Which Hand Holds the Scalpel? The Untested Question in Emergency Neck

A perspective piece in Frontiers in Anesthesiology says 2025 guidance for emergency front-of-neck access (eFONA) embeds an assumption that hasn’t been tested: where the operator stands based on handedness. eFONA is used only after failed attempts at tracheal intubation, supraglottic airway ventilation, and facemask ventilation in “cannot intubate, cannot oxygenate” scenarios. Researchers led by Daniele Salvatore Paternò of the “Giovanni Paolo II” Hospital in Ragusa analyzed the Difficult Airway Society (DAS) guidelines describing 19 steps of the scalpel-bougie-tube technique. Eleven steps specify which hand performs key actions and even require a hand swap mid-procedure. While the steps are anatomically plausible, the authors note limited evidence and contradictory guidance on standing side for right-handed operators. They also cite NAP4 findings that 61% of ICU major airway events occurred outside operating theatres.