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BURP and laryngoscopy
  1. Simon Carley,
  2. Rupert Jackson
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
  1. Correspondence to: Kevin Mackway-Jones, Consultant (kevin.mackway-jones{at}

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Report by Simon Carley;Specialist RegistrarChecked by Rupert JacksonSpecialist Registrar

Clinical scenario

A 35 year old man with a severe head injury is brought to the emergency department. He has fallen from a ladder and is leaking CSF from the left ear suggesting a base of skull fracture. He has a GCS of 3 and dilated pupils. There are no other apparent injuries. You decide to intubate him using an RSI technique. Laryngoscopic view is poor despite the use of a McCoy laryngoscope and cricoid pressure. You eventually intubate using a gum elastic bougie. Your assistant performing cricoid pressure asks during the procedure if you want a BURP. Other bodily functions come to mind! Later your colleague explains that BURP (backwards, upwards, to the right, with pressure) on the thyroid cartilage improves the view. You wonder if in fact it is any better than simple cricoid.

Three part question

In [patients in with a poor laryngoscopic view] is [the BURP technique better than simple cricoid pressure] at [improving laryngoscopic view]?

Search strategy

Medline 1966–07/2001 using the OVID interface. [{exp laryngoscopy OR OR exp intubation, intratracheal OR OR intubate$.mp} AND [{( OR backward$.mp OR AND} OR] LIMIT to human AND english.

Search outcome

Altogether 72 papers were found of which three were relevant to the three part question. These three papers are shown in table 2.

Table 2


Optimising the view at laryngoscopy is an important step in successfully intubating patients in the emergency department. Although these studies only contain small numbers of true grade 3 patients (and no grade 4) there was a consistent improvement in laryngoscopic view. The BURP technique seems to be an additional step beyond simple backward pressure (which is likely to have a similar effect as cricoid pressure). It should therefore be taught to people assisting in RSI in the emergency department.

Clinical bottom line

The BURP technique can improve the laryngoscopic view and should be taught to those assisting in anaesthetic procedures.

Report by Simon Carley;Specialist RegistrarChecked by Rupert JacksonSpecialist Registrar