Can We Cric a Patient Sitting Up? The Numbers Behind "Train What You'll Do"

Civilian pooled estimates vs. the battlefield.

Mabry and Frankfurt reported that the military medic failure rate was three to five times higher than comparable civilian studies. Most patients in both combat series had major head, face or neck injuries, which is exactly the anatomy that makes positioning a live question. Survival was low in both, about one-third and one-half respectively, reflecting injury severity more than the airway alone.

No trial answers it; here's what does inform it.

The patient who needs a cric while sitting up is usually the one with massive maxillofacial trauma who can only keep an airway by leaning forward and letting blood drain. Current TCCC guidelines tell providers to allow a conscious casualty to assume any position that best protects the airway, including sitting up and/or leaning forward. The same guidelines direct lidocaine for surgical cricothyroidotomy in a conscious casualty, so a cric on an awake patient who has been holding their own airway upright is a scenario the doctrine anticipates. Laying that patient flat may make the anatomy easier to find while making the airway worse.

So the trade-off is real on both sides. Supine with suction gives the most familiar landmarks and hand position, but risks aspiration and loss of a self-maintained airway. Upright preserves drainage and airway, but changes neck angle, operator position and the feel of the landmarks, which is the post's point if the operator has never trained it. We found no published comparison of upright and supine cricothyrotomy success in live patients.

The post's recommendation, made concrete.

1. Volume first, supine. The post's observation that many medics don't grip the larynx or handle equipment correctly matches the failure modes in the combat series: wrong anatomic placement, subcutaneous passage, main-stem tube.
2. Higher-fidelity reps. Tissue-based or high-fidelity models over plastic necks, so landmarks and bleeding feel real.
3. Then add position and stress. Seated, leaning forward, low light, blood in the field, once supine performance is reliable.
4. Decision training, not just technique. Barnard et al. explicitly called for training in when to cric, not only how.

Laryngeal handshake, scalpel–bougie–tube with a vertical incision when landmarks aren't palpable (the Difficult Airway Society 2015 technique, which names scalpel cricothyroidotomy the preferred rescue and calls for regular practice), and confirming placement with end-tidal CO₂ are the elements most transferable between positions.

• @nextgenerationcombatmedic. "Can we cric a patient sitting up? Should we?" Instagram video and caption. Watch the original before relying on this summary.
• Mabry RL, Frankfurt A. An analysis of battlefield cricothyrotomy in Iraq and Afghanistan. J Spec Oper Med. 2012;12(1):17–23. doi:10.55460/FYQG-8E49
• Barnard EBG, Ervin AT, Mabry RL, Bebarta VS. Prehospital and en route cricothyrotomy performed in the combat setting: a prospective, multicenter, observational study. J Spec Oper Med. 2014;14(4):35–39. doi:10.55460/62V1-UIZC
• Hubble MW, Wilfong DA, Brown LH, Hertelendy A, Benner RW. A meta-analysis of prehospital airway control techniques part II: alternative airway devices and cricothyrotomy success rates. Prehosp Emerg Care. 2010;14(4):515–530. doi:10.3109/10903127.2010.497903
• Brown LH, Hubble MW, Wilfong DA, Hertelendy A, Benner RW. Airway management in the air medical setting. Air Med J. 2011;30(3):140–148. doi:10.1016/j.amj.2010.11.010
• Committee on Tactical Combat Casualty Care. TCCC Guidelines, Tactical Field Care: Airway Management (2024 update; unchanged in current edition). Deployed Medicine / J Spec Oper Med.
• Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827–848. doi:10.1093/bja/aev371
• Metadata and abstracts retrieved via PubMed.