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CervicalSpinalInjuryandAirwayManagementSalfordTraumaCourse,2018

DrMattWilesConsultant(Neuroanaesthesia &MajorTrauma)Sheffield

Editor,Anaesthesiahttp://sthjournalclub.wordpress.com/

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NICESpinalInjuryGuidelines2016

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AANS/CNSJointGuidelines2016TheodoreNetal.Neurosurgery2013;72:22-34

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Guidancevs.Rules

“Aguidelineisastatementbywhichtodetermineacourseofaction.Aguidelineaimstostreamlineparticularprocessesaccordingtoasetroutineorsoundpractice.Bydefinition,followingaguidelineisnevermandatory.Guidelinesarenotbindingandarenotenforced.”U.S.DepartmentofVeteranAffairs(http://www.va.gov/trm/TRMGlossaryPage.asp)

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ThebirthofimmobilisationKossuth LC.Trauma1965;5:703-8

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TheThreeCommandmentsofITU

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Assumptions1. Traumapatientsareatriskofunstablespinalinjuries

2. Anyspinalinjurywhichhasbeensustainedmaybeworsenedbyfurthermovement(s)

3. Theapplicationofasemi-rigidcervicalcollarandspinalimmobilisation devicepreventspotentiallyharmfulmovementofthespine

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Assumption1

“Traumapatientsareatriskofunstablespinalinjuries”

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EpidemiologyofSCIMcCaugheyEJetal.SpinalCord2016;54:270-6

• 0.8%oftotaltraumaadmissions

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SCIWORA/SCIWOCTETHendrey GWetal.JTraumaAcuteCareSurg 2002;53:1-4ComoJJetal.JTraumaAcuteCareSurg 2012;73:1261-6

• NEXUSdata• n=34,069;2.4%cervicalspineinjury• 27patientsSCIWORA[0.08%oftotal]

• TwoMTCs(2005-2009)• n=15,102• 25patientsSCIWOCTET[0.14%oftotal]

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Assumption2

“Anyspinalinjurywhichhasbeensustained/ispresentmaybeworsenedbyfurthermovement(s)”

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ImmobilisationandCordInjurySundstrømTetal.JNeurotrauma2014;31:531-40CrosbyET.Anesthesiology 2006;104:1293-1318

• Mostspinalinjuriesarestable;thosethatareunstablehavealreadycausedirreversibledamage

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ImmobilisationandCordInjurySundstrømTetal.JNeurotrauma2014;31:531-40CrosbyET.Anesthesiology 2006;104:1293-1318

• Mostspinalinjuriesarestable;thosethatareunstablehavealreadycausedirreversibledamage

• Improvementsinmortalityratessince1973attributedtoimmobilisation

• “Missed”injurieswithdeterioration(10-29%)arehistoricalandpredominatelyduetoimagingissues

• 2-10%ofcordinjuriesworsenregardless• ExaggeratedrateofsecondarySCIwithoutcollars

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TraumaticSpinalCordInjuryAmerica/CanadaSinghAetal.ClinicalEpidemiology2014;6:309-331

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TraumaticSpinalCordInjuryinDevelopingCountriesRahimi-Movaghar Vetal.Neuroepidemiology2013;41:65-85

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Assumption3

“Theapplicationofasemi-rigidcervicalcollarand/orspinalimmobilisation devicepreventspotentiallyharmfulmovementofthespine”

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EfficacyofCollarsHollaMetal.Eur SpineJ2016;25:2023-2036

0% 20% 40% 60% 80%

• Flexion/Extension42%-78%• Lateral13%-40%• Rotation13%-40%

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ManualIn-lineStabilisationManoach S&PaladinoL.AnnEmerg Med2007;50:236-45

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ManualIn-lineStabilisationManoach S&PaladinoL.AnnEmerg Med2007;50:236-45

• Originuncertain– ATLSguidance1984• Datafromcadavericstudies,healthyvolunteersandcaseseries(n=96)

• SeveralstudiessuggestMILShasnoeffectoncervicalsegmentmovementStudy Method Grade1 GradeII GradeIII GradeIVNolan&Wilson.Anaesthesia1993;48:630-33

Optimalposition 129 26 2 -

MILS 75 48 34 -

Heath.Anaesthesia1994;49:843-45

Optimalposition 46 4MILS 12 27 11Collar/tape/sandbags 2 16 25 7

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Assumption4

“Cervicalcollarapplicationand/orspinalimmobilisation arebenigninterventions,andthereforecanbeappliedtolargenumbersofpatientsasaprecautionarymeasure”

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CollarsmayworseninjuriesBen-Galim PGetal.JournalofTrauma2010;69:447-50

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TransportDelayswithImmobilisationHaut ERetal.JournalofTrauma2010;68:115-120

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Mvs.EHertfordshireHA1991Athanassoglou Vetal.TrendsAnaes Crit Care2015;5:57-60

“Wecannotassertthatcricoidpressureisnoteffectiveuntiltrialshavebeenperformed,(i.e.wemustassumeitsefficacy)especiallyasitisanintegralpartofanaesthetic technique…thathasbeenassociatedwithareducedmaternaldeathratefromaspirationsincethe1960s."

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• 10casereportsofworseningSCIafterintubation– Littletoimplicatelaryngoscopyascause

RiskofLaryngoscopyMcLeodAD&CalderI.BrJAnaes 2000;84:705-9

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• ClosedClaimsAnalysis:– 1970-2007(n=7740)– 37casesofcervicalcordinjury(0.9%ofGAclaims)– Majority(>75%)hadstablec-spinespriortoprocedure– 24/37underwentcervicalspinesurgery– Ninehadunstablecervicalspines

• Twocasesofcordinjurywithdirectlaryngoscopyimplicated• TwocasesoccurreddespiteAFOI• TwocasedespiteMILS

RiskofLaryngoscopyHindman BJetal.Anesth 2011;114:782-795

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• 1995-2007• 40,165totalclaims,841relatingtoanaesthesia• £31million($17million)total• Nilrelatingtoc-spinedamageandintubation

RiskofLaryngoscopyCookTMetal.Anaesthesia2009;64:706-718

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NeurologicalDeteriorationafterSurgeryHarrop Jetal.Spine2001;26:340-46

CarlsonGDetal.JBoneJt Surg 2003;85A:86-94

• Duetoprolongeddeformationand/orhypotension– Hyperflexion worsethanhyperextension– Inanimalmodelsneed>30minofcontinuouscordcompression

• BothareunlikelyduringDL• 6%patientswithSCIwilldeteriorate– Early(24h)– Later(24hto7days)– Late(weeks[post-traumaticascendingmyelopathy])

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AnatomyofSpinalCordInjuryCrosbyET.Anesth 2006;104:1293-318

Spaceavailableforspinalcord(SAC):1/3odontoid;1/3cord;1/3space

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CervicalSpine&DirectLaryngoscopySawin PDetal.Anesth 1996;85:26-36

• Tenvolunteerswithnormalcervicalspines• Minimalglottic exposure• MajorityofmotionatC0-C1&C1-C2

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CervicalSpine&DirectLaryngoscopySawin PDetal.Anesth 1996;85:26-36

• Tenvolunteerswithnormalcervicalspines• Minimalglottic exposure• MajorityofmotionatC0-C1&C1-C2

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CervicalSpine&DirectLaryngoscopyMcCahon RMetal.Anaesthesia2015;70:452-61

• Odontoidpegfractureincadavers

• Minimalglottic exposure• MILS• Assessed“spaceavailableforspinalcord”

• Airtraq,McCoy&Mac3– nosignificantdifference

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VideoLaryngoscopySuppan Letal.BJA2016;116:27-36

• Meta-analysis(n=1886)• Primaryoutcome:– Intubationsuccess

• C/Lviewnotrelevant• Noassessmentof:– SAC– Cervicalspinemovement

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CervicalSpine&AirwayManoeuvresDonaldsonWFetal.Spine1997;22:1215-18DonaldsonWFetal.Spine1993;18:1220-23

• CadaverswithunstableC1-2– MILS– Glottic viewachievednotstated– Spaceavailableforcordassessed

• Jawthrust>chinlift>laryngoscopy• CadaverswithunstableC5-6– NoMILS– Glottic viewachievednotstated– Cervicalspinemotionassessed

• Chinlift/jawthrust≈cricoidpressure≈laryngoscopy

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CervicalSpine&BVMVentilationHauswald Metal.AmJEmerg Med1991;9:535-8

• Cadaversstudiedwithin40minofdeath– Collar,spinalboard,tape– Glottic viewachievednotstated– Neckmaintainedinneutral

• Maskventilation>>trachealintubation[P=0.00004]

0

1

2

3

4

5

MaskA MaskB Miller3 MacIntosh3

FOIOral FOINasal

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CervicalSpine&OtherAirwayTechniques• LMA[Kilic Ketal.AmJEmerg Med2013;31:1034-36]– Doneincervicalcollars– LMA&iLMA similartoMacintosh

• GlideScope [RobitailleAetal.Anesth Analg 2008;106:935-41]– MILS– NodifferencebetweenMacintoshandGlideScope

• Fibreoptic intubation[Sawin PDetal.EJA2004;21:819-23]– NoMILS– Bestpossibleglottic viewachieved– FOIsignificantlylessmovementatC1/2(8°)butnotC2/3comparedtodirectlaryngoscopy

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Summary• Maximalinsulttothespinalcordoccursatthetimeofinjury

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Summary• Maximalinsulttothespinalcordoccursatthetimeofinjury

• Thecervicalspineshouldbestabilised,notimmobilisedandthisshouldnotinterferewithclinicalmanagement(especiallyABCinterventions)atanypoint

• Intubatethetracheausingthe“best”techniqueinyour hands

• Ifcervicalimmobilisationwasanoveltechnique,wouldweinstituteitintocurrentpractice?

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Anyquestions?