Overall, 2% to 4% of blunt trauma patients have cervical spine (C-spine) injuries (most often motor vehicle accidents), of which 7% to 15% are unstable.
- Initial Evaluation. Accurate and timely evaluation is important because 2% to 10% of patients with blunt trauma–induced C-spine injury develop new or worsening neurologic deficits after admission.
- Clearance of the neck at the earliest possible time after airway management should be performed to minimize the complications associated with the collar such as pressure ulceration, intracranial pressure (ICP) elevation in head-injured patients, compromised central venous access, and airway management challenges if reintubation is needed.
- Routine computed tomography (CT) in addition to clinical evaluation is recommended to rule out C-spine injury in major trauma victims.
- The Canadian C-spine rule for radiography after trauma is a tool designed to identify low-risk patients (Fig. 52-2: Canadian cervical spine (C-spine) rule designed to diagnose C-spine injury and identify patients who require further radiographic (computed tomography) evaluation).
- Airway Management. Almost all airway maneuvers, including jaw thrust, chin lift, head tilt, and oral airway placement, result in some degree of C-spine movement. To secure the airway with direct laryngoscopy, manual in-line stabilization (MILS) of the neck is the standard care of these patients in the acute stage. A hard cervical collar alone, which is routinely placed, does not provide absolute protection, especially for rotational movements of the neck.
- MILS is best accomplished by having two operators in addition to the physician who is actually managing the airway. The first operator stabilizes and aligns the head in neutral position without applying cephalad traction, and the second stabilizes both shoulders by holding them against the table or stretcher.
- In the presence of MILS, the glottic view may be suboptimal in 10% to 15% of patients during direct laryngoscopy because of limitation of neck extension.
- The more the restriction of the glottic view during direct laryngoscopy, the greater the pressure on the tongue, the spine, and the unstable segment with potential displacement of the unstable fragment.
- During various phases of direct laryngoscopy and intubation, the pressures exerted on the tongue and indirectly to the spine are greater with MILS than without MILS. Nevertheless, it cannot be concluded airway management without MILS is associated with a favorable spinal cord outcome. However, it is reasonable to allow some relaxation of the MILS to improve the glottic view when visualization of the larynx is restricted.