Nasotracheal intubation:

B. Is preferred for patients with suspected cervical spine injury.

DISCUSSION: The first principle in the management of any injured patient is to secure an adequate airway. This can be particularly difficult in the presence of facial or laryngeal trauma, or in the unconscious patient with a suspected cervical spine injury. The mechanical removal of oral debris followed by the “chin lift” or “jaw thrust” maneuvers to relieve soft tissue obstruction of the pharynx are the first steps. However, when there is any question regarding the adequacy of the airway, or in the presence of severe head injury, or when the patient is in profound shock, more definitive airway control is required. In most patients this involves oral endotracheal intubation. However, the insertion of an oral endotracheal tube often involves hyperextension of the neck with the potential for aggravating cervical spine ligamentous or bony injury. Nasotracheal intubation is the preferred option for the patient with suspected cervical spine ligamentous or bony injury since the head and neck can be maintained in the neutral position with minimal manipulation. This technique requires a breathing patient, as the passage of air must be heard through the nasotracheal tube prior to its insertion through the larynx into the trachea. Nasotracheal intubation is contraindicated in the presence of mid-face fractures. In this situation, a surgical airway (cricothyroidotomy, tracheostomy, or needle cricothyroidotomy) is the preferred option.