What is the acute management of suspected cervical spine injuries?

Acute Management of Suspected Cervical Spine Injuries

The acute management of suspected cervical spine injuries centers on immediate spinal immobilization using a rigid cervical collar combined with supportive blocks on a backboard with straps, while avoiding sandbags and tape alone, followed by meticulous airway management using videolaryngoscopy with manual in-line stabilization when intubation is required. 1

Immediate Immobilization at Scene

Apply manual in-line stabilization (MILS) immediately for all trauma patients with potential cervical spine injury. 2

• Use a rigid cervical collar combined with supportive blocks on a backboard with straps—this combination is most effective at limiting cervical spine motion 3
• Do NOT use sandbags and tape alone—this outdated method is specifically not recommended as it allows dangerous neck extension 4, 3
• Apply a semi-rigid collar for initial immobilization due to its effectiveness in limiting movement and ease of application 5
• Transport patients on a rigid backboard with head fixation and vacuum mattress 2
• Avoid traction during immobilization—while in-line stabilization reduces cervical spine movement, traction causes clinically significant distraction and should be avoided 6

Hemodynamic Stabilization

Maintain systolic blood pressure >110 mmHg during initial assessment to reduce mortality. 2

• Target mean arterial pressure ≥70 mmHg continuously during the first week post-injury to limit neurological deterioration 2
• Recognize that hemodynamic instability may indicate spinal shock in high cervical injuries 2

Airway Management Principles

When airway management is required, use videolaryngoscopy with manual in-line stabilization and removal of the anterior cervical collar portion. 1, 2

Pre-oxygenation and Basic Airway Maneuvers

• Minimize cervical spine movement during pre-oxygenation and facemask ventilation 1
• Use jaw thrust rather than head tilt plus chin lift when a simple maneuver is needed to maintain the airway 1

Intubation Technique

Videolaryngoscopy should be used for tracheal intubation when possible (Grade A recommendation)—this is the single strongest recommendation in the 2024 guidelines. 1

• Remove the semi-rigid or rigid cervical collar during intubation attempts, preferably by removing only the anterior part—this minimizes cervical spine movement while improving glottic exposure 1, 2
• Maintain manual in-line stabilization throughout the intubation procedure 2
• Consider using an adjunct such as a stylet or bougie when performing tracheal intubation with cervical spine immobilization 1
• Use rapid sequence induction with direct laryngoscopy and gum elastic bougie while maintaining cervical spine axis 2
• Avoid the Sellick maneuver to maximize first-attempt success 2

Supraglottic Airway Devices

• Use second-generation supraglottic airway devices (SADs) in preference to first-generation SADs 1
• When intubation through a SAD is indicated, use devices that are familiar and available—no specific device is clearly superior 1

Respiratory Management

Identify respiratory complications immediately, as they are life-threatening in high cervical injuries. 2

• Consider early tracheostomy (<7 days) when prolonged airway support is anticipated or when residual vital capacity is significantly decreased 2
• Monitor closely for respiratory insufficiency, particularly in injuries above C5 2

Prevention of Secondary Injury

Multidisciplinary planning, preparation, and optimization of human factors should occur before airway management. 1

• Implement comprehensive pressure ulcer prevention from the acute phase 2
• Remove indwelling catheters as soon as medically stable to minimize urological complications 2
• Implement multimodal analgesia combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids to prevent prolonged pain syndromes 2

Transport Decisions

Transport patients directly to Level 1 trauma centers within the first hours after trauma—this reduces morbidity and mortality, enables earlier surgical procedures, and improves neurological outcomes. 2

• Transport patients with red flags (history of cancer, unexplained weight loss, age >50 years, fever, significant trauma, rapidly progressive neurological deficits, bladder/bowel dysfunction) to facilities with appropriate specialty care 7
• Continue monitoring vital signs and neurological status during transport 7

Early Rehabilitation

Begin rehabilitation immediately after spinal stabilization to maximize neurological recovery. 2

• Physical exercise enhances CNS regeneration through neurotrophic factor elaboration 2
• Initiate range-of-motion exercises immediately to prevent contracture progression 8

Critical Pitfalls to Avoid

• Never use sandbags and tape alone for immobilization—this allows dangerous neck extension 4, 3
• Never apply traction during immobilization—this causes clinically significant distraction 6
• Never leave the cervical collar fully in place during intubation—remove the anterior portion to improve glottic exposure while maintaining manual in-line stabilization 1, 2
• Failing to maintain systolic blood pressure >110 mmHg increases mortality risk 2
• Delaying transport to Level 1 trauma centers worsens outcomes 2
• The actual risk of secondary spinal cord injury from airway management is extremely low (0.34% in a meta-analysis of 1177 patients), so airway management should not be delayed when clinically indicated 1