Direct laryngoscopy and endotracheal intubation in the prone position following traumatic thoracic spine injury

Abstract

incidence of diffi cult ventilation, diffi cult airway instrumentation, and cervical/thoracic spine injury [4][5][6][7][8]. We herein present the fi rst reported case of an adult trauma patient who underwent direct laryngoscopy and endotracheal intubation under general anesthesia in the prone position. Case reportA 43-year-old, 166-cm, 65-kg, previously healthy woman (a hospital employee) was suddenly attacked by a psychiatric ward patient with a pair of scissors. One of the scissor blades was inserted 8 cm deep into the middle region of her upper back/posterior upper thorax. The patient was immediately immobilized on a "spine board" in the prone position ( Fig. 1) and transferred to a neighboring trauma center for further care.Upon arrival at the trauma center, she was conscious, and hemodynamically stable, and was breathing spontaneously. Her neurological examination was unremarkable. Thoracic radiographic studies and a computerized tomography scan (both conducted in the prone position) ruled out pneumothorax and established the exact position of the scissors' blade (between the processi spinosi, in close proximity to the spinal cord at the T7 level, with the blade's tip lodged 2 cm into the corpus of the T7 vertebra; Fig. 2). No traumatic fracture/s of the corpus of the vertebra could be demonstrated, nor was there any indication of thoracic spinal dura mater penetration.The patient was transferred to the operating theater. As the trauma surgeon did not want to move the patient (to avoid possible neurological compromise) the anesthesia team decided to establish the airway (intubate the patient's trachea) in the prone position. It was determined that the patient had had nothing per os (NPO) for more than 5 h. Her airway examination was normal (Mallampati class one), and she had a good mouth Abstract Perioperative airway management in trauma victims presenting with penetrating thoracic spine injury poses a major challenge to the anesthesiologist. To avoid further neurological impairment it is essential to ensure maximal cervical and thoracic spine stability at the time of airway manipulation (e.g., direct laryngoscopy and endotracheal intubation). Airway management in the prone position additionally increases the incidence of cervical/thoracic spine injury, diffi cult ventilation, and diffi cult airway instrumentation. Although awake fi beroptic intubation of the trachea is considered the gold standard for airway instrumentation in patients with posterior thoracic/ cervical trauma, this technique requires the patient's cooperation, special equipment, and extensive training, all of which might be diffi cult to accomplish in emergency situations. We herein present the fi rst reported case of an adult trauma patient who underwent direct laryngoscopy and endotracheal intubation under general anesthesia in the prone position. Although the prone position is not the standard position for airway instrumentation with direct laryngoscopy and endotracheal intubation under general anesthesia, our experience indicates that ...

Tracheal intubation in the prone position with an intubating laryngeal mask airway following posterior spine impaled knife injury

“…The various options for airway management in the prone position are (1) awake fiberoptic intubation,[2] (2) DL and ETI,[3] and (3) insertion of a laryngeal mask airway (LMA). [145]…”

Management of difficult airway in penetrating cervical spine injury

“…[5] Conventional anaesthetic management for patient undergoing surgery in prone position usually starts with induction of general anaesthesia in supine position; then the patient is shifted to prone position. [6] Use of laryngeal mask airway has been used successfully in many emergency situations. Intubating laryngeal mask airway has been reported in many cases with success in clinically acceptable time.…”

Should we induce general anesthesia in the prone position?

“…There are scattered reports of patients being successfully intubated using a fibre-optic bronchoscope [4,30,32,33] or intubating laryngeal mask [1] in the prone position and even a report of successful direct laryngoscopy in the prone position [31]. The first reported use of a supraglottic airway following induction in the prone position was by McCaughey and Bhanumurthy in 1993 [19].…”

“…The primary outcome was time to readiness for radiographic imaging following anesthesia and positioning. The prone induction group were ready, on average, 5 min faster than the supine induction group (25 min vs. 30 min[26][27][28][29][30][31][32][33], P < 0.001). Two patients in the prone group had insufficient seal with the ProSeal LMA necessitating return to the supine position.…”