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In the emergency trauma situation, in-line stabilization (ILS) of the cervical spine is used to reduce head and neck extension during laryngoscopy. The Bullard laryngoscope may result in less cervical spine movement than the Macintosh laryngoscope. The aim of this study was to compare cervical spine extension (measured radiographically) and time to intubation with the Bullard and Macintosh laryngoscopes during a simulated emergency with cervical spine precautions taken.Twenty-nine patients requiring general anesthesia and endotracheal intubation were studied. Patients were placed on a rigid board and anesthesia was induced. Laryngoscopy was performed on four occasions: with the Bullard and Macintosh laryngoscope both with and without manual ILS. Cricoid pressure was applied with ILS. To determine cervical spine extension, radiographs were exposed before and during laryngoscopy. Times to intubation and grade view of the larynx were also compared.Cervical spine extension (occiput-C5) was greatest with the Macintosh laryngoscope (25.9 [degree sign] +/- 2.8 [degree sign]). Extension was reduced when using the Macintosh laryngoscope with ILS (12.9 +/- 2.1 [degree sign]) and the Bullard laryngoscope without stabilization (12.6 +/- 1.8 [degree sign]; P < 0.05). Times to intubation were similar for the Macintosh laryngoscope with ILS (20.3 +/- 12.8 s) and for the Bullard without ILS (25.6 +/- 10.4 s). Manual ILS with the Bullard laryngoscope results in further reduction in cervical spine extension (5.6 +/- 1.5 [degree sign]) but prolongs time to intubation (40.3 +/- 19.5 s; P < 0.05).Cervical spine extension and time to intubation are similar for the Macintosh laryngoscope with ILS and the Bullard laryngoscope without ILS. However, time to intubation is significantly prolonged when the Bullard laryngoscope is used in a simulated emergency with cervical spine precautions taken. This suggests that the Bullard laryngoscope may be a useful adjunct to intubation of patients with potential cervical spine injury when time to intubation is not critical.