Manual in‐line stabilisation during tracheal intubation: effective protection or harmful dogma?

SummaryBackgroundThere are concerns that airway management in patients with suspected or confirmed cervical spine injury may exacerbate an existing neurological deficit, cause a new spinal cord injury or be hazardous due to precautions to avoid neurological injury. However, there are no evidence‐based guidelines for practicing clinicians to support safe and effective airway management in this setting.MethodsAn expert multidisciplinary, multi‐society working party conducted a systematic review of contemporary literature (January 2012–June 2022), followed by a three‐round Delphi process to produce guidelines to improve airway management for patients with suspected or confirmed cervical spine injury.ResultsWe included 67 articles in the systematic review, and successfully agreed 23 recommendations. Evidence supporting recommendations was generally modest, and only one moderate and two strong recommendations were made. Overall, recommendations highlight key principles and techniques for pre‐oxygenation and facemask ventilation; supraglottic airway device use; tracheal intubation; adjuncts during tracheal intubation; cricoid force and external laryngeal manipulation; emergency front‐of‐neck airway access; awake tracheal intubation; and cervical spine immobilisation. We also signpost to recommendations on pre‐hospital care, military settings and principles in human factors.ConclusionsIt is hoped that the pragmatic approach to airway management made within these guidelines will improve the safety and efficacy of airway management in adult patients with suspected or confirmed cervical spine injury.

Section: Resultsmentioning

confidence: 99%

Airway management in patients with suspected or confirmed cervical spine injury

Wiles,

Iliff,

Brooks

et al. 2024

“…Although introduced on the basis of the precautionary principle, MILS continues to be used commonly during tracheal intubation, in an attempt to stabilise the cervical spine and minimise the risk of secondary cord injury. The efficacy of MILS in protecting the cervical spinal cord had been discussed in a recent review [12], with little evidence found that MILS reduces cervical segment movement; MILS may in fact increase subluxation of damaged segments [13]. In addition, MILS has several potentially deleterious effects that are of direct relevance to tracheal intubation.…”

Section: Resultsmentioning

confidence: 99%

Airway management in patients with suspected or confirmed traumatic spinal cord injury: a narrative review of current evidence

Wiles

2022

Self Cite

Summary Around 1 million people sustain a spinal cord injury each year, which can have significant psychosocial, physical and socio‐economic consequences for patients, their families and society. The aim of this review is to provide clinicians with a summary of recent studies of direct relevance to the airway management of patients with confirmed or suspected traumatic spinal cord injury to promote best clinical practice. All airway interventions are associated with some degree of movement of the cervical spine; in general, these are very small and whether these are clinically significant in terms of impingement of the spinal cord is unclear. Manual in‐line stabilisation does not effectively immobilise the cervical spine and increases the likelihood of difficult and failed tracheal intubation. There is no clear evidence of benefit of awake tracheal intubation techniques in terms of prevention of secondary spinal cord injury. Videolaryngoscopy appears to cause a similar degree of cervical spine displacement as flexible bronchoscope‐guided tracheal intubation and is an appropriate alternative approach. Direct laryngoscopy does cause a slightly greater degree of cervical spinal movement during tracheal intubation than videolaryngoscopy, but this does not appear to increase the risk of spinal cord compression. The risk of spinal cord injury during tracheal intubation appears to be minimal even in the presence of gross cervical spine instability. Depending on the clinical situation, practitioners should choose the tracheal intubation technique with which they are most proficient and that is most likely to minimise cervical spine movement.

“…The benefits and efficacy of immobilisation of the cervical spine as a routine following trauma continues to be a matter of debate [62]. A meta‐analysis examined the effect of cervical collar application on ICP.…”

Section: Other Interventions For Traumamentioning

confidence: 99%

Management of traumatic brain injury: a narrative review of current evidence

Wiles

2022

Self Cite

Globally, approximately 70 million people sustain traumatic brain injury each year and this can have significant physical, psychosocial and economic consequences for patients, their families and society. The aim of this review is to provide clinicians with a summary of recent studies of direct relevance to the management of traumatic brain injury in order to promote best clinical practice. The use of tranexamic acid in the management of traumatic brain injury has been the focus of several studies, with one large randomised controlled trial suggesting a reduction in all-cause mortality within 24 h of injury. The use of therapeutic hypothermia does not improve neurological outcomes and maintenance of normothermia remains the optimal management strategy. For seizure management, levetiracetam appears to be as effective as phenytoin, but the optimal dose remains unclear. There has been a lack of clear outcome benefit for any individual osmotherapy agent, with no difference in mortality or neurological recovery. Early tracheostomy (< 7 days from injury) for patients with traumatic brain injury is associated with a reduction in the incidence of ventilator-associated pneumonia and duration of mechanical ventilation, critical care and hospital stay. Further research is needed in order to determine the optimal package of care and interventions. There is a need for research studies to focus on patient-centred outcome measures such as long-term neurological recovery and quality of life.