Introduction

Acute victims often require immediate tracheal intubation and when this is necessary there are a number of concurrent problems to consider. There may or may not be immediate airway obstruction caused by extensive disruption to normal airway anatomy from both blunt and penetrating injuries. Airway haematoma and oedema may be present and certain injury patterns are recognized as causing airway compromise including the ‘flail’ mandible, where loss of support for the tongue anteriorly encourages it to fall backwards. Additionally, there may be severe haemorrhage and other debris present in the airway, which can make fibre-optic techniques impractical. There is invariably a full stomach with the associated risk of aspiration and finally, one must always consider injuries to the cervical spine.

Cervical spine injury

Approximately, 5% of severe, blunt injuries to the head and neck have cervical spine damage. Up to 14% of these injuries may be unstable, and between 1% and 5% of these injuries are initially missed. Fractures most commonly occur at the level of C2 and dislocations at the C5/6/7 regions (Figure 18.1). All such injuries may predispose to further airway obstruction from haematoma formation and soft tissue oedema in the neck (Table 18.1). Sadly, about 5% of patients admitted to hospital with cervical spine trauma will suffer a neurological deterioration after admission. Some of these deteriorations occur for no discernible reason, but some are associated with general anaesthesia. It seems sensible, therefore, to assume that there is an un-quantified risk of neurological deterioration in patients undergoing general anaesthesia with cervical spine injuries.