Airway difficulties caused by improperly applied cricoid pressure

Cricoid Pressure: Contradictory Evidence Regarding a Standard Practice

The purpose of applying cricoid pressure is to prevent pulmonary aspiration of regurgitated gastric contents during airway management in mask-ventilated patients who are at risk of aspiration. Providers may apply cricoid pressure during induction and intubation if they expect a difficult intubation or if the patient has a high risk for regurgitation. Although the application of cricoid pressure has been accepted as a standard practice worldwide, controversy persists because pulmonary aspiration can occur even when cricoid pressure is applied. The perioperative nurse should have thorough knowledge of the anatomy of the upper respiratory and gastrointestinal tracts, be able to demarcate the surface landmarks of the neck, and be skilled in applying cricoid pressure properly and safely. This article discusses cricoid pressure in the context of safe airway management as well as the perioperative nurse's role as an assistant to the anesthesia professional when applying cricoid pressure.

Effect of Paratracheal Pressure on the Glottic View During Direct Laryngoscopy: A Randomized Double-Blind, Noninferiority Trial

BACKGROUND

Cricoid pressure has been used as a component of the rapid sequence induction and intubation technique. However, concerns have been raised regarding the effectiveness and safety of cricoid pressure. Paratracheal pressure, a potential alternative to cricoid pressure to prevent regurgitation of gastric contents or aspiration, has been studied to be more effective to cricoid pressure in preventing gastric insufflation during positive pressure ventilation. However, to adopt paratracheal compression into our practice, adverse effects including its effect on the glottic view during direct laryngoscopy should be studied. We conducted a randomized, double-blind, noninferiority trial comparing paratracheal and cricoid pressures for any adverse effects on the view during direct laryngoscopy, together with other secondary outcome measures.

METHODS

In total, 140 adult patients undergoing general anesthesia randomly received paratracheal pressure (paratracheal group) or cricoid pressure (cricoid group) during anesthesia induction. The primary end point was the incidence of deteriorated laryngoscopic view, evaluated by modified Cormack-Lehane grade with a predefined noninferiority margin of 15%. Secondary end points included percentage of glottic opening score, ease of mask ventilation, change in ventilation volume and peak inspiratory pressure during mechanical mask ventilation, ease of tracheal intubation, and resistance encountered while advancing the tube into the glottis. The position of the esophagus was assessed by ultrasound in both groups to determine whether pressure applied to the respective area would be likely to result in esophageal compression. All secondary outcomes were tested for superiority, except percentage of glottic opening score, which was tested for noninferiority.

RESULTS

Paratracheal pressure was noninferior to cricoid pressure regarding the incidence of deterioration of modified Cormack-Lehane grade (0% vs 2.9%; absolute risk difference, -2.9%; 95% confidence interval, -9.9 to 2.6, P <.0001). Mask ventilation, measured on an ordinal scale, was found to be easier (ie, more likely to have a lower score) with paratracheal pressure than with cricoid pressure (OR, 0.41; 95% confidence interval, 0.21-0.79; P = .008). The increase in peak inspiratory pressure was significantly less in the paratracheal group than in the cricoid group during mechanical mask ventilation (median [min, max], 0 [-1, 1] vs 0 [-1, 23]; P = .001). The differences in other secondary outcomes were nonsignificant between the groups. The anatomical position of the esophagus was more suitable for compression in the paratracheal region, compared to the cricoid cartilage region.

CONCLUSIONS

Paratracheal pressure was noninferior to cricoid pressure with respect to the effect on glottic view during direct laryngoscopy.

The Knowledge of Health Professionals About the Application of Cricoid Pressure in a Low-Income Country: A Single-Center Survey Study

BACKGROUND

The application of cricoid pressure requires good knowledge and practice of health professionals who are working in operation theatres to prevent pulmonary aspiration. This study aims to assess the application of cricoid pressure knowledge and practice in health professionals who are working in the operation theatres.

METHODS

This survey-based study was conducted in health care professionals who are working in the operation theatre of Debre Tabor Comprehensive Specialized Hospital from November 1 to December 1, 2020. A structured checklist was used to collect data regarding the knowledge and practice of the application of cricoid pressure.

RESULTS

A total of 43 health professionals who are working in the operation theaters were involved in this study with a response rate of 81%. The correct anatomic position of cricoid cartilage was not identified in 67% of nurses. We found that 78% of anesthetists did not use the nasogastric tube for decompression, and 83% of them complain of difficult intubation during the application of cricoid pressure.

CONCLUSION

Health care professionals who are working in operation theatres had poor knowledge and practice in the application of cricoid pressure.

Clinical Impact of External Laryngeal Manipulation During Laryngoscopy on Tracheal Intubation Success in Critically Ill Children

OBJECTIVES

External laryngeal manipulation is a commonly used maneuver to improve visualization of the glottis during tracheal intubation in children. However, the effectiveness to improve tracheal intubation attempt success rate in the nonanesthesia setting is not clear. The study objective was to evaluate the association between external laryngeal manipulation use and initial tracheal intubation attempt success in PICUs.

DESIGN

A retrospective observational study using a multicenter emergency airway quality improvement registry.

SETTING

Thirty-five PICUs within general and children's hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand).

PATIENTS

Critically ill children (< 18 years) undergoing initial tracheal intubation with direct laryngoscopy in PICUs between July 1, 2010, and December 31, 2015.

MEASUREMENTS AND MAIN RESULTS

Propensity score-matched analysis was performed to evaluate the association between external laryngeal manipulation and initial attempt success while adjusting for underlying differences in patient and clinical care factors: age, obesity, tracheal intubation indications, difficult airway features, provider training level, and neuromuscular blockade use. External laryngeal manipulation was defined as any external force to the neck during laryngoscopy. Of the 7,825 tracheal intubations, the initial tracheal intubation attempt was successful in 1,935/3,274 intubations (59%) with external laryngeal manipulation and 3,086/4,551 (68%) without external laryngeal manipulation (unadjusted odds ratio, 0.69; 95% CI, 0.62-0.75; p < 0.001). In propensity score-matched analysis, external laryngeal manipulation remained associated with lower initial tracheal intubation attempt success (adjusted odds ratio, 0.93; 95% CI, 0.90-0.95; p < 0.001).

CONCLUSIONS

External laryngeal manipulation during direct laryngoscopy was associated with lower initial tracheal intubation attempt success in critically ill children, even after adjusting for underlying differences in patient factors and provider levels. The indiscriminate use of external laryngeal manipulation cannot be recommended.

Effect of Cricoid Pressure on Laryngeal View During Macintosh, McGrath MAC X-Blade and GlideScope Video Laryngoscopies

Objective

Cricoid pressure is useful in fasted patients requiring emergency intubation. We compared the effect of cricoid pressure on laryngeal view during Macintosh, McGrath MAC X-Blade and GlideScope video laryngoscopy.

Methods

After obtaining approval from the Human Research Ethics Committee and written informed consent from patients, we enrolled 120 patients (American Society of Anesthesiologists I-II, age 18-65 years) undergoing elective surgery that required endotracheal intubation in this prospective randomised study. Patients were divided into three groups (Macintosh, McGrath MAC X-Blade and GlideScope).

Results

Demographic and airway variables were similar in the groups. Cormack-Lehane grades were improved or unchanged on using cricoid pressure in Macintosh and McGrath MAC X-Blade groups. However, laryngeal views worsened in 12 patients (30%), remained unchanged in 26 patients (65%) and improved in 2 patients (5%) in the GlideScope group (p<0.001). Insertion and intubation times for Macintosh and McGrath MAC X-Blade video laryngoscopes were similar. Insertion times for GlideScope and Macintosh video laryngoscopes were similar, but were longer than those for the McGrath MAC X-Blade video laryngoscope (p=0.02). Tracheal intubation took longer with the GlideScope video laryngoscope than with the other devices (p<0.001 and p=0.003). Mean arterial pressures after insertion increased significantly in Macintosh and GlideScope groups (p=0.004 and p=0.001, respectively) compared with post-induction values. Heart rates increased after insertion in all three groups compared with post-induction values (p<0.001). Need for optimisation manoeuvres and postoperative minor complications were comparable in all three groups.

Conclusion

Although all three devices are useful for normal or difficult intubation, cricoid pressure improved Cormack-Lehane grades of Macintosh and McGrath MAC X-Blade video laryngoscopes but statistically significantly worsened that of the GlideScope video laryngoscope.

Comprehensive cardiopulmonary life support (CCLS) for cardiopulmonary resuscitation by trained paramedics and medics inside the hospital

The cardiopulmonary resuscitation (CPR) guideline of comprehensive cardiopulmonary life support (CCLS) for management of the patient with cardiopulmonary arrest in adults provides an algorithmic step-wise approach for optimal outcome of the patient inside the hospital by trained medics and paramedics. This guideline has been developed considering the infrastructure of healthcare delivery system in India. This is based on evidence in the international and national literature. In the absence of data from the Indian population, the extrapolation has been made from international data, discussed with Indian experts and modified accordingly to ensure their applicability in India. The CCLS guideline emphasise the need to recognise patients at risk for cardiac arrest and their timely management before a cardiac arrest occurs. The basic components of CPR include chest compressions for blood circulation; airway maintenance to ensure airway patency; lung ventilation to enable oxygenation and defibrillation to convert a pathologic 'shockable' cardiac rhythm to one capable to maintaining effective blood circulation. CCLS emphasises incorporation of airway management, drugs, and identification of the cause of arrest and its correction, while chest compression and ventilation are ongoing. It also emphasises the value of organised team approach and optimal post-resuscitation care.

Cricoid Pressure Controversies

Since cricoid pressure was introduced into clinical practice, controversial issues have arisen, including necessity, effectiveness in preventing aspiration, quantifying the cricoid force, and its reliability in certain clinical entities and in the presence of gastric tubes. Cricoid pressure–associated complications have also been alleged, such as airway obstruction leading to interference with manual ventilation, laryngeal visualization, tracheal intubation, placement of supraglottic devices, and relaxation of the lower esophageal sphincter. This review synthesizes available information to identify, address, and attempt to resolve the controversies related to cricoid pressure. The effective use of cricoid pressure requires that the applied force is sufficient to occlude the esophageal entrance while avoiding airway-related complications. Most of these complications are caused by excessive or inadequate force or by misapplication of cricoid pressure. Because a simple-to-use and reliable cricoid pressure device is not commercially available, regular training of personnel, using technology-enhanced cricoid pressure simulation, is required. The current status of cricoid pressure and objectives for future cricoid pressure–related research are also discussed.

Determinants of Success and Failure in Prehospital Endotracheal Intubation

Introduction

This study aimed to identify factors associated with successful endotracheal intubation (ETI) by a multisite emergency medical services (EMS) agency.

Methods

We collected data from the electronic prehospital record for all ETI attempts made from January through May 2010 by paramedics and other EMS crew members at a single multistate agency. If documentation was incomplete, the study team contacted the paramedic. Paramedics use the current National Association of EMS Physicians definition of an ETI attempt (laryngoscope blade entering the mouth). We analyzed patient and EMS factors affecting ETI.

Results

During 12,527 emergent ambulance responses, 200 intubation attempts were made in 150 patients. Intubation was successful in 113 (75%). A crew with paramedics was more than three times as likely to achieve successful intubation as a paramedic/emergency medical technician-Basic crew (odds ratio [OR], 3.30; p=0.03). A small tube (≤7.0 inches) was associated with a more than 4-fold increased likelihood of successful ETI compared with a large tube (≥7.5 inches) (OR, 4.25; p=0.01). After adjustment for these features, compared with little or no view of the glottis, a partial or entire view of the glottis was associated with a nearly 13-fold (OR, 12.98; p=0.001) and a nearly 40-fold (OR, 39.78; p<0.001) increased likelihood of successful intubation, respectively.

Conclusion

Successful ETI was more likely to be accomplished when a paramedic was partnered with another paramedic, when some or all of the glottis was visible and when a smaller endotracheal tube was used.

Overinflation of the cuff and pressure on the neck reduce the preventive effect of supraglottic airways on pulmonary aspiration: an experimental study in human cadavers

BACKGROUND

The oesophageal leak pressure is defined as the pressure which breaks the seal between the cuff of a supraglottic airway and the peri-cuff mucosa, allowing penetration of fluid into the pharynx and the oral cavity. As a consequence, a decrease in this variable increases the risk of reflux and can lead to pulmonary aspiration. The aim of this study was to analyse the effects of cuff overinflation and pressure on the neck on the oesophageal leak pressure of seven supraglottic airways.

METHODS

Three laryngeal masks, two laryngeal tubes, and two oesophageal-tracheal tubes were tested in an experimental setting. In five human cadavers, we simulated a sudden increase in oesophageal pressure. To measure baseline values (control), we used an intracuff pressure as recommended by the manufacturer. The first intervention included overinflation of the cuff by applying twice the amount of pressure recommended. A second intervention was defined as external pressure on the neck.

RESULTS

The oesophageal leak pressure was decreased for laryngeal masks (control, 28 cm H2O; overinflation, 9 cm H2O; pressure on the neck, 8 cm H2O; P<0.01) and for laryngeal tubes (control, 68 cm H2O; overinflation, 37 cm H2O; pressure on the neck, 39 cm H2O; P<0.01) and was unaffected for oesophageal-tracheal tubes (control, 126 cm H2O; overinflation/pressure on the neck, 130 cm H2O; n.s.).

CONCLUSION

Cuff overinflation and pressure on the neck can enhance the risk of gastro-oesophageal reflux when using supraglottic airways. Therefore, both manoeuvres should be avoided in clinical practice.

Development of a guideline for the management of the unanticipated difficult airway in pediatric practice

BACKGROUND

Most airway problems in children are identified in advance; however, unanticipated difficulties can arise and may result in serious complications. Training for these sporadic events can be difficult. We identified the need for a structured guideline to improve clinical decision making in the acute situation and also to provide a guide for teaching.

OBJECTIVE

Guidelines for airway management in adults are widely used; however, none have been previously devised for national use in children. We aimed to develop guidelines for the management of the unanticipated difficult pediatric airway for use by anesthetists working in the nonspecialist pediatric setting.

METHOD

We reviewed available guidelines used in individual hospitals. We also reviewed research into airway management in children and graded papers for the level of evidence according to agreed criteria. A Delphi panel comprising 27 independent consultant anesthetists considered the steps of the acute airway management guidelines to reach consensus on the best interventions to use and the order in which to use them. If following the literature review and Delphi feedback, there was insufficient evidence or lack of consensus, regarding inclusion of a particular point; this was reviewed by a Second Specialist Group comprising 10 pediatric anesthetists.

RESULTS

Using the Delphi group's deliberations and feedback from the Second Specialist Group, we developed three guidelines for the acute airway management of children aged 1-8 years.

CONCLUSIONS

This paper provides the background, available evidence base, and justification for each step in the resultant guidelines and gives a rationale for their use.

Effectiveness of cricoid pressure in preventing gastric aspiration during rapid sequence intubation in the emergency department: study protocol for a randomised controlled trial

Background

Cricoid pressure is considered to be the gold standard means of preventing aspiration of gastric content during Rapid Sequence Intubation (RSI). Its effectiveness has only been demonstrated in cadaveric studies and case reports. No randomised controlled trials comparing the incidence of gastric aspiration following emergent RSI, with or without cricoid pressure, have been performed. If improperly applied, cricoid pressure increases risk to the patient. The clinical significance of aspiration in the emergency department is unknown. This randomised controlled trial aims to; 1. Compare the application of the 'ideal" amount of force (30 - 40 newtons) to standard, unmeasured cricoid pressure and 2. Determine the incidence of clinically defined aspiration syndromes following RSI using a fibrinogen degradation assay previously described.

Methods/design

212 patients requiring emergency intubation will be randomly allocated to either control (unmeasured cricoid pressure) or intervention groups (30 - 40 newtons cricoid pressure). The primary outcome is the rate of aspiration of gastric contents (determined by pepsin detection in the oropharyngeal/tracheal aspirates or treatment for aspiration pneumonitis up to 28 days post-intubation). Secondary outcomes are; correlation between aspiration and lowest pre-intubation Glasgow Coma Score, the relationship between detection of pepsin in trachea and development of aspiration syndromes, complications associated with intubation and grade of the view on direct largyngoscopy.

Discussion

The benefits and risks of cricoid pressure application will be scrutinised by comparison of the incidence of aspiration and difficult or failed intubations in each group. The role of cricoid pressure in RSI in the emergency department and the use of a pepsin detection as a predictor of clinical aspiration will be evaluated.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611000587909

Challenges and advances in intubation: airway evaluation and controversies with intubation

Management of the airway is the first priority in any patient. Dealing with a difficult airway can be a challenge, whether or not it involves facemask ventilation, an intermediate airway device, laryngoscopy and intubation, or a surgical airway. Various scales predict which patient is likely to have a difficult airway. The goal of rapid sequence intubation (RSI) is to eliminate or mitigate untoward reflex responses to intubation. Although controversy has arisen regarding the various steps in RSI, it remains an essential component of emergency medicine practice.

Cricoid Pressure in Emergency Department Rapid Sequence Tracheal Intubations: A Risk-Benefit Analysis

Cricoid pressure is considered an integral part of patient safety in rapid sequence tracheal intubation and emergency airway management. Cricoid pressure is applied to prevent the regurgitation of gastric contents into the pharynx and subsequent aspiration into the pulmonary tree. This review analyzes the published evidence supporting cricoid pressure, along with potential problems, including increased difficulty with tracheal intubation and ventilation. According to the evidence available, the universal and continuous application of cricoid pressure during emergency airway management is questioned. An awareness of the benefits and potential problems with technique allows the practitioner to better judge when cricoid pressure should be used and instances in which it should be removed.

Airway Management in Trauma: An Update

This article reviews the more recent theoretic and practical information that pertains to airway management in the trauma setting. This is followed by a presentation of the newer airway devices that may be advantageous in the management of the airway in trauma as well as a discussion of other devices, techniques, or maneuvers that are useful in the trauma setting but may be underused. Each clinician needs to be knowledgeable about the various airway options and then, based on one's own particular skills and resources, construct an airway management algorithm that works best for him or her. Each clinician needs to be knowledgeable about the various airway options, and then, based on the clinician's particular skills and resources, construct an airway management algorithm that works best.

Rapid sequence induction: a survey of practices in three French prehospital mobile emergency units

OBJECTIVES

This prospective study was conducted in three mobile emergency and intensive care units.

METHODS

The patients were over 15 years of age and were not in cardiac arrest. The study was to compare practices in the three units with the guidelines drawn up by the Commission of Experts so as to define the main parameters for quality assurance. All of the patients involved were considered to have full stomachs and required rapid sequence induction.

RESULTS

This procedure comply the guidelines only in 45% of cases; in the other cases succinylcholine should have been administered (mobile emergency and intensive care unit A) and the Sellick manoeuvre should have been used (mobile emergency and intensive care unit A and B). Notwithstanding, these two centres treated more traumatized patients than mobile emergency and intensive care unit C, and use of the Sellick manoeuvre in such circumstances is questionable.

CONCLUSIONS

More training and greater diffusion of the protocols are required, especially with regard to doctors who intervene intermittently.

Literature review of safe use of cricoid pressure

This article, written by a third year diploma student in operating department practice, examines the literature relating to the safe use of cricoid pressure. To ensure that the patient is adequately protected from acid aspiration syndrome, the anaesthetic practitioner should be aware of the dangers of faulty technique when utilising Sellick's manoeuvre.

Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy

STUDY OBJECTIVE

External cricoid and thyroid cartilage manipulations are commonly taught to facilitate laryngeal view during intubation. We compare the laryngeal views during laryngoscopy with 4 manipulations (no manipulation, cricoid pressure, backward-upward-rightward pressure [BURP], and bimanual laryngoscopy) to determine the method that optimizes laryngeal view.

METHODS

This was a randomized intervention study involving emergency physicians participating in airway training courses from December 2003 to November 2004. Direct laryngoscopies were performed with curved blades on fresh, non-fixed cadavers by using each of the 4 methods. The percentage of glottic opening (POGO), a validated scoring scale, was recorded for each laryngoscopy. Scores for bimanual laryngoscopy were recorded before the assistant applied external pressure.

RESULTS

A total of 1,530 sets of comparative laryngoscopies were performed by 104 participants. One thousand one hundred eighteen of 1,530 sets (73%) had POGO scores less than 100 with no manipulation. Compared to no manipulation, mean POGO scores with bimanual laryngoscopy improved by 25 (95% confidence interval [CI] 23 to 27); mean POGO score improvement with cricoid pressure and BURP were 5 (95% CI 3 to 8) and 4 (95% CI 1 to 7), respectively. POGO scores with bimanual laryngoscopy were higher compared to cricoid pressure (mean difference 20, 95% CI 17 to 22) and BURP (mean difference 21, 95% CI 19 to 24). Among laryngoscopies with no manipulation in which the POGO score greater than 0 (n=1,434), laryngeal view worsened in 60 cases (4%, 95% CI 3% to 5%) with bimanual laryngoscopy, in 409 cases (29%, 95% CI 26% to 31%) with cricoid pressure, and in 504 cases (35%, 95% CI 33% to 38%) with BURP.

CONCLUSION

Using a cadaver model, we found pressing on the neck during curved blade laryngoscopy greatly affects laryngeal view. Overall, bimanual laryngoscopy improved the view compared to cricoid pressure, BURP, and no manipulation. Cricoid pressure and BURP frequently worsen laryngoscopy. These data suggest bimanual laryngoscopy should be considered when teaching emergency airway management.

Resuscitation of the morbidly obese patient

Obesity is a major health care problem in the United States. The body mass index (BMI) is the standard measure of obesity. A BMI >25 kg/m2 is defined as overweight and obesity as a BMI > 30 kg/m2. Recent surveys indicate that 54% of adults, or roughly 97 million people, are overweight. Given the incidence of obesity in the general population, it is likely that EM physicians will be involved in the emergency care of critically ill or injured obese patients. The objective of this article is to present the clinical problems associated with the resuscitation of the critically ill or injured obese patient and their potential solutions.

Cricoid pressure: indications and complications

Cricoid pressure to occlude the upper end of the oesophagus, also called the Sellick manoeuvre, may be used to decrease the risk of pulmonary aspiration of gastric contents during intubation for rapid induction of anaesthesia. Effective and safe use of the technique requires training and experience. Cricoid pressure is contraindicated in patients with suspected cricotracheal injury, active vomiting, or unstable cervical spine injuries. The technique may be particularly difficult in patients with a history of difficult intubation. The recommended pressure to prevent gastric reflux is between 30 and 40 Newtons (N, equivalent to 3-4 kg), but pressures greater than 20 N cause pain and retching in awake patients and a pressure of 40 N can distort the larynx and complicate intubation. The recommended procedure is, therefore, to induce anaesthesia and apply a pressure of about 30 N, either manually or with the cricoid yoke, to facilitate intubation. Reported complications of cricoid pressure during intubation include oesophageal rupture and exacerbation of unsuspected airway injuries.

Cricoid ring integrity: implications for cricothyrotomy

STUDY OBJECTIVES

The rapid 4-step technique for cricothyrotomy was originally described as making use of a single traction hook on the cricoid ring. However, it is possible that such hook placement could lead to damage of the cricoid ring. As an alternative, a double-hook device was developed to augment the rapid 4-step technique by dispersing forces applied to the cricoid ring. The objectives of this study were to compare the requisite forces for intubation and the structural tolerances of the cricoid ring between the single- and double-hook techniques.

METHODS

We randomized 56 human cadaver specimens to undergo either cricothyrotomy with intubation followed by cricoid ring breakage or cricoid ring breakage alone. We randomized those cadaver specimens undergoing cricothyrotomy with intubation with respect to the initial hook technique used and then crossed over to the alternate technique for repeat intubation and subsequent cricoid ring breakage. We performed all cricothyrotomies in a similar manner with a consistent technique. We measured the intubation and breakage forces for the single- and double-hook techniques and calculated 95% confidence intervals (CIs).

RESULTS

The mean force to intubate with the single-hook technique was 18 N (95% CI 14 to 22 N), and the mean force to intubate with the double-hook technique was 23 N (95% CI 17 to 29 N). There was a significant difference between the mean forces required to break the cricoid ring with the single-hook technique (54 N; 95% CI 47 to 62 N) versus with the double-hook technique (101 N; 95% CI 89 to 113 N; difference in means 47 [95% CI 34 to 60 N]).

CONCLUSION

When applying the rapid 4-step technique for cricothyrotomy, the force required to intubate with either the single- or double-hook technique is small. The cricoid ring, however, tolerates significantly more force without breakage when the double-hook technique is used.

Cervical spine injury and airway management

Cervical spine injuries occur in 2-5% of blunt trauma patients, and 1-5% of these injuries are initially missed. Data from the large National Emergency X-Radiography Utilisation Study have helped to define the problem in some detail. There is a consensus on how to clear the cervical spine in patients who are alert, but in patients with altered mental status the choice of strategy for spinal clearance is more controversial. Despite obtaining extensive radiological studies, some clinicians will not clear the patient's cervical spine until full recovery of consciousness. As long as manual in-line neck stabilization is applied, rapid sequence induction of anaesthesia, followed by direct laryngoscopy and oral intubation appears to be safe in the patient with a cervical spine injury. If intubation is not urgent, an awake fibreoptic technique is a useful option. If intubation of the patient with a potential cervical spine injury fails, or appropriate experienced personnel are unavailable, the laryngeal mask airway or one of its various modifications are useful alternatives.

Gastric rupture following bag-valve-mask ventilation

Bag-valve-mask ventilation is a frequently used, generally safe and effective method of oxygenating and ventilating patients who are unable to do so themselves. The common complications of aspiration, inability to oxygenate, and gastric dilatation are recognized fairly quickly, although not always easily remedied. We report a case of a much rarer complication: gastric rupture with pneumoperitoneum. Prompt recognition and surgical intervention help minimize adverse outcomes from complications such as tension pneumoperitoneum with shock, peritonitis, and sepsis.