A method of intubation for cervical spine injured patients.

Each year, a total of 11,200 persons receive spinal cord injuries. Approximately 4,200 of those injured die before they can reach a hospital, and another 1,150 die during hospitalization.,' 8 Respiratory disturbance during the acute phase of upper thoracic or cervical spinal injury accounts for the high morbidity and mortality rate.2 The diaphragm is innervated by the phrenic nerve, which exits the spinal canal at C4 ; smaller branches exit at Ca and C5 . When lesions are present above C5, diaphragmatic innervation is completely lost. Partial diaphragmatic innervation is preserved when lesions are present at C 5. When lesions are present at C6 , diaphragmatic innervation is intact but intercostal and abdominal support to ventilation is lost. The intercostal muscles are innervated by the intercostal nerves, which exit the spinal canal at T 1 through T6 . Innervation of the abdominal muscles is through T7 to T 12 and L1 ; the scalene muscles are innervated through C4 to CS; and the sternomastoid muscles through C2 and the spinal accessory nerve. 8 Clearly, ventilatory function must be carefully evaluated in all cervical and thoracic spine injuries. An ascending level of spinal cord edema can also seriously compromise ventilation.4 Immobilization and/or traction of the head and neck is essential in cervical spine injuries. This means that extension and flexion maneuvers used during intubation will not be possible. Generally, these patients are intubated awake after adequate sedatives and narcotics have been administered. However, to avoid further spinal cord damage, the patient must be restrained from the rapid, jerky head movements associated with straining on the endotracheal tube while it is being advanced and once it is in place. Superior laryngeal nerve block and transtracheal block have proven to be tremendously helpful in these situations.