Airway risk in hospitalized trauma patients with cervical injuries requiring halo fixation

Abstract

Objective: To identify the incidence and outcomes of emergent and semiemergent intubations in hospitalized trauma patients with cervical fractures and/or dislocations treated with halo fixation.

Summary background data: Intubating a trauma patient in halo fixation can be extremely difficult, with the potential for dire consequences.

Methods: The authors retrospectively reviewed the medical records of trauma patients with cervical injuries requiring halo fixation admitted to a level 1 trauma center between January 1992 and January 1997. The in-hospital need for emergent or semiemergent intubation was assessed and correlated with a variety of patient characteristics, including outcome.

Results: Of the 105 patients identified, 14 (13%) required an emergent or semiemergent intubation. Injury Severity Score, cardiac history, and intubation on arrival were significant indicators of the need for an in-hospital emergent or semiemergent intubation or reintubation. A total of seven deaths were reported, six of which were associated with an emergent or semiemergent in-hospital intubation. Although age did not appear significant in predicting the need for an emergent intubation, it was significant in predicting arrest-related deaths. A total of 17 tracheostomies were performed. Eight were considered "initial" in that they were performed before an emergent intubation, and nine were performed after an emergent intubation. Patients in the initial tracheostomy group did not differ in terms of the variables investigated from those who required an emergent intubation. None of the patients who underwent initial tracheostomy, however, had an airway emergency or died.

Conclusions: A significant number of trauma patients treated with halo fixation ultimately require an in-hospital emergent or semiemergent intubation. Given the difficulty and potential lethality associated with these intubations, heightened vigilance regarding the airway is warranted. The authors recommend that early tracheostomy be considered in patients with a history of cardiac disease, especially when a high Injury Severity Score is present. Older patients (older than 60 years) are more at risk for arrest-related death and may also benefit from early tracheostomy.

Figure 1. Mechanism of injury.