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Step 3

Failed Attempt / Difficult Airway

After every failed attempt, change a meaningful variable and escalate early.

This static page is designed for simulation, prebriefing, and source review. It does not save encounter state, analyze a patient, or generate a treatment directive. Verify current local protocols and the clinical context.

Learning objectives

  • Stop repeating the same failed attempt
  • Change device, operator, positioning, or technique
  • Call for help early
  • Move to supraglottic backup when appropriate
  • Move to surgical airway for CICO

Simulation discussion prompt

The attempt failed. The current failure mode is __. For the next move we are changing __. Help is coming. Backup oxygenation is __. If we cannot intubate and cannot oxygenate, we move to surgical airway.

Discussion points

After each failed attempt - change one variable

Device
Operator
Positioning
Technique

Escalation

Call for help
Activate DART or the local difficult-airway response
Place a supraglottic airway when appropriate
Proceed to surgical airway if CICO

Teaching pearl

A second attempt should not be a replay of the first. Make the next attempt meaningfully different and keep oxygenation as the priority.

Common pitfalls

  • Repeating the same device, operator, position, and technique
  • Failure to call for help early
  • Continuing attempts while oxygenation deteriorates
  • Delaying supraglottic backup or front-of-neck access in CICO
  • Using DART language without defining the local equivalent

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About this resource
Created by: Andrew Pirotte, MD; Kyle Brown, MD; Reba Hodge, MD; Amanda Vanderwerf, PharmD, BCEMP; Morgan Kimball, PharmD, BCEMP; Joshua Mohess Clinical review: Emergency medicine faculty review completed. Medication content reviewed by Amanda Vanderwerf, PharmD, BCEMP, and Morgan Kimball, PharmD, BCEMP. Last reviewed: 2026-07-23 Next scheduled review: 2027-01-23 Designed for: EM residents, emergency physicians, EMS clinicians, airway educators, and simulation faculty Important: Educational resource and clinical-reference guide only; not a bedside order set or substitute for local protocol, medical direction, or clinical judgment. Website contact: [email protected]