Airway management in unstable cervical spine fracture patient is always challenging. The primary reason for intubation may differ in different situations.It can be both difficult as well as dangerous due to various factors and always needs to be individualised with minimised spine movements.

Patient related factors-

Urgency of intubation- can be immediate, emergent, urgent or elective- actually dictates the decision, technique of airway management as well as drug used. The patient may be hypoxic, almost in arrest to relatively stable.

Level of injury (e.g. C1-C2 or lower cervical), Degree of instability and Severity of spinal cord compression, Anterior or posterior compression (which movement can aggravate the compression and hence to avoid), Presence of Spinal shock, Immobilisation

Presence of traumatic brain injury (increased ICP) and/ or polytrauma leading to shock or crush injury (dose and response to drugs) Facial or airway trauma, Full stomach status, Anatomical factors for difficult airway.

Other factors to be considered-

Level of experience of the person performing intubation

Equipments available for intubation (special equipments- videolaryngoscopes or flexible scopes), Drugs available for intubation, Time and place of intubation (ER/ Trauma ICU/ primary care center before transfer).

Later on, presence/absence of major neurological deficit also affects technique of airway management though such assessment may not be possible in emergent unconscious patients.

Additionally, often the issue is whether to intubate (in inadequately equipped place by inexperienced person) and then transfer to higher center is safer or the other way round. Mode of transport also needs to be addressed.

It must be appreciated that airway management is not just a technique bur a sequence of pharmacological and technical interventions right from suction and oxygenation done in least detrimental way.

Thanks for your reply! May I ask you which technique you use? Direct or video laryngoscopy? Macintosh or hyperangulated blade? Streched on a spineboard or manual in-line stabilization? SGA?

Thanks @Manuel for raising this important matter, and thanks @Hemangi Karnik for your enlightening answer.

Most commonly used techniques for emergency intubation in such cases at our place are either direct laryngoscopy using flexitip blade with manual inline axial stabilisation with bougie guided intubation or when available-use of channelled videolaryngoscope( Airtraq or Kingvision). One need not attempt to view complete glottic opening during DL for successful intubation. For elective stuations -especially neurologically preserved cases- fiberoptic intubation is preferred when instability/cord compression is severe.

In emergency cases, using video-laringoscopy is excellent, but sometimes need time. In unstable cervical spine fracture patient FIRST is put cervical collar, and than you can try something quick – insert adequate i-gel mask in pharynx and try to intubate through i-gel. It works – see paramedics skills in ATLS courses. Only what do you have to know is number of i-gel and adequate diameter of endotracheal tube. Saved many airways on that way. Of course, first is training on manikin! In case that you fail, you have (more-than-less) insured patient’s airway with i-gel.

The point is that with this method you do not have to move head (and neck!) and that you can do it in “sniffing” position.

Thank you Nikola Bradic for your contribution. Although I read about the intubation-through-LMA technique, I haven't known anybody who already did it. What's your experience with neurologic complications after insertion of i-gel (you need some extent of force/manipulation to insert LMAs)?

Does anyone have experience with fiberoptic intubation in critical patients (usually considered to take too long and though reserved for stable patients)?

It is a sensitive and critical situation no matter how you approach it, however, my approach is quite similar to Hemangi Karnik's description. I have quite successful (as far as I know) with manual attempt.

First priority stabilise the neck with conscious effort by placing cervical collar then take decision for intubation these days videolayngoscope is a good option for intubation without neck movements.

...most of the time, you can intubate without moving the neck, which better to be kept stabilized anyway by an assistant. If problems can be envisaged on DL pre-ETI a VL can be used and all those who have done it confirm an excellent success rate. As long you maintain oxygenation all along and the neck is not unduly or improperly or roughly manipulated, CSI has never been a problem. Nowadays many schools recommend using VL as a standard device in predictable or risky intubations ab initio. The real question is 'use or not use myorelaxation? I would not unless I see the inlet after induction.......the risk of a hypertensive or cough reflex response is to be prevented. MBV can be optimized only if the neck is manipulated and an RCA or CA in a setting of CSI would be a nightmare!

Intubation should be done with manual inline stabilization using VLS.Only the front portion of the hard cervical collar can be removed.

They may be full stomach hence anti aspiration prophylaxis and RSI should be considered.