February 26, 2021

Bougie-Assisted Cricothyrotomy

Background: Cricothyrotomy is a high acuity low occurrence (HALO) procedure that is time critical.  It is the common final step in the cannot intubate cannot oxygenate (CICO) and/or cannot intubate cannot ventilate (CICV) situation. Due to the time critical nature of the procedure, any approach must include three facets:

  1. Be as simple and rapid as possible
  2. No special equipment required
  3. High success and low complication rate

14 minute video on anatomy and procedure of bougie-assisted cricothyrotomy

Hardest Part of the Procedure:

  • Making the decision to cut
  • Cricothyrotomy typically performed too late to prevent poor outcome
    • The time taken to act
    • The time taken to prepare
  • Important to remember there is no absolute contraindications to this procedure

Equipment Needed:

  • 10 or 11 blade scalpel
  • Bougie
  • 6.0 – 6.5 endotracheal tube

Anatomy You Need to Know:

  • Thyroid Cartilage
  • Cricothyroid Membrane/Ligament
    • In adults this is 9 to 19mm horizontally & 9 to 20mm vertically)
  • Cricoid Cartilage
  • Trachea

Laryngeal Handshake:

  • Palpate thyroid cartilage
  • Palpate cricoid cartilage
  • Cricothyroid membrane/ligament will be a slight depression between the two

The Procedure:

  • Vertical incision
  • Place finger into incision and palpate ligament prior to stab incision
  • Horizontal incision (stab blade into membrane then drag, flip, drag without removing scalpel)
    • Want to make horizontal incision in lower half of the cricothyroid membrane
    • Potentially avoids cricothyroid arteries and vocal cords
  • Remove the scalpel and insert the tip of the finger into the incision
    • Confirms that the incision has penetrated into the laryngeal lumen
    • Confirms the incision is large enough to accommodate an endotracheal tube
  • Bougie slides in right behind finger
  • Endotracheal tube slide over bougie
    • Cricothyroid membrane is located below vocal cords therefore avoid feeding endotracheal tube too far in (Feed until cuff disappears into tracheal lumen)

Practice Practice Practice:

  • Training should be repeated at least once a month to maintain fidelity with the procedure
    • Can use 3D printed models
    • Electrical Tape = Membrane
    • Foam Tape = Skin


  1. Sorbello M et al. Front-of-Neck Access and Bougie Trapping. Anaesthesia 2018. PMID: 30132808
  2. Paix BR et al. Emergency Surgical Cricothyroidotomy: 24 Successful Cases Leading to a Simple ‘Scalpel-Finger-Tube’ Method. Emerg Med Australas 2012. PMID: 22313556
  3. Langvad S et al. Emergency Cricothyrotomy – A Systematic Review. Scand J Trauma Resusc Emerg Med 2013. PMID: 23725520

For More Thoughts on This Topic:

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami)

Cite this article as: Salim Rezaie, "Bougie-Assisted Cricothyrotomy", REBEL EM blog, February 26, 2021. Available at: https://rebelem.com/bougie-assisted-cricothyrotomy/.
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Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of REBEL EM
  • Jedd Hart
    Posted at 03:35h, 27 February Reply

    Do you have any advice when attempting a cric on an obese patient? Ultrasound-guided over-the-wire, or large vertical incision and blunt dissection?

    • Salim Rezaie
      Posted at 08:04h, 27 February Reply

      Hey Jedd,

      I would do nothing different…make sure you do your laryngeal handshake, and make a vertical incision big enough that you can feel and see what you are looking for. Again trying to keep the procedure as simple as possible. You can use POCUS, however I suspect the time it would take to find it, get it warmed up and use it would be far too long before this procedure would need to be done. Hope this helps.


  • Duncan R Smith
    Posted at 14:38h, 01 March Reply

    Hey guys – how do you make an unresponsive patient in a CICO/CICV situation’s trachea dance?

    You put a little bougie in it!

  • bougie-assisted cricothyrotomy by Salim R. Rezaie | ACUTE GENERAL INTERNAL MEDICINE
    Posted at 12:27h, 20 March Reply

    […] Bougie-Assisted Cricothyrotomy […]

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