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AIRWAY MANAGEMENT IN PATIENTS WITH UNSTABLE CERVICAL SPINES STRATEGIES AND TECHNIQUES

Endotracheal Intubation in Patients With Cervical Spine Instability. Secure airway without causing/worsening neurologic injuryThese patients are often a

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AIRWAY MANAGEMENT IN PATIENTS WITH UNSTABLE CERVICAL SPINES STRATEGIES AND TECHNIQUES

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    1. AIRWAY MANAGEMENT IN PATIENTS WITH UNSTABLE CERVICAL SPINES STRATEGIES AND TECHNIQUES Brad Hindman, M.D. Department of Anesthesia University of Iowa, College of Medicine

    2. Endotracheal Intubation in Patients With Cervical Spine Instability Secure airway without causing/worsening neurologic injury These patients are often a “difficult intubation” Disease process Methods to stabilize cervical spine

    3. Motion & Force During Conventional Direct Laryngoscopy & Intubation Normal Spine

    4. Normal Spine Cervical Spine Motion during Direct Laryngoscopy/Intubation

    5. Normal Spine Lifting Force during Direct Laryngoscopy/Intubation a,b

    6. Summary Normal Cervical Spines Cervical motion may be reduced by limiting glottic exposure Poor glottic view could pose risk with unstable cervical spines “Too much” force across unstable segments

    7. Motion & Force Conventional Direct Laryngoscopy & Intubation Unstable Spine

    8. Unstable Cervical Spine Moves abnormally with motion/force of laryngoscopy Where pathologic motion occurs depends on Specific location & nature of instability Force applied across unstable segment

    9. Unstable Spine O-C1-C2 Complex Laxity of Transverse Ligament (Rheumatoid Arthritis, Down Syndrome) Flexion: Odontoid moves posteriorly towards cord Intubation (extension): Theoretically, not at risk Abnormal odontoid and/or O-C1-C2 articulations Flexion/Extension: C1 subluxes on C2, compressing cord Intubation (extension): AT RISK Combined bony & ligamentous abnormalities - ?

    10. Unstable Spine Sub-axial Segments (C3-C7) Spine Movement during Laryngoscopy/Intubation

    11. Summary Unstable Cervical Spine Difficult to predict net spine motion during laryngoscopy When cervical spine instability present Minimize force applied across unstable segments Minimize cervical spine motion Maintain neck in neutral position

    12. Effects of External Cervical Spine Stabilization Methods Normal Spine

    13. Normal Spine Collars and Manual In-Line Stabilization (MILS) Concept: Prevent spine movement during intubation Majernick TG: Ann Emerg Med 1986; 15:417 16 normal subjects Collars did not reduce spine motion MILS did appear to reduce spine motion

    14. Normal Spine Effect of MILS during Direct Laryngoscopy & Intubation

    15. Effects of External Cervical Spine Stabilization Methods Unstable Spine

    16. Unstable Spine Effect of Stabilization Aprahamian C: Ann Emerg Med 1984; 13:584 1 cadaver: complete C5-C6 ligamentous instability Rigid Collar did not appear to affect spine movement Donaldson WF: Spine 1993; 18:2020 5 cadavers: incomplete C5-C6 ligamentous instability “Head stabilization” may have ? subluxation & angulation Lennarson PJ: J Neurosurg (Spine 2) 2000; 92:201 16 cadavers: incomplete C4-C5 ligamentous instability MILS did not prevent abnormal flexion

    17. Unstable Spine Complete ligamentous laxity at C4-C5a

    18. Unstable Spine Axial Traction Can result in severe distraction Bivins HG: Ann Emerg Med 1988; 17:25 Donaldson WF 3rd: Spine 1993; 18:2020 Axial traction is to be avoided during intubation, unless...

    19. Unstable Spine Effect of MILS with O-C1-C2 Instability

    20. Summary External Stabilization Maneuvers & Spine Movement During Laryngoscopy and Intubation Axial Traction O-C2: Probably dangerous C3-C7: Probably dangerous Cervical Collars O-C2: ? C3-C7: No indication of benefit MILS O-C2: May be of benefit, maybe not C3-C7: May be of benefit, maybe not Nevertheless, it is the standard of care

    21. Method of Manual In-Line Stabilization (MILS) During Conventional Direct Laryngoscopy Patient supine, head flat on table in neutral position Assistant Grasps both mastoid processes with fingertips Cup occiput in hands without applying axial traction Anterior portion of cervical spine collar removed Allows maximal mouth opening Expose anterior neck (cricoid pressure, retrograde wire, or surgical airway)

    22. Method of MILS, continued Preoxygenation (& cricoid pressure if “full stomach”) Sedatives/anesthetics & paralytics as indicated Assistant applies force(s) equal & opposite to those of DL to keep the head/neck in neutral position

    23. By limiting extension at O-C2 MILS often worsens glottic view with conventional DL Glottic View with Standard Head & Neck Position vs. MILSa

    24. MILS & Conventional Direct Laryngoscopy ~10% risk of not seeing glottis Lifting harder may not be advisable Airway aids (bougie, light wand, fiberoscope) Alternatives to Conventional Direct Laryngoscopy Bullard, WuScope, Intubating LMA

    25. Clinical Scenarios & General Approaches to Endotracheal Intubation Emergent Intubation with Traumatic Cervical Spine Injury

    26. Emergent Intubation and C-Spine Trauma/Instability The Cervical Spine in the Setting of Trauma 2-4% of blunt trauma patients have C-spine fx/dislocations Cluster around C1-C2 & C5-C6 70% have major associated injuries 50% have neurologic signs/symptoms 25-50% require intubation within 24 h Before complete/definitive C-spine evaluation In presence of known instability Effect of DL/intubation difficult to predict

    27. Emergent Intubation and C-Spine Trauma/Instability Neurologic Injury from Conventional DL & Intubation “Low” but Real Hastings RH: Anesthesiology 1993; 78:580 Unrecognized fx at C6-C7 Muckart DJJ: Anesthesiology 1997; 87:418 2 patients: Unrecognized fxs at C2 & C6 Redl G: Anesthesiology 1998; 89:1262 Unrecognized C2 instability

    28. Emergent Intubation and C-Spine Trauma/Instability Advanced Trauma Life Support (ATLS) Guidelines-1980’s Blind nasotracheal intubation for emergent intubation (n=1) Aprahamian C: Ann Emerg Med 1984; 13:584 (n=7) Bivins HG: Ann Emerg Med 1988; 17:25 Problems Often not easy Often not fast Often not successful Sometimes contraindicated (basilar- mid-face fx)

    29. Emergent Intubation and C-Spine Trauma/Instability Intubation Methods In Patients with Acute Cervical Spine Injury

    30. Emergent Intubation and C-Spine Trauma/Instability Risk of Neurologic Injury Conventional Direct Laryngoscopy & MILS (±anesthesia, ±paralysis) 0/374: 95% confidence: 0-1% Awake Nasotracheal Intubation 0/240: 95% confidence: 0-2%

    31. Emergent Intubation and C-Spine Trauma/Instability Advanced Trauma Life Support (ATLS) Guidelines-NOW

    32. Emergent Intubation and C-Spine Trauma-Instability Conventional DL & Intubation with MILS/Trauma Failed intubation reported 2-10% MILS can limit glottic visualization Blood & secretions Altered anatomy (prevertebral swelling) Difficult Airway algorithm (Caplan RA: Anesthesiology 1993; 78:597)

    33. Clinical Scenarios & General Approaches to Endotracheal Intubation NON-Emergent Intubation with Cervical Spine Instability

    34. NON-Emergent Intubation with Cervical Spine Instability Rosenblatt WH: Anesth Analg 1998; 87:153

    35. NON-Emergent Intubation with Cervical Spine Instability Airway Anesthesia Supraglottic (Superior Laryngeal Nerve) Internal br.: Sensory: Pharynx to false cords External br.: Motor to cricothyroid muscle Blockade: Thyrohyoid membrane or pyriform fossa Subglottic (Recurrent Laryngeal Nerve) Sensory: True vocal cords to trachea Motor: Intrinsic muscles of larynx Blockade: Transcricoid injection of local anesthetic Combined (Topical) Inhalation f nebulized local anesthetic

    36. NON-Emergent Intubation with Cervical Spine Instability Airway Anesthesia Nasal Mucosae (Trigeminal) Anesthesia and vasoconstriction 4% cocaine or 3-4% lidocaine/0.25-1.00% phenylephrine Oral/Gag (Glossopharyngeal) Lingual br.: Posterior 1/3rd of tongue Blockade: Palatoglossal arch (injection or topical)

    37. Airway Anesthesia: Topical vs. Blocks Reasoner DK: J Neurosurg Anesth 1995; 7:94

    38. NON-Emergent Intubation…, Fiberoptics Difficulties Encountered during Elective Fiberoptic Intubation in Patients with Cervical Spine Diseasea,b,c,d

    39. NON-Emergent Intubation…, Fiberoptics Endotracheal tube “catching” on Glottic Structuresa

    40. NON-Emergent Intubation…, Fiberoptics Endotracheal tube “catching” on Glottic Structures

    41. NON-Emergent Intubation…, Fiberoptic Endotracheal tube “catching” on Glottic Structures Rotate tube counterclockwise during advancement Pull tongue forward during advancement Patient persistence

    42. NON-Emergent Intubation with Cervical Spine Instability The Bullard Laryngoscope

    43. NON-Emergent Intubation with Cervical Instability The Bullard Laryngoscope Potential Advantages Can be faster than fiberoptics Neck can be maintained in neutral position Better glottic visualization with MILS

    44. NON-Emergent Intubation with Cervical Spine Instability Conventional Laryngoscopy vs. Bullarda

    45. NON-Emergent Intubation with Cervical Spine Instability The Bullard Laryngoscope Notes of Caution Significant “learning curve” Not evaluated in patients with unstable spines Successful intubation not “a sure thing” 15% failure (MacQuarrie K: Can J Anesth 1999; 46:760)

    46. NON-Emergent Intubation with Cervical Spine Instability The WuScope

    47. NON-Emergent Intubation with Cervical Spine Instability WuScope & MILS vs. Conventional DL & MILSa

    48. NON-Emergent Intubation with Cervical Spine Instability The WuScope Potential Advantages Neck can be maintained in neutral position Better glottic visualization with MILS Notes of Caution Learning Curve Not evaluated in patients with unstable spines Not a “sure thing”

    49. NON-Emergent Intubation with Cervical Spine Instability The Intubating LMA (ILMA)

    50. NON-Emergent Intubation with Cervical Spine Instability The ILMA Can be inserted with head & neck neutral Designed to allow rapid blind orotracheal intubation Fiberoptic guided intubation also possible Case reports of use in patients with unstable spinesa,b a. Schuschnig C: Anaesthesia 1999; 54:793 b. Wong JK: J Clin Anesth 1999; 11:346

    51. NON-Emergent Intubation with Cervical Spine Instability The ILMA Patients in Cervical Collarsa Placement generally difficult Ventilation poor 40%; blind intubation success 20% Patients with Cervical Spine Disease (25% unstable)b ?2 attempts to place 25% Blind intubation success 63%; esophageal intubation 8% Patients with Cervical Spine Disease (15% unstable)c ?2 attempts to place 45% C2-C5 displaced posteriorly; 1.5-3.0° of flexion a. Wakeling HG: Br J Anaesth 2000; 84:254 b. Nakazawa K: Anesth Analg 1999; 89:1319 c. Kihara S: Anesth Analg 2000; 91:195

    52. NON-Emergent Intubation with Cervical Spine Instability The ILMA Cadavers with Stable Necksa ILMA Insertion/adjustment: 200-400 cm H2O pressure on C2-C3 C3 displaced 1-3 mm Cadavers with Unstable Necks (posterior C3)b ILMA 1.7±1.3 mm post. displacement Conventional DL 2.6±1.6 mm post. displacement Combitube placement 3.2±1.6 mm post. displacement Nasal Fiberoptic 0.1±0.7 mm post. displacement a. Keller C: Anesth Analg 1999;89:1296 b. Brimacombe J: Anesth Analg 2000; 91:1274

    53. NON-Emergent Intubation with Cervical Spine Instability The ILMA Notes of Caution Multiple attempts to correctly place often necessary Relatively low success rate with blind intubation High pressure on C2-C3, risk of spine displacement

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