Christopher M. Grande

Appropriate techniques for airway management of emergency patients with suspected spinal cord injury.

While we would like to respectfully express skepticism about the proposal recently made by Gorback (1) regarding manipulations of the endotracheal tube (ETT) cuff to achieve blind nasal intubation, we would, more importantly, like to protest the fact that he, along with so many other anesthesiologists, continues to automatically assume that nasotracheal intubation is either necessary or desirable in patients with suspected or actual spinal cord injuries. As clinicians at the Shock Trauma Center of the Maryland Institute for Emergency Medical Services Systems (MIEMSS), we appreciate the difficulty of intubating the trauma patient with suspected cervical spine instability. Each year since 1983, more than 600 patients with suspected or actual spinal cord injury (SCI) requiring emergency intubation have been admitted to our facility, the statewide referral center for neurotrauma. Predominately using an oral intubation technique as an alternative to nasal intubation, we have afforded safe and efficient airway management to this large patient population. Difficulties encountered when using blind nasal intubation techniques have prompted the development of various modifications using the tactile, visual, and auditory senses. Additionally, combinations of techniques can be used to improve the efficacy of blind nasal intubation if one feels compelled to use this approach. Although some anesthesiologists consider nasal intubation to be the ideal approach for securing the airway in a patient with cervical SCI, we believe this technique may be contraindicated in the majority of traumatically injured patients. Nasal intubation (blind or fiberoptically guided) is associated with complications and limitations. Nasal intubation should not be used if the patient is apneic, nor should it be used if the patient has a basilar skull fracture because bacteria and foreign materials (including the ETT) could enter the cerebral subarachnoid space through the skull defect. Nasal intubation may induce nosebleeds, which may be aggravated by dilutional coagulopathy. Nasally intubated patients are at risk for postoperative sepsis due to sinusitis. Nasal intubation should not be performed in frightened, inebriated, obtunded, and combative patients, who may thrash about during intubation and cause further damage to a cervical SCI. Concerning Gorback’s technique of blind nasal intubation, we have several comments:

Trauma care: Challenge of the 21st century

Jon Michael Moore Trauma Center, Robert C. Byrd Health Sciences Center, West Virginia University School of Medicine, Morgantown, West Virginia 26508 USA; Erie County Medical Center, State University New York, Buffalo, Buffalo, New York, USA; International Trauma Anesthesia and Critical Care Society, P.O. Box 4826, Baltimore, Maryland 21211 USA; Case Western Reserve University Faculty of Medicine, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, Ohio 44109-1998 USA.

Anesthesia and Analgesia in Emergency Medicine

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