Canadian Journal of Anaesthesia

, Volume 39, Issue 2, pp 114–117

The safety of awake tracheal intubation in cervical spine injury

  • Alfio Meschino
  • J. Hugh Devitt
  • Jean-Paul Koch
  • John Paul Szalai
  • Michael L. Schwartz
Reports of Investigation

Abstract

As a referral centre for cervical spine injuries, we have routinely performed awake tracheal intubation when intubation was indicated. A retrospective case control study was undertaken to review the frequency of neurological deterioration and aspiration associated with our approach. Neurological deterioration was assessed by a change in level of injury or neurological grade at admission and discharge. Four hundred and fifty-four patients with critical cervical spine and/or cord injuries were reviewed over an eight-year period. A case group of 165 patients under-went tracheal intubation awake within two months of injury. A control group of 289 remained unintubated during the same period. A comparison of spinal neurological status between admission and discharge revealed no statistically significant difference in neurological deterioration between the two groups. This occurred despite a greater injury severity score in the case group. No evidence of aspiration during intubation was documented. We conclude that awake tracheal intubation is a safe method of airway management in patients with cervical spine injuries.

Key words

complications: intubation, trauma intubation, tracheal: complications, technique surgery: orthopaedics, cervical spine 

Résumé

En tant que centre de référence pour les traumatismes du rachis cervical, nous avons effectué de routine des intubations trachéales chez des patients éveillés lorsqu’indiquées. Une étude de dossier rétrospective a été menée afin de reviser la fréquence de détérioration neurologique et d’aspiration associée à notre approche. Une détérioration neurologique était évaluée par un changement dans le niveau du traumatisme ou dans le grade neurologique à l’admission et au depart. Quatre cent cinquantequatre patients avec un traumatisme critique de la moëlle épinière ou du rachis cervical ont été réévalués sur une période de huit ans. Un group étude de 165 patients a subi une intubation trachéale lorsque éveillé en dedans de deux mois du traumatisme. Un groupe contrôle comprenait 289 patients n’ayant pas eu besoin d’intubation pendant la miême période. Une comparaison de l’état neurologique rachidien entre les deux groupes, de l’admission au départ, n’a révélé aucune différence statistiquement significative dans la détérioration neurologique, et ce malgré un pointage de sévérité du traumatisme plus grand dans le groupe étude. Aucune évidence d’aspiration n’a été documentée durant les intubations. Nous en concluons que l’intubation trachéale chez un patient éveillé est une méthode sécuritaire pour contrôler les voies aériennes des patients avec des traumatismes du rachis cervical.

References

  1. 1.
    Doolan LA, O’Brien FJ. Safe intubation in cervical spine injury. Anaesth Intensive Care 1985; 13: 319–24.PubMedGoogle Scholar
  2. 2.
    Suderman VS, Crosby ET. Elective intubation in the unstable cervical spine patient. Can J Anaesth 1990; 37: S122.PubMedGoogle Scholar
  3. 3.
    Tator CH, Rowed DW, Schwartz ML. Sunnybrook cord injury scales for assessing neurological injury and neurological recovery.In: Tator CH (Ed.). Seminars in Neurological Surgery; Early Management of Acute Spinal Cord Injury. New York: Raven Press, 1982: 7–24.Google Scholar
  4. 4.
    Fleiss JL. Statistical methods for rates and proportions. 2nd ed. New York: John Wiley and Sons, 1981: 39.Google Scholar
  5. 5.
    Dunnell CW, Gent M. Significance testing to establish equivalence between treatments with special reference to data in the form of 2 by 2 tables. Biometrics 1977: 33: 593–602.CrossRefGoogle Scholar
  6. 6.
    Detsky AS, Sackett AL. When is a “negative” clinical trial big enough? How many patients you need depends on what you found. Arch Intern Med 1985; 145: 709–12.PubMedCrossRefGoogle Scholar
  7. 7.
    Reid DC, Henderson R, Saboe L, Miller JDR. Etiology and clinical course of missed spine fractures. J Trauma 1987; 27: 980–6.PubMedCrossRefGoogle Scholar
  8. 8.
    Donner A. Approaches to sample size estimation in the design of clinical triais; a review. Statistics in Medicine 1984; 3: 199–214.PubMedCrossRefGoogle Scholar
  9. 9.
    Frost EAM. Effects of positive end-expiratory pressure on intracranial pressure and compliance in brain injured patients. J Neurosurg 1977; 47: 195–200.PubMedCrossRefGoogle Scholar
  10. 10.
    Schwartz ML, Tator CH, Rowed DW et al. The University of Toronto head injury treatment study: a prospective randomized comparison of Pentobarbital and Mannitol. Can J Neurolog Sci 1984; 2: 434–40.Google Scholar
  11. 11.
    Ovassapian A, Krejcie T, Yelich S, Dykes M. Awake fiber-optic intubation in the patient at high risk of aspiration. Br J Anaesth 1989; 62: 13–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Zigler J, Rockowitz N, Capen D, Nelson R, Waters R. Posterior cervical fusion with local anaesthesia: the awake patient as the ultimate spinal cord monitor. Spine 1987; 12: 206–8.PubMedCrossRefGoogle Scholar
  13. 13.
    Jacobs LM, Schwartz R. Prospective analysis of acute cervical spine injury: a methodology to predict injury. Ann Emerg Med 1986; 15: 44–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Shaffer MA, Doris PE. Limitation of the cross table lateral view in detecting cervical spine injurjes: a retrospective analysis. Ann Emerg Med 1981; 10: 508–13.PubMedCrossRefGoogle Scholar
  15. 15.
    Streitwieser DR, Knopp R, Wales LR et al. Accuracy of standard radiographic views in detecting cervical spine fractures. Ann Emerg Med 1983; 12: 538–42.PubMedCrossRefGoogle Scholar
  16. 16.
    Aprahamian C, Thompson BM, Finger WA, Darin JC. Experimental cervical spine injury model: evaluation of airway management and splinting techniques. Ann Emerg Med 1984; 13: 584–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet 1961; 2: 404–6.PubMedCrossRefGoogle Scholar

Copyright information

© Canadian Anesthesiologists 1992

Authors and Affiliations

  • Alfio Meschino
    • 1
    • 2
    • 3
  • J. Hugh Devitt
    • 1
    • 2
    • 3
  • Jean-Paul Koch
    • 1
    • 2
    • 3
  • John Paul Szalai
    • 1
    • 2
    • 3
  • Michael L. Schwartz
    • 1
    • 2
    • 3
  1. 1.Department of Anaesthesia, Sunnybrook Health Science CentreUniversity of TorontoToronto
  2. 2.Department of Neurosurgery, Sunnybrook Health Science CentreUniversity of TorontoCanada
  3. 3.Department of Biostatistics, Sunnybrook Health Science CentreUniversity of TorontoCanada

Personalised recommendations