AIRWAY MANAGEMENT AFTER

CERVICAL SPINE INJURY

DINO A. O. ALTMANN, M.D.HOSPITAL SÃO LUIZ

BRAZIL

CERVICAL SPINE INJURY x HEAD INJURY

14,755 ADMISSIONS292 (2.0%) CERVICAL SPINE INJURIES

GLASGOW COMA SCALECSI 13 – 15

1.4% 9 – 12

6.8% ≤ 8

10.2%Demetriades et al J Trauma, 2000

Airway management after cervical spine injury

CERVICAL SPINE INJURY x HEAD INJURY

447 HEAD INJURIES

24 (5.4%) CERVICAL SPINE INJURIES

Holly et al J Neurosurg, 2002

Airway management after cervical spine injury

CERVICAL SPINE INJURY34,069 Blunt Tauma Victims

818 CERVICAL SPINE INJURIES2.4%

C224.0%

C6 + C739.3%

NOT CLINICALLY SIGNIFICANT29.3%

Goldberg W et al Ann Emerg Med, 2001

Airway management after cervical spine injury

CERVICAL SPINE INJURY

STABLE UNSTABLE

Instability occurs when physiologic loading causes patterns of vertebral displacement that jeopardize the spinal cord or nerve roots

Airway management after cervical spine injury

CERVICAL SPINE INJURIESNot clinically significant (NEXUS)

- Spinous process fractures- Wedge compression fractures ≤ 25%

body - Isolated avulsion without ligament

injury- Type I odontoid fracture- End-plate fractures- Isolated osteophyte fractures- Trabecular fractures- Isolated transverse process fractures

Goldberg W et al Ann Emerg Med, 2001

Airway management after cervical spine injury

MECHANISMS OF SPINAL INJURYHyperextension and Hyperflexion

Airway management after cervical spine injury

MECHANISMS OF SPINAL CORD INJURYPrimary shear forces

compressiondistracting forcesbone fragments

SecondaryFAILURE TO IMMOBILIZE THE SPINE IN NEUTRAL

POSITION

local perfusion deficitsystemic hypotensionhypoventilationincreased vena cava

pressure

Airway management after cervical spine injury

MANUAL IN-LINE IMMOBILIZATION

MILI

Airway management after cervical spine injury

“NEUTRAL POSITION”

Airway management after cervical spine injury

2.0 cm OCCIPUT ELEVATION

INCREASES SPINAL CANAL/SPINAL CORD RATIO AT C5-C6

De Lorenzo et al, Ann Energ Med 1996

MILI x CERVICAL COLLAR During Laringoscopy

Less spinal movement

Improves laryngeal visualization

Airway management after cervical spine injury

CERVICAL SPINE INJURYClinical Predictors

SEVERE HEAD INJURY

FOCAL NEUROLOGICAL DEFICIT

Airway management after cervical spine injury

URGENT AIRWAY INTERVENTION

Blunt Trauma PatientLESS LIKELY to have a

complete neurological

evaluation

MORE LIKELY neurological injury

SUSPECT CERVICAL SPINE INJURY

Airway management after cervical spine injury

ANTERIOR LARYNGEAL OR CRICOID PRESSURE

Improves laryngeal visualization

Do not cause upper cervical spine movement

Protects against aspiration

Airway management after cervical spine injury

SPACE AVAILABLE FOR THE SPINAL CORDSAC

Airway management after cervical spine injury

CERVICAL MOTION DURING AIRWAY MANAGEMENT

Most significant at Oc – C1

Airway management after cervical spine injury

MASK VENTILATIONx

TRACHEAL INTUBATION More cervical spine

movementwith mask ventilation

Airway management after cervical spine injury

COMPARABLE SPINAL MOVEMENT

Direct laringoscopyVideo-laryngoscopy (Glidescope)Nasotracheal intubationLaryngeal mask insertionCombitube and PTLCricothyrotomyFlexible bronchoscope intubation

Airway management after cervical spine injury

AIRWAY MANAGEMENT AT SCENE

NASOPHARYNGEAL AIRWAYOXYGEN MASK WITH NON-REBREATHING BAG

RAPID SEQUENCE INTUBATION WITH MILI

INITIAL INTUBATION ATTEMPTS

INITIAL INTUBATION ATTEMPTS

SUCCESSFUL UNSUCCESSFUL

FACE MASK VENTILATION0?

PHARYNGEAL-TRACHEAL LUMEN AIRWAY (PTL)

VENTILATION ADEQUATE VENTILATION INADEQUATE

CONSIDER CRICOPHARINGOSTOMY

TRACHEAL TUBE INTRODUCERORO-TRACHEAL INTUBATION

Airway management after cervical spine injury

PHARYNGEAL – TRACHEAL LUMEN AIRWAY

PTL

Airway management after cervical spine injury

PHARYNGEAL – TRACHEAL LUMEN AIRWAY

PTL

Airway management after cervical spine injury

PHARYNGEAL – TRACHEAL LUMEN AIRWAY

PTL

Airway management after cervical spine injury

PHARYNGEAL – TRACHEAL LUMEN AIRWAY

PTL

Airway management after cervical spine injury

AIRWAY MANAGEMENT AT MEDICAL CENTER

CONSIDER FLEXIBLE BRONCHOSCOPE INTUBATION

Airway management after cervical spine injury

CONCLUSIONS

Lack of prospective studiesApply MILI for all airway maneuvresAvoid face-mask ventilationRapid sequence intubationComparable airway methodsTailor and follow your own

ALGORITHM

Airway management after cervical spine injury