Protection of the Cervical Spine

Standard practice dictates that all blunt trauma victims, even those without high-risk mechanisms of cervical spine injury, should be assumed to have an unstable cervical spine until this condition is ruled out^[18] (also see Chapter 53 ). The airway management of these patients receives much attention from anesthesiologists because direct laryngoscopy causes cervical motion, with the potential to exacerbate spinal cord injury (SCI).^[19] Stabilization of the cervical spine will generally occur in the prehospital environment, with the patient arriving at the ED with a rigid cervical collar already in place. This collar may be kept in place for several days before the complete gamut of tests to rule out cervical spine instability have been completed (see later). The presence of an "uncleared" cervical spine mandates the use of in-line manual stabilization (not traction) throughout any intubation attempt.^[20] This approach allows the front of the cervical collar to be removed, thereby permitting wider mouth opening and jaw displacement. In-line stabilization has been tested through considerable clinical experience and is the standard of care in the ATLS curriculum. Emergency awake fiberoptic intubation, though requiring less manipulation of the neck, is generally very difficult because of airway secretions and hemorrhage, rapid desaturation, and lack of patient cooperation; it is more appropriately reserved for cooperative patients with a known cervical instability.