key findings. The size-22 blade was associated with the quickest tracheal tube placement. It also resulted in a longer skin incision compared to the size-10 and size-11 blades. Novice anaesthetists found the size-22 blade easier to use, reported higher confidence levels, and subjectively preferred it in an emergency scenario. While all blades enabled correct tube placement, the size-22 blade stood out in terms of speed and user preference.

What is the significance of the difference in incision length among the scalpel blades used in the study?

The incision length, specifically longer with the size-22 blade, has implications on the speed and ease of the procedure. A longer incision may facilitate easier insertion of the tracheal tube, contributing to the quicker placement time observed with the size-22 blade. However, the optimal incision length is still an area of investigation. The study highlights that there's a trade-off between incision size and procedure speed and ease of use, impacting overall procedure efficiency and potentially patient outcomes.

Who were the participants in the study, and how did they prepare for the FONA procedure?

The study involved training two novice anaesthetists, who had no prior experience with FONA techniques. They received a 15-minute training session, during which they watched a training video and practiced on an animal larynx specimen under expert supervision. This training allowed them to familiarize themselves with the FONA procedure before performing the simulated cricothyroidotomies using different scalpel blades. The study design aimed to evaluate the performance of different blades in a controlled setting with individuals who had limited prior experience, mimicking a real-world emergency scenario.

What recommendations did the Difficult Airway Society give, and how did the study challenge them?

The Difficult Airway Society recommends a size-10 scalpel blade for the FONA procedure. The study, however, challenged this recommendation by suggesting that a size-22 blade might offer advantages in terms of speed, ease of use, and user preference. The study's findings indicated that the size-22 blade led to faster tracheal tube placement and was preferred by the trainees, which prompted the authors to highlight the need for more research to validate and possibly revise current guidelines based on these emerging insights.