Can a patient with a suspected cervical fracture be intubated?

Airway Management in Patients with Suspected Cervical Fracture

Yes, patients with suspected cervical fractures can be safely intubated using appropriate techniques that minimize cervical spine movement. 1

Key Principles for Intubation in Suspected Cervical Fracture

Preparation and Positioning

• Remove the anterior portion of the cervical collar during intubation attempts while maintaining spine stabilization to improve mouth opening and glottic visualization 1
• Use manual in-line stabilization rather than cervical collar alone during the intubation procedure to minimize cervical spine movement 1, 2
• Ensure multidisciplinary planning and preparation before airway management in these high-risk patients 1

Recommended Intubation Techniques

• Videolaryngoscopy should be the first-choice technique for tracheal intubation in patients with suspected or confirmed cervical spine injury 1
• Consider using an adjunct such as a stylet or bougie when performing tracheal intubation to improve first-pass success 1, 2
• When performing basic airway maneuvers, use jaw thrust rather than head tilt plus chin lift to maintain the airway, as this causes significantly less cervical spine movement 1

Alternative Approaches

• Second-generation supraglottic airway devices (SADs) can be used as a rescue technique or primary airway management tool if appropriate 1
• For elective or stable situations where time is not critical, flexible bronchoscopic intubation (awake or asleep) may cause the least cervical spine movement 3
• If tracheal intubation through a supraglottic airway device is indicated, use devices that are familiar to the clinician 1

Important Considerations

Safety Evidence

• The incidence of neurological deterioration directly attributable to airway management in patients with cervical spine injuries is extremely low (approximately 0.34%) 1, 4
• A meta-analysis of 1177 patients with cervical spine injury who underwent intubation showed minimal neurological complications 1
• Delayed neurological deterioration occurs in 2-10% of spinal cord injuries even without airway interventions, which may lead to incorrect attribution of deterioration to airway management 1

Training and Preparation

• Clinicians who perform tracheal intubation in patients with suspected cervical spine injury should receive regular training in videolaryngoscopy techniques with cervical spine immobilization 1
• Have backup airway equipment immediately available, including emergency front-of-neck airway access tools 5
• Limit the number of intubation attempts (maximum 2-3) to prevent airway trauma and hypoxemia 5, 6

Common Pitfalls and How to Avoid Them

• Attempting multiple direct laryngoscopy attempts when initial attempt fails—instead, switch to an alternative technique after 1-2 unsuccessful attempts 5, 6
• Inadequate positioning—ensure proper alignment while maintaining cervical spine stabilization 5
• Using unfamiliar equipment in a crisis—train regularly with videolaryngoscopy and other advanced airway devices 5
• Forgetting to confirm tube placement—always verify with capnography after intubation 5