Pediatric emergency medicine trisk 3586 3586
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carefully removed. Helmet removal, if possible, should involve at least two people
to avoid potential neck motion. Occasionally, mechanical bivalving of the helmet
may be required for safe removal.
Caution must be exercised when applying airway maneuvers to a child with a
possible cervical spine injury. Airway interventions, however, often cannot wait
until the cervical spine is cleared. The clinician must prioritize and proceed with
lifesaving airway maneuvers while minimizing motion of and risk to a potentially
unstable cervical spine. Hyperextension of the neck to facilitate intubation should
be avoided. A vigorous chin lift or jaw thrust may also inadvertently hyperextend
the unstable cervical spine. Gentle cricoid pressure should not cause excessive
movement to the cervical spine; however, if applied vigorously, it may cause
flexion of the spine. When inline neck immobilization is used to assist with
airway maneuvers, the clinician should be careful to avoid applying traction to the
spine because this pressure can also stress the unstable cervical column. Tracheal
intubation in a patient with a potential cervical spine injury ideally requires at
least two providers to perform the procedure safely and efficiently. One provider
should maintain inline immobilization of the neck while another performs the
intubation. The immobilization is often best accomplished from below, allowing
the intubator as much room as possible to maneuver ( Fig. 112.11 ). The hard
cervical collar should be opened anteriorly, or removed. It is difficult to intubate a
child unless the reduction in mouth opening and jaw immobilization afforded by
the collar is temporarily removed, as the trachea is more anterior than in an adult.
Oral intubation is the preferred method because of the child’s airway position and
the usual experience of providers. Adjunctive airway techniques that do not
require vigorous laryngoscopy, such as video fluoroscopy and optical stylets, may
be useful in managing the airway of these patients. The collar should be resecured
after the airway intervention is complete.
