Airway Management of the Trauma Victim
for cervical spine injury makes airway management more complex in
the trauma patient. A cervical spine injury should be suspected
in all injury mechanisms involving blunt trauma. Patients with injury
above the clavicles are at increased risk, and this is increased
4-fold (9) if there is a clinically significant head injury (GCS
< 9). Cervical spine injury is often occult, and secondary injury
to the spinal cord must be avoided.
Immobilization of the cervical spine must
be instituted until a complete clinical and radiological evaluation
has excluded injury.
- The fully conscious, talking patient
is able to maintain his own airway and needs no further airway
manipulation. However patients' status may deteriorate at any
time, and ABC's must constantly be reassessed.
- The following categories of patients
require a definitively secured airway :
Coma Scale < 9 or sustained seizure activity.
- Unstable mid-face trauma.
- Airway injuries.
- Large flail segment or respiratory
- High aspiration risk.
- Inability to otherwise maintain an
airway or oxygenation.
- The urgency
of airway intubation is the most important factor in planning
which technique of securing the airway is the safest and most
appropriate. One must evaluate and assess the risk of further
cord injury given head and neck movement, the degree of cooperation
from the patient, anatomy and trauma to the airway and one's own
expertise in each technique.
airway should be cleared of debris, blood and secretions. It should
be opened using the 'chin lift' or 'jaw thrust' manoeuvres. The 'sniffing
the morning air' position for standard tracheal intubation flexes
the lower cervical spine and extends the occiput on the atlas. However,
studies (2) have shown that 'jaw thrust' and 'chin lift' both cause
distraction of at least 5mm in a cadaver with C5/6 instability. This
movement was unaffected by use of a rigid collar. Manual stabilization
did however reduce movement.
An oral (Guedel) or nasopharyngeal airway
may be necessary to maintain patency until a definitive airway is
secured. Insertion of an airway produces minimal disturbance to
the cervical spine. Bag and mask ventilation also produces a significant
degree of movement at zones of instability.
The safest method of securing
a tracheal tube remains debatable. In general, the technique used
should be the one the operator is most familiar with. The method
is generally unimportant as long as the (potential) cervical spine
injury is recognised and reasonable care taken (4).
The ATLS recommends a nasotracheal tube
in the spontaneously breathing patient, and orotracheal intubation
in the apnoeic patient. MANUAL in-line axial stabilization must
be maintained throughout. The hard collar may interfere with intubation
efforts and the front part may be removed to facilitate intubation
as long as manual stabilisation is in effect.
Blind nasal intubation is successful in
90% of patients but requires multiple attempts in up to 90% of these.
Nasotracheal intubation is (relatively) contraindicated in patients
with potential base of skull fracture or unstable mid-face injuries.
In addition, it may produce haemorrhage in the airway, making other
airway manipulations difficult or impossible. Nasotracheal intubation
in non-trauma patients is often accomplished by rotating or flexing
the neck to align the tube correctly. This is not possible in the
trauma patient and the procedure becomes more difficult. In the
spontaneously breathing patient however, one can hear movement of
air at the end of the tracheal tube and thus line the tube up with
Orotracheal intubation is generally accepted
as the more usual method for securing the airway in the trauma patient.
It is the fastest and surest method of intubating the trachea. At
Shock Trauma in Baltimore, Maryland (5) more than 3000 patients
were intubated orally with a modified rapid sequence induction technique
with pre-oxygenation and cricoid pressure. Ten percent of these
patients were found to have cervical spine injury and none deteriorated
neurologically following intubation.
Atlanto-occipital extension is necessary
to bring the vocal cords within line-of-sight of the mouth. Thus
patients with unstable C1 or C2 injuries might be at more risk from
this technique. Direct laryngoscopy has been shown to disturb the
cervical spine both in anaesthetised volunteers (3) and in cadavers
(7). Manual axial in-line stabilisation reduces this movement by
60%. Papers showing no neurological deficit after direct laryngoscopy
have small patient numbers, and there are cases in the literature
of quadriplegia following laryngoscopy without manual stabilization.
Rotando et al evaluated the use of induction
agents and muscle relaxants to facilitate intubation and found them
to be safe and effective. If possible, patients requiring tracheal
tube intubation should be anaesthetised unless very cooperative.
In the obtunded head injured patient, anaesthesia is vital to prevent
pressor responses to intubation increasing intracranial pressure.
Carbon dioxide levels are also much better controlled in the anaesthetised
The ideal induction agent probably does
not exist, and once again it is down to operator experience. Propofol
is not recommended for trauma because of the potential for hypotension
(as with most IV agents) but has many advantages in these patients
and is used in many centres. Its ability to provide total intravenous
anaesthesia with good control over the depth of anaesthesia is also
very valuable. Thiopentone (pentothal) requires making up to solution
but otherwise is very effective and is the standard for rapid sequence
induction. Etomidate has been reported to produce less cardiovascular
depression than other intravenous induction agents, but this research
was done on healthy individuals, and this is not the case for hypovolaemic
patients. In addition, the potential adrenal and immunological suppression
caused by even one bolus of etomidate puts a question mark on its
use in these cases. Ketamine is a very under-used induction agent
which maintains cardiovascular stability better than the other intravenous
agents. As a non-competitive NMDA receptor antagonist it has neuroprotective
effects. Its use is currently contraindicated in patients at risk
from raised intracranial pressure as it has been shown to increase
cerebral blood flow and so ICP in head injured patients. However,
evidence is accumulating that this may not be the case, especially
in hypotensive patients, and its effects on ICP may be modulated
by agents such as propofol.
Awake intubation is also a feasible option
and is favoured by some practitioners. It has been shown to be safe
in the patient with cervical spine injury (8). It may be performed
via the nasotracheal route, direct oral laryngoscopy or by fibreoptic
Successful fibreoptic tracheal intubation
requires a cooperative patient, a secretion and blood free airway,
a pharynx unrestricted by oedema and adequate supraglottic and infraglottic
anaesthesia. Such ideal conditions often do not exist, and local
anaesthetic preparation of the airway is time consuming and might
increase the risk of aspiration.
Failed or difficult
intubation is always a problem. It is important not to waste time
with repeated attempts at intubation while the patient is desaturating.
Alternative methods of securing the airway should be instituted
as soon as a problem is recognised.
Mask Airway (LMA)
The LMA is gaining
wider support in the management of patients with cervical spine
injury. As well as maintaining the airway, a tracheal tube (size
6 or less) may be placed, either blindly or via flexible fibreoptic
laryngoscopy. The LMA does not however protect the airway from aspiration,
and by acting as a bolus in the pharynx, may actually relax the
lower oesophageal sphincter and increase reflux. It's use should
probably be limited to maintenance of the airway after a failed
attempt at intubation.
The Combitube is a double lumen
tube inserted blindly into the oesophagus or trachea. The position
of the tube is confirmed by the presence of breath sounds or capnography.
By inflating one of the two cuffs present, the lungs may then be
ventilated. Problems arise after positioning with definitive securing
of a tracheal tube, and again with protection of the airway from
aspiration, although stomach suctioning is possible through the
The need for
a surgical airway should be recognised quickly and performed by
an experienced person without delay. It may be used as a primary
airway, with injuries to the pharynx for example, or after failure
of orotracheal intubation. It may be a full surgical approach or
via a percutaneous needle cricothyroidotomy with high flow oxygen.
The potential for carbon dioxide retention with this technique must
be remembered and the levels in arterial samples monitored. There
are no studies regarding movement of the neck during cricothyroidotomy,
ease of cricothyroidotomy with neck immobilisation, or neurological
deterioration following cricothyroidotomy.
of Tracheal Tube Placement
It is vital that the position of the tube is confirmed to be in
the trachea. Clinical methods of verification are notoriously unreliable,
and patients with chest injuries increase the likelihood of mistakes
in this area. Capnography is the gold standard in the operating
room to assess tracheal tube position, and this should probably
be transferred to the trauma area too.
1. Abrams K.J., Grande C.M. "Airway Management
of the trauma patient with cervical spine injury", Current Opinion
in Anesthesiology 1994;7:184-190.
2. Aphramian C. et al "Experimental Cervical
Spine Injury Model : Examination of Airway Management and Splinting
Techniques", Ann Emerg Med 1984;13:584-587.
3. Bivins H. et al "The Effect of Axial
Traction during Orotracheal Intubation of the Trauma Victim with
an Unstable Cervical Spine". Ann Emerg Med 1988;17:25-9.
4. Crosby E, Lui A "The Adult Cervical
Spine : Implications for Airway Management" Can J Anaesth 1990;37:77-93.
5. Grande C.M., Barton C.R., Stene J.K. "Appropriate
Techniques for Airway Management of Emergency Patients with Suspected
Spinal Cord Injury." Anesth Analg 1988;67:714-715.
6. Hastings R.H., Marks J.D. "Airway Management
for Trauma Patients with Potential Cervical Injuries", Anesth
7. Majernick T. et al "Cervical Spine
Movement during Orotracheal Intubation" Ann Emerg Med 1986;15:417-20.
8. Meschino A. et al "The Safety of Awake
Tracheal Intubation in Cervical Spine Injury" Can J Anaesth
9.Ross S.E. et al "Clinical Predictors
of Unstable Cervical Spine Injury in Multiply Injured Patients",
10. Abrams KJ. General management issues
in severe head injuries: Airway management and mechanical ventilation.
New Horizons 1995;3:479-487