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Airway management for patients with cervical spine disorders

Airway management for patients with cervical spine disorders. Presented by R3 吳佳展 . Case presentation. 30 year-old man Hyperextension injury C4-5 HIVD Muscle power: lower extremities 1, upper 3 HR, BP, vital capacity within normal range Intubated with light wand under general anesthesia

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Airway management for patients with cervical spine disorders

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  1. Airway management for patients with cervical spine disorders Presented by R3 吳佳展

  2. Case presentation • 30 year-old man • Hyperextension injury • C4-5 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

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

  4. 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

  5. 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

  6. 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

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

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

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

  10. 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

  11. Effect of airway maneuver • Cadaver study • Unstable C5-C6: chin lift=jaw thrust=oral intubation>nasal intubation in spine movement • Unstable C1-C2: space available for spinal cord oral=nasal>chin lift and jaw thrust

  12. 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

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

  14. Fastrach • Patients with cervical pathology (metastasis, disc prolapse, OPLL) • With light wand guide • Flexion and posterior displacement C0~C5

  15. Fastrach • Cadaver • Pressure sensor placed at C2-3 • Control: nasal/oral, laryngoscope/ fiberscope • Fastrach produces greater pressure against cervical spine and greater posterior displacement

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

  17. 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

  18. Thanks for your attention

  19. Thanks for your attention

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