External Laryngeal Manipulation (Bimanual Laryngoscopy) – Help From Drs. Weingart, Cardogan, And Nickson

This post is about external laryngeal manipulation ( ELM) [bimanual laryngsocopy], a technique to improve the success rate for intubation.

Dr. Weingart, EMCrit, reviewed his checklist for rapid sequence intubation in Podcast 176 – Updated EMCrit Rapid Sequence Intubation Checklist [link is to the show notes and vidcast]. And in that vidcast he discusses how to perform ELM as follows:

you brief someone for external laryngeal manipulation [ELM] which means you say: If I ask you to put your hand on the neck, you’ll put it right on the thyroid [cartilege] and you’ll show them right where it is. Just let me move you wherever I want and you keep your hand there.

This is slightly different from the YouTube video below (better, I think) because in the video the airway operator does the ELM with his hand and then replaces it with the assistant’s hand.

I found this video and all that follows on the post Bimanual Laryngoscopy from the emergency medicine blog Life In The Fast Lane by Drs. Cardogan and Nickson and their team:


  • Bimanual laryngoscopy using external laryngeal manipulation (ELM) is the single most practical and effective airway management technique for facilitating intubation during laryngoscopy.


  • During laryngoscopy, the laryngoscopist reaches around with the right hand, manipulating the larynx while directly observing the effect on laryngeal view.
  • the force on the neck is in the opposite direction to the force of lift with the laryngoscope.
  • After the view is optimized, an assistant maintains pressure at this location, freeing the laryngoscopist’s right hand to place the tube.
  • [In Dr. Weingart’s method (above) the laryngospist simply places his hand over the asisistant’s hand on the thyroid cartilege and guides the assistant’s hand to the proper position on the neck and then maintain that position after the laryngospist removes his hand from the assistant’s.]

The above video is published by AirwayCam
Uploaded on Nov 24, 2007

The following references are from Drs. Carrdogan and Nickson’s post above:

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