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:

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