Cervical Immobilization Research Articles

Magnitude of Intracranial Pressure Changes Following Rigid External Cervical Collar Immobilization in Cases Sustaining Traumatic Brain Injury: Impact Analysis Current Status

Abstract Rigid collars are routinely used to immobilise the cervical spine during early phase of management of trauma cases until cervical clearance is obtained or else diagnosed as case of cervical spine injury following detailed clinical as well as neurological evaluation. Spinal injuries commonly coexist in patients sustaining severe head injury. Till date, there is no clear cut consensus about effect of application of a rigid collar in cases suffering with traumatic brain injury. However, concern are regularly raised over collar application, such practice may have adverse effect on cerebrovascular regulation and ultimately affecting intracranial pressure and outcome. Authors made detailed Pubmed, EMBASE, AMED, and Thomson Reuters, Medline line search and could find out six articles. According to existing literature, the cervical collar has the potential to influence intracranial pressure in patients suffering with head injury. There are several reports in the literature showing that cervical immobilization may alter intracranial pressure and the changes in ICP closely depend on the types of cervical collars used. Authors discuss the current status based on review of updated literature on possible effect on the intracranial pressure produced by application of rigid cervical collar and briefly literature is reviewed.

Wednesday, September 26, 2018 10:35 AM – 12:00 PM Cervical Spine Trauma: 28. Clinical and radiological outcome of odontoid fractures treated with soft collar immobilization

BACKGROUND CONTEXT Nonoperative treatment of odontoid fractures can be achieved with non-rigid cervical immobilization (either hard or soft cervical collars). Hard collars are commonly used but are associated with a risk of skin breakdown. Soft collars may reduce this risk but raise concerns that they do not provide sufficient immobilization for these injuries. PURPOSE To identify the clinical and radiological outcomes of odontoid fractures treated with soft collar immobilization. STUDY DESIGN/SETTING Tertiary level spinal injuries unit retrospective review of cases. PATIENT SAMPLE Consecutive patients presenting to a tertiary level spinal injuries unit over a five-year period (July 2010 to July 2015) with nonoperatively treated odontoid fractures. OUTCOME MEASURES Radiological and clinical outcome measures. METHODS Consecutive patients presenting to a tertiary level spinal injuries unit over a five-year period (July 2010 to July 2015) with nonoperatively treated odontoid fractures. All patients receiving external non-rigid immobilization were treated with soft cervical collars. RESULTS Fifty-four patients (34 female, 20 male). Mean age 77 years (range 29-104). Mechanism of injury was fall (37), MVA (13), syncope (2) and blunt trauma (2). There were 28 type 3 fractures, 23 type 2 fractures and 3 type 1 fractures (Anderson and D'Alonzo classification). At presentation mean angulation was 14.6° (range 0-50°) and mean displacement was 1.9mm (range 0mm–11mm). Two failed nonoperative treatment and required fixation (one at 2 weeks and one at 4 months following injury). Radiological union was demonstrated in 25% of cases. At final follow-up, mean angulation was 16.9° (range 0-63°) and mean displacement was 2.6 mm (range 0 mm–16 mm). Overall mortality was 18.5%. There were no cases of skin breakdown. CONCLUSIONS Clinical and radiological outcomes for soft collars are comparable to those reported in the literature for hard collars. Soft collars are a safe and effective alternative to hard collars for the treatment of odontoid fractures and reduce the risk of skin breakdown. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Occipital Condyle Fractures and Concomitant Cervical Spine Fractures: Implications for Management

Occipital condyle fractures (OCFs) have traditionally been described based on anatomic characteristics; however, recent literature has proposed management based on biomechanical stability and neural element compression. The treatment of biomechanically stable fractures varies between observation and cervical immobilization. Before determining the best management approach, an understanding of concomitant cervical spine fractures in the presence of OCFs is important. The primary aim of this pilot study was to determine the rate of occurrence of biomechanically significant cervical spine fractures with OCFs. A retrospective chart review was performed of 13,363 patients presenting to a level 1 trauma center between 2013 and 2017 with a diagnosis of OCF. Forty-six patients presented with OCFs, with an average Glasgow Coma Scale score of 12 on presentation and an average Injury Severity Score of 23. The average patient age was 42.1 years, and 4 patients had bilateral OCFs. Approximately 30% of these patients had associated intracranial injuries and 59% had an associated cervical spine injury. The overall rate of associated potentially biomechanically significant cervical spine fracture was 43.5%. Treatment of OCFs included collar immobilization (83%) and observation (17%). The average duration of follow-up was 3.37 months. This study characterizes cervical spine fractures that occur concomitantly with OCFs. The results indicate that more than one-half of patients with OCFs do not have biomechanically significant fractures elsewhere in the cervical spine. This subset of patients will be the cohort for a prospective study to assess whether collar immobilization is necessary.

Surgical treatment improves survival of elderly with axis fracture—a national population-based multiregistry cohort study

Background ContextFractures of the axis (C2) are the most common cervical spinal injuries in the elderly population. Several authors have reported improved survival among elderly patients with C2 fractures when treated surgically. PurposeWe aimed to analyze whether surgery improves survival of elderly with C2 fractures. Study Design/SettingAn observational population-based longitudinal multi-registry study was carried out. Patient SampleSwedish Patient Registry 1997 to 2014 and Swedish Cause of Death Registry 1997 to 2014 served as source of patient sample. Outcome measuresSurvival after C2 fracture according to non-surgical and surgical treatment was the outcome measure. MethodsWe included all patients treated for the primary diagnosis of C2 fracture (10th revision of the International Statistical Classification of Diseases and Related Health Problems or ICD-10: S12.1) at an age ≥70 years and receiving treatment at a health-care facility. Non-surgical treatment comprises cervical collar or halo-vest treatment. Surgical treatment was identified in the Swedish patient registry extract using the Swedish classification of procedural codes. Survival was determined using the Kaplan-Meier method. Comorbidity was determined using the Charlson Comorbidity Index. ResultsOf the included 3,375 elderly patients with C2 fractures (43% men, aged 83±7 years), 22% were treated surgically. Surgical treatment was assigned based on age, gender, and year of treatment. The 1-year survival of 2,618 non-surgically treated patients was 72% (n=1,856), and 81% (n=614) for the 757 surgically treated (p<.001, relative risk reduction=11%). Adjusted for age, gender, comorbidity, and year of injury, surgically treated patients had greater survival than non-surgically treated patients (hazard ratio=0.88, 95% confidence interval: 0.79–0.97). Among those above 88 years of age (95% confidence interval: 85–92), surgical treatment lost its effect on survival. ConclusionsDespite the frailty of elderly patients, the morbidity of cervical external immobilization with a rigid collar seemingly weighs greater than surgical morbidity, even in octogenarians. For those above 88 years of age, non-surgical treatment should be primarily attempted.

Comparison of three types of intubation stylets for tracheal intubation with a McGrath MAC® video laryngoscope by novice intubators in simulated cervical immobilisation: A randomised crossover manikin study

Introduction: Tracheal intubation using video laryngoscopes has been a better approach for trauma patients requiring cervical immobilisation. The aim of this study was to compare the time to successful intubation by novice intubators using three types of intubation stylets with the new McGrath MAC video laryngoscope in a manikin model. Methods: This was a randomised crossover manikin study. The participants performed tracheal intubations using three intubation stylets (arcuate shape malleable stylet, McGrath MAC-shaped malleable stylet and McGrath MAC-shaped rigid stylet) in a difficult airway model with cervical immobilisation. The order of the stylets was randomised. The primary outcome was the time to successful intubation. The secondary outcomes were the overall success rates, incidence of dental trauma and ease of intubation. All intubation attempts were assessed by trained assistants. The data were analysed using a multilevel model followed by Tukey’s post hoc test. Results: A total of 68 nurses participated in this study. The time to successful intubation of the McGrath MAC-shaped malleable stylet was significantly shorter than that of the arcuate shape malleable stylet (24.5 (18.0–51.0) s vs 31.5 (21.0–89.0) s, p = 0.005). The overall success rate of the McGrath MAC-shaped malleable stylet was also higher than that of the arcuate shape malleable stylet ( p = 0.047). The participants indicated that intubation was easier using the McGrath MAC-shaped malleable stylet compared with the other stylets. Conclusion: The McGrath MAC-shaped malleable stylet, when used by novice intubators, may be an optimal stylet shape for tracheal intubation using the McGrath MAC in cervical immobilisation.

Primary Bone Diffuse Large B-cell Lymphoma with Multifocal Osteolytic Lesions: A Rare Entity

Bone lymphomas can be classified as primary (PBL), or secondary (SBL). PBL is a rare entity, accounting for approximately 7% of malignant bone tumors, 5% of extra nodal lymphomas and <1% of all non-Hodgkin lymphomas. We present here a case of multifocal bone lymphoma in a 72-year old female patient, who was admitted to our clinic for further investigation of persistent back pain, anorexia, weight loss and fatigue. There were no palpable lymph nodes, no hepatosplenomegaly or neurological signs. Her laboratory tests showed a moderate elevation of LDH, ESR and beta-2 microglobulin. In CT and MRI scan a complete fracture of the left hip and multiple vertebral lesions were revealed. Bone biopsy of the left hip showed a Diffuse Large B-cell Lymphoma. She was treated with combined chemotherapy (R-CHOP regimen) plus radiation, followed by bracing with cervical immobilization and cimentoplasty of lumbar vertebrae. She achieved complete response and she is alive at last follow-up.

Cervical spine motion during intubation: a fluoroscopic comparison between three intubation techniques

Background Anaesthetists are responsible for the management of the airway in patients with unstable cervical spine (C spine). The optimal tracheal intubation technique for patients with potential C spine injury remains controversial. Videolaryngoscopes are used in an attempt to balance the need to limit cervical motion and overcome the difficulty of obtaining laryngeal views especially with manual in-line stabilization or cervical collar. Aim The current study aimed to compare the degree of C spine movement during intubation using different devices, Macintosh direct laryngoscope, C-MAC D-Blade videolaryngoscope and flexible intubation video endoscope (FIVE), in anaesthetized patients with normal airway and simulated C spine immobilization. Patients and methods This study was carried out on 45 adult patients scheduled for radiographic procedures under general anaesthesia with endotracheal intubation (ETT). Patients were randomly divided into three equal groups (15 patients each) using the sealed envelope technique: group M (Macintosh direct laryngoscope), group D (C-MAC D-Blade) and group F (FIVE). C spine movement was recorded with continuous fluoroscopy at 3–8 frames/s using a digital videofluoroscopy unit during both laryngoscopy and intubation to capture the maximal extent of C spine movement. The following parameters were evaluated: age, BMI, airway score, haemodynamic parameters, glottic view grade (Cormack and Lehane), time to successful ETT insertion and maximum segmental spine motion. Results The three studied groups were matching as regards age, BMI and airway score. Heart rate and mean arterial blood pressure observed after insertion of the ETT were statistically higher in group M compared with groups D and F. However, there were no significant differences in mean observed HR and mean arterial blood pressure between groups D and F at all time intervals. The Macintosh (group M) had significantly higher C and L grades than the two other devices in groups D and F. There was no significant difference in C and L grades attainted by the D-Blade in group D and the FIVE in group F. D-Blade had significantly shorter intubation time compared with Macintosh and FIVE. Macintosh direct laryngoscope resulted in significantly greater cervical movement at all measured motion segments compared with D-Blade and FIVE. Meanwhile, FIVE caused significantly less motion compared with D-Blade. Conclusion In patients with potential C spine injury and cervical immobilization, D-Blade results in less cervical motion, better glottic views and shorter intubation time compared with Macintosh laryngoscope. Flexible intubation scope causes the least cervical motion but with the longest intubation time.

Refusal of cervical spine immobilization after blunt trauma: Implications for initial evaluation and management: A retrospective cohort study

IntroductionRigid cervical collars are routinely placed in the pre-hospital setting after significant blunt trauma. Patients who are deemed competent by field personnel (Glasgow Coma Scale (GCS) ≥13, no major distracting injury and not grossly intoxicated) may refuse cervical collar placement. Material and methodsA retrospective review was conducted of all adult trauma patients presenting to a Level 1 trauma center after blunt trauma with a GCS≥13 and no distracting injury or gross intoxication from January 2014 to December 2014. Pre-hospital data was collected from emergency medical service reports and hospital data from patient charts. Cervical spine injury was identified by International Classification of Disease-9th Revision codes. Patients refusing cervical spine immobilization prior to arrival are compared to those who were compliant. ResultsA total of 629 patients met inclusion criteria. Cervical spine immobilization was refused by 28 patients, while 601 complied. There were 16 cervical spine injuries (2.5%), with 3 (10.7%) in noncompliant patients and 13 (2.2%) among those who were complaint (p = 0.03). ConclusionThe incidence of cervical spine injuries in patients refusing cervical collar immobilization is higher than in compliant patients. Patients arriving for initial evaluation having refused cervical collar immobilization should be treated with caution.

Halo-Vest Immobilization in Elderly Odontoid Fracture Patients: Evolution in Treatment Modality and In-Hospital Outcomes.

Retrospective cohort study. To evaluate the utilization and effectiveness of halo-vest (HV) immobilization for type II odontoid fractures from 2004 to 2014. Controversy persists regarding the optimal treatment method for odontoid fractures in the elderly. Management options include immobilization in a cervical orthosis, HV immobilization, and operative intervention. Over the past decade, high mortality and morbidity rates have been reported following HV immobilization in this patient population. In a retrospective study, patient demographics, presentation, Charlson comorbidity index, treatment method, and outcome data for patients over 65 who had suffered type II odontoid fractures from 2004 to 2014 were compared with a historical cohort from 1997 to 2004. One hundred twenty-six patients met inclusion criteria. The mean age was 82.7±8.8 compared with 80.7±0.9 in the 1997-2004 cohort. The in-hospital mortality rate from 2004 to 2014 was 11.1% (14/126) compared with 31% in the historical cohort, and 10 (7.9%) patients were treated with HV compared with 49%. Mortality in the HV group was higher than the surgical group (P=0.01) but no different from the orthosis group (P=0.63).There were no differences in injury severity score, Charlson comorbidity index, or complications between treatment groups. Over the past decade, HV use for elderly odontoid fractures has decreased at our institution. Mortality and morbidity of elderly patients treated with HV has also decreased. These findings are likely the result of improved patient selection and greater attention to respiratory care. This study demonstrates that HV immobilization of odontoid fractures in elderly patients can be as safe as cervical orthosis treatment in select patients.

CERVICAL BRUCELLOSIS, WITH OR WITHOUT BONE INJURY

Brucellosis is a zoonotic infectious systemic, endemic in Albania, which is accompanied by multi-organ involvement. A common complication is also the vertebral affection. Manifestation in the lower lumbar spine is frequently seen, while cervical involvement is more rare. Diagnose of vertebral involvement is difficult because of non-specific clinical symptoms. We present two cases of cervical brucellosis, with various cervical injuries. Spondylodiscitis with epidural abscess were the cervical manifestation in the first patient, which is very rare and a serious complication and the second patient had epidural involvement without spondylodiscitis. The Rose Bengal, Wright test, ELISA were positive for both patients. The cervical injury was confirmed with MRI exams. After prolonged combination therapy with cervical immobilization, the follow up evaluation demonstrated resolution of the cervical injury. Because vertebral destruction is in the base of this complication, early diagnosis of vertebral brucellosis is important to prevent serious morbidity, if diagnosis and treatment are delayed. Standard Brucella tube agglutination (Wright) test is the primary test and should be performed as a first step in the differential diagnosis of spondylodiscitis. An MRI is recommended for early diagnosis of spinal involvement. Medically treatment of cervical brucellosis has a good prognosis with early diagnosis.

A Comparison Between the Conventional and the Laryngoscope-Assisted Lightwand Intubation Techniques in Patients With Cervical Immobilization: A Prospective Randomized Study

Positioning of a lightwand in the midline of the oral cavity can be challenging in patients with cervical immobilization. Direct laryngoscopy may permit the lightwand tip to more easily access the glottic opening. We tested our hypothesis that a laryngoscope-assisted lightwand technique allows more successful endotracheal intubation than does a conventional lightwand approach. A total of 162 patients requiring cervical immobilization during intubation for cervical spine surgery were allocated randomly to 2 groups. The conventional lightwand technique (group C, n = 80) or the laryngoscope-assisted lightwand technique (group L, n = 82) was used for endotracheal intubation. In the group L, a Macintosh laryngoscope was inserted into the oral cavity, advanced until the epiglottis tip was visible, but not used to lift the epiglottis tip. The lightwand tip was placed below the epiglottis under direct view of the epiglottis tip. The primary outcome (the initial intubation success rate) and secondary outcomes (intubation time, hemodynamic changes, and postoperative airway complications) were evaluated. The initial intubation success rate was significantly lower (75% vs 89%; relative risk [95% confidence interval]: 1.2 [1.0-1.4]; P = .034) in group C than group L. The intubation time (22 ± 13 vs 24 ± 12 seconds; mean difference [98.33% confidence interval]: 2.4 [-2.3 to 7.2]; P = .217) did not differ between groups. Postoperative sore throat score, incidences of hypertension and tachycardia, postoperative oral mucosal bleeding, and hoarseness also did not differ between groups. Laryngoscope-assisted lightwand intubation did not increase intubation time, and it increased first attempt intubation rates compared with traditional lightwand intubation in patients requiring cervical immobilization for cervical spine surgery.

Une cause traumatique de syndrome de la tête tombante

We report a case of dropped head syndrome that developed after traumatic injury by hyperflexion of the cervical spine in a female Muay Thai boxer. The clinical presentation was dramatic as the patient was unable to maintain the head in an upright position. In this case, the dropped head syndrome was related to trauma-induced muscle injury. In accordance with the Quebec Task Force guidelines, this type of injury implies careful search for vertebral instability. In the event of an isolated injury, the outcome is favorable with adequate cervical immobilization with a rigid cervical collar.

Blunt cervical spine injury in adult polytrauma: incidence, injury patterns and predictors of significant ligament injury on CT

To describe the pattern of cervical spine fractures in adult major trauma and identify computed tomography (CT) parameters that can predict significant ligament injury when fractures are absent; to define the normal range for parameters used; and identify common variations due to position of cervical immobilisation in a trauma patient. In this retrospective study all polytrauma patients imaged using multidetector CT over a period of 5 years were identified. Patients with cervical spine fracture and suspected ligament injury in the absence of fracture were collated based on the polytrauma CT report. Predictors of ligament injury were defined based on published historical data on plain radiographs and posterior paraspinal fat pad assessment at CT. These parameters were recorded for each study with comparison to subsequent magnetic resonance imaging (MRI) as the reference standard. Significant ligament injury on MRI was detected at the craniocervical junction, when CT showed a basion dens interval of >10mm, widened incongruous C0/C1 facet joint space of >3mm, and widened C1/2 facet joint space of >6mm. In the subaxial cervical spine, facet subluxation >50% and obscured posterior paraspinal fat pad were the only reliable predictors of ligament injury, as confirmed on subsequent MRI. When fractures are absent, signs of significant ligament injury on CT at the craniocervical junction were increased basion dens interval and widened facet joints. In the subaxial cervical spine, >50% subluxation of a facet joint and obscured posterior paraspinal fat pad are indicators of significant ligament injury.

A Randomized Crossover Study Comparing Cervical Spine Motion During Intubation Between Two Lightwand Intubation Techniques in Patients With Simulated Cervical Immobilization: Laryngoscope-Assisted Versus Conventional Lightwand Intubation.

In patients with cervical immobilization, jaw thrust can cause cervical spine movement. Concurrent use of a laryngoscope may facilitate lightwand intubation, allowing midline placement and free movement of the lightwand in the oral cavity without jaw thrust. We compared the effects of laryngoscope-assisted lightwand intubation (LALI) versus conventional lightwand intubation (CLI) on cervical spine motion during intubation in patients with simulated cervical immobilization. In this randomized crossover study, the cervical spine angle was measured before and during intubation at the occiput-C1, C1-C2, and C2-C5 segments in 20 patients with simulated cervical immobilization who underwent intubation using both the LALI and CLI techniques. Cervical spine motion was defined as the change from baseline in angle measured at each cervical segment during intubation. Cervical spine motion at the occiput-C1 segment was 5.6° (4.3) and 9.3° (4.5) when we used the LALI and CLI techniques, respectively (mean difference [98.33% CI]; -3.8° [-7.2 to -0.3]; P = .007). At other cervical segments, it was not significantly different between the 2 techniques (-0.1° [-2.6 to 2.5]; P = .911 in the C1-C2 segment and -0.2° [-2.8 to 2.5]; P = .795 in the C2-C5 segment). The LALI technique produces less upper cervical spine motion during intubation than the CLI technique in patients with simulated cervical immobilization.

Changes in use of cervical spine magnetic resonance imaging for pediatric patients with nonaccidental trauma

OBJECTIVE Past studies have suggested correlations between abusive head trauma and concurrent cervical spine (c-spine) injury. Accordingly, c-spine MRI (cMRI) has been increasingly used in radiographic assessments. This study aimed to determine trends in cMRI use and treatment, and outcomes related to c-spine injury in children with nonaccidental trauma (NAT). METHODS A total of 503 patients with NAT who were treated between 2009 and 2014 at a single pediatric health care system were identified from a prospectively maintained database. Additional data on selected clinical events were retrospectively collected from electronic medical records. In 2012, a clinical pathway on cMRI usage for patients with NAT was implemented. The present study compared cMRI use and clinical outcomes between the prepathway (2009-2011) and postpathway (2012-2014) periods. RESULTS There were 249 patients in the prepathway and 254 in the postpathway groups. Incidences of cranial injury and Injury Severity Scores were not significantly different between the 2 groups. More patients underwent cMRI in the years after clinical pathway implementation than before (2.8% vs 33.1%, p < 0.0001). There was also a significant increase in cervical collar usage from 16.5% to 27.6% (p = 0.004), and more patients were discharged home with cervical collar immobilization. Surgical stabilization occurred in a single case in the postpathway group. CONCLUSIONS Heightened awareness of potential c-spine injury in this population increased the use of cMRI and cervical collar immobilization over a 6-year period. However, severe c-spine injury remains rare, and increased use of cMRI might not affect outcomes markedly.

A comparison of McGrath MAC\xae and standard direct laryngoscopy in simulated immobilized cervical spine pediatric intubation: a manikin study

Emergency airway management in children is generally considered to be challenging, and endotracheal intubation requires a high level of personal skills and experience. Immobilization of the cervical spine is indicated in all patients with the risk of any cervical spine injury but significantly aggravates endotracheal intubation. The best airway device in this setting has not been established yet, although the use of videolaryngoscopes is generally promising. Seventy-five moderately experienced paramedics of the Emergency Medical Service of Poland performed endotracheal intubations in a pediatric manikin in three airway scenarios: (A) normal airway, (B) manual in-line cervical immobilization, and (C) cervical immobilization using a Patriot cervical extrication collar and using two airway techniques: (1) McGrath videolaryngoscope and (2) Macintosh blade in a randomized sequence. First-attempt intubation success rate, time to intubation, glottis visualization, and subjective ease of intubation were investigated in this study. Intubation of difficult airways, including manual in-line and cervical collar immobilization, using the McGrath was significantly faster, with a higher first-attempt intubation success rate, better glottic visualization, and ease of intubation, compared to Macintosh-guided intubation. In the normal airway, both airway techniques performed equal.Conclusion: Our manikin study indicates that the McGrath may be a reasonable first intubation technique option for endotracheal intubation in difficult pediatric emergencies. Further clinical studies are therefore indicated.What is known: • Airway management in pediatrics is challenging and requires a high level of skills and experience. Cervical immobilization is indicated in all patients with any risk of cervical spine injury, but it significantly aggravates endotracheal intubation in these patients. Videolaryngoscopes have been reported to ease intubation and provide better airway visualization in the regular clinical setting.What is new: • The McGrath is an easy-to-use and clinically often used videolaryngoscope, but it has never been investigated in pediatrics with an immobilized cervical spine. In the normal airway, the McGrath provided better airway visualization compared to Macintosh laryngoscopy. However, better visualization did not lead to decreased time to intubation and a higher success rate of the first intubation attempt. In difficult airways, the McGrath provided better airway visualization and this led to faster intubation, a higher first-attempt intubation success rate, and better ease of intubation compared to Macintosh-guided intubation.

C-MAC compared with direct laryngoscopy for intubation in patients with cervical spine immobilization: A manikin trial

IntroductionThe aim of this study was to compare C-MAC videolaryngoscopy with direct laryngoscopy for intubation in simulated cervical spine immobilization conditions. MethodsThe study was designed as a prospective randomized crossover manikin trial. 70 paramedics with <5years of medical experience participated in the study. The paramedics attempted to intubate manikins in 3 airway scenarios: normal airway without cervical immobilization (Scenario A); manual inline cervical immobilization (Scenario B); cervical immobilization using cervical extraction collar (Scenario C). ResultsScenario A: Nearly all participants performed successful intubations with both MAC and C-MAC on the first attempt (95.7% MAC vs. 100% C-MAC), with similar intubation times (16.5s MAC vs. 18s C-MAC). Scenario B: The results with C-MAC were significantly better than those with MAC (p<0.05) for the time of intubation (23 s MAC vs. 19 s C-MAC), success of the first intubation attempt (88.6% MAC vs. 100% C-MAC), Cormack-Lehane grade, POGO score, severity of dental compression, device difficulty score, and preferred airway device. Scenario C: The results with C-MAC were significantly better than those with MAC (p<0.05) for all the analysed variables: success of the first attempt (51.4% MAC vs. 100% C-MAC), overall success rate, intubation time (27 s MAC vs. 20.5 s C-MAC), Cormack-Lehane grade, POGO score, dental compression, device difficulty score and the preferred airway device. ConclusionThe C-MAC videolaryngoscope is an excellent alternative to the MAC laryngoscope for intubating manikins with cervical spine immobilization.

Should cervical spinal immobilisation be applied to alert adult patients following blunt traumatic injury?

Should cervical spinal immobilisation be applied to alert adult patients following blunt traumatic injury?

Cervical collars and immobilisation: A South African best practice recommendation.

IntroductionThe consequences of spinal injury as a result of trauma can be devastating. Spinal immobilisation using hard trauma boards and rigid cervical collars has traditionally been the standard response to suspected spinal injury patients even though the risk may be extremely low. Recently, adverse events due to the method of immobilisation have challenged the need for motion restriction in all trauma patients. International guidelines have been published for protection of the spine during transport and this article brings those guidelines into the South African context.RecommendationsTrauma patients need to be properly assessed using both an approved list of high and low risk factors, as well as a thorough examination. They should then be managed accordingly. Internationally validated assessment strategies have been developed, and should be used as part of the patient assessment. The method of motion restriction should be selected to suit the situation. The use of a vacuum mattress is the preferable technique, with the use of a trauma board being the least desirable.ConclusionThe need for motion restriction in suspected spinal injury should be properly evaluated and appropriate action taken. Not all trauma patients require spinal motion restriction.

Comparison of Airtraq™, McCoy™ and Macintosh laryngoscopes for endotracheal intubation in patients with cervical spine immobilisation: A randomised clinical trial.

Background and Aims:The study aimed at comparing the performance of the novel optical Airtraq™ laryngoscope with the McCoy™ and conventional Macintosh laryngoscopes for ease of endotracheal intubation in patients with neck immobilisation using manual inline axial cervical spine stabilisation (MIAS) technique.Methods:Ninety consenting American Society of Anaesthesiologist's physical status I–II patients, aged 18–60 years, scheduled for various surgeries requiring tracheal intubation were randomly assigned into three groups of thirty each to undergo intubation with Macintosh, Airtraq™, or McCoy™ laryngoscope with neck immobilisation by MIAS technique. The ease of intubation based on Intubation difficulty scale (IDS) score, Cormack-Lehane grade of glottic view, optimisation manoeuvres and impact on haemodynamic parameters were recorded. Statistical analysis was performed with ANOVA and Bonferroni correction for post hoc tests.Results:All patients in three groups had a comparable demographic profile and were successfully intubated. The Airtraq™ laryngoscope significantly reduced the IDS (mean − 0.43 ± 0.81) as compared with both McCoy™ (mean − 1.63 ± 1.49, P = 0.001) and Macintosh laryngoscope (mean −2.23 ± 1.92, P < 0.001) and improved the Cormack-Lehane glottic view (77% grade 1 view and no patients with grade 3 or 4 view). There were less haemodynamic variations during laryngoscopy with the Airtraq™ compared to the Macintosh laryngoscope, but there was not between the Airtraq™ and McCoy™ laryngoscope groups.Conclusion:In patients undergoing endotracheal intubation with cervical immobilisation, Airtraq™ laryngoscope was superior to the McCoy™ and Macintosh laryngoscopes, with greater ease of intubation and lower impact on haemodynamic variables.