Airway management with cervical spine injury
Stem
A 34-year-old man, 85 kg, crashed his motorcycle five hours ago. He is in a rigid collar with a C5–C6 fracture-dislocation on CT, weak hand grips and reduced sensation below the clavicles. He is alert, cooperative and has no facial injury. He ate a large meal just before the crash. Blood pressure is 96/54, heart rate 58. He is booked for urgent reduction and fixation.
Question
How will you secure his airway?
Ideal answer
HeadlineOxygenate, hold the pressure and move the neck least: norepinephrine infusion and arterial line first for neurogenic shock, then a videolaryngoscope RSI with in-line stabilization.
- MAP at least 75–80 mmHg, not above 90–95,1 because hypoxia and hypotension extend cord injury, and no airway technique has been proven to change neurological outcome.2
- Preoxygenate head-up on the board, jaw thrust, not head tilt, if he needs support,2 since tilt moves the injured neck.
- Videolaryngoscope, the guideline's preferred device, bougie loaded,2 an assistant holding in-line stabilization from below, collar front removed so he can open his mouth.2
- Reduced-dose etomidate and rocuronium 1.2 mg/kg, about 100 mg, for his full stomach;3 cricoid by a trained assistant, released if it hinders the view.2
- Predicted difficult airway: awake flexible-scope intubation instead, keeping his own airway; neurology rechecked before induction.
Breaking down the answer
- The cord is hurt by hypoxia and hypotension, not just by laryngoscopy — delayed neurological deterioration happens in 2–10% of cord injuries without a clear cause, so blaming the intubation is often wrong.2
- Videolaryngoscopy is the one moderate-grade recommendation — the guideline does not prefer a particular blade; I use the one I am best with.2
- Collars and MILS make intubation harder — rigid collars reduce mouth opening, and MILS worsens the glottic view with little evidence that it prevents injury. Changes if: the view is poor; I loosen it early.2
- Succinylcholine is also acceptable this early — it becomes dangerous only after the acute phase of cord injury.4
- Awake is an option, not a mandate — the historic gold standard, but with no evidence of superiority in preventing secondary cord injury; it suits a cooperative patient with predicted difficulty.2
- Rescue devices — a second-generation supraglottic airway is preferred, and a front-of-neck airway follows the DAS technique.2 Under a collar, that means a vertical skin incision by default, unless the membrane is clearly palpable or ultrasound-marked.5
- Pressure is part of the airway plan — neurogenic shock makes induction a hypotension risk; the older AANS/CNS target was MAP 85–90 mmHg for 7 days, and the 2024 guideline suggests augmenting MAP for 3–7 days.1
Follow-up question
With in-line stabilization, your first videolaryngoscopy attempt shows only the arytenoids, the bougie will not pass, and his saturation falls to 88%. What now?
Follow-up answer
HeadlineA failed first attempt with falling saturation, and I say so: "Failed attempt, mask ventilate, call for help."
Two-hand mask ventilation with jaw thrust, cricoid released. For the second attempt the assistant eases the in-line stabilization, because a poor view with MILS is a reason to relax it, and I adjust the bougie angle or switch to a hyperangulated blade with a stylet.2 If that fails, a second-generation supraglottic airway to oxygenate; if I cannot oxygenate by any route, I declare a can't-intubate, can't-oxygenate emergency and perform an emergency front-of-neck airway following the DAS technique.2 Once stable, I reassess his pressure and document a neurological examination when he wakes.
Pitfalls that cost points
- Saying awake fiberoptic intubation is mandatory for every cervical injury.
- Persisting with in-line stabilization through repeated failed attempts.
Rapid-fire
Q: Which simple airway manoeuvre moves the neck least? A: Jaw thrust rather than head tilt and chin lift.2
Q: Can you mark the cricothyroid membrane with the collar on? A: Yes; ultrasound marking before induction is reasonable in a predicted difficult airway.2
Q: When is cricoid force avoided altogether? A: When laryngeal injury is suspected.2
Q: Why the bradycardia and hypotension? A: Cervical cord injury interrupts cardiac sympathetic outflow, leaving unopposed vagal tone and vasodilation.
Q: When does succinylcholine become contraindicated? A: After the acute phase of an upper motor neuron injury, because of severe hyperkalemia and cardiac arrest.4
Numbers to know
| Item | Value |
|---|---|
| Rocuronium for RSI | 0.6–1.2 mg/kg3 |
| MAP target (2024) | At least 75–80, not above 90–95 mmHg1 |
| MAP augmentation duration | 3–7 days1 |
| Delayed neurological deterioration | 2–10% of cord injuries2 |
| DAS cervical spine recommendations | 232 |
Links
- Spinal cord injury and autonomic hyperreflexia, Trauma: initial management and damage control, Rapid sequence induction and full stomach, Awake fiberoptic intubation: topicalization and sedation, Anticipated difficult airway and the ASA algorithm
- DAS/multi-society guidelines for airway management in cervical spine injury (2024); AO Spine acute SCI guideline (2024)
Sources
- 1.A Clinical Practice Guideline on the Timing of Surgical Decompression and Hemodynamic Management of Acute Spinal Cord Injury: Introduction, Rationale, and Scope · AO Spine / Praxis (Global Spine Journal), 2024 · ebi.ac.ukFull text via Europe PMC (PMC10964894); summarizes the 2013 AANS/CNS 85-90 mmHg for 7 days and the 2024 MAP recommendations.
- 2.Airway management in patients with suspected or confirmed cervical spine injury: Guidelines from the Difficult Airway Society (DAS), Association of Anaesthetists (AoA), BSOA, ICS, NACCS, Faculty of Prehospital Care and RCEM · DAS and partner societies (Anaesthesia), 2024 · ora.ox.ac.ukWiles et al., Anaesthesia 2024;79:856-68; open-access PDF from the Oxford repository. 23 recommendations.
- 3.Rocuronium bromide injection prescribing information · FDA / DailyMed · dailymed.nlm.nih.govRapid sequence intubation dose 0.6-1.2 mg/kg.
- 4.QUELICIN (succinylcholine chloride) injection prescribing information · FDA / DailyMed · dailymed.nlm.nih.govContraindicated after the acute phase of upper motor neuron injury.
- 5.Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults · DAS, 2025 · sea.org.ecAhmad et al., Br J Anaesth 2026;136:283-307 (online 7 Nov 2025), doi 10.1016/j.bja.2025.10.006; full English text hosted by the Sociedad Ecuatoriana de Anestesiología. Plan D: vertical skin incision (up to 8 cm) is the default eFONA incision unless the cricothyroid membrane is clearly palpable or ultrasound-marked; number 10 blade, bougie, 6.0 cuffed tube.
Facts on this page were checked against these sources on Oct 15, 2026. Guidelines change; confirm doses against current institutional protocols.