Cervical fracture, Intubation techniques

Cervical Precaution

According to Barash, chapter 36, “Maintenance of immobilization of the injured spine is of paramount importance. If a cervical spine fracture is suspected, immobilization or manual inline stabilization of the neck is necessary before the patient is moved. If the patient has a thoracic or lumbar injury, a careful log-rolling maneuver should be used”

Further in Chapter 53, “Airway management is critical in patients with cervical spinal cord injury. The most common cause of death with acute cervical spinal cord injury is respiratory failure. All patients with severe trauma or head injuries should be assumed to have an unstable cervical fracture until proven otherwise radiographically. During transport, the patient should be moved on a spine board with the neck immobilized to prevent further injury. Awake fiberoptic-assisted intubation may be necessary, with general anesthesia induced only after voluntary upper and lower extremity movement is confirmed. Blind nasotracheal intubation may be used if there is no evidence of facial or basal skull fractures. In a truly emergent situation, oral intubation with direct laryngoscopy is the usual approach. The trachea should be intubated with minimum flexion or extension of the neck.”

According to Injuries to the Cervical Spine, Trauma.org, Accessed 2/27/15

“The safety of orotracheal intubation for patients with potential C-spine injury has been documented in recent years. For patients requiring immediate and/or urgent airway control, we recommend rapid sequence induction followed by orotracheal intubation with cricoid pressure and manual in-line immobilization of the head and neck.Precise cervical spine in-line immobilization should be maintained throughout the intubation maneuvers. This technique, also called manual in-line axial traction is an active process done by a second individual who is responsible for applying a varying amount of force to counteract the movements of the laryngoscopist, in an attempt to stabilize the cervical spine. The patient lies supine with the head in neutral position; an assistant applies manual in-line immobilization by grasping the mastoid processes, whereupon the front of a rigid collar can be removed safely; the collar can impede mouth opening, does not contribute significantly to neck stabilization during laryngoscopy, and will be an obstruction if surgical airway is required. This technique of emergency airway management involves a minimum of three, but ideally four individuals: the first to pre- oxygenate and intubate, the second to apply cricoid pressure, the third to maintain manual in-line immobilization of the head and neck and the fourth to give intravenous drugs and assist.”

Intubation Techniques

Awake Fiberoptic

Video Laryngoscope (eg Glidescope)