The document discusses airway management considerations for patients with traumatic brain injury (TBI) or cervical spine injury. It notes that secondary insults like hypoxia, hypercarbia, or hypotension can worsen outcomes for TBI patients. Precautions must be taken during airway procedures to avoid further increases in intracranial pressure. Proper patient positioning, preoxygenation, and titrating induction agents can help make intubation smoother. Vigilance is needed to prevent hypoxia, hypercapnia, neck rotation, or other factors that could negatively impact intracranial dynamics during airway management of these complex patients.

1. AIRWAY MANAGEMENT IN
TRAUMATIC BRAIN INJURY AND
CERVICAL SPINE INJURY
I Putu Pramana Suarjaya
Department of Anesthesiology and Intensive Care
Sanglah Hospital – Faculty of Medicine Udayana University
Bali - Indonesia

2. Outline
 Review of airway anatomy
 Traumatic Brain Injury
 Airway evaluation
 Ventilation and intubation
 The difficult airway

3. Airway anatomy

4. Normal Airway
 Patent nares
 Ability to open mouth widely withTMJ rotation and subluxation (3
– 4 cm or two finger breaths)
 MallampatiClass I
 Patient sitting straight up, opening mouth as wide as possible, with
protruding tongue; the uvula, posterior pharyngeal wall, entire
tonsillar pillars, and fauces can be seen
 At least 6 cm (3 finger breaths) from tip of mandible to thyroid
notch with neck extension
 At least 9 cm from symphysis of mandible to mandible angle
NekhendzyV, Kristensen MS, Claure RE. Anesthetic andAirway Management of Microlaryngeal Surgery and UpperAirway
Endoscopy. In: HagberC, editor. Benumof and Hagberg’sAirway Management: Fiftth Edition [Internet]. 5th ed. Philadelphia
PA: Elsevier Inc.; 2022. p. 785–812.Available from: http://dx.doi.org/10.1016/B978-1-4377-2764-7.00038-5

6. Traumatic Brain Injury

7.  The anesthesiologist caring for the patient with
TBI must understand that although primary
mechanisms of injury (primary insults) are a large
determinant of patient outcome, secondary
insults can impact dramatically on morbidity,
mortality, and quality of life of the TBI patient.
Schreiber M, Aoki N, Scott B, et al: Determinants of mortality in patients with severe blunt head injury. Arch Surg
137:285–290, 2002.
Capizzi A,Woo J,Verduzco-gutierrez M.Traumatic Brain Injury An Overview of Epidemiology , Pathophysiology , and
Medical Management. Med Clin NA [Internet]. 2020;104(2):213–38. Available from:
https://doi.org/10.1016/j.mcna.2019.11.001

8. Capizzi A,Woo J,Verduzco-gutierrez M.Traumatic Brain Injury An Overview of Epidemiology ,
Pathophysiology , and Medical Management. Med Clin NA [Internet]. 2020;104(2):213–38. Available from:
https://doi.org/10.1016/j.mcna.2019.11.001

9. Epidemiology
 CDC documented 2.53 millionTBI-related
emergency department (ED) visits in 2014.
 Approximately 288,000TBI-related
hospitalizations and 56,80TBI-related deaths
 The most common causes ofTBI-related
deaths are intentional self-harm (32.5%),
unintentional falls (28.1%), and
motor vehicle crashes (MVC) (18.7%)
Capizzi A,Woo J,Verduzco-gutierrez M.Traumatic Brain Injury An Overview of Epidemiology , Pathophysiology ,
and Medical Management. Med Clin NA [Internet]. 2020;104(2):213–38. Available from:
https://doi.org/10.1016/j.mcna.2019.11.001

10. Severity of TBI

11. Patophysiology

12. TRAUMATIC BRAIN INJURY
 Improperly planned airway technique can
severely compromise intracranial
dynamics and increase morbidity and
mortality
 Predictors of mortality in adult brain-
injured patients are:
 Hypoxia (mortality rate doubles to 50%)
 Hypercarbia (mortality rate increases to 67%)
 Systemic hypotension resulting in cerebral
 Hypoperfusion/decreased CPP
 Intracranial hypertension
 Hypothermia
Jeremitsky E, Omert L, Dunham CM, et al: Harbingers of poor outcome the day after severe brain injury:
hypothermia, hypoxia, and hypoperfusion. JTrauma 54:312–319, 2003.

13.  A reasonable clinical estimate can be made in
head injured patients who are not sedated:
 Drowsy and confused (GCS 13-15): ICP = 20-30 mmHg
 Severe brain swelling (GCS ≤ 8): ICP ≥ 30 mmHg

14.  Techniques minimizing head movement
should be used inTBI. However, concern
about a cervical inury should never take
precedence over relieving hypoxemia.
 It is of critical importance to ensure that
appropriate monitoring is present
throughout airway maneuvers.
 Caution should be exercised in “blindly”
inserting “devices/appliances” into the
nasal cavity of patients with known or
suspected basilar skull fractures and
sinus injuries:
 A nasotracheal tube / nasopharyngeal airway
for airway control
 An NGT for gastric decompression or
 A Foley catheter for control of massive epistaxis.

15. ETT inside the
AnteriorCranial
Fossa after “blind”
nasotracheal
intubation in patient
with basal skull
fracture
Marlow, Troy J. et al. Intracranial placement of a nasotracheal
tube after facial fracture: A rare complication. Journal of
Emergency Medicine , Volume 15 , Issue 2 , 187 - 191
15

16. Foley Catheter Placed for Epistaxis
Inside Anterior Cranial Fossa
16

17. 42
Genú et al. Inadvertent Intracranial Placement
of an NG Tube. J Oral Maxillofac Surg 2004.
Most of these patients
are assumed to have a
“full stomach,” so it is
important to weigh
the risk of aspiration
during laryngoscopy
and intubation vs.
prior stomach
decompression with
NGT insertion Computed axial tomography showing
pneumoencephalus and a localized intracranial
NGT

18. Intracranial Dynamics

19. Unique Challenges
1. Airway management in the face of
intracranial hypertension or limited
intracranial compliance
2. During the processes of achieving,
maintaining, and/or rescuing the difficult
neurosurgical airway, there is the need to:
a) balance and maintain CNS hemodynamics
(CBF,CBV,CMRO2,CSF dynamics),
b) avoid increases in ICP, yet
c) maintain cerebral/spinal perfusion
Bekker AY, Mistry A, Ritter AA, et al: Computer simulation of intracranial pressure changes during induction of anesthesia:
comparison of thiopental, propofol, and etomidate. J Neurosurg Anesthesiol 11:69–80, 1999
Wells AJ, Hutchinson PJA. The management of traumatic brain injury. Surgery [Internet]. 2021;39(8):470–8. Available from:
https://doi.org/10.1016/j.mpsur.2021.06.009

20. • FACTS:
• Airway obstruction and difficult Bag/Mask
Ventilation may quickly lead to hypercarbia,
hypoxemia, and increasedCBF aggravating
intracranial hypertension
• Laryngoscopy and intubation result in acute
increases in ICP and MAP (also undue cranio-
cervical spine motion)
• THE PRIMARYGOALS are to avoid:
• further increases in ICP and
• further neurologic injury.
Burney RG, Winn R: Increased cerebrospinal fluid pressure during laryngoscopy and intubation for induction of anesthesia. Anesth Analg
54:687–690, 1975.
Capizzi A, Woo J, Verduzco-gutierrez M. Traumatic Brain Injury An Overview of Epidemiology , Pathophysiology , and Medical
Management. Med Clin NA [Internet]. 2020;104(2):213–38. Available from: https://doi.org/10.1016/j.mcna.2019.11.001
Gamberini L, Baldazzi M, Coniglio C, Gordini G, Bardi T. Prehospital Airway Management in Severe Traumatic Brain Injury. 2019;38.

21. General Airway Considerations in
Patients for Craniotomy
1) Airway Assessment (history and PE) of the
neurosurgical patient requires similar
considerations
• A previous history of difficult airway
management (mask ventilation,
laryngoscopy, and/or intubation) warrants
particular attention
Capizzi A,Woo J,Verduzco-gutierrez M.Traumatic Brain Injury An Overview of Epidemiology , Pathophysiology ,
and Medical Management. Med Clin NA [Internet]. 2020;104(2):213–38. Available from:
https://doi.org/10.1016/j.mcna.2019.11.001

22. Weintraub, et. al. (MRA flow analysis of 160 cases in 1998): “sustained neck hyperextension greater than
12 minutes appears to be a neglected potential hemodynamic factor that may play a pivotal role in the
pathogenesis of perioperative stroke” Stroke. 1998;29:1644-1649
• Patients with signs and symptoms of Intracranial
vascular insufficiency should receive special attention to
neck position not only during tracheal intubation &
surgery but also in the perioperative period.
i. “Beauty parlor stroke syndrome” & “Adolescent stretch
syncope” [vertebro-basilar insufficiency],
ii. Transient ischemic attacks (TIA),
iii. Stroke, and
iv. Presence of carotid bruit

23. MOUTHSAcronym(modified from Davis J, 1991)
Components Description Assessment Activities
Mandible
Length, subluxation
Measure hyomental
distance (A)
and anterior
displacement A
of mandible
Opening
Base, symmetry,
range
Assess and measure mouth opening in
centimeters or patient’s own 3-finger breadth.
0
Uvula
Visibility (to include
palatal configuration)
Assess pharyngeal
structures and classify
[Mallampati Class]
Teeth Dentition Assess for presence of loose teeth and dental appliances,
occlusion (bite), incisor prominence
Head
Flexion, extension,
rotation of head/neck
and cervical spine
Assess all ranges of movement
[Belhouse-Doré Grade, axial rotation,
instability, sternomental distance]
Silhouette
Upper body AP
abnormalities
(to include thyroid
cartilage tilt)
Identify potential impact on airway control
by large breasts, buffalo hump, kyphosis,
short (position of larynx to base of the
tongue) & large neck circumference, etc.
19

24. Summaryof Pooled SensitivityandSpecificityof
CommonlyUsedMethodsof AirwayEvaluation
24
EXAMINATION SENSITIVITY (%) SPECIFICITY (%)
Mallampati classification 49 86
Thyromental distance 20 94
Sternomental distance 62 82
Mouth opening 46 89
Anterior tilt of larynx* 70 95
Data derived from Shiga T, Wajima Z, Inoue T et al: Predicting Difficult Intubation in
Apparently Normal Patients: A Meta-analysis of Bedside Screening Test Performance.
Anesthesiology 2005; 103: 429
* Roberts JT, Ali HH, Shorten GD. Using the bubble inclinometer to measure laryngeal tilt
and predict difficulty of laryngoscopy. J Clin Anesth 1993;5:306–309
Shiga, et al. META-ANALYSIS: “…only poor to
moderate sensitivity and moderate to fair specificity”

25. • In clinical practice, unexpected
difficulties may occur in 25-30% of cases.
Approximately 50% of these had been
labelled as “pseudo-difficulties”
resulting from:
1) unskilled operators,
2) incorrect execution of maneuvers, or
3) lack of working guidelines/protocols
25

26. 2) In addition to the history and physical
examination, preoperative
• plain radiographs,
• computed tomography (CT) or
• magnetic resonance imaging (MRI), &
• angiography
may give valuable information of the
patient’s intracranial status -
signs of increased ICP
presence of hemorrhage/infarct/vasospasm/edema
Bedford RF, Morris L, Jane JA: Intracranial hypertension during surgery for supratentorial tumor: correlation with preoperative tomography
scans. Anesth Analg 61:430–433, 1982
Capizzi A,Woo J,Verduzco-gutierrez M.Traumatic Brain InjuryAn Overview of Epidemiology , Pathophysiology , and Medical
Management. Med Clin NA [Internet]. 2020;104(2):213–38. Available from: https://doi.org/10.1016/j.mcna.2019.11.001

27. • Signs of increased
intracranial
pressure on a skull
plain x-ray
– Increased vascular
markings
– Widening of the
sella turcica
– Erosion of the sella
turcica
– Gyri may make
prominent markings
on the inner table of
the skull
– The pineal gland is
displaced from the
midline.
“Copper beaten” skull
Tuite GF, Evanson J, Chong WK et-al. The beaten copper cranium: a correlation between intracranial pressure, cranial
radiographs, and computed tomographic scans in children with craniosynostosis.
Neurosurgery. 1996;39 (4): 691-9

28. CT appearance of normal brain. CT scan appearance of tumor
with edema and midline shift.
Lesions associated with greater than 10 mm in
midline shift or cerebral edema usually
indicate intracranial hypertension
Bedford RF, Morris L, Jane JA: Intracranial hypertension during surgery for supratentorial tumor:
correlation with preoperative tomography scans. AnesthAnalg 61:430–433, 1982

29. CT scan appearance of Intracranial
Hemorrhage
27
Acute Sub-acute Chronic

30. Routine Measures to achieve optimal airway
control &/or “smooth” intubation include:
1) proper head positioning*,
2) preoxygenation, and
3) appropriate dosing of induction agents
(hypnotics, opioids) and relaxants (with or
without adjuvant agents)
30
* Ng I, Lim J, Wong HB: Effects of head posture on cerebral hemodynamics: its influences on intracranial pressure, cerebral
perfusion pressure, and cerebral oxygenation. Neurosurgery 54:593–597, 2004.

31. • Techniques currently being employed to
“blunt” the sympathetic response to
laryngoscopy and intubation:
1) an additional dose of thiopental or propofol
&/or opioids,
2) use of beta-blockers or other
antihypertensive agents, and
3) use of intravenous (IV) lidocaine
31

32. GENERAL PRINCIPLES IN THE ANESTHETIC MANAGEMENT TO
AVOID INCREASED INTRACRANIAL PRESSURE
Technique Precaution(s)
Avoid marked
hypertension
Be vigilant to changes in degree of painful stimulation.
Ensure adequate depth of anesthesia before intubation
attempts or surgical/procedural attempts.
Avoid hypoxia
Be vigilant of patient’s respiratory status.
Take precautions to avoid aspiration.
Preoxygenation before induction of anesthesia or
tracheal intubation.
Avoid hypercapnia
Be vigilant of patient’s respiratory status.
Avoid undue sedation.
Avoid severe neck
rotation
Attempt to maintain neck in neutral position.
Be vigilant to head positioning of patient during surgery.
32

33. GENERAL PRINCIPLES IN THE ANESTHETIC MANAGEMENT
TO AVOID INCREASED INTRACRANIAL PRESSURE
Technique Precaution(s)
Avoid compression of
jugular veins
Consider avoiding internal jugular neck lines
when possible.
Elevate head
If backup position not possible, use reverse
Trendelenburg (avoid hypotension).
Decrease blood viscosity
and intracerebral BV
Avoid rapid infusion of mannitol, which may
paradoxically increase intracranial pressure.
Avoid sustained
increases in
intrathoracic pressure
Use maneuvers or pharmacologic agents to
avoid bucking, movement, and vomiting.
Avoid high ventilatory pressures when possible.
Avoid cerebral
venodilators
Consider beta-blocker use to treat hypertension.
Consider calcium channel blockers.
Avoid nitroglycerine and nitroprusside, if possible.
33

34. Airway Evaluation
 Take very seriously history
of prior difficulty
 Head and neck movement
(extension)
 Alignment of oral,
pharyngeal, laryngeal axes
 Cervical spine arthritis or
trauma, burn, radiation,
tumor, infection,
scleroderma, short and thick
neck

35. Airway Evaluation
 Jaw Movement
 Both inter-incisor gap and
anterior subluxation
 <3.5cm inter-incisor gap
concerning
 Inability to sublux lower
incisors beyond upper
incisors
 Receding mandible
 Protruding Maxillary
Incisors (buck teeth)

36. Airway Evaluation
 Obesity
 Distribution, i. e.
short, thick neck
more concerning
 Neck circumference

37. Airway Evaluation
 Thyromental distance:
bony point on mentum
(mandible) to thyroid
notch
 If short (<3FB’s or 6cm),
pharyngeal and
laryngeal axis off

38. Airway Evaluation
 Oropharyngeal visualization
 Mallampati Score
 Sitting position, protrude tongue, don’t say “AHH”

39. Mallampati Classification
 Class I: soft palate, tonsillar fauces, tonsillar
pillars, and uvuala visualized
 Class II: soft palate, tonsillar fauces, and uvula
visualized
 Class III: soft palate and base of uvula visualized
 Class IV: soft palate not visualized
 Class III and IV Difficult to Intubate

40. Airway Evaluation
 Difficulty ventilating
 Age >55
 Beard
 History of snoring
 Lack of teeth
 BMI >26

41. Ventilation and Intubation

42. Mask Ventilation
 Downward displacement
of mask with thumb and
index finger
 Upward traction of
remaining fingers upward
 Fingers on bony mandible
 Fifth digit at angle
displacing mandible
anteriorly
www.aic.cuhk.edu.hk

46. Intubation
Indications for Intubation
 Ventilatory Support
 Decreased GCS
 Protection of Airway
 Ensuring Airway patency
 Anesthesia and surgery
 Suctioning and PulmonaryToilet
 Hypoxic and Hypercarbic respiratory Failure
 Pulmonary lavage

47. Endotracheal Intubation
Depends Upon Manipulation of:
 Cervical spine
 Atlanto-occipital Joint
 Mandible
 Oral soft tissues
 Neck hyoid bone
 Additionally:
 Dentition
 Pathology - Acquired and
Congenital

48. Intubation Technique
 Preparation:
 Equipment Check
 100% oxygen at high flows (> 10 Lpm) during
bask/mask ventilation
 Suction apparatus
 Intubation tray
 Two laryngoscopic handles and blades
 Airways
 ET tubes
 Needles and syringes
 Stylet
 KY Jelly
 SuctionYankauer
 Magill Forceps
 LMA’s

49. Pre - oxygenation
 Traditional:
 3 minutes of tidal volume breathing at 5 ml/kg 100%
O2
 Rapid
 8 deep breaths within 60 seconds at 10 L/min
 Always ensure pulse oximetry on patient

50. Positioning
 Optimal Position – “sniffing position”
 Flexion of the neck and extension of the antlanto-
occipital joint

51. Other Methods to Determine
Placement of ETT tube
 Auscultation
 Visualization of tube through cords
 Fiberoptic bronchoscopy
 Pulse oximetry not improving or worsening
 Movement of the chest wall
 Condensation in ET tube
 Negative PressureTest
 CXR

52. Endotracheal Intubation
Open the mouth with right hand
 Scissor technique
Gently insert laryngoscope into right side of mouth pushing
tongue to the left
Careful with insertion not to hit teeth
Advance laryngoscope further into oropharynx with applied
traction 45 degrees

53. Endotracheal Intubation
Look for epiglottis
 If initially not found insert
laryngoscope further
 If this maneuver does not
work slowly pull
laryngoscope back
Once epiglottis visualized,
push laryngoscope into
vallecula and apply traction
at 45 degree angle to “push”
epiglottis up and out of the
way
www.int-med.uiowa.edu/Research/TLIRP/Bronchos

54. Endotracheal Intubation
 Look for vocal cords or arytenoid
cartilages and try to optimize view
 (i.e. lift head, apply more traction
at 45 degree angle if necessary)
 Do not move once view is
optimized!
 Assistant will hand you ETT
 Insert ETT into far right aspect of
mouth
 Traction of laryngoscope slightly
to left may assist
 Traction of laryngoscope at 45
degrees will also help keep
mouth open

55. Causes of Failed
Intubation
 Poor positioning of the head
 Tongue in the way
 Pivoting laryngoscope against upper teeth
 Rushing
 Being overly cautious
 Inadequate sedation
 Inappropriate equipment
 Unskilled laryngoscopist

56. Risk Factors For Difficult
Intubation
 El-Canouri et al. - prospective study of 10, 507
patients demonstrating difficult intubation with
objective airway risk criteria
 Mouth opening < 4 cm
 Thyromental distance < 6 cm
 Mallampati grade 3 or greater
 Neck movement < 80%
 Inability to advance mandible (prognathism)
 Body weight > 110 kg
 Positive history of difficult intubation

57. Signs Indicative of a Difficult
Intubation
 Trauma, deformity: burns, radiation therapy,
infection, swelling, hematoma of face, mouth,
larynx, neck
 Stridor or air hunger
 Intolerance in the supine position
 Hoarseness or abnormal voice
 Mandibular abnormality
 Decreased mobility or inability to open the mouth at least 3
finger breaths
 Micrognathia, receding chin
 Treacher Collins, Peirre Robin, other syndromes
 Less than 6 cm (3 finger breaths) from tip of the mandible to
thyroid notch with neck in full extension
 < 9 cm from the angle of the jaw to symphysis
 Increased anterior or posterior mandibular length

58.  Laryngeal Abnormalities
 Fixation of larynx to other structures of neck,
hyoid, or floor of mouth.
 Macroglossia
 Deep, narrow, high arched oropharynx
 Protruding teeth
 Mallampati Class 3 and 4
Signs Indicative of a Difficult
Intubation

59. Neck Abnormalities
 Short and thick
 Decreased range of motion (arthritis, spondylitis, disk disease)
 Fracture (subluxation)
 Trauma
Thoracoabdominal abnormalities
 Kyphoscoliosis
 Prominent chest or large breasts
 Morbid obesity
 Term or near term pregnancy
Age 50 – 59
Male gender
Signs Indicative of a Difficult
Intubation

60.  Previous Intubations
 Dental problems (bridges, caps, dentures, loose teeth)
 Respiratory Disease (sleep apnea, smoking, sputum,
wheeze)
 Arthritis (TMJ disease, ankylosing spondylitis,
rheumatoid arthritis)
 Clotting abnormalities (before nasal intubation)
 Congenital abnormalities
 Type I DM
 NPO status
Difficult Intubation -
History

61. Difficult Intubation -
Diabetes Mellitus
 Difficult intubation 10 x higher in long term
diabetics
 Limited joint mobility in 30 – 40 %
 Prayer sign
 Unable to straighten the interpharyngeal joints of the
fourth and fifth fingers
 Palm Print
 100% sensitive of difficult airway

62. Difficult Intubation -
Physical Exam
 General:
 LOC, facies and body habitus, presence or absence of
cyanosis, posture, pregnancy
 Facies:
 Abnormal facial features
 Pierre Robin
 Treacher Collins
 Klippel – Feil
 Apert’s syndrome
 Fetal Alcohol syndrome
 Acromegaly
 Nose:
 For nasal intubation
 Patency

63. Difficult Intubation -
Physical Exam
 Oral Cavity
 Foreign bodies
 Teeth:
 Long protruding teeth can restrict access
 Dental damage 25% of all anesthesia litigations
 Loose teeth can aspirate
 Edentulous state
 Rarely associated with difficulty visualizing airway
 Tongue:
 Size and mobility

64. Pierre Robin

65. Treacher Collins

66.  TMJ Joint – articulation and movement
between the mandible and cranium
 Diseases:
 Rheumatoid arthritis
 Ankylosing spondylitis
 Psoriatic arthritis
 Degenerative join disease
 Movements: rotational and advancement
of condylar head
 Normal opening of mouth 5 – 6 cm
Difficult Intubation -
Physical Exam

68. Cedera Servikal

69. Epidemiology
1) Incidence of spinal injuries in polytrauma
patients is approximately 13% to 30%
• Cervical spine injury (CSI) represents about
0.9% to 3% of these.
2) The relative risk of having concomitant CSI
is increased in the presence of severe head
injury by a factor greater than 8.
– if GCS score is 13-15, the incidence of CSI is 1.4%
– if GCS score is <8, the incidence of CSI is 10.2%
69
Schmidt OI, Gahr RH, Gosse A, et al: ATLS and damage
control in spine trauma. World J Emerg Surg 4:9, 2009.
Goldberg W, Mueller C, Panacek E, et al: Group distribution
and patterns of blunt traumatic cervical spine injury. Ann
Emerg Med 38:17–21, 2001.

70. Epidemiology
• If a CSI is missed or its detection
delayed:
– the incidence of secondary neurologic
deficit increases from 1.4% to 10.5%.
– almost one-third of patients may
develop permanent neurologic deficit.
46
American College of Surgeons: Advanced trauma
life support, Chicago, 2008, ACS, pp 157-169.

71. How then is the best way to “clear” the
cervical spine in the trauma patient?
– Detection of CSI requires a variety of
modalities that vary in sensitivity, including:
• clinical evaluation,
• plain radiography,
• CT,
• MRI, and
• dynamic fluoroscopy.
47

72. Clinical Evaluation
To clear the cervical spine clinically, the following criteria
must be met:
1. GCS score of 15, with the patient alert and oriented
2. Absence of injuries that may draw attention away
from a CSI
3. Absence of drugs or intoxicants that may interfere
with the patient’s sensorium
4. Absence of signs or symptoms on examining the
neck, specifically:
a. No midline pain or tenderness
b. Full range of active movement
c. No neurologic deficit attributable to the cervical spine
48
Clinical Clearance of Cervical Spine Injury Karim Brohi, trauma.org 7:4, April 2002

73. Plain Radiography
• The cross-table lateral view alone,
even if technically adequate and
interpreted by an expert, will still
miss 15% of cervical injuries.
• BEST PRACTICE: A 3-view cervical series
1. cross-table lateral view,
2. open-mouth odontoid view, and
3. anteroposterior (AP) view
49
Nguyen GK, Clark R: Adequacy of plain radiographyin the diagnosis
of cervical spine injuries. Emerg Radiol 11:158–161, 2005.

74. Normal odontoid
cervical spine x-
ray view
Normal AP
cervical spine x-
ray view
Normal
lateral
cervical
x-ray view
50
In low-risk patients,
plain
radiography is an
efficient
diagnostic
examination with
specificity of
100%.
In high-risk patients,
plain radiography
+ CT scan =
sensitivity of
93.3% and
specificity of
95%.

75. Computed Tomography
• CT scan of either the entire cervical spine or
directed at areas missed by plain radiographs,
provides a complementary approach when used
in addition to the three-view cervical series,
reducing the risk of missing a CSI to less than 1%.
• The more costly Helical CT is the preferred initial
screening test for detection of cervical spine
fractures among moderate- to high-risk patients.
– It reduces the incidence of paralysis resulting from
false-negative imaging studies together with eventual
institutional costs, when settlement costs are taken
into account.
51
Grogan EL, Morris JA Jr, Dittus RS, et al: Cervical spine evaluation in
urban trauma centers: lowering institutional costs and complications
throughhelical CT scan. J Am Coll Surg 200:160–165, 2005.

76. AIRWAY TECHNIQUES FOR ELECTIVE PATIENTS WITH UNSTABLE CERVICAL SPINE
1. Awake flexible fiberoptic intubation
2. Nasal intubation (if without basal skull &/or sinus fractures)
3. Indirect rigid laryngoscopy: Bullard, Wu, Upsher & TruView laryngoscopes
4. Videolaryngoscopy [DCI (direct coupled interface)/CMOS/wireless systems;
channeled/non-channeled]
5. Direct laryngoscopy with in-line stabilization
6. Fiberoptic intubation using appropriate SGAs as conduit (e.g. ILMA, ILA)
7. Lightwands (e.g. Trachlight)
8. Fiberoptic optical stylets [rigid/semi-rigid/”hybrids”]: Bonfils, Shikani, Clarus
video system, SensaScope, StyletScope, IntubaidFlex
9. Retrograde intubation
10. Percutaneous/Surgical airway: Cricothyrotomy, Tracheostomy
52
Modified from Osborn IP, Ferrario L. The Difficult Airway in
Neurosurgery. In BENUMOF AND HAGBERG’S AIRWAY MANAGEMENT,
3rd edition, 2013. Hagberg CA editor.

77. Alternative airway devices when the head
must remain immobilized in an emergent
setting
53
1. Video laryngoscopes
2. Indirect rigid laryngoscopes
3. Supraglottic airway as conduit for
Fiberoptic Intubation
4. Fiberoptic stylets
(rigid/malleable/”hybrid”)
5. “Invasive”
Mosier JM, Stolz U, Chiu S, Sakles JC: Difficult airway management
in the emergency department: GlideScope videolaryngoscopy
compared to direct laryngoscopy. J Emerg Med 2011

78. • Retrograde intubation had been
deemed as the alternative technique
of choice in resource-constrained
theatre complexes/settings provided
that the care-giver is adept at the
technique.
Hodgson RE. Which airway devices should be on difficult
intubation trolleys in resource-constrained settings? South
Afr J Anaesth Analg 2011;17(1)
54

79. Immobilization Options
1. Manual in-line immobilization (not traction)
2. Immobilization of the head between two (2)
sandbags
3. Rigid cervical collar and spinal board
• Significant morbidity and mortality
• Increase the difficult intubation and airway
compromise
• Risk of aspiration
• Does not necessarily protect against movement at
the occipito-cervical and cervico-thoracic junction
55
American College of Surgeons. Advanced Trauma Life Support for
Doctors, 8th Edn. published by the American College of Surgeons

80. Manual In-Line Stabilization
Techniques
From Austin N, Krishnamoorthy V, Dagal A. Airway management
in cervical spine injury. Int J Crit Illn Inj Sci 2014;4:50-6.
80

81. STUDIES OF VIDEO LARYNGOSCOPY ON INTUBATION PERFORMANCE FOR THE PATIENT MAINTAINED
IN MANUAL IN-LINE STABILIZATION
Author Device Control Sample
Outcome
Assessed
Major Findings
Malik et
al, 2008
GlideScope
(Verathon,
Bothell, WA)
DL 120 Laryngeal view
IDS
Intubation time
Success rate
Improved laryngeal view and IDS
Slower intubation time
No difference in success
Maharaj et
al, 2008
Airtraq (Prodol,
Vizcaya, Spain)
DL 40 IDS
Intubation attempts
Laryngeal view
Reduced number of intubation
attempts. Improved IDS, improved
laryngeal view
Smith et al,
1999
WuScope (Pentax,
Orange-burg, NY)
DL 87 IDS
Laryngeal view,
intubation attempts
Improved IDS and laryngeal view
No difference in success or number of
attempts
Malik et al,
2009
AWS (Pentax,
Hoya, Japan)
DL 90 IDS, laryngeal view Improved IDS and laryngeal view
Enomoto et
al, 2008
AWS DL 203 Laryngeal view,
intubation time,
success rate
Improved laryngeal view
Increased success rate
Faster intubation time
Liu et al,
2009
AWS Glide-
Scope
70 IDS, Intubation time,
success rate within a
defined time interval
Faster intubation time
Lower IDS, Improved laryngeal view
and higher intubation success with
AWS
IDS = Intubation Difficulty Scale AWS = Airway Scope DL = direct laryngoscopy
81

82. STUDIES OF CERVICAL MOTION WHILE USING VIDEO LARYNGOSCOPES
Study Device Control Cervical Precautions Fluoroscopy Major Findings
Hastings et al,
1995
Bullard (Circon ACMI,
Stamford, CT)
DL None
In selected patients
(C0–C4)
Angle finder used in
the entire sample
Reduced extension across
(C0–C4)
Robitaille et al,
2008
GlideScope DL MILS
Continuous C0–C5
duringseveral time
points
No decrease in cervical
movement
Maruyama et al,
2008
AWS
DL and
McCoy
None C1/C2, C3/C4
Reduced extension at
adjacent vertebra
Hirabayashi et al,
2007
AWS DL None C0–C4
Reduced extension at all
segments
Turkstra et al,
2005
GlideScope
Lightwand
(Trachlight, Laerdal,
Armonk, NY)
DL MILS C0–C5
Reduced C2–C5 motion with
Glidescope
Reduced motion across all
segments with Lightwand
Watts, Gelb,
Bach, Pelz, 1997
Bullard DL
One arm with MILS
One arm without
C0–C5
Reduced cervical extension in
the Bullard 1MILS arm
Maruyama et al,
2008
AWS DL MILS C0–C4
Reduced cumulative cervical
motion
Turkstra et al,
2009
Airtraq DL MILS C0-Thoracic
No difference at C1–C2
segment, less extension at
C2–C5, and C5-Thoracic
82

83. Section Summary
83
1. The problem with airway management in
patients with CSI is that the techniques normally
employed to secure the airway have the
potential to cause movement and thereby risk
causing secondary neurologic injury.
• Effect of Direct Laryngoscopy (Mac 3 Blade) on cervical
spine:
 Occiput and C1, superior rotation
 C2, remains neutral
 C3-C5, mild inferior rotation
 Atlanto-occipital and atlanto-axial joints - most significant
movements
• Chin lift – greater movement than intubation
• Cricoid pressure – no significant cervical movement

84. Section Summary
84
2. It is essential to proceed in the most
expedient manner with the techniques
that the care-giver is familiar and
proficient with.
• Due to the emergent nature of
management of these often multiply-
injured patients, time constraint may not
permit “clearing” the cervical spine to be
performed. Therefore, a group of patients
remain whose cervical spinal integrity is
uncertain and who must be managed as if
their cervical spine is, in fact, injured.