Orotracheal intubation in trauma patients with cervical fractures

Anesthetic considerations for patients with acute cervical spinal cord injury

Anesthesiologists work to prevent or minimize secondary injury of the nervous system and improve the outcome of medical procedures. To this end, anesthesiologists must have a thorough understanding of pathophysiology and optimize their skills and equipment to make an anesthesia plan. Anesthesiologists should conduct careful physical examinations of patients and consider neuroprotection at preoperative interviews, consider cervical spinal cord movement and compression during airway management, and suggest awake fiberoptic bronchoscope intubation for stable patients and direct laryngoscopy with manual in-line immobilization in emergency situations. During induction, anesthesiologists should avoid hypotension and depolarizing muscle relaxants. Mean artery pressure should be maintained within 85-90 mmHg (1 mmHg = 0.133 kPa; vasoactive drug selection and fluid management). Normal arterial carbon dioxide pressure and normal blood glucose levels should be maintained. Intraoperative neurophysiological monitoring is a useful option. Anesthesiologists should be attentive to postoperative respiratory insufficiency (carefully considering postoperative extubation), thrombus, and infection. In conclusion, anesthesiologists should carefully plan the treatment of patients with acute cervical spinal cord injuries to protect the nervous system and improve patient outcome.

Should Neonatologists Give Opinions Withdrawing Life-sustaining Treatment?

An infant has a massive intracranial hemorrhage. She is neurologically devastated and ventilator-dependent. The prognosis for pulmonary or neurologic recovery is bleak. The physicians and parents face a choice: withdraw the ventilator and allow her to die or perform a tracheotomy? The parents cling to hope for recovery. The physician must decide how blunt to be in communicating his own opinions and recommendations. Should the physician try to give just the facts? Or should he also make a recommendation based on his own values? In this article, experts in neonatology, decision-making, and bioethics discuss this situation and the choice that the physician faces.

Critical pitfalls in the immediate assessment of the trauma patient

In the immediate assessment of trauma patients, critical pitfalls exist that may interfere with optimal clinical care. Failure to recognize the need for early anaesthesia and endotracheal intubation may put the patient at unnecessary risk and delay the assessment and treatment process. Pressure to clear the cervical spine may lead to inadequate imaging and premature removal of neck immobilization devices. The limitations of the initial chest X-ray in diagnosing pneumothoraces may not be appreciated and needle thoracentesis may be ineffective. ‘Springing’ the pelvis to assess for instability may cause life-threatening haemorrhage and should not be done prior to the initial pelvic X-ray. Log rolling may dislodge crucial clot formation and promote bleeding, and should only be used for diagnostic purposes. Applying clinical common sense to the assessment of trauma patients may avoid the pitfalls whilst allowing the clinician to operate within internationally agreed assessment and treatment frameworks.

Neurological deterioration during intubation in cervical spine disorders

Anaesthesiologists are often involved in the management of patients with cervical spine disorders. Airway management is often implicated in the deterioration of spinal cord function. Most evidence on neurological deterioration resulting from intubation is from case reports which suggest only association, but not causation. Most anaesthesiologists and surgeons probably believe that the risk of spinal cord injury (SCI) during intubation is largely due to mechanical compression produced by movement of the cervical spine. But it is questionable that the small and brief deformations produced during intubation can produce SCI. Difficult intubation, more frequently encountered in patients with cervical spine disorders, is likely to produce greater movement of spine. Several alternative intubation techniques are shown to improve ease and success, and reduce cervical spine movement but their role in limiting SCI is not studied. The current opinion is that most neurological injuries during anaesthesia are the result of prolonged deformation, impaired perfusion of the cord, or both. To prevent further neurological injury to the spinal cord and preserve spinal cord function, minimizing movement during intubation and positioning for surgery are essential. The features that diagnose laryngoscopy induced SCI are myelopathy present on recovery, short period of unconsciousness, autonomic disturbances following laryngoscopy, cranio-cervical junction disease or gross instability below C3. It is difficult to accept or refute the claim that neurological deterioration was induced by intubation. Hence, a record of adequate care at laryngoscopy and also perioperative period are important in the event of later medico-legal proceedings.

Airway management in cervical spine injury

To minimize risk of spinal cord injury, airway management providers must understand the anatomic and functional relationship between the airway, cervical column, and spinal cord. Patients with known or suspected cervical spine injury may require emergent intubation for airway protection and ventilatory support or elective intubation for surgery with or without rigid neck stabilization (i.e., halo). To provide safe and efficient care in these patients, practitioners must identify high-risk patients, be comfortable with available methods of airway adjuncts, and know how airway maneuvers, neck stabilization, and positioning affect the cervical spine. This review discusses the risks and benefits of various airway management strategies as well as specific concerns that affect patients with known or suspected cervical spine injury.

[Cervical spine instability in the surgical patient]

Many congenital and acquired diseases, including trauma, may result in cervical spine instability. Given that airway management is closely related to the movement of the cervical spine, it is important that the anesthesiologist has detailed knowledge of the anatomy, the mechanisms of cervical spine instability, and of the effects that the different airway maneuvers have on the cervical spine. We first review the normal anatomy and biomechanics of the cervical spine in the context of airway management and the concept of cervical spine instability. In the second part, we review the protocols for the management of cervical spine instability in trauma victims and some of the airway management options for these patients.

Difficult airway intubation with flexible bronchoscope

BACKGROUND AND OBJECTIVE

To describe the efficacy and safety of a flexible bronchoscopy intubation (FBI) protocol in patients with difficult airway.

METHOD

We reviewed the medical records of patients diagnosed with difficult airway who underwent flexible bronchoscopy intubation under spontaneous ventilation and sedation with midazolam and fentanyl from March 2009 to December 2010.

RESULTS

The study enrolled 102 patients, 69 (67.7%) men and 33 (32.3%) women, with a mean age of 44 years. FBI was performed in 59 patients (57.8%) with expected difficult airway in the operating room, in 39 patients (38.2%) in the Intensive Care Unit (ICU), and in 4 patients (3.9%) in the emergency room. Cough, decrease in transient oxygen saturation, and difficult progression of the cannula through the larynx were the main complications, but these factors did not prevent intubation.

CONCLUSION

FBI according to the conscious sedation protocol with midazolam and fentanyl is effective and safe in the management of patients with difficult airway.

Cervical spine trauma in children and adults: perioperative considerations

A wide spectrum of cervical spine injuries, including stable and unstable injuries with and without neurologic compromise, account for a large percentage of emergency department visits. Effective treatment of the polytrauma patient with cervical spine injury requires knowledge of cervical spine anatomy and the pathophysiology of spinal cord injury, as well as techniques for cervical spine stabilization, intraoperative positioning, and airway management. The orthopaedic surgeon must oversee patient care and coordinate treatment with emergency department physicians and anesthesia services in both the acute and subacute settings. Children are particularly susceptible to substantial destabilizing cervical injuries and must be treated with a high degree of caution. The surgeon must understand the unique anatomic and biomechanical properties associated with the pediatric cervical spine as well as injury patterns and stabilization techniques specific to this patient population.

Pre-hospital care management of a potential spinal cord injured patient: a systematic review of the literature and evidence-based guidelines

An interdisciplinary expert panel of medical and surgical specialists involved in the management of patients with potential spinal cord injuries (SCI) was assembled. Four key questions were created that were of significant interest. These were: (1) what is the optimal type and duration of pre-hospital spinal immobilization in patients with acute SCI?; (2) during airway manipulation in the pre-hospital setting, what is the ideal method of spinal immobilization?; (3) what is the impact of pre-hospital transport time to definitive care on the outcomes of patients with acute spinal cord injury?; and (4) what is the role of pre-hospital care providers in cervical spine clearance and immobilization? A systematic review utilizing multiple databases was performed to determine the current evidence about the specific questions, and each article was independently reviewed and assessed by two reviewers based on inclusion and exclusion criteria. Guidelines were then created related to the questions by a national Canadian expert panel using the Delphi method for reviewing the evidence-based guidelines about each question. Recommendations about the key questions included: the pre-hospital immobilization of patients using a cervical collar, head immobilization, and a spinal board; utilization of padded boards or inflatable bean bag boards to reduce pressure; transfer of patients off of spine boards as soon as feasible, including transfer of patients off spinal boards while awaiting transfer from one hospital institution to another hospital center for definitive care; inclusion of manual in-line cervical spine traction for airway management in patients requiring intubation in the pre-hospital setting; transport of patients with acute traumatic SCI to the definitive hospital center for care within 24 h of injury; and training of emergency medical personnel in the pre-hospital setting to apply criteria to clear patients of cervical spinal injuries, and immobilize patients suspected of having cervical spinal injury.

Central acetylcholinesterase inhibition improves hemodynamic counterregulation to severe blood loss in alcohol-intoxicated rats

Acute alcohol intoxication results in impaired hemodynamic counterregulation to blood loss and is associated with an attenuated hemorrhage-induced release of catecholamines and AVP. We speculated that restoration of the neuroendocrine response to hemorrhage would improve mean arterial blood pressure (MABP) recovery during acute alcohol intoxication. Previously, we demonstrated that intracerebroventricular (i.c.v.) choline, a precursor of acetylcholine, transiently increases sympathetic nervous system (SNS) outflow but is not capable of improving neuroendocrine and hemodynamic compensation to hemorrhage in alcohol-treated rats. We hypothesized that prolongation of the observed effect via i.c.v. neostigmine, an acetylcholinesterase inhibitor, would enhance SNS outflow, restore the neuroendocrine response, and in turn improve hemodynamic responses to hemorrhage during acute alcohol intoxication. I.c.v. neostigmine (1 microg) increased MABP, catecholamines, and AVP within 5 min and reversed hypotension due to 40% hemorrhage and intragastric alcohol (30% wt/vol, 2.5 g/kg) administration in chronically catheterized male Sprague-Dawley rats (225-250 g body wt). Acute alcohol intoxication before 50% hemorrhage decreased basal MABP, accentuated hypotension midhemorrhage, suppressed the hemorrhage-induced release of norepinephrine and AVP, and prevented restoration of MABP to basal levels after fluid resuscitation with lactated Ringer solution. I.c.v. neostigmine (0.5 microg) produced a sustained increase in MABP beginning at 30 min of hemorrhage that persisted throughout fluid resuscitation in control and alcohol-treated animals. I.c.v. neostigmine enhanced epinephrine responses and restored the hemorrhage-induced release of norepinephrine and AVP in alcohol-treated rats. These results demonstrate that inhibition of acetylcholinesterase in the central nervous system enhances SNS outflow, restores the neuroendocrine response to severe blood loss, and thereby improves hemodynamic counterregulation during acute alcohol intoxication. This study provides evidence for a central (and not peripheral) role of alcohol in impairing hemodynamic stability during hemorrhagic shock.

Internal decapitation: survival after head to neck dissociation injuries

STUDY DESIGN

Case series.

OBJECTIVE

To describe survival and outcomes after occipitocervical dissociation injuries.

SUMMARY OF BACKGROUND DATA

Historically, occipitocervical dissociation injuries have a high rate of associated neurologic deficit with a relatively high incidence of mortality.

METHODS

Six patients with occipitocervical dissociation injuries are reported and their management and imaging findings reviewed. Possible contributory factors for survival are discussed.

RESULTS

All patients had upper neck and head dissociation injuries. The pattern of injury in all of these cases included a distraction type mechanism. All cases demonstrated soft tissue disruption in the zone of injury, which was consistent and apparent on all imaging studies. In these patients, the extent and severity of injury was more apparent on magnetic resonance imaging (MRI) than on radiograph or computed tomography scan. Management of these injuries included immobilization followed by surgery with particular care taken to avoid application of distraction forces to the neck.

CONCLUSION

Patients with occipitocervical dissociation injuries may survive their injury and even retain neurologic integrity. Initial in-line head stabilization is emphasized to prevent catastrophic neurologic injury. The resting osseous relationships and vertebral alignment at the time of imaging evaluation may be deceivingly normal, and the damage often primarily or exclusively involves disruption of the perivertebral soft tissue structures. Prevertebral soft tissue swelling was apparent in all cases. For these injuries that involve primarily damage to the ligamentous structures, MRI seems to be the optimal test for revealing the magnitude of the injury.

Manual In-Line Stabilization for Acute Airway Management of Suspected Cervical Spine Injury: Historical Review and Current Questions

Direct laryngoscopy with manual in-line stabilization is standard of care for acute trauma patients with suspected cervical spine injury. Ethical and methodologic constraints preclude controlled trials of manual in-line stabilization, and recent work questions its effectiveness. We searched MEDLINE, Index Medicus, Web of Knowledge, the Cochrane Database, and article reference lists. According to this search, we present an ancestral review tracing the origins of manual in-line stabilization and an analysis of subsequent studies evaluating the risks and benefits of the procedure. All manual in-line stabilization data came from trials of uninjured patients, cadaveric models, and case series. The procedure was adopted because of reasonable inference from the benefits of stabilization during general care of spine-injured patients, weak empirical data, and expert opinion. More recent data indicate that direct laryngoscopy and intubation are unlikely to cause clinically significant movement and that manual in-line stabilization may not immobilize injured segments. In addition, manual in-line stabilization degrades laryngoscopic view, which may cause hypoxia and worsen outcomes in traumatic brain injury. Patients intubated in the emergency department with suspected cervical spine injury often have traumatic brain injury, but the incidence of unstable cervical lesions in this group is low. The limited available evidence suggests that allowing some flexion or extension of the head is unlikely to cause secondary injury and may facilitate prompt intubation in difficult cases. Despite the presumed safety and efficacy of direct laryngoscopy with manual in-line stabilization, alternative techniques that do not require direct visualization warrant investigation. Promising techniques include intubation through supraglottic airways, along with video laryngoscopes, optical stylets, and other imaging devices.

Considerations for airway management for cervical spine surgery in adults

Surgery on the cervical spine runs the gamut from minor interventions done in a minimally invasive fashion on a short-stay or ambulatory basis, to major surgical undertakings of a high-risk, high-threat nature done to stabilize a degraded skeletal structure to preserve and protect neural elements. Planning for optimum airway management and anesthesia care is facilitated by an appreciation of the disease processes that affect the cervical spine and their biomechanical implications and an understanding of the imaging and operative techniques used to evaluate and treat these conditions. This article provides background information and evidence to allow the anesthesia practitioner to develop a conceptual framework within which to develop strategies for care when a patient is presented for surgery on the cervical spine.

Characterizing the need for mechanical ventilation following cervical spinal cord injury with neurologic deficit

BACKGROUND

Patients who sustain cervical spinal cord injury (C-SCI) with neurologic deficit may require a definitive airway and/or prolonged mechanical ventilation. The purpose of this study was to characterize factors associated with a high risk for respiratory failure and/or the need for mechanical ventilation in C-SCI patients.

METHODS

Patients with C-SCI and neurologic deficit admitted to a Level I Trauma Center between July 1, 2000 and June 30, 2002 were retrospectively reviewed for demographics, level and completeness of neurologic deficit, need for definitive airway, need for tracheostomy, need for mechanical ventilation at hospital discharge (MVDC), and outcomes. The level and completeness of injury were defined by American Spinal Injury Association standards.

RESULTS

One hundred nineteen patients with C-SCI and neurologic deficit were identified over this period. Of these, 45 were identified as complete C-SCI: 12 (27%) patients had levels of C1 to C4; 19 (42%) had a level of C5; and 14 (31%) had levels of C6 and below. There were 37 males and 8 females. There were 36 blunt and 9 penetrating injuries. The average age of these patients was 40 +/- 21, and the average ISS was 45+/-22. Eight of the patients with complete C-SCI died, for a mortality of 18%. Of the 37 survivors, 92% received a definitive airway, 81% received tracheostomy, and 51% required MVDC. All patients with complete injuries at the C5 level and above required a definitive airway and tracheostomy, and 71% of survivors required MVDC. Of the patients with complete injuries of C6 and below, 79% received a definitive airway, 50% required tracheostomy, and 15% of survivors required MVDC. Only 35% of incomplete injuries required a definitive airway, and only 7% required tracheostomy.

CONCLUSIONS

The need for definitive airway control, tracheostomy, and ventilator dependence is significant, especially for patients with high complete C-SCI. Based on these results we recommend consideration of early intubation and tracheostomy for patients with complete C-SCI, especially for those with levels of C5 and above.

Potential cervical spine injury and difficult airway management for emergency intubation of trauma adults in the emergency department--a systematic review

BACKGROUND

Emergency airway management for trauma adults is practised by physicians from a range of training backgrounds and with differing levels of experience. The indications for intubation and technique employed are factors that vary within EDs and between hospitals.

OBJECTIVES

To provide practical evidence based guidance for airway management in trauma resuscitation: first for the trauma adult with potential cervical spine injury and second the management when a difficult airway is encountered at intubation.

SEARCH STRATEGY AND METHODOLOGY

Full literature search for relevant articles in Medline (1966-2003), EMBASE (1980-2003), and the Cochrane Central Register of Controlled Trials. Relevant articles relating to adults and written in English language were appraised. English language abstracts of foreign articles were included. Studies were critically appraised on a standardised data collection sheet to assess validity and quality of evidence. The level of evidence was allocated using the methods of the Australian National Health and Medical Research Council.

Emergency department intubation of trauma patients with undiagnosed cervical spine injury

OBJECTIVES

Some trauma patients have an undiagnosed cervical spine injury but require immediate airway control. This paper reports an emergency department's (ED) experience with these patients. In particular, is there a worse neurological outcome?

METHODS

A retrospective study over 6.5 years, based on prospectively collected data from the Royal Perth Hospital trauma registry. Patients with a cervical spine injury were identified and clinical data were abstracted. The primary outcome measure was evidence of exacerbation of cervical spine injury as a result of intubation by ED medical staff.

RESULTS

308 patients (1.9%) of the 15 747 trauma patients were intubated by ED medical staff. Thirty seven (12%) were subsequently verified to have a cervical spine injury, of which 36 were managed with orotracheal intubation. Twenty five (69%) survived to have a meaningful post-intubation neurological examination. Fourteen (56%) of these 25 patients had an unstable cervical spine injury. Ninety per cent of all ED intubations were by ED medical staff. No worsening of neurological outcomes occurred.

CONCLUSIONS

Every ninth trauma patient that this ED intubates has a cervical spine injury. Intubation by ED medical staff did not worsen neurological outcome. In the controlled setting of an ED staffed by senior practitioners, patients with undiagnosed cervical spine injury can be safely intubated.

An assessment of protection of the airway from aspiration of oropharyngeal contents using the Combitube airway

A Combitube airway was inserted blindly into 27 American Society of Anaesthesiologist (ASA) grade 1 and 2 patients undergoing general anaesthesia. All had Cormack and Lehane grade 1 direct views of the larynx. Ten ml of 0.1% methylene blue dye was instilled into each patients mouth for the duration of surgery. The oropharynx was then aspirated and dried at completion of surgery and the Combitube removed. The laryngeal inlet and trachea were examined for dye staining. In 25/27 patients (93%) no tracheal soiling was seen. In 2/27 patients (7%) tracheal soiling was seen (95% confidence interval 0.9-24.3%). The Combitube protects the airway in the majority of patients from aspiration of dye within the oral cavity, but the failure rate means it cannot be relied upon absolutely to do so. This has implications for management of the trauma patient.

A comparison of the bullard laryngoscope versus the flexible fiberoptic bronchoscope during intubation in patients afforded inline stabilization

STUDY OBJECTIVE

To compare the Bullard laryngoscope (BL) with the flexible fiberoptic bronchoscope (FFB) in a cervical spine injury model, using inline stabilization.

DESIGN

Randomized clinical trial.

SETTING

Main operating room of a tertiary care hospital.

PATIENTS

50 adult, ASA physical status I, II, and III patients undergoing an elective general anesthetic.

INTERVENTIONS

Each patient's trachea was intubated with both techniques. Cricoid pressure was applied to half of the study patients.

MEASUREMENTS

The time for laryngoscopic view and the time to intubation were recorded for each technique. The effects of cricoid pressure on laryngoscopic view and intubation time were determined.

MAIN RESULTS

The times for laryngoscopy and intubation were longer in the FFB group than in the BL group (p < 0.004). There was a significantly lower success rate of laryngoscopy view in the FFB group in the presence of cricoid pressure (15 of 25 patients, or 60%) than either of the BL groups or the FFB no-cricoid pressure group.

CONCLUSIONS

The BL is more reliable, quicker, and more resistant to the effects of cricoid pressure than is the FFB.

The effect of single-handed cricoid pressure on cervical spine movement after applying manual in-line stabilisation -- a cadaver study

Six adult cadavers had 40 N cricoid pressure applied using a cricoid 'yoke' whilst maintaining manual in-line stabilisation of the cervical spine. No other spinal supports were used. Lateral radiographs were taken before and after applying pressure to the cricoid cartilage and the degree of cervical spine movement accurately determined. The median vertical displacements measured from the body of C5 and two other reference points (A and B) on the cervical spine were 0.5 mm (range 0-1.5 mm) and 0.5 mm (range 0-3 mm), respectively. There was no disruption to the lines formed by the anterior or posterior borders of the cervical bodies. We have been unable to demonstrate that single-handed cricoid pressure causes clinically significant displacement of the cervical spine in a cadaver model. This conflicts with previous studies.

Effects of cervical spine immobilization technique and laryngoscope blade selection on an unstable cervical spine in a cadaver model of intubation

STUDY OBJECTIVE

Orotracheal intubation (OTI) is commonly used to establish a definitive airway in major trauma victims, with several different cervical spine immobilization techniques and laryngoscope blade types used. This experimental, randomized, crossover trial evaluated the effects of manual in-line stabilization and cervical collar immobilization and 3 different laryngoscope blades on cervical spine movement during OTI in a cadaver model of cervical spine injury.

METHODS

A complete C5-C6 transection was performed by using an osteotome on 14 fresh-frozen cadavers. OTI was performed in a randomized crossover fashion by using both immobilization techniques and each of 3 laryngoscope blades: the Miller straight blade, the Macintosh curved blade, and the Corazelli-London-McCoy hinged blade. Intubations were recorded in real time on fluoroscopy and then transferred to video and color still images. Outcome measures included movement across C5-C6 with regard to angulation expressed in degrees of rotation and axial distraction and anteroposterior displacement with values expressed as a proportion of C5 body width. Cormack-Lehane visualization grades were also recorded as a secondary outcome measure. Data were analyzed by using multivariate analysis of variance to test for differences between immobilization techniques and between laryngoscope blades and to detect for interactions. Significance was assumed for P values of less than.05.

RESULTS

Manual in-line stabilization resulted in significantly less movement than cervical collar immobilization during OTI with regard to anteroposterior displacement. Use of the Miller straight blade resulted in significantly less movement than each of the other 2 blades with regard to axial distraction. The Cormack-Lehane grade was significantly better with manual in-line stabilization versus cervical collar immobilization; no differences were observed between blades.

CONCLUSION

Manual in-line stabilization results in less cervical subluxation and allows better vocal cord visualization during OTI in a cadaver model of cervical spine injury. The Miller laryngoscope blade allowed less axial distraction than the Macintosh or Corzelli-London-McCoy blades. The clinical significance of this degree of movement is unclear.

Use of the intubating laryngeal mask airway to facilitate awake orotracheal intubation in patients with cervical spine disorders

Airway management in patients with unstable cervical spines remains a challenge for anesthesia providers. Because neurologic evaluations may be required following tracheal intubation and positioning for the surgical procedure, an awake intubation technique is desirable in this patient population. In this report, we describe the use of an intubating laryngeal mask airway (ILMA) to facilitate awake tracheal intubation in two patients with cervical spine disorders. After topical local analgesia, the ILMA was inserted easily, and a tracheal tube was passed through the glottic opening without complications. Thus, the ILMA may be an acceptable alternative to the fiberoptic bronchoscope for awake tracheal intubation.

Insertion of the Combitube airway with the cervical spine immobilised in a rigid cervical collar

The Combitube is a twin lumen device designed to establish the airway after blind insertion. Under general anaesthesia a rigid cervical collar was used to immobilise the neck in 15 ASA 1 and 2 patients. Insertion of the Combitude airway was then attempted. In 10/15 (66%) patients, blind insertion was not possible. In 5/15 (33%) successful blind insertions the Combitube entered the oesophagus on each occasion. In 8/10 of the failures, re-insertion of the Combitude was attempted with the aid of a Macintosh laryngoscope. In 6/8 cases (75%) satisfactory placement was then possible with the Combitube again entering the oesophagus on each occasion. Ventilation was satisfactory in all patients when insertion was successful. Blood staining of the Combitube was present in 7/15 (47%) patients. The Combitude cannot be recommended for use in patients whose necks are immobilised in rigid cervical collars.

The intubating laryngeal mask. Use in failed and difficult intubation

The use of the intubating laryngeal mask in three patients is described. In two patients for whom tracheal intubation using traditional techniques had failed, the intubating laryngeal mask was used to achieve successful tracheal intubation. The trachea of one of these patients was subsequently re-intubated for a second procedure using the same technique. A third patient with a cervical spine fracture whose trachea was electively intubated using the intubating laryngeal mask is also presented.

Cervical spine injury in maxillofacial trauma

OBJECTIVE

To find out the incidence of associated facial injuries and injuries to the cervical spine.

DESIGN

Retrospective study.

SETTING

Teaching hospital, India.

SUBJECTS

536 patients treated for maxillofacial injuries between January 1992 and November 1993.

INTERVENTIONS

Review of hospital case notes and radiographs.

MAIN OUTCOME MEASURES

Coexisting facial and cervical spine injuries, morbidity and mortality.

RESULTS

16 patients (3%) had sustained both facial and cervical spine injuries. There were 14 men (median age 40, range 21-64) and 2 women (aged 19 and 30). In 10 of the 16 patients the cause of the injury was a road traffic accident. In 11 patients the facial injury was to the soft tissue only, in 4 it was to both hard and soft tissue, and in 1 it was to hard tissue only. Soft tissue damage to the midface was more likely to be associated with injuries in the area of C5-7 and that to the lower third of the face was more likely to be associated with damage to the upper cervical spine. 11 patients had neurological deficits as a result of their injuries and 2 died.

CONCLUSION

If diagnosis and treatment of simultaneous facial and cervical spine injuries are to be improved, further study of the biomechanics of injury is necessary.

Spinal cord syndromes

In summary, a working knowledge of the spinal cord's anatomy is critical in understanding the various presentations of the spinal cord syndromes. A careful history and physical, including a systematic neurologic examination, will direct the diagnostic work-up. There are a number of disorders that may affect the spine which are slowly progressive and do not necessarily require an emergent evaluation. However, patients with spinal cord trauma and spinal cord metastatic lesions are at risk for rapid and progressive deterioration. These patients require high priorization in care because morbidity and mortality may be significantly impacted by rapid diagnosis and initiation of therapeutic interventions.

Efficacy of prehospital surgical cricothyrotomy in trauma patients

OBJECTIVE

The use of surgical cricothyrotomy (SC) in the prehospital setting is controversial, and the need to teach this procedure to paramedics and intermediate emergency medical technicians remains unclear. The purpose of this study is to define the efficacy, complication rate, and overall survival after SC performed in the prehospital setting.

METHODS

In our region, emergency medical technicians receive training in this technique using an animal model with bi-annual updates required. We retrospectively reviewed data in our regional trauma register (15,686 injured patients) for the years 1991-1995.

RESULTS

Prehospital emergency airway intubation was required in 376 patients, 56 of whom received SC. The primary indications for SC were facial fractures and deformities (32%) and blood in the airway (30%). In 79% of the patients requiring SC, attempted orotracheal intubation prior to SC was unsuccessful, with a mean of 1.9 attempts per patient. SC was judged to provide an adequate airway in the field in 89% of attempts. Complications at the scene included six failed attempts, one case of excessive bleeding, and one adverse patient reaction (agitation). When patients arrived at the trauma center, the SC was judged to be acceptable in 64%, whereas 16% were functioning with some question of adequacy and required airway manipulation (most commonly a mainstem bronchial intubation). Overall survival to hospital discharge was 27%; however, survival to emergency department discharge (an indicator of emergency airway adequacy) was 62%. Using TRISS methodology, there were five unexpected survivors and six unexpected deaths. Only three patients were discharged with a "good neurologic recovery."

CONCLUSION

(1) Prehospital SC can be performed effectively with few complications after training on animal models (2) Good neurologic outcome is rare after the use of this procedure. (3) Although it is effective, clear indications must be developed and followed for the prehospital use of SC.

Laryngoscopy using the McCoy laryngoscope after application of a cervical collar

A rigid cervical collar was applied to 102 patients under general anaesthesia. Laryngoscopy was performed using a McCoy laryngoscope blade (size 3) initially in the standard Macintosh configuration followed by activation of the distal hinged tip. The two views obtained at laryngoscopy were graded according to standard guidelines. In 46/102 (45.1%) patients the laryngoscopic view was improved by one or more grades. In 10/102 (9.8%) the view was improved by two grades. Difficult laryngoscopy (grade 3 or 4) was encountered in 26/102 patients using the McCoy laryngoscope in the unactivated position (Macintosh configuration). Of these 26 patients, 24 (92.3%) had glottic structures identified (grade 1 or 2) when the distal tip of the laryngoscope blade was activated (p < 0.001). The McCoy laryngoscope significantly improves the view at laryngoscopy in the patient whose neck is immobilised in a rigid cervical collar.

Does the ambulance environment adversely affect the ability to perform oral endotracheal intubation?

OBJECTIVE

Oral endotracheal intubation (ETI) is the preferred method of controlling the airway in critically ill or injured patients. It was postulated that time could be saved if intubation was performed in the ambulance en route to the hospital. This study was designed to determine whether the ambulance environment adversely affected the ability of emergency medical technicians at the advanced-intermediate level (EMT-AI) to perform oral ETI.

HYPOTHESIS

The restrictive environment of a moving ambulance would affect adversely the ability of EMT-AIs to perform ETI compared with a controlled setting. This would result in a significant increase in the time necessary to perform ETI in the ambulance compared with a controlled setting not complicated by restrictive space and motion.

METHODS

Twenty on-duty EMT-AIs were recruited to volunteer for this prospective, nonrandomized, nonblinded trial. All participants performed three consecutive oral ETIs on an airway mannequin in two settings: 1) in the back of a moving ambulance; and 2) on a table in the rescue squad station. Of the participants, 10 performed the intubations in the ambulance first; the remainder performed the intubations at the station first. Time for intubation with the mannequin was recorded by stopwatch. The mean times for intubation in both settings were compared by Student's t-test (p < 0.05).

RESULTS

All intubation attempts were successful. The mean time for intubation in the station was 13.0 +/- 3.4 seconds. The mean time in the ambulance setting was 13.2 +/- 5.3 seconds. There was no significant difference between the intubation times in the two settings (p = 0.88).

CONCLUSION

The environment of a moving ambulance does not appear to hinder the ability of EMT-AIs to perform oral ETI in a laboratory setting with a mannequin model.

Traumatic brain injury

Traumatic brain injury (TBI) contributes significantly to the mortality and morbidity rates of traumatized patients. This article presents current concepts in the pathophysiology of TBI, including mechanisms of injury, biomolecular mediators of injury, and the occurrence of secondary injury. Emergency management, monitoring, and imaging of TBI also are reviewed.

The safety of orotracheal intubation in patients with unstable cervical spine fracture or high spinal cord injury

BACKGROUND

The potential merits and dangers of orotracheal and nasotracheal intubation in patients with injury to the cervical spine or spinal cord continue to be debated. To address this issue, a prospective study was conducted at a level 1 trauma center in patients with respiratory embarrassment and either or both of these injuries.

MATERIALS AND METHODS

Over a 7-year period, all such patients underwent neurologic examination by a trauma surgeon on arrival at the trauma center, immediately after endotracheal intubation, and at frequent intervals throughout hospitalization. Cervical immobilization was maintained manually during endotracheal intubation. When necessary, patients were sedated or paralyzed with short-acting pharmacologic agents.

RESULTS

During the study period, there were 81 patients with 98 cervical vertebral body fractures, but without evidence of spinal cord injury on initial examination. Sixty-seven patients (83%) were legally intoxicated, and 12 patients had closed head injury. Endotracheal intubation was performed in 26 patients with unstable fractures, and 22 patients were intubated via the oral route. No patient manifested a subsequent neurologic deficit. Sixty-nine additional patients presented with high spinal cord injury; 16 had no cervical spine fracture, and 53 patients had 61 fractures of the cervical vertebrae. Sixty patients (87%) were intoxicated, and 8 patients had closed head injury. Endotracheal intubation was performed in 29 of these patients, and 26 patients were intubated via the oral route. No patient experienced further neurologic deficit following endotracheal intubation.

CONCLUSION

In trauma victims with or at high risk of cervical spinal cord injury, orotracheal intubation is a rapid, safe means of achieving airway control.