How should I perform rapid‑sequence intubation on a patient with suspected cervical spine injury while maintaining spinal protection?

Intubation of Patients with Suspected Cervical Spine Injury

Use videolaryngoscopy with manual in-line stabilization (MILS) after removing the anterior portion of the cervical collar, employing rapid sequence induction with a bougie or stylet as your primary approach. 1

Pre-Intubation Preparation

Multidisciplinary planning should occur before airway management whenever possible to optimize team performance and minimize complications. 1 Key preparation steps include:

• Remove only the anterior portion of the rigid cervical collar while maintaining MILS by an assistant—leaving the full collar in place significantly worsens glottic visualization and increases intubation failure rates. 1, 2, 3
• Minimize cervical spine movement during pre-oxygenation and facemask ventilation. 1
• Use jaw thrust rather than head tilt-chin lift if airway maneuvers are needed during pre-oxygenation. 1
• Maintain systolic blood pressure >110 mmHg throughout the procedure to reduce mortality risk. 2, 3, 4

Primary Intubation Technique

Videolaryngoscopy is the preferred technique (Grade A recommendation) as it provides superior glottic visualization compared to direct laryngoscopy, though it does not significantly reduce cervical spine movement. 1 The evidence shows:

• No specific videolaryngoscope blade type (hyperangulated vs. Macintosh-style) has proven superiority—use what you are most familiar with. 1
• Add a stylet or bougie as an adjunct during intubation attempts with cervical immobilization to improve first-pass success. 1, 2
• Studies comparing GlideScope videolaryngoscopy to direct laryngoscopy found better glottic views with videolaryngoscopy but similar cervical spine movement at all levels (occiput to C5). 5

Rapid Sequence Induction Protocol

Perform rapid sequence induction with the following approach:

• Do NOT use cricoid pressure (Sellick maneuver)—it increases cervical spine movement and should be avoided. 2, 3
• Succinylcholine can be safely used within 48 hours of injury; after 48 hours, switch to rocuronium to avoid hyperkalemia from denervation. 2
• Maintain continuous MILS throughout laryngoscopy and tube insertion—one study showed this reduces complications despite being based on low-quality evidence. 2, 3, 4

Awake vs. Asleep Intubation Decision

The decision between awake and asleep intubation should be made case-by-case, as there is no evidence demonstrating that awake tracheal intubation prevents secondary spinal cord injury better than techniques performed under general anesthesia. 1 Consider:

• Awake flexible bronchoscopy was historically considered the gold standard but is now used less frequently (only 2.3% in one 252-patient study) since videolaryngoscopy adoption. 1
• One study comparing awake flexible bronchoscopy to McGrath videolaryngoscopy in 46 patients with unstable cervical spines found less cervical motion at C1/C2 with flexible bronchoscopy but similar motion at C3, with no neurological complications in either group. 1
• Another study comparing awake flexible bronchoscopy to asleep AirTraq videolaryngoscopy found similar safety profiles, with higher first-pass success using AirTraq (95% vs. 85%). 1
• The overall neurological complication rate after tracheal intubation is only 0.34% (4/1177 patients) based on systematic review data. 1

Alternative Airway Devices

If intubation through a supraglottic airway device (SAD) is indicated:

• Use second-generation SADs in preference to first-generation devices (Grade D, strong recommendation). 1
• No specific SAD design is clearly superior for reducing cervical spine movement—use devices familiar to you. 1
• Be aware that the intubating laryngeal mask produces segmental cervical flexion (1-3 degrees at C0-5) during insertion and intubation, which is opposite to the extension produced by direct laryngoscopy. 6

Critical Pitfalls to Avoid

Common errors that worsen outcomes include:

• Never leave the cervical collar fully in place during intubation—this dramatically worsens visualization and increases failure rates. 2, 3
• Do not allow systolic blood pressure to drop below 110 mmHg—hypotension increases mortality. 2, 3, 4
• Avoid applying traction to the cervical spine—while MILS reduces movement, traction causes clinically significant distraction and should be avoided. 7
• Do not use cricoid pressure—it increases cervical spine movement. 2, 3

Evidence Quality and Practical Reality

The 2024 Difficult Airway Society guidelines acknowledge that evidence supporting most recommendations is modest, with only one moderate and two strong recommendations possible from their systematic review of 67 articles. 1 Importantly:

• No contemporary evidence explicitly links any airway maneuver to adverse spinal cord outcomes—most data infer risk based on surrogate measures of head and neck movement. 1
• A prospective 7-year study of 150 trauma patients with cervical spine fractures or high spinal cord injury found zero neurological deterioration after orotracheal intubation when performed with manual cervical immobilization. 8
• Cervical spine motion during intubation occurs mainly as extension concentrated in the rostral spine, predominantly during glottic visualization rather than tube insertion. 5

Regular training in videolaryngoscopy with cervical spine immobilization is essential for all clinicians performing these procedures. 1