Scalpel-finger-bougie cricothyrotomy: Passing bougie into trachea with a finger in the opening

(A) Withdraw the scalpel, immediately insert an index finger through the horizontal incision, and dilate the opening in the cricothyroid membrane. Once the index finger is deeply in the cricothyroid space, it keeps the larynx in place and the surgical pathway into the airway controlled.

(B) Rotate the palm upwards while keeping the finger inside the rigid cartilaginous structure, keeping it stabilized. Using the volar pad, direct the bougie caudally down the trachea. Placement is confirmed by palpating tracheal rings as the bougie is advanced and by appreciating resistance if the bougie reaches the carina or mainstem bronchus.