Airway management for patients with cervical spine disorders

Airway management for patients with cervical spine disorders Presented by R 3 吳佳展

Case presentation • 30 year-old man • Hyperextension injury • C 4 -5 HIVD • Muscle power: lower extremities 1, upper 3 • HR, BP, vital capacity within normal range • Intubated with light wand under general • anesthesia No neurological deterioration after surgery

Trauma patients • Pathology of cervical spine • Stability • Preoperative neurological deficits • Airway patency • Respiratory function • Cardiovascular compromise • Full stomach

Trauma patients • Other associated injuries • Facial injury: interfere with mask ventilation • 1~2% of trauma patients have cervical spine • • injury 10% of high-risk patients (head-first fall, high speed motor vehicle accidents) Stabilization makes intubation more difficult

evaluation • Neck pain or tenderness: only valid in alert patients without other painful lesions • Neurological examination • Plain films: lateral, AP, open mouth. Sensitivity~90% • CT scan • MRI

Airway management • No guidelines in this area • Awake or under general anesthesia • Nasal or oral • Blind, larygoscope, fiberoptic bronchoscope, • Bullard scope, Combitube, light wand, LMA, Fastrach, gum elastic bougie, Wu’s scope Surgical airway: tracheostomy, cricothyroitomy

Factors determining methods used • Urgency: most rapid and secure method is preferred • Experience of anesthesiologist • Patients’ cooperation • Airway anatomy • Mechanism of injury: flexion, extension

“standard” • Oral laryngoscope with manual in-line stablization • Blind nasal intubation in awake patients • Nasal fiberoptic intubation

Comparison between methods • Outcome • Radiological study: normal patients, with cervical spine pathology but without instability, cadaver • Upper or lower cervical spine injury

Outcome study • No difference between awake or GA, nasal or oral intubation (retrospective) • few studies comparing other airway management methods based on outcome, possibly because they are not widely used

Effect of airway maneuver • Cadaver study • Unstable C 5 -C 6: chin lift=jaw thrust=oral intubation>nasal intubation in spine movement • Unstable C 1 -C 2: space available for spinal cord oral=nasal>chin lift and jaw thrust

Bullard vs. Macintosh • Patients requiring GA with normal cervical spine • Measured with c-arm • Extension: BUL with ILS (in-line stabilization)< BUL=MAC with ILS<MAC • Intubation time: in reversed order

No neck motion? • Blind nasal • Nasal fiberoptic intubation: may cause the least movement compared other conventional methods • Trachlight • Fastrach • Combitube

Fastrach • Patients with cervical pathology (metastasis, disc prolapse, OPLL) • With light wand guide • Flexion and posterior displacement C 0~C 5

Fastrach • Cadaver • Pressure sensor placed at C 2 -3 • Control: nasal/oral, laryngoscope/ fiberscope • Fastrach produces greater pressure against cervical spine and greater posterior displacement

Fastrach vs. laryngoscope • Flexion vs. extension • Fastrach used in extension injury? • Laryngoscope used in flexion injury?

Trachlight vs. Fastrach Patients with cervical spine pathology Higher success rate at first attempt Less time required No data about cervical spine movement was provided

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