cervical spinal injury and airway management · 1. trauma patients are at risk of unstable spinal...
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CervicalSpinalInjuryandAirwayManagementSalfordTraumaCourse,2018
DrMattWilesConsultant(Neuroanaesthesia &MajorTrauma)Sheffield
Editor,Anaesthesiahttp://sthjournalclub.wordpress.com/
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NICESpinalInjuryGuidelines2016
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AANS/CNSJointGuidelines2016TheodoreNetal.Neurosurgery2013;72:22-34
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Guidancevs.Rules
“Aguidelineisastatementbywhichtodetermineacourseofaction.Aguidelineaimstostreamlineparticularprocessesaccordingtoasetroutineorsoundpractice.Bydefinition,followingaguidelineisnevermandatory.Guidelinesarenotbindingandarenotenforced.”U.S.DepartmentofVeteranAffairs(http://www.va.gov/trm/TRMGlossaryPage.asp)
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ThebirthofimmobilisationKossuth LC.Trauma1965;5:703-8
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TheThreeCommandmentsofITU
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Assumptions1. Traumapatientsareatriskofunstablespinalinjuries
2. Anyspinalinjurywhichhasbeensustainedmaybeworsenedbyfurthermovement(s)
3. Theapplicationofasemi-rigidcervicalcollarandspinalimmobilisation devicepreventspotentiallyharmfulmovementofthespine
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Assumption1
“Traumapatientsareatriskofunstablespinalinjuries”
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EpidemiologyofSCIMcCaugheyEJetal.SpinalCord2016;54:270-6
• 0.8%oftotaltraumaadmissions
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SCIWORA/SCIWOCTETHendrey GWetal.JTraumaAcuteCareSurg 2002;53:1-4ComoJJetal.JTraumaAcuteCareSurg 2012;73:1261-6
• NEXUSdata• n=34,069;2.4%cervicalspineinjury• 27patientsSCIWORA[0.08%oftotal]
• TwoMTCs(2005-2009)• n=15,102• 25patientsSCIWOCTET[0.14%oftotal]
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Assumption2
“Anyspinalinjurywhichhasbeensustained/ispresentmaybeworsenedbyfurthermovement(s)”
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ImmobilisationandCordInjurySundstrømTetal.JNeurotrauma2014;31:531-40CrosbyET.Anesthesiology 2006;104:1293-1318
• Mostspinalinjuriesarestable;thosethatareunstablehavealreadycausedirreversibledamage
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ImmobilisationandCordInjurySundstrømTetal.JNeurotrauma2014;31:531-40CrosbyET.Anesthesiology 2006;104:1293-1318
• Mostspinalinjuriesarestable;thosethatareunstablehavealreadycausedirreversibledamage
• Improvementsinmortalityratessince1973attributedtoimmobilisation
• “Missed”injurieswithdeterioration(10-29%)arehistoricalandpredominatelyduetoimagingissues
• 2-10%ofcordinjuriesworsenregardless• ExaggeratedrateofsecondarySCIwithoutcollars
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TraumaticSpinalCordInjuryAmerica/CanadaSinghAetal.ClinicalEpidemiology2014;6:309-331
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TraumaticSpinalCordInjuryinDevelopingCountriesRahimi-Movaghar Vetal.Neuroepidemiology2013;41:65-85
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Assumption3
“Theapplicationofasemi-rigidcervicalcollarand/orspinalimmobilisation devicepreventspotentiallyharmfulmovementofthespine”
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EfficacyofCollarsHollaMetal.Eur SpineJ2016;25:2023-2036
0% 20% 40% 60% 80%
• Flexion/Extension42%-78%• Lateral13%-40%• Rotation13%-40%
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ManualIn-lineStabilisationManoach S&PaladinoL.AnnEmerg Med2007;50:236-45
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ManualIn-lineStabilisationManoach S&PaladinoL.AnnEmerg Med2007;50:236-45
• Originuncertain– ATLSguidance1984• Datafromcadavericstudies,healthyvolunteersandcaseseries(n=96)
• SeveralstudiessuggestMILShasnoeffectoncervicalsegmentmovementStudy Method Grade1 GradeII GradeIII GradeIVNolan&Wilson.Anaesthesia1993;48:630-33
Optimalposition 129 26 2 -
MILS 75 48 34 -
Heath.Anaesthesia1994;49:843-45
Optimalposition 46 4MILS 12 27 11Collar/tape/sandbags 2 16 25 7
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Assumption4
“Cervicalcollarapplicationand/orspinalimmobilisation arebenigninterventions,andthereforecanbeappliedtolargenumbersofpatientsasaprecautionarymeasure”
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CollarsmayworseninjuriesBen-Galim PGetal.JournalofTrauma2010;69:447-50
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TransportDelayswithImmobilisationHaut ERetal.JournalofTrauma2010;68:115-120
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Mvs.EHertfordshireHA1991Athanassoglou Vetal.TrendsAnaes Crit Care2015;5:57-60
“Wecannotassertthatcricoidpressureisnoteffectiveuntiltrialshavebeenperformed,(i.e.wemustassumeitsefficacy)especiallyasitisanintegralpartofanaesthetic technique…thathasbeenassociatedwithareducedmaternaldeathratefromaspirationsincethe1960s."
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• 10casereportsofworseningSCIafterintubation– Littletoimplicatelaryngoscopyascause
RiskofLaryngoscopyMcLeodAD&CalderI.BrJAnaes 2000;84:705-9
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• ClosedClaimsAnalysis:– 1970-2007(n=7740)– 37casesofcervicalcordinjury(0.9%ofGAclaims)– Majority(>75%)hadstablec-spinespriortoprocedure– 24/37underwentcervicalspinesurgery– Ninehadunstablecervicalspines
• Twocasesofcordinjurywithdirectlaryngoscopyimplicated• TwocasesoccurreddespiteAFOI• TwocasedespiteMILS
RiskofLaryngoscopyHindman BJetal.Anesth 2011;114:782-795
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• 1995-2007• 40,165totalclaims,841relatingtoanaesthesia• £31million($17million)total• Nilrelatingtoc-spinedamageandintubation
RiskofLaryngoscopyCookTMetal.Anaesthesia2009;64:706-718
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NeurologicalDeteriorationafterSurgeryHarrop Jetal.Spine2001;26:340-46
CarlsonGDetal.JBoneJt Surg 2003;85A:86-94
• Duetoprolongeddeformationand/orhypotension– Hyperflexion worsethanhyperextension– Inanimalmodelsneed>30minofcontinuouscordcompression
• BothareunlikelyduringDL• 6%patientswithSCIwilldeteriorate– Early(24h)– Later(24hto7days)– Late(weeks[post-traumaticascendingmyelopathy])
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AnatomyofSpinalCordInjuryCrosbyET.Anesth 2006;104:1293-318
Spaceavailableforspinalcord(SAC):1/3odontoid;1/3cord;1/3space
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CervicalSpine&DirectLaryngoscopySawin PDetal.Anesth 1996;85:26-36
• Tenvolunteerswithnormalcervicalspines• Minimalglottic exposure• MajorityofmotionatC0-C1&C1-C2
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CervicalSpine&DirectLaryngoscopySawin PDetal.Anesth 1996;85:26-36
• Tenvolunteerswithnormalcervicalspines• Minimalglottic exposure• MajorityofmotionatC0-C1&C1-C2
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CervicalSpine&DirectLaryngoscopyMcCahon RMetal.Anaesthesia2015;70:452-61
• Odontoidpegfractureincadavers
• Minimalglottic exposure• MILS• Assessed“spaceavailableforspinalcord”
• Airtraq,McCoy&Mac3– nosignificantdifference
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VideoLaryngoscopySuppan Letal.BJA2016;116:27-36
• Meta-analysis(n=1886)• Primaryoutcome:– Intubationsuccess
• C/Lviewnotrelevant• Noassessmentof:– SAC– Cervicalspinemovement
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CervicalSpine&AirwayManoeuvresDonaldsonWFetal.Spine1997;22:1215-18DonaldsonWFetal.Spine1993;18:1220-23
• CadaverswithunstableC1-2– MILS– Glottic viewachievednotstated– Spaceavailableforcordassessed
• Jawthrust>chinlift>laryngoscopy• CadaverswithunstableC5-6– NoMILS– Glottic viewachievednotstated– Cervicalspinemotionassessed
• Chinlift/jawthrust≈cricoidpressure≈laryngoscopy
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CervicalSpine&BVMVentilationHauswald Metal.AmJEmerg Med1991;9:535-8
• Cadaversstudiedwithin40minofdeath– Collar,spinalboard,tape– Glottic viewachievednotstated– Neckmaintainedinneutral
• Maskventilation>>trachealintubation[P=0.00004]
0
1
2
3
4
5
MaskA MaskB Miller3 MacIntosh3
FOIOral FOINasal
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CervicalSpine&OtherAirwayTechniques• LMA[Kilic Ketal.AmJEmerg Med2013;31:1034-36]– Doneincervicalcollars– LMA&iLMA similartoMacintosh
• GlideScope [RobitailleAetal.Anesth Analg 2008;106:935-41]– MILS– NodifferencebetweenMacintoshandGlideScope
• Fibreoptic intubation[Sawin PDetal.EJA2004;21:819-23]– NoMILS– Bestpossibleglottic viewachieved– FOIsignificantlylessmovementatC1/2(8°)butnotC2/3comparedtodirectlaryngoscopy
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Summary• Maximalinsulttothespinalcordoccursatthetimeofinjury
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Summary• Maximalinsulttothespinalcordoccursatthetimeofinjury
• Thecervicalspineshouldbestabilised,notimmobilisedandthisshouldnotinterferewithclinicalmanagement(especiallyABCinterventions)atanypoint
• Intubatethetracheausingthe“best”techniqueinyour hands
• Ifcervicalimmobilisationwasanoveltechnique,wouldweinstituteitintocurrentpractice?
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Anyquestions?