Orotracheal Intubation is the Best Method to Secure This Airway
In this patient with severe head injury (GCS 8/15) and signs of basilar skull fracture (periorbital ecchymosis/"raccoon eyes" and nasal blood), orotracheal intubation (Answer A) is the definitive airway management approach. Nasotracheal intubation is absolutely contraindicated due to the risk of intracranial passage through a fractured cribriform plate, while cricothyroidotomy and tracheostomy are reserved for failed intubation scenarios 1.
Why Orotracheal Intubation
Videolaryngoscopy should be used preferentially for this intubation, as it reduces cervical spine movement and improves first-pass success rates 1. The 2024 Difficult Airway Society guidelines provide Grade A evidence (moderate recommendation) that videolaryngoscopy is superior to direct laryngoscopy in patients with suspected cervical spine injury 1.
Key Technical Considerations
Remove the anterior portion of the cervical collar during intubation attempts while maintaining manual in-line stabilization to minimize cervical spine movement and improve glottic visualization 1.
Use jaw thrust rather than head-tilt/chin-lift for airway positioning, as this reduces cervical spine movement (mean 4.8° vs 14.7° flexion-extension) 1.
Consider using a bougie or stylet as an adjunct, particularly given the anticipated difficult view with cervical immobilization—studies show 22% of patients have nothing visible beyond the epiglottis with in-line stabilization 1, 2.
Why NOT the Other Options
Nasotracheal intubation (Answer B) is contraindicated in this patient with clear signs of basilar skull fracture (Battle's sign equivalent with periorbital ecchymosis and nasal bleeding). There is documented risk of intracranial passage of the endotracheal tube through fractured skull base 1.
Cricothyroidotomy (Answer C) and tracheostomy (Answer D) are not first-line procedures but rather rescue techniques for failed orotracheal intubation 1. Emergency front-of-neck airway access should follow Difficult Airway Society guidelines and is reserved for "cannot intubate, cannot oxygenate" scenarios 1.
Clinical Evidence Base
Multiple prospective studies demonstrate the safety of orotracheal intubation in cervical spine injury:
No neurological deterioration occurred in 150 patients with cervical spine fractures (81 with unstable fractures, 69 with spinal cord injury) who underwent orotracheal intubation with manual in-line stabilization 3.
Zero cases of neurologic worsening were documented in 81 patients with cervical fractures intubated orotracheally, including 38 with unstable fractures 4.
Current consensus states that orotracheal intubation with in-line stabilization is the safest and quickest method for patients with suspected cervical spine injury requiring emergency airway control 5.
Critical Pitfalls to Avoid
Do not use high-flow nasal oxygen for pre-oxygenation in this patient—there are case reports of pneumocephalus with basilar skull fractures 1.
Do not delay intubation for awake fiberoptic technique in a patient with GCS 8/15—this patient requires immediate definitive airway control, and videolaryngoscopy has comparable safety with faster execution 1.
Do not apply excessive cricoid pressure if it impairs visualization, as it should be removed if intubation difficulty is encountered 1.