Direct laryngoscopy and endotracheal intubation in the prone position following traumatic thoracic spine injury

Department of Anesthesiology, ICU and Pain Therapy, Catharina Hospital-Brabant Medical School, Michelangelolaan 2, Eindhoven, The Netherlands.
Journal of Anesthesia (Impact Factor: 1.18). 02/2008; 22(2):170-2. DOI: 10.1007/s00540-007-0596-9
Source: PubMed


Perioperative airway management in trauma victims presenting with penetrating thoracic spine injury poses a major challenge to the anesthesiologist. To avoid further neurological impairment it is essential to ensure maximal cervical and thoracic spine stability at the time of airway manipulation (e.g., direct laryngoscopy and endotracheal intubation). Airway management in the prone position additionally increases the incidence of cervical/thoracic spine injury, difficult ventilation, and difficult airway instrumentation. Although awake fiberoptic intubation of the trachea is considered the gold standard for airway instrumentation in patients with posterior thoracic/cervical trauma, this technique requires the patient's cooperation, special equipment, and extensive training, all of which might be difficult to accomplish in emergency situations. We herein present the first reported case of an adult trauma patient who underwent direct laryngoscopy and endotracheal intubation under general anesthesia in the prone position. Although the prone position is not the standard position for airway instrumentation with direct laryngoscopy and endotracheal intubation under general anesthesia, our experience indicates that this technique is possible (and relatively easy to perform) and might be considered in an emergency situation.

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Available from: Eric W. Wilhelm geert Weber, Sep 08, 2014
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    • "In this planned type of surgery tracheal intubation has been performed in the supine position and the patient then turned to the prone position for the surgical procedure. The need for tracheal intubation in the prone position has been reported in only a few emergency situations (2,3), and this need has been met (2) or resolved by using a laryngeal mask (4,5). In some types of surgery in the prone position with short operation times, induction of anaesthesia and use of a laryngeal mask with the patient in the prone position facilitate the procedure, since the patient can position himself/herself comfortably (6–8). "
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    ABSTRACT: Background. Tracheal intubation in the prone position has previously been reported only as a necessity in a very few emergency situations. It emerged at our clinic as a routine after invention of a test aimed at pinpointing a painful motion segment in patients with chronic low back pain who were candidates for lumbar fusion operation. Material and methods. During a 6-year period 247 consecutive patients were treated at our clinic, 91 men and 156 women, mean age 42.8 years, range 25.3–62.8. Classification of the pharyngeal structures according to Mallampati et al. was done the day before surgery, and grading of visualization of the glottis as described by Cormack and Lehane was done during intubation, with the aim of revealing factors of importance for the possibility of performing tracheal intubation in the prone position. Results. The large majority of patients classified preoperatively as Mallampati class 1 had Cormack and Lehane grade 1 at laryngoscopy, although some patients had grades 2, 3, and 4. Most problems with intubation in the prone position were anticipated among those classified preoperatively as Mallampati class 3, but tracheal intubation in the prone position was still possible in 21 of the 23 patients in this group. In all, tracheal intubation in the prone position was successful in 244 of the 247 patients (98.8%). Conclusion. Routine tracheal intubation in the prone position can be performed effectively by experienced anaesthesiologists, but this requires continuous training and good support from the anaesthesiology staff.
    Full-text · Article · May 2012 · Upsala journal of medical sciences
    • "Sudden airway compromise during surgery, when the patient is in the lateral or prone position, is hazardous because tracheal intubation can be difficult.[5] Conventional anaesthetic management for patient undergoing surgery in prone position usually starts with induction of general anaesthesia in supine position; then the patient is shifted to prone position.[6] Use of laryngeal mask airway has been used successfully in many emergency situations. "
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    ABSTRACT: Management of airway in trauma victim with penetrating cervical/thoracic spine injury has always been a challenge to the anaesthesiologist. Stabilisation of spine during airway manipulation, to prevent any further neural damage, is of obvious concern to the anaesthesiologist. Most anaesthesiologists are not exposed to direct laryngoscopy and intubation in lateral position during their training period. Tracheal intubation in the lateral position may be unavoidable in some circumstances. Difficult airway in an uncooperative patient compounds the problem to secure airway in lateral position. We present a 46-year-old alcoholic, hypertensive, morbidly obese person who suffered a sharp instrument (screwdriver) spinal injury with anticipated difficult intubation; the case was managed successfully.
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