airway management after cervical spine injury dino a. o. altmann, m.d. hospital sÃo luiz brazil
TRANSCRIPT
AIRWAY MANAGEMENT AFTER
CERVICAL SPINE INJURY
DINO A. O. ALTMANN, M.D.HOSPITAL SÃO LUIZ
BRAZIL
CERVICAL SPINE INJURY x HEAD INJURY
14,755 ADMISSIONS292 (2.0%) CERVICAL SPINE INJURIES
GLASGOW COMA SCALECSI 13 – 15
1.4% 9 – 12
6.8% ≤ 8
10.2%Demetriades et al J Trauma, 2000
Airway management after cervical spine injury
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
CERVICAL SPINE INJURY34,069 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
CERVICAL SPINE INJURY
STABLE UNSTABLE
Instability occurs when physiologic loading causes patterns of vertebral displacement that jeopardize the spinal cord or nerve roots
Airway management after cervical spine injury
CERVICAL SPINE INJURIESNot 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
MECHANISMS OF SPINAL INJURYHyperextension and Hyperflexion
Airway management after cervical spine injury
MECHANISMS OF SPINAL CORD INJURYPrimary shear forces
compressiondistracting forcesbone fragments
SecondaryFAILURE TO IMMOBILIZE THE SPINE IN NEUTRAL
POSITION
local perfusion deficitsystemic hypotensionhypoventilationincreased vena cava
pressure
Airway management after cervical spine injury
MANUAL IN-LINE IMMOBILIZATION
MILI
Airway management after cervical spine injury
“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
MILI x CERVICAL COLLAR During Laringoscopy
Less spinal movement
Improves laryngeal visualization
Airway management after cervical spine injury
CERVICAL SPINE INJURYClinical Predictors
SEVERE HEAD INJURY
FOCAL NEUROLOGICAL DEFICIT
Airway management after cervical spine injury
URGENT AIRWAY INTERVENTION
Blunt Trauma PatientLESS LIKELY to have a
complete neurological
evaluation
MORE LIKELY neurological injury
SUSPECT CERVICAL SPINE INJURY
Airway management after cervical spine injury
ANTERIOR LARYNGEAL OR CRICOID PRESSURE
Improves laryngeal visualization
Do not cause upper cervical spine movement
Protects against aspiration
Airway management after cervical spine injury
SPACE AVAILABLE FOR THE SPINAL CORDSAC
Airway management after cervical spine injury
CERVICAL MOTION DURING AIRWAY MANAGEMENT
Most significant at Oc – C1
Airway management after cervical spine injury
MASK VENTILATIONx
TRACHEAL INTUBATION More cervical spine
movementwith mask ventilation
Airway management after cervical spine injury
COMPARABLE SPINAL MOVEMENT
Direct laringoscopyVideo-laryngoscopy (Glidescope)Nasotracheal intubationLaryngeal mask insertionCombitube and PTLCricothyrotomyFlexible bronchoscope intubation
Airway management after cervical spine injury
AIRWAY MANAGEMENT AT SCENE
NASOPHARYNGEAL AIRWAYOXYGEN MASK WITH NON-REBREATHING BAG
RAPID SEQUENCE INTUBATION WITH MILI
INITIAL INTUBATION ATTEMPTS
INITIAL INTUBATION ATTEMPTS
SUCCESSFUL UNSUCCESSFUL
FACE MASK VENTILATION0?
PHARYNGEAL-TRACHEAL LUMEN AIRWAY (PTL)
VENTILATION ADEQUATE VENTILATION INADEQUATE
CONSIDER CRICOPHARINGOSTOMY
TRACHEAL TUBE INTRODUCERORO-TRACHEAL INTUBATION
Airway management after cervical spine injury
PHARYNGEAL – TRACHEAL LUMEN AIRWAY
PTL
Airway management after cervical spine injury
PHARYNGEAL – TRACHEAL LUMEN AIRWAY
PTL
Airway management after cervical spine injury
PHARYNGEAL – TRACHEAL LUMEN AIRWAY
PTL
Airway management after cervical spine injury
PHARYNGEAL – TRACHEAL LUMEN AIRWAY
PTL
Airway management after cervical spine injury
AIRWAY MANAGEMENT AT MEDICAL CENTER
CONSIDER FLEXIBLE BRONCHOSCOPE INTUBATION
Airway management after cervical spine injury
CONCLUSIONS
Lack of prospective studiesApply MILI for all airway maneuvresAvoid face-mask ventilationRapid sequence intubationComparable airway methodsTailor and follow your own
ALGORITHM
Airway management after cervical spine injury