Ear-to-Sternal-Notch Positioning
Objective: Put the external auditory canal level with the sternal notch so BVM, VL, and DL have a chance — especially when the occiput, pannus, or gravid uterus is in the way.
Why This Is Hard
You lie them flat because that is how the stretcher arrived. The tongue, the occiput, and a big belly all drop the airway axis. DAS and ASA difficult-airway teaching start with position. A pretty laryngoscope view you cannot get because the neck is flexed is a positioning problem, not a skill problem.
- You have blankets, a pillow, the head of the stretcher, and maybe a ramp built from trauma pads.
- You do not have an OR table with a built-in ramp.
- Build ear-to-sternal-notch before the first look. Pregnant patients after ~20 weeks also need left uterine displacement — see trauma-in-pregnancy.
Field Rules (Education)
- Target: external auditory canal roughly level with the sternal notch (ear-to-sternal-notch). That is sniffing done right, not “chin to sky.”
- Kids: a big occiput flexes the neck on a flat surface — a thin pad under the shoulders, not a huge adult pillow under the head, is the usual teaching. See pediatric airway.
- Obesity / late pregnancy: ramp the upper back and head so the ear comes up to the notch. Flat-and-flexed is a desaturation plan.
- C-collar: manual in-line stabilization does not mean you cannot pad under the shoulders. Airway still wins.
Field Pitfalls
- Intubating on the floor with the head hanging in flexion “because we were in a hurry.”
- A giant pillow under an infant’s head.
- Blaming the bougie when the axis was never aligned.
Practice
60-second drill
Partner names: toddler on a flat board; 400 lb on a stair chair landing; 34 weeks, vomiting. For each, say where the pad/ramp goes in one sentence.
Related: Preoxygenation, Difficult Airway.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; protocol still wins
- Difficult Airway Society guidelines hub — positioning and ramping before advanced airway attempts
- ASA 2022 Difficult Airway Practice Guidelines — optimize position before repeated attempts
- Your RSI/airway protocol owns when you remove a collar and how you ramp.
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.