Airway management in patients with suspected or confirmed cervical spine injury: Guidelines from the Difficult Airway Society (DAS), Association of Anaesthetists (AoA), British Society of Orthopaedic Anaesthetists (BSOA), Intensive Care Society (ICS), Neuro Anaesthesia and Critical Care Society (NACCS), Faculty of Prehospital Care and Royal College of Emergency Medicine (RCEM)

Matthew D Wiles^{1

2}, Helen A Iliff³, Katherine Brooks⁴, Egidio J Da Silva⁵, Mike Donnellon⁶, Adrian Gardner^{7

8}, Matthew Harris⁹, Caroline Leech^{10

11}, Steve Mathieu¹², Paul Moor^{13

14}, Lara Prisco^{15

16}, Kate Rivett¹⁷, Frances Tait¹⁸, Kariem El-Boghdadly^{19

20}

Affiliations

¹ Department of Anaesthesia and Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
² Centre for Applied Health and Social Care Research, Sheffield Hallam University, Sheffield, UK.
³ Cardiff and Vale University Health Board, Wales, UK.
⁴ Barts and the London School of Anaesthesia, London, UK.
⁵ Department of Anaesthesia, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK.
⁶ Education and Standards Committee, College of Operating Department Practitioners, London, UK.
⁷ Department of Spine Surgery, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK.
⁸ Aston University, Birmingham, UK.
⁹ University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.
¹⁰ Department of Emergency Medicine, Institute for Applied and Translational Technologies in Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.
¹¹ Prehospital Emergency Medicine, Air Ambulance Service, Rugby, UK.
¹² Department of Critical Care, Portsmouth Hospitals University NHS Trust, Portsmouth, UK.
¹³ Army Health Branch, Army HQ, Marlborough Lines, Andover, Hants, UK.
¹⁴ Department of Anaesthesia, Plymouth Hospitals NHS Trust, Plymouth, UK.
¹⁵ Neurosciences Intensive Care Unit, John Radcliffe Hospital, Oxford, UK.
¹⁶ Nuffield Department of Clinical Neurosciences, University of Oxford, UK.
¹⁷ Patient Representative, Difficult Airway Society, London, UK.
¹⁸ Critical Care Department, Northampton General Hospital, Northampton, UK.
¹⁹ Department of Anaesthesia and Perioperative Care, Guy's and St Thomas' NHS Foundation Trust, London, UK.
²⁰ King's College London, London, UK.

PMID: 38699880
DOI: 10.1111/anae.16290

Free article

Practice Guideline

Airway management in patients with suspected or confirmed cervical spine injury: Guidelines from the Difficult Airway Society (DAS), Association of Anaesthetists (AoA), British Society of Orthopaedic Anaesthetists (BSOA), Intensive Care Society (ICS), Neuro Anaesthesia and Critical Care Society (NACCS), Faculty of Prehospital Care and Royal College of Emergency Medicine (RCEM)

Matthew D Wiles et al. Anaesthesia. 2024 Aug.

Free article

. 2024 Aug;79(8):856-868.

doi: 10.1111/anae.16290. Epub 2024 May 3.

Authors

Affiliations

¹ Department of Anaesthesia and Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
² Centre for Applied Health and Social Care Research, Sheffield Hallam University, Sheffield, UK.
³ Cardiff and Vale University Health Board, Wales, UK.
⁴ Barts and the London School of Anaesthesia, London, UK.
⁵ Department of Anaesthesia, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK.
⁶ Education and Standards Committee, College of Operating Department Practitioners, London, UK.
⁷ Department of Spine Surgery, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK.
⁸ Aston University, Birmingham, UK.
⁹ University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.
¹⁰ Department of Emergency Medicine, Institute for Applied and Translational Technologies in Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.
¹¹ Prehospital Emergency Medicine, Air Ambulance Service, Rugby, UK.
¹² Department of Critical Care, Portsmouth Hospitals University NHS Trust, Portsmouth, UK.
¹³ Army Health Branch, Army HQ, Marlborough Lines, Andover, Hants, UK.
¹⁴ Department of Anaesthesia, Plymouth Hospitals NHS Trust, Plymouth, UK.
¹⁵ Neurosciences Intensive Care Unit, John Radcliffe Hospital, Oxford, UK.
¹⁶ Nuffield Department of Clinical Neurosciences, University of Oxford, UK.
¹⁷ Patient Representative, Difficult Airway Society, London, UK.
¹⁸ Critical Care Department, Northampton General Hospital, Northampton, UK.
¹⁹ Department of Anaesthesia and Perioperative Care, Guy's and St Thomas' NHS Foundation Trust, London, UK.
²⁰ King's College London, London, UK.

PMID: 38699880
DOI: 10.1111/anae.16290

Abstract

Background: There are concerns that airway management in patients with suspected or confirmed cervical spine injury may exacerbate an existing neurological deficit, cause a new spinal cord injury or be hazardous due to precautions to avoid neurological injury. However, there are no evidence-based guidelines for practicing clinicians to support safe and effective airway management in this setting.

Methods: An expert multidisciplinary, multi-society working party conducted a systematic review of contemporary literature (January 2012-June 2022), followed by a three-round Delphi process to produce guidelines to improve airway management for patients with suspected or confirmed cervical spine injury.

Results: We included 67 articles in the systematic review, and successfully agreed 23 recommendations. Evidence supporting recommendations was generally modest, and only one moderate and two strong recommendations were made. Overall, recommendations highlight key principles and techniques for pre-oxygenation and facemask ventilation; supraglottic airway device use; tracheal intubation; adjuncts during tracheal intubation; cricoid force and external laryngeal manipulation; emergency front-of-neck airway access; awake tracheal intubation; and cervical spine immobilisation. We also signpost to recommendations on pre-hospital care, military settings and principles in human factors.

Conclusions: It is hoped that the pragmatic approach to airway management made within these guidelines will improve the safety and efficacy of airway management in adult patients with suspected or confirmed cervical spine injury.

Keywords: airway management; cervical spinal injury; intubation; spinal cord injury; trauma.

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References

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1. Hasler RM, Exadaktylos AK, Bouamra O, et al. Epidemiology and predictors of spinal injury in adult major trauma patients: European cohort study. Eur Spine J 2011; 20: 2174–2180. https://doi.org/10.1007/s00586-011-1866-7.
1. Liao S, Jung MK, Hörnig L, Grützner PA, Kreinest M. Injuries of the upper cervical spine—how can instability be identified? Int Orthop 2020; 44: 1239–1253. https://doi.org/10.1007/s00264-020-04593-y.
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