How is rapid sequence intubation (RSI) performed on a patient with C-spine precautions?

Updated: Apr 07, 2020
  • Author: Keith A Lafferty, MD; Chief Editor: Guy W Soo Hoo, MD, MPH  more...
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To intubate a trauma patient with C-spine precautions, the cervical collar may be removed with a dedicated assistant providing inline immobilization. Removing the anterior part of the cervical collar while maintaining inline cervical spine immobilization is acceptable and may cause less cervical spine movement than cervical collar immobilization during laryngoscopy for endotracheal intubation.

Position the head and neck in the sniffing position by flexing the neck and extending the atlanto-occipital joint. Reposition the head if an adequate view of the glottic opening is not achieved.

The patient must be adequately preoxygenated to prevent desaturation during the period of apnea after the paralytic agent has been administered (to minimize the risk of gastric content aspiration). The least amount of ventilation support required to obtain good oxygen saturation should be used during this period. Blow-by high-flow oxygen via a nonrebreather mask is usually used, but for patients who are noted to desaturate (eg, beyond 90%), breaths delivered via 100% oxygen bag-valve-mask (BVM) may be required.

To minimize the risk of gastric aspiration, the Sellick maneuver (firm pressure over the thyroid cartilage) may be initiated as soon as positive-pressure ventilation is started (eg, during pretreatment if the patient is not able to maintain airway reflexes) and should be continued until inflation of the tracheal cuff of the endotracheal tube in the trachea. Note, however, that recent evidence questions the benefit of this modality. [9, 10]

Firm backward, upward, and rightward pressure (BURP) on the patient's thyroid cartilage can improve the Cormack/Lehane view up to one full grade. Typically, the assistant performing the Sellick maneuver can assist, resulting in a combined Sellick-BURP maneuver.

A No. 3 Macintosh or No. 3 Miller blade is generally sufficient for most patients, but a No. 4 blade (ie, next larger size) may be required in some adults. Note, some clinicians routinely use a No. 4 Macintosh blade, as it can be used in substitution of a Miller without switching blades.

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