Airway management of patients with the potential to have an unstable injury of the cervical spine challenges clinical judgment. There is no single best algorithm. Cervical spine radiography without a thorough and reliable neurologic examination does not "clear the neck." From 20 to 30 percent of cervical spine injuries are not appreciated on a single cross-table lateral view. In addition, patients with blunt major trauma requiring tracheal intubation have associated unstable cervical spine injuries that range from 1 to 12 percent. Spinal cord injury without radiographic abnormality (SCIWORA), is an important consideration, especially in adolescents and children.
The initial decision is to determine whether immediate airway intervention is really needed. Patients not in urgent need of an airway should be neurologically and radiographically evaluated as thoroughly as is practical given their condition. The need for in-line cervical stabilization should not be considered a license for axial in-line traction. For example, attempting to visualize C7 radiographically by countertracting on the head and shoulders of the near-hanging patient is counterintuitive.
There is a large selection of airway options to consider while attempting to maintain cervical spine immobilization. The selection is far less critical than the timing. Nasotracheal intubation, transillumination, fiberoptic laryngoscopy, and RTI are commonly selected options. Oral intubation appears safe when achieved without hyperdistraction, flexion, or extension of the neck. Maintenance of cervical spine immobilization is the paramount issue—not the approach to secure the airway. Careful endotracheal intubation (ETI) causes less cervical spine motion than bag-valve-mask (BVM) ventilation.
Visualization of the larynx prior to cervical spine clearance is difficult, since alignment of the oropharyngeolaryngeal axis is not possible. One method to move the tip of the tube anteriorly is to use a slightly flexed directional-tip tube (Endotrol) coupled with the Sellick maneuver. Another is to use a flexible stylet, such as the Flexiguide, which passes through the tube and has a trigger similar to the Endotrol. Another option is to aim the tip of the tube anteriorly with Magill forceps while an assistant advances the tube.
There are several new commercially available laryngoscope blade designs that allow vocal cord visualization without manipulation of the neck. Most designs have fiberoptic attachments to the blade. This allows elevation of the tongue to avoid the blood or secretions. Technically, these blades may prove simpler to use than conventional fiberoptic laryngoscopes.
The Bullard blade incorporates a fiberoptic bundle along the posterior aspect of the straight blade. After visualization, a stylet carries the ET tube, which is advanced through the vocal cords. The Direct View blade incorporates fiberoptics with a curved MacIntosh-style blade. A nonfiberoptic design is the Bainton blade; this has a tubular, square design to facilitate visualization when there is significant soft tissue swelling. This design helps displace tissue circumferentially.
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