1. AIRWAY MANAGEMENT AFTER CERVICAL SPINE INJURY DINO A. O. ALTMANN, M.D. HOSPITAL SÃO LUIZ BRAZIL

2. CERVICAL SPINE INJURY x HEAD INJURY 14,755 ADMISSIONS 292 (2.0%) CERVICAL SPINE INJURIES GLASGOW COMA SCALECSI 13 – 151.4% 13 – 151.4% 9 – 126.8% 9 – 126.8% ≤ 8 10.2% ≤ 8 10.2% Demetriades et al J Trauma, 2000 Airway management after cervical spine injury

3. CERVICAL SPINE INJURY x HEAD INJURY 447 HEAD INJURIES 24 (5.4%) CERVICAL SPINE INJURIES Holly et al J Neurosurg, 2002 Airway management after cervical spine injury

4. CERVICAL SPINE INJURY 34,069 Blunt Tauma Victims 818 CERVICAL SPINE INJURIES2.4% C224.0% C6 + C739.3% NOT CLINICALLY SIGNIFICANT29.3% Goldberg W et al Ann Emerg Med, 2001 Airway management after cervical spine injury

5. CERVICAL SPINE INJURY STABLEUNSTABLE Instability occurs when physiologic loading causes patterns of vertebral displacement that jeopardize the spinal cord or nerve roots Airway management after cervical spine injury

6. CERVICAL SPINE INJURIES Not clinically significant (NEXUS) -Spinous process fractures -Wedge compression fractures ≤ 25% body -Isolated avulsion without ligament injury -Type I odontoid fracture -End-plate fractures -Isolated osteophyte fractures -Trabecular fractures -Isolated transverse process fractures Goldberg W et al Ann Emerg Med, 2001 Airway management after cervical spine injury

7. MECHANISMS OF SPINAL INJURY Hyperextension and Hyperflexion Airway management after cervical spine injury

8. MECHANISMS OF SPINAL CORD INJURY Primary shear forces compression distracting forces bone fragments Secondary FAILURE TO IMMOBILIZE THE SPINE IN NEUTRAL POSITION local perfusion deficit systemic hypotension hypoventilation increased vena cava pressure Airway management after cervical spine injury

9. MANUAL IN-LINE IMMOBILIZATION MILI Airway management after cervical spine injury

10. “NEUTRAL POSITION” Airway management after cervical spine injury 2.0 cm OCCIPUT ELEVATION INCREASES SPINAL CANAL/SPINAL CORD RATIO AT C5-C6 De Lorenzo et al, Ann Energ Med 1996

11. MILI x CERVICAL COLLAR During Laringoscopy Less spinal movement Improves laryngeal visualization Airway management after cervical spine injury

12. CERVICAL SPINE INJURY Clinical Predictors SEVERE HEAD INJURY FOCAL NEUROLOGICAL DEFICIT Airway management after cervical spine injury

13. URGENT AIRWAY INTERVENTION Blunt Trauma Patient LESS LIKELYto have a complete neurological evaluation MORE LIKELYneurological injury SUSPECT CERVICAL SPINE INJURY Airway management after cervical spine injury

14. ANTERIOR LARYNGEAL OR CRICOID PRESSURE Improves laryngeal visualization Do not cause upper cervical spine movement Protects against aspiration Airway management after cervical spine injury

15. SPACE AVAILABLE FOR THE SPINAL CORD SAC Airway management after cervical spine injury

16. CERVICAL MOTION DURING AIRWAY MANAGEMENT Most significant at Oc – C1 Airway management after cervical spine injury

17. MASK VENTILATION x TRACHEAL INTUBATION More cervical spine movement More cervical spine movement with mask ventilation Airway management after cervical spine injury

18. COMPARABLE SPINAL MOVEMENT Direct laringoscopy Video-laryngoscopy (Glidescope) Nasotracheal intubation Laryngeal mask insertion Combitube and PTL Cricothyrotomy Flexible bronchoscope intubation Airway management after cervical spine injury

19. AIRWAY MANAGEMENT AT SCENE NASOPHARYNGEAL AIRWAY OXYGEN MASK WITH NON-REBREATHING BAG RAPID SEQUENCE INTUBATION WITH MILI INITIAL INTUBATION ATTEMPTS SUCCESSFULUNSUCCESSFUL FACE MASK VENTILATION0? PHARYNGEAL-TRACHEAL LUMEN AIRWAY (PTL) VENTILATION ADEQUATE VENTILATION INADEQUATE CONSIDERCRICOPHARINGOSTOMY TRACHEAL TUBE INTRODUCER ORO-TRACHEAL INTUBATION Airway management after cervical spine injury

20. PHARYNGEAL – TRACHEAL LUMEN AIRWAY PTL Airway management after cervical spine injury

21. PHARYNGEAL – TRACHEAL LUMEN AIRWAY PTL Airway management after cervical spine injury

22. PHARYNGEAL – TRACHEAL LUMEN AIRWAY PTL Airway management after cervical spine injury

23. PHARYNGEAL – TRACHEAL LUMEN AIRWAY PTL Airway management after cervical spine injury

24. AIRWAY MANAGEMENT AT MEDICAL CENTER CONSIDER FLEXIBLE BRONCHOSCOPE INTUBATION Airway management after cervical spine injury

25. CONCLUSIONS Lack of prospective studies Apply MILI for all airway maneuvres Avoid face-mask ventilation Rapid sequence intubation Comparable airway methods Tailor and follow your own ALGORITHM Airway management after cervical spine injury