This is a procedure performed at the last stage of the “can’t intubate, can’t oxygenate” (CICO) algorithm.




  • Can’t intubate, can’t oxygenate
    • Premorbid difficult airway
    • Airway burns
    • Severe facial trauma
    • Obliteration of airway view by massive haemorrhage or vomit





  • Alternative method of securing airway is available
    • If intubation is “urgent” as opposed to “emergent” and a difficult intubation is anticipated, enlist expert help and consider other techniques (eg: awake fibreoptic intubation)
  • Age <8 (consider jet-insufflation technique)


Severe neck or laryngeal trauma is a relative contraindication – if there is no other way of securing that patient’s airway, then this might be the only option




  • Scalpel
  • Bougie
  • Hook or artery forceps
  • 6.0 ETT tube




The following assumes that the patient has been sedated and paralysed in preparation for RSI which has resulted in “CICO” situation. If the patient is awake, local anaesthetic and sedation (usually ketamine) will need to be used


  • Declare an airway emergency
  • Don PPE
    • Gloves, gown, eye protection
  • Rapidly disinfect skin with betadine or similar
    • This is not an aseptic procedure in an emergency
  • Locate the cricothyroid membrane and stabilise the larynx with your non-dominant hand
  • Make a 2-3 cm vertical incision over the skin then proceed to make a horizontal incision through the membrane
    • Note: some debate regarding whether to create vertical incision first, or to go straight to a horizontal incision. Will depend upon how easily the cricothyroid membrane landmarks are felt – if obscured, making a vertical skin incision can make it easier to then find the cricothyroid membrane
  • Dilate the hole slightly (pull down with hook, or use forceps) to allow bougie to be passed aiming caudally
  • Pass 6.0 ETT over bougie – only need to pass tube a few centimetres to reach past the cords
  • Remove bougie
  • Inflate tube and ventilate patient
  • Secure tube


Post procedure care as per standard intubation




The following is a youtube video of this procedure being performed on a cadaver






  • Bleeding
  • Incorrect tube placement
    • Subcutaneous (with subsequent subcutaneous emphysema – can be severe)
    • Oesophageal
  • Vocal cord or laryngeal injury
  • Oesophageal perforation




  • Infection
  • Scar formation
  • Long term vocal cord dysfunction
  • Glottic or subglottic stenosis
  • Tracheooesphageal fistula


Special Patients – Guideline: Elderly Patients

About this guideline

Published: February 2018
Author: Emma Batistich
Updated: Nicholas Longley April 2021
Approved by: Northern Region Trauma Network, ADHB, WDHB, CMDHB, NDHB, NRHL, St. John
Review due: 2 years