Airway Control in Trauma Patients with Cervical Spine Fractures

Abstract

Introduction:Proper airway control in trauma patients who have sustained cervical spine fracture remains controversial.Purpose:This study was undertaken to survey the preferred methods of airway management in cervical spine fracture (CSF) patients, to evaluate the experience of handling such patients at a level-I trauma center, and to contrast the findings with recommendations of the American College of Surgeons Committee on Trauma.Hypothesis:The methods used for control of the airway in patients with fractures of their cervical spine support the recommendation of the American College of Surgeons (ACS) Committee on Trauma.Methods:The study consisted of two parts: 1) a survey; and 2) a retrospective study. Survey questionnaires were sent to 199 members of the Eastern Association for the Surgery of Trauma and to 161 anesthesiology training programs throughout the United States. Three resuscitation scenarios were posed: 1) Elective airway—CSF—breathing spontaneously, stable vital signs; 2) Urgent airway—CSF—breathing spontaneously, unstable vital signs; and 3) Emergent airway—CSF—apneic, unstable. In addition, a three-year retrospective study was conducted at a level-I trauma center to determine the method of airway control in patients with cervical spine fractures.Results:Responses to the questionnaires were received from 101 trauma surgeons (TS) and 58 anesthesiologists (ANESTH). Respondents indicated their preference of airway methods: Elective airway: Nasotracheal intubation: TS 69%, ANESTH 53%. Orotracheal intubation: TS and ANESTH 27%. Surgical airway: TS 4%. Intubation with fiberoptic bronchoscope (FOB): ANESTH 20%. Urgent airway: Nasotracheal intubation: TS 48%, ANESTH 38%. Orotracheal intubation: TS 47%, ANESTH 45%. Surgical airway: TS 4%. FOB: ANESTH 16%. Emergent airway: Orotracheal intubation: TS 81 %, ANESTH 78%. Surgical Airway: TS 19%, ANESTH 7%. FOB: ANESTH 15%.The retrospective review at the trauma center indicated that 102 patients with CSF were admitted; 62 required intubation: four (6%) on the scene, seven (11%) en route, five (8%) in the emergency department, 42 (67%) in the operating room, and four (6%) on the general surgery floor. Airway control methods used were nasotracheal: 14 (22%); orotracheal: 27 (43%); FOB: 17 (27%); tracheostomy: one (2%); unknown: three (4%). No progression of the neurological status resulted from intubation.Conclusion:The choice of airway control in the trauma patient with CSF differs between anesthesiologists and surgeons. However, the method selected does not have an adverse affect on neurological status as long as in-line stabilization is maintained. The methods available are safe, effective, and acceptable. The recommendations of the American College of Surgeons Committee on Trauma for airway control with suspected cervical spine injury are useful. The technique utilized is dependent upon the judgment and experience of the intubator.

Guidelines for Emergency Tracheal Intubation Immediately after Traumatic Injury

“…Principal indications for emergency NTI in trauma patients were jaw rigidity and cervical spine injury. 18,26,36,41,44,87,239,243 …”

“…Nineteen studies of trauma patients undergoing emergency tracheal intubation provide evidence that cervical spine neutrality should be maintained during tracheal intubation. 14,18,20,[22][23][24][37][38][39]49,63,81,[87][88][89]229,233,237,238 The majority of the 7,927 patients in these studies underwent emergency tracheal intubation. Some of the studies described the maintenance of cervical spine neutrality as a…”

“…[83][84][85][86] The need for emergency tracheal intubation in these patients with cervical spine injury is 22% (range, 14 -48%). 41,63,[87][88][89] There is also substantial documentation that patients with other severe neck injuries may have airway obstruction secondary to cervical hematoma and laryngeal or tracheal injury. 90 -108 Additional literature indicates that patients with severe neck injury have airway obstruction and commonly need emergency tracheal intubation (11-100%).…”

“…[152][153][154][155] The need for emergency tracheal intubation in these patients with cervical spine injury is 22% (range, 14 -48%). 41,63,[87][88][89] There is also documentation that patients with severe cognitive impairment have abnormal breathing patterns and can have hypoventilation. 11,156 -159 Severe cognitive impairment patients typically undergo emergency tracheal intubation.…”

Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all?

“…All are relatively safe in experienced hands 58 so long as the technique is one with which the clinician is most confident 86 . All have been shown to be safe even in the presence of an unstable cervical spine injury.…”