Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection: 2024 Update.

The Wilderness Medical Society reconvened an expert panel to update best practice guidelines for spinal cord protection during trauma management. This panel, with membership updated in 2023, was charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in wilderness environments. Recommendations are made regarding several parameters related to spinal cord protection. These recommendations are graded based on the quality of supporting evidence and balance the benefits and risks/burdens for each parameter according to American College of Chest Physicians methodology. Key recommendations include the concept that interventions should be goal-oriented (spinal cord/column protection in the context of overall patient and provider safety) rather than technique-oriented (immobilization). An evidence-based, goal-oriented approach excludes the immobilization of suspected spinal injuries via rigid collars or backboards.

Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection.

The Wilderness Medical Society reconvened an expert panel to update best practice guidelines for spinal cord protection during trauma management. This panel, with membership updated in 2018, was charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in wilderness environments. Recommendations are made regarding several parameters related to spinal cord protection. These recommendations are graded based on the quality of supporting evidence and balance the benefits and risks/burdens for each parameter according to the methodology stipulated by the American College of Chest Physicians. Key recommendations include the concept that interventions should be goal oriented (spinal cord/column protection in the context of overall patient and provider safety) rather than technique oriented (immobilization). This evidence-based, goal-oriented approach does not support the immobilization of suspected spinal injuries via rigid collars or backboards.

Radiologic Imaging in Trauma Patients with Cervical Spine Immobilization at a Pediatric Trauma Center.

BACKGROUND: Pediatric trauma patients with cervical spine (CS) immobilization using a cervical collar often require procedural sedation (PS) for radiologic imaging. The limited ability to perform airway maneuvers while CS immobilized with a cervical collar is a concern for emergency department (ED) staff providing PS. OBJECTIVE: To describe the use of PS and analgesia for radiologic imaging acquisition in pediatric trauma patients with CS immobilization. METHODS: Retrospective medical record review of all trauma patients with CS immobilization at a high-volume pediatric trauma center was performed. Patient demographics, imaging modality, PS success, sedative and analgesia medications, and adverse events were analyzed. Patients intubated prior to arrival to the ED were excluded. RESULTS: A total of 1417 patients with 1898 imaging encounters met our inclusion criteria. A total of 398 patients required more than one radiographic imaging procedure. The median age was 8 years (range 3.8-12.75 years). Computed tomography of the head was used in 974 of the 1898 patients (51.3%). A total of 956 of the 1898 patients (50.4%) required sedatives or analgesics for their radiographic imaging, with 875 (91.5%) requiring a single sedative or analgesic agent, and 81 (8.5%) requiring more than one medication. Airway obstruction was the most common adverse event, occurring in 5 of 956 patients (0.3%). All imaging procedures were successfully completed. CONCLUSION: Only 50% of CS immobilized, nonintubated patients required a single sedative or analgesic medication for their radiologic imaging. Procedural success was high, with few adverse events.

Time in Collars and Collar-Related Complications in Older Patients.

BACKGROUND: Cervical spine immobilization, including cervical collars, has been recommended in most trauma guidelines. However, cervical spine immobilization can be associated with harm, and an increasing body of evidence has demonstrated associated complications. We hypothesized that older trauma patients placed in cervical collars for >24 hours were at greater risk of developing collar-related complications compared with those placed in cervical collars for ≤24 hours. METHODS: We conducted a retrospective cohort study of injured patients without a fracture of the cervical vertebrae, aged ≥65 years, who had been placed in a cervical collar during the period from January 1, 2015 to December 31, 2015. The primary outcome was the composite of the in-hospital development of nosocomial pneumonia and collar-related pressure ulcers. RESULTS: A total of 1154 patients had been treated with cervical collars during the study period, and 61 (5.1%) had developed collar-related complications. Male sex, a lower initial Glasgow Coma Scale score, a history of congestive heart failure, a history of chronic obstructive pulmonary disease or asthma, operative management, and longer hospital and intensive care unit lengths of stay demonstrated a univariable association with collar-related complications (P < 0.10), in addition to a duration in the collar for >24 hours. An independent association was found between collar duration >24 hours and the outcome of interest (adjusted odds ratio, 2.50; 95% confidence interval, 1.16-5.39; P = 0.02). CONCLUSIONS: Among older patients without a cervical vertebral fracture, duration of cervical collar use for >24 hours was associated with the development of collar-related complications. We recommend attention to early collar clearance for older trauma patients.

Retrospective audit of airway management practices in children with craniocervical pathology.

BACKGROUND: Craniocervical immobilization using halo body orthoses may be required in the management of children with craniocervical junction pathology. To date, the effect of such immobilization on perioperative anesthetic management has not been addressed in large series. AIMS: The aim of this study was to review the airway management of children requiring halo body orthoses undergoing general anesthesia. METHODS: The study was a retrospective case note review from a single institution. The neurosurgical database was interrogated to identify all patients less than 16 years of age that required a halo body orthosis from 1996 to 2015. We used the electronic patient record to identify all procedures performed under general anesthesia for these patients, either for halo application, or with the halo in situ. Details of techniques used for airway management were recorded, and paired data between individuals pre- and post-halo application were compared. Demographic data, diagnosis, and perioperative complications were also recorded. RESULTS: We identified 90 children that underwent placement of a halo body orthosis. A total of 269 anesthetic records from these patients were analyzed and classified as pre-halo application, or halo in situ. Facemask ventilation was achieved in all patients, though some required simple airway adjuncts and may have been more difficult in the presence of the halo. Supraglottic airways were used successfully in many patients. There was a significant increase in the number of patients classed as Cormack and Lehane grades 3 or 4 on direct laryngoscopy with the halo in situ compared with before the halo was applied. The incidence of intubation using fiberoptic or videolaryngoscopy was higher with the halo in situ. Multiple intubation attempts were required in 3.4% (1/29) of patients undergoing anesthesia for halo placement compared with 15.1% (11/73) undergoing anesthesia with a halo in situ. CONCLUSION: Airway management in children with cervical spine pathology should be anticipated to be more difficult than the general pediatric population. This is likely to be due to co-existing pathology associated with cervical spine disease in children, limitation of neck movement to prevent further neurological injury, and the halo itself limiting access to the head. We recommend advanced preparation, and ensuring the immediate availability of an anesthetist with skills in managing the pediatric difficult airway to avoid complications in this patient population.

Errors in cervical spine immobilization during pediatric trauma evaluation.

BACKGROUND: The purpose of this study was to identify factors during trauma evaluation that increase the likelihood of errors in cervical spine immobilization ('lapses'). MATERIALS AND METHODS: Multivariate analysis was used to identify the associations between patient characteristics, event features, and tasks performed in proximity to the head and neck and the occurrence and duration of a lapse in maintaining cervical spine immobilization during 56 pediatric trauma evaluations. RESULTS: Lapses in cervical spine immobilization occurred in 71.4% of patients (n = 40), with an average of 1.2 ± 1.3 lapses per patient. Head and neck tasks classified as oxygen manipulation occurred an average of 12.2 ± 9.7 times per patient, whereas those related to neck examination and cervical collar manipulation occurred an average of 2.7 ± 1.7 and 2.1 ± 1.2 times per patient, respectively. More oxygen-related tasks were performed among patients who had than those who did not have a lapse (27.3 ± 16.5 versus 11.5 ± 8.0 tasks, P = 0.001). Patients who had cervical collar placement or manipulation had a two-fold higher risk of a lapse than those who did not have these tasks performed (OR 1.92, 95% CI 0.56, 3.28, P = 0.006). More lapses occurred during evaluations on the weekend (P = 0.01), when more tasks related to supplemental oxygen manipulation were performed (P = 0.02) and when more tasks associated with cervical collar management were performed (P < 0.001). CONCLUSIONS: Errors in cervical spine immobilization were frequently observed during the initial evaluation of injured children. Strategies to reduce these errors should target approaches to head and neck management during the primary and secondary phases of trauma evaluation.

Intubation through 2 supraglottic airway device in cervical spine immobilization: a randomized trial of residents' use of the intubating laryngeal mask airway and the intubating laryngeal tube in manikins. / Intubación realizada por profesionales sin experiencia en un maniquí mediante un dispositivo de vía aérea supraglótico con inmovilización de la columna cervical: comparación entre el uso de la máscara laríngea de intubación y el tubo de intubación laríngea.

OBJECTIVES: The aim of this study was to compare the intubating laryngeal mask (iLM) airway and the new intubating laryngeal tube (iLTS-D) in use by residents with minimal previous intubation experience during simulated conditions of reduced cervical spine mobility. MATERIAL AND METHODS: Thirty first-year residents in anesthesiology participated in the study (18 women). All participants had minimal intubation experience (fewer than 10 previously performed intubations) and were novices in the specialty. Both devices were used by each participant after random assignment of order. We recorded the time required to insert the device and start to ventilate through it (T1) and the time from insertion and intubation to successful ventilation (T2). Efficacy of intubation and each resident's assessment of ease of use were also assessed.Observational study using biomechanical inertial sensors to detect movement in the spinal column during removal of helmets. RESULTS: The residents' mean (SD) T1 values were similar for the 2 devices (iLMA, 15.3 [5.5] seconds; iLTS-D, 15.4 [5.5] seconds; P=.938). T2 was shorter with the iLTS-D (25.4 [8.6] seconds vs 31.9 [8.8] seconds with the iLMA; P=.005). There were no failed intubation attempts with the iLTS-D. CONCLUSION: The new iLTS-D may be a good alternative to the iLMA because a patient can be intubated and successfully ventilated in less time. The rate of successful intubation is also better with the iLTS-D.

OBJETIVO: El objetivo de este estudio fue evaluar el uso de la mascarilla de intubación laríngea y el reciente tubo de intubación laríngea en manos de residentes con poca experiencia previa en intubación, simulando condiciones de movilidad reducida en la columna cervical. METODO: Treinta residentes de anestesia de primer año participaron en el estudio (18 mujeres). Todos ellos tenían una experiencia mínima en intubación (< 10 intubaciones realizadas previamente). Los dos dispositivos fueron utilizados por cada participante con asignación al azar del orden. Se registró tanto el tiempo requerido para insertar el dispositivo supraglótico y ventilar a través de él (T1), como el tiempo de colocación del tubo hasta la intubación y ventilación con éxito (T2). También se evaluó la eficacia de la intubación y la facilidad de su uso. RESULTADOS: El tiempo medio requerido para insertar el dispositivo de vía aérea supraglótica y ventilar a través de él fue similar para ambos dispositivos estudiados (15,3 s [DE 5,5] vs 15,4 s [DE 5.5]; p = 0,938). El tubo de intubación laríngea se asoció con un menor tiempo desde su inserción hasta la intubación y ventilación exitosa (25,4 s [DE 8,6] vs 31,9 s [SD 8,8], p = 0,005). No hubo intubaciones fallidas con el uso del tubo de intubación laríngea. CONCLUSIONES: El nuevo tubo laríngeo puede ser una buena alternativa a la mascarilla laríngea, ya que acorta el tiempo requerido para intubar y ventilar con éxito el paciente. También mejora la tasa de intubaciones exitosas.

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

INTRODUCTION: Rigid 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 METHODS: A 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. RESULTS: A 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). CONCLUSION: The 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.

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

INTRODUCTION: The aim of this study was to compare C-MAC videolaryngoscopy with direct laryngoscopy for intubation in simulated cervical spine immobilization conditions. METHODS: The 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). RESULTS: Scenario 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. CONCLUSION: The C-MAC videolaryngoscope is an excellent alternative to the MAC laryngoscope for intubating manikins with cervical spine immobilization.

Comparison of intubation success and glottic visualization using King Vision and C-MAC videolaryngoscopes in patients with cervical spine injuries with cervical immobilization: A randomized clinical trial.

BACKGROUND: Glottic visualization can be difficult with cervical immobilization in patients with cervical spine injury. Indirect laryngoscopes may provide better glottic visualization in these groups of patients. Hence, we compared King Vision videolaryngoscope, C-MAC videolaryngoscope for endotracheal intubation in patients with proven/suspected cervical spine injury. METHODS: After standard induction of anesthesia, 135 patients were randomized into three groups: group C (conventional C-MAC videolaryngoscope), group K (King Vision videolaryngoscope), and group D (D blade C-MAC videolaryngoscope). Cervical immobilization was maintained with Manual in line stabilization with anterior part of cervical collar removed. First pass intubation success, time for intubation, and glottic visualization (Cormack - Lehane grade and percentage of glottic opening) were noted. Intubation difficulty score (IDS) was used for grading difficulty of intubation. Five-point Likert scale was used for ease of insertion of laryngoscope. RESULTS: First attempt success rate were 100% (45/45), 93.3% (42/45), and 95.6% (43/45) in patients using conventional C-MAC, King Vision, and D blade C-MAC videolaryngoscopes, respectively. Time for intubation in seconds was significantly faster with conventional C-MAC videolaryngoscope (23.3 ± 4.7) compared to D blade C-MAC videolaryngoscope (26.7 ± 7.1), whereas conventional C-MAC and King Vision were comparable (24.9 ± 7.2). Good grade glottic visualization was obtained with all the three videolaryngoscopes. CONCLUSION: All the videolaryngoscopes provided good glottic visualization and first attempt success rate. Conventional C-MAC insertion was significantly easier. We conclude that all the three videolaryngoscopes can be used effectively in patients with cervical spine injury.

Application of HC video laryngoscope combined with fiberoptic bronchoscopy in tracheal intubation in patients with cervical spine immobilization / 中国内镜杂志

Objective To explore the application of HC video laryngoscope combined with fiberoptic bronchoscopy in tracheal intubation in patients with cervical spine immobilization.Methods 80 cases of cervical spine immobilization to surgery patients under general anesthesia were randomly divided into bronchoscopy group (F group), HC video laryngoscope composite fiber bronchoscope nasotracheal intubation group (H group), 40 cases in each group. Full of local anesthesia and intravenous anesthesia, spontaneous breathing, tracheal intubation. Recorded before induction (T0), immediately before intubation (T1), immediately after intubation (T2), 1 minutes after tracheal intubation (T3) mean arterial pressure (MAP), heart rate (HR) changes, record for the first time intubation success rate, intubation time of patients. The incidence of complications related to intubation operation.Results there were no significant differences between the two groups before and after tracheal intubation (T1) MAP and HR (t = 0.75,-0.51,P = 0.453, 0.611); After the two groups were intubated immediately (T2), MAP and HR than immediately before intubation (T1), the differences were statistically significant MAP (t = 5.08, 4.36,P = 0.021, 0.013) and HR (t = 7.22, 6.54,P = 0.026, 0.031), hemodynamics were maintained in the normal range, after intubation immediately (T2) between the two groups compared differences in MAP and HR had no statistical significance (t = -0.51, -0.31, P = 0.411, 0.518); There was no significant difference in HR and MAP between the two groups (t = 0.38, 0.26, P = 0.681, 0.372) in 1 min after intubation (T3). Patients with tracheal intubation success rate for the first time H group was obviously higher than that of group F, the difference was statistically significant (χ2 = 7.31,P = 0.007). The two group intubation time in H group was significantly less than that in F group, the difference was statistically significant (t = 5.75,P = 0.000). The incidence of sore throat in group F was significantly higher than H group, the difference was statistically significant (χ2 = 5.00,P = 0.025).Conclusions The patients with cervical spine immobilization of nasotracheal intubation, HC video laryngoscope combined with fiberoptic bronchoscopy, compared with the traditional fiberoptic intubation, intubation for the first time a higher success rate, shorter intubation time, no aggravation of hemodynamic lfuctuations, lower incidence of sore throats.

Comparison of intubation of Shikani optical stylet and Clarus Video Stylet in patients with cervical spine immobilization / 实用医学杂志

Objective To compare the application of Shikani optical stylet(SOS)and Clarus Video Sty-let(Tracway)in patient with cervical spine immobilization in tracheal intubation. Method Sixty patients,ASAⅠ~Ⅱ,undergoing cervical internal fixation operation,were randomly divided into Shikani optical stylet group (Group S,n = 30)and Clarus Video Stylet group(Group T,n = 30). MAP,HR and RPP(The rate-pressure product)were recorded at the point before induction of anesthesia(T1),before intubation(T2),at the immediate time of intubation(T3)and 1 min(T4),3 mins(T5),and 5 mins after intubation(T6).The intubation time,one-time success rate of intubation,the number of intubation times and the incidence of sore throat and other complica-tions were observed. Results The one-time intubation time in group S was obviously shorter than that in group T (P<0.05).The incidence of mild sore throat and intubation throat injury rate were lower in group S than those in group T(P<0.05).Compared with those at T1,MAP and RPP decreased significantly at point of T2~T6in both of two groups(P<0.05).There was no significantly difference in MAP,HR and RPP at any points of time between the two groups. The one-time success rate of intubation,the number of intubation times and the incidence of air-way complications in two groups(P>0.05)were no significantly different. Conclusions Compared with Clarus Video Stylet(Tracway),Shikani optical stylet can shorten the intubation time in patients with cervical spine immo-bilization,but no difference was found in regard to the hemodynamic influence on intubation,success rate of intu-bation,the intubation times,the sore throat and the other related complications.

Comparison of tracheal intubations using video intubationscope and Macintosh direct laryngoscope in patients with cervical spine immobilization / 中国内镜杂志

Objective To compare the clinical efficacy of the video intubationscope and Macintosh direct laryngoscope in simulated cervical spine immobilization. Methods Sixty patients, ASA Ⅰ or Ⅱ , between 19 and 68 years old, underwent general anesthesia requiring oro-tracheal intubation, were randomly assigned to undergo intubation using video intubationscope (group V) or Macintosh direct laryngoscope (group M), 30 cases in each. Each patient was provided mannal in-line axial stabilization of the head and neck by an experienced assistant. The following data were recorded and analyzed: glottic exposure time, Cormark-Lehane grade (C-L classification), tracheal intubation time, total intubation attempts, manoeuvre needed to aid tracheal intubation, failure for tracheal intubation, one-time success rate of tracheal intubation and total success rate of tracheal intubation, mean arterial pressure (MAP) and heart rate (HR) before induction of anesthesia, before intubation, at glottic exposure, at intubation, 1 and 3 min after intubation, and complications. Results Compared with group M, better glottic exposure view (C-L classification) was achieved in group V (P 0.05) and were significantly increased at T3~T5 (P < 0.05); compared with group M, MAP at T2~T4 in group V were significantly lower (P < 0.05). Compared with T1, HR in group V were no significantly changed at T2~T5, HR in group M were significantly increased at T2~T4 (P < 0.05), and significantly higher than that in group V at the same time point (P < 0.05). Conclusion Compared with Macintosh direct laryngoscopy in patients with cervical spine immobilization, Video intubationscope could provide better view of glottic exposure, decrease the difficulty of intubation and increase the success rate of intubation, have less complications and influence on patient’s hemodynamics.

Wilderness Medical Society practice guidelines for spine immobilization in the austere environment: 2014 update.

In an effort to produce best practice guidelines for spine immobilization in the austere environment, the Wilderness Medical Society convened an expert panel charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in an austere (dangerous or compromised) environment. Recommendations are made regarding several parameters related to spinal immobilization. These recommendations are graded on the basis of the quality of supporting evidence and balance between the benefits and risks or burdens for each parameter according to the methodology stipulated by the American College of Chest Physicians. A treatment algorithm based on the guidelines is presented. This is an updated version of original WMS Practice Guidelines for Spine Immobilization in the Austere Environment published in Wilderness & Environmental Medicine 2013;24(3):241-252.

Approaches to manual ventilation.

Manual ventilation is a basic skill that involves airway assessment, maneuvers to open the airway, and application of simple and complex airway support devices and effective positive-pressure ventilation using a bag and mask. An important part of manual ventilation is recognizing its success and when it is difficult or impossible and a higher level of support is necessary to sustain life. Careful airway assessment will help clinicians identify what and when the next step needs to be taken. Often simple airway maneuvers such as the head tilt/chin lift and jaw thrust can achieve a patent airway. Appropriate use of airway adjuncts can further aid the clinician in situations in which airway maneuvers may not be sufficient. Bag-mask ventilation (BMV) plays a vital role in effective manual ventilation, improving both oxygenation and ventilation as well as buying time while preparations are made for endotracheal intubation. There are, however, situations in which BMV may be difficult or impossible. Anticipation and early recognition of these situations allows clinicians to quickly make adjustments to the method of BMV or to employ a more advanced intervention to avoid delays in establishing adequate oxygenation and ventilation.

Wilderness Medical Society practice guidelines for spine immobilization in the austere environment.

In an effort to produce best-practice guidelines for spine immobilization in the austere environment, the Wilderness Medical Society convened an expert panel charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in an austere (dangerous or compromised) environment. Recommendations are made regarding several factors related to spinal immobilization. These recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks or burdens for each factor according to the methodology stipulated by the American College of Chest Physicians. A treatment algorithm based on the guidelines is presented.