Cervical Immobilization at the Expense of Proper Airway Management

Review of: Manoach S, Paladino L: “Manual in-line stabilization for acute airway management of suspected cervical spine injury: historical review and current questions.” Annals of Emergency Medicine. 50(3):236-245, 2007.

The Science

This excellent review of the world’s literature on cervical immobilization found the following; “Direct laryngoscopy with manual in-line stabilization is standard of care for acute trauma patients with suspected cervical spine injury. Ethical and methodologic constraints preclude controlled trials of manual in-line stabilization, and recent work questions its effectiveness. We searched MEDLINE, Index Medicus, Web of Knowledge, the Cochrane Database, and article reference lists. According to this search, we present an ancestral review tracing the origins of manual in-line stabilization and an analysis of subsequent studies evaluating the risks and benefits of the procedure. All manual in-line stabilization data came from trials of uninjured patients, cadaveric models and case series. The procedure was adopted because of reasonable inference from the benefits of stabilization during general care of spine-injured patients, weak empirical data and expert opinion. More recent data indicate that direct laryngoscopy and intubation are unlikely to cause clinically significant movement and that manual in-line stabilization may not immobilize injured segments.

In addition, manual in-line stabilization degrades laryngoscopic view, which may cause hypoxia and worsen outcomes in traumatic brain injury. Patients intubated in the emergency department (ED) with suspected cervical spine injury often have traumatic brain injury, but the incidence of unstable cervical lesions in this group is low. The limited available evidence suggests that allowing some flexion or extension of the head is unlikely to cause secondary injury and may facilitate prompt intubation in difficult cases.

Despite the presumed safety and efficacy of direct laryngoscopy with manual in-line stabilization, alternative techniques that do not require direct visualization warrant investigation. Promising techniques include intubation through supraglottic airways, along with video laryngoscopes, optical stylets, and other imaging devices.”

The Street

This is an article Bryan Bledsoe dreams about. There are so many things we do in medicine simply because we have always done it that way. Cervical immobilization is one of them. This article provides a clear history of why we do what we do. Maintaining in-line immobilization arose from the fact that patients were found to have major cervical spine injuries once they arrived at the ED. However, this was in the very early days of EMS, when cervical immobilization during transport consisted of sand bags and soft foam collars.

These findings led to the perception, which persists today, that if we don’t do everything possible to keep the head from moving we are going to paralyze our patient and get sued. The NEXUS study shows that patients who suffer devastating cervical spine injuries do so at the time of the injury, and its highly unlikely that anything we do is going to affect the clinical outcome. This becomes a significant issue to consider when dealing with airway management in the head-injured patient, for whom we have been admonished, “Don t move the neck.” The author provide a clear argument that hypoxia from poor airway management and care of the brain injury is far more likely to affect the patient’s outcome than anything we do with the spine.

Now, I’m not advocating that we start performing range-of-motion exercises on our patient’s neck in the field, but simply that we weigh the risk and benefits of what we do to the patient to accomplish proper airway control. If this requires a slight extension of the neck, then so be it. The study’s authors show that there is an insignificant probability that you will harm the patient.

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