INTRODUCTION: A patient that cannot be oxygenated or ventilated requires immediate and effective assessment, treatment, and transportation. Pediatric needle cricothyrotomy is used infrequently, therefore providers have a tendency to lose proficiency. Simulation training and evaluation are valuable tools to improve provider experience and skill. METHODS: A case was designed involving a 3-year-old male with a peanut allergy that presents with rash, swelling, and severe respiratory distress. The patient's respiratory distress and swelling worsens despite treatment with epinephrine and other allergic reaction medications. The patient then becomes unresponsive and impossible to oxygenate or ventilate. The primary objective of this case is airway management with needle cricothyrotomy in the pediatric population. A secondary objective is appropriate postprocedure management including appropriate ventilation rates and emergency medical transportation methods. RESULTS: This case was initially presented to 45 paramedics. Provider comfort with managing airway emergencies in young children improved from 47% to 89%. Confidence in performing pediatric needle cricothyrotomy improved from 16% to 87%. All providers felt the exercise was valuable and 98% felt the simulation provided appropriate realism. DISCUSSION: This scenario provides an outstanding opportunity for paramedic evaluation and training in pediatric needle cricothyrotomy and significantly improved the comfort level of providers' management of a failed pediatric airway. As we reflected on the use of this module, it was apparent that this was a very beneficial opportunity to spend one-on-one time between participants and their medical director. The training staff also benefited from the repeated emphasis of good assessment and treatment of a complex patient scenario.