How would you intubate a case with highly suspected C-spine injury?

1. Would you do it with the rigid neck collar in place (despite an assistant is available to do the in-line immobilization).
2. Would you have tried the nasal route first if there is no significant facial trauma and the patient is not apneic?
3. If N-M blocking agent was not available, and you decided to intubate orally aided with deep sedation, which drug would you prefer : midazolam or diprivan? Why?

Any suggestion is welcomed.

Removing the cervical collar makes the positioning of the laryngoscope easier. Therefore if an assistant is present to hold in line traction that is the method I would use. If sedation is needed propofol is probably prefered as its short duration of action is probably better that a benzodiazapine.

Stephen M. Stowe, M.D.

If you want to hold cricoid pressure (a good idea to prevent aspiration), you have to at least remove the front of the C-collar.

Gail Waldby, MD
Huron Clinic SD

Prevent regurgitation when the tracheal intubation is performed in trauma patient ( if you always consider this patients as "full stomach")but it has some problems: the force that you should apply is tremendous ( about 40 Kg !!!) to prevent regurgitation in 95% of cases; it is describile a high incidence of esophagus perforation due the high pressure produced by regorgitation. But the problem discussed is the same: how intubed with move the head and neck and without a assistance ?

Marcio Lacerda

Some collars (at least some of the ones I have seen) have a cut-out anteriorly to allow cricoid pressure with the collar in place. I usually give the patient one attempt at an intubation with the collar, but, by the time I am called, someone has usually taken that one try and I do it without the collar, with inline traction.

-- Louis Brusco Jr., M.D.
Director, Critical Care Anesthesiology
Co-Director, Surgical Intensive Care Unit
St. Luke's-Roosevelt Hospital Center, NYC

Nasotracheal intubation in a patient with suspected C-spine injury is never performed by our Emergency Team, as these patients may also have undiagnosed skull base fractures. Orotracheal intubation is preferred. Midazolam is preffered over propofol as we had a few cases with marked hypotension during induction, which should be avoided in trauma patients, especially in the field.

Jan J. De Waele, MD
Dept. of Surgery
University Hospital Ghent
Belgium.

Re: intubations in pt with suspected c-spine injury:

1)No, I would remove the ant. portion of the collar while an assistant provides in-line stabilization (not traction) while another assistant applies cricoid pressure. I would induce the pt with pentothal and paralyze with rocuronium - *notes: would use etomidate if hypotensive or 'near-hypotensive' if concomittant head injury is suspected. If hypotensive without head injury would give ketamine. Would add lidocaine (miniscule benefit) if head injured. Might add fentanyl if hypertensive and head injured. If continued anesthesia/deep sedation deemed likely in head injured patient, may start with propofol and continue gtt.

2)Would not try nasal route first. My take on the literature is that RSI with in-line stabilization provides the best protection against c-spine movement. *notes: would not do an RSI technique if a difficult airway is suspected. Would then deep sedate, topically anesthetize the airway and look with blade, if easy visualization is found, would then administer paralytic and intubate. If no visualization of larynx, would intubate over fiberoptic scope. If pt can't maintain airway - would cut.

3)N-M drugs are available.

Daniel M. Joyce, MD
SUNY HSC-Syracuse, Dept. of EM

I work in hospital, so my answer must be read with this taken into consideration.

1) Usually yes, but I do sometimes take off the collar. Depends on which I feel will make intubation easiest in that case.

2) No Never. I do a lot of nasal intubations in controlled conditions in the operating theatre. IM (not very) HO, the concept of nasal intubation in trauma cases is crazy. To intubate nasally, you either need to do it blind, and that should result in a lot more neck movement than oral intubation, or you do it with the aid of a laryngoscope, in which case why on earth put the tube down the nose, and expose the patient to the increased risk of sinusitis, nose bleed, mucosal damage, retropharyngeal intubation ( tube goes behind the mucosa), small tube causing increased resistance to respiration, increased risk of blocking... need I go on?

3) Never the case in hospital. If I had to intubate without neuromuscular blocker, I would use 1 mg Alfentanil, 200 mg Propofol. Gives good conditions, and has been written up, but I would not do this in a trauma case ( hypotension, what if I fail to intubate etc.)

Dr NJD Macartney MBBS FRCA
ICU, Chase Farm Hospital
Enfield
Middlesex EN2 8JL

disclaimer: I'm just a good old fashioned country doc whose ATLS is a bit out of date, so if our big city breathren have a difference based on number of cases, I won't complain. That said...

Personally, I would prefer to intubate nasally with the collar in place if possible, especially if I've got one of those fancy tubes with the draw string attatched to the tip (which allows you to flex the tip of the tube up a little bit at the critical time...). One problem with nasal route (outside of certain problems with facial trauma) is that you are limited in size- making it difficult to slide a 'scope down the ETT if tracheal exploration is needed. Haven't had to do much with either NMB or sedation, but our gas passer swears by Diprivan for same.

also, consider using the oral route with tube over flexible bronchoscope- allows direct visualization of cords, and cannulation of same even when the head is in an odd position or there is trauma. Haven't had to do same, but have had some surgical trauma types indicate that it works.

ck
Charles S. Krin, DO FAAFP
Member, PGBFH
KC5EVN

There is no best way to do tracheal intubation in patients with c spine trauma. It depends on the patient status, hemodynamics, presence of head injury, aspiration risks, clinician experience, etc. In general, if the patient is cooperative, I would opt for awake, sedated fiberoptic intubation (flexible fiberoptic bronchoscope, Bullard laryngoscope or WuScope). This technique requires a certain amount of patient cooperation, ~ 10-15 min time, local anesthesia, antisialagogue agent, and sedation. The advantage of this method is that optimal visualization of the glottis can be achieved without any head and neck movement, and the patient can be examined afterwards.

Note that a poorly performed or inadequately performed fiberoptic intubation is frankly dangerous and will probably cause more problems than one done with induction of general anesthesia and neuromuscular blockade. Also note that there is no data to support one method of intubation over another as long as the head and neck remain immobilized.

However, with head and neck immobilization, there will be a higher incidence of grade III views of the larynx (i.e., only the epiglottis can be seen with standard direct laryngoscopy- 20% in one study). This is not usually a problem if one uses a fiberoptic device. Alternatively, a gum-elastic bougie is very useful for intubating patients with grade III views because all you have to do is direct the bougie under the epiglottis anteriorly towards the glottis and then thread the tracheal tube over the bougie.

I know necks tend to take priority these days, but people DIE from airway obstruction. They only end up paralysed from c.spine trauma.

Double-take. All I'm trying to say is that if push comes to shove, airway ALWAYS takes priority. If you're not skilled enough to intubate without risking c.spine damage, then I'm afraid you have to just go right on ahead and risk it, if you're the only one there.

--
Dr. Ed Walker FRCA
Staff Grade Practitioner, A&E
Dewsbury, Yorkshire, UK.

You have to be careful with cricoid. pressure. C6 is the structure that you are pressing teh cricoid against and it probable is not good form to displace it if it is fractured :-)

Stephen M. Stowe, M.D.

Sellick's original article was a TINY little piece in the BMJ in 1962 (I think). It has revolutionised anaesthetic practice ever since. Makes you think, when you see the length of some of the 'research' articles these days....

I wouldn't worry too much about gastric contents. Their importance is over- stressed. In the US I understand it is now standard practice to allow clear fluids up until an hour pre-op. And how many times have I seen a supposedly 'starved' patient vomit a whole truckload when they wake up?

I generally agree that the cricoid pressure is important and use it routinely since I really do not believe all NPO patients are NPO. I am talking here about a specific cercumstance when there is C--Spine injury that may involve an unstable C-6. Here the relative risks of dispalcing bone into the cord with the resultant quadrapelegia must be weighted against the risk of aspiration.

A Combitube is not an LMA it is a device with a large intraoral balloon and a second balloon more distal. It is designed to be passed blindly into either the esophagus or trachea. Inflating both balloons isolates the oropharynx and permit ventilation.

Inline traction is a misnomer. The correct semantic phrase should be in-line immobilization. Traction on some cervical injuries makes the injury worse by recreating the mechanism of the injury such as "hanging". Just remove the front of the collar and hold the head and neck to prevent flexion.

I would first place an LMA and then place an MLT endotracheal tube through the lumen of the LMA. Using this technique you can place an ET without ever having to visualize the cord or removing the patient from the collar. This technique also works VERY well in the emergency situation in which intubation in not possible. I would attempt this prior to a surgical airway.

Jeffrey S. Guy, MD