Ear-to-Sternal-Notch Positioning
Objective: Put the ear canal level with the sternal notch before you bag or look. This matters most when the back of the skull, belly fat, or a pregnant uterus is in the way.
Why this matters
Crews lay the patient flat because that is how the stretcher arrived. The tongue, the occiput, and a large belly all bend the airway. The occiput is the back of the skull.
Position the head before you pick up the blade. If you cannot see the cords because the neck is flexed, that is a positioning problem, not a skill problem. A video laryngoscope does not replace this position.
- From the side, the ear canal should sit about level with the sternal notch. That is the sniffing position. Do not tip the chin straight up at the ceiling.
- Build the position with blankets, a pillow, the head of the stretcher, or a ramp made from trauma pads. You do not have an operating-room table that does this for you.
- Build it before the first look. After about 20 weeks of pregnancy, also move the uterus to the patient’s left.
Clinical sequence
- Look from the side before you pick up a blade. Line the ear canal up with the sternal notch.
- For a large adult, ramp the upper back and head so the ear comes up to the notch. A flat, flexed neck will drop the oxygen saturation.
- For late pregnancy, ramp the same way. After about 20 weeks, also move the uterus to the patient’s left. See Trauma in Pregnancy.
- For a toddler, a large occiput flexes the neck on a flat board. Put a thin pad under the shoulders. Do not put a large adult pillow under the head. See pediatric airway.
- A cervical collar does not stop you from padding under the shoulders. Holding the neck in line still leaves you room to pad. The airway still comes first.
Teaching points
- The drawing is the target. The ear canal is about level with the sternal notch. The chin is not pointed at the ceiling.
- Infants and toddlers usually need a thin pad under the shoulders. Large adults and late pregnancy usually need a ramp under the upper back and head.
- This is positioning, not a device setting. Do it before the first look, including when you plan to use a video laryngoscope.
Common errors
- Intubating on the floor with the neck flexed because the crew was in a hurry.
- Putting a large pillow under an infant’s head.
- Blaming the bougie when the ear and the sternal notch were never lined up.
Practice
One-minute check
Your partner names three patients: a toddler on a flat board, a 400-pound patient on a stair landing, and a patient at 34 weeks of pregnancy who is vomiting. For each, say in one sentence where you put the pad or the ramp.
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; follow your protocol
- 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
Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.