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LETTER TO THE EDITOR

Retrograde Tracheal Intubation in a Patient with a Halo Traction Device

Department of Anaesthesia and Intensive Care (Bhardwaj, Yaddanapudi) Department of Plastic Surgery; Postgraduate Institute of Medical Education and Research; Chandigarh, India; neerja.bhardwaj{at}gmail.com (Makkar)

To the Editor:

Halo traction for stabilization of the cervical spine limits access to the face and immobilizes the neck, making tracheal intubation difficult. Fiberoptic and Bullard laryngoscopes, intubating laryngeal mask airway, and Combitube have been used for airway management in such cases (1–4). We describe retrograde tracheal intubation in a patient with halo traction.

A 42-year-old woman sustained scalp avulsion and C₂ spine fracture when her hair was caught in a thresher. A halo device was applied to stabilize the cervical spine in mild flexion (Fig. 1). We did not have access to a fiberoptic laryngoscope, which limited our options. We elected to perform awake retrograde intubation.

View larger version (108K): [in this window] [in a new window]   Figure 1. Radiograph (lateral view) of the cervical spine showing the C2 fracture and the halo device in situ.

After explaining the procedure to the patient, we administered topical anesthesia to the airway, and then introduced an 18-guage IV cannula into the trachea through the cricotracheal membrane. We then threaded a ureteral stent as a guidewire from the cricotracheal membrane into the mouth. We were unable to thread a 7.0 mm endotracheal tube over the guidewire, as it could not navigate past the glottis. We advanced the guidewire into the nasopharynx, and brought it out through the nose. We could easily advance the endotracheal tube through the nose and into the trachea.

Figure 2 explains why the nasal route was successful, when the oral route failed. During oral intubation, the guidewire traversed the anterior part of the glottis and formed an acute curve, accentuated by the flexed neck. This curve caused the tube to impinge on the anterior glottis. The nasal guidewire forms a wider curve and passes through the wider posterior glottis, resulting in successful intubation (Fig. 2).

View larger version (29K): [in this window] [in a new window]   Figure 2. (a) The oral guidewire lies in the anterior part of the glottis and forms an acute curve; (b) The nasal guidewire lies in the posterior glottis and forms a wide curve.

Retrograde intubation can be performed through either the cricothyroid or the cricotracheal membrane. The cricotracheal approach is more likely to be successful because the guidewire makes a wider curve at the laryngeal inlet. It also avoids other complications of the cricothyroid approach, such as hematoma, hoarseness, and subcutaneous emphysema (5).

REFERENCES

1. Fuchs G, Schwarz G, Baumgartner A, et al. Fibreoptic intubation in 327 neurosurgical patients with lesions of the cervical spine. J Neurosurg Anesthesiol 1999;11:11–16.[Medline]
2. Cohn AI, Lau M, Leonard J. Emergent airway management at a remote hospital location in a patient wearing a halo traction device. Anesthesiology 1998;89:545–6.[Web of Science][Medline]
3. Senor EB, Sarihasan B, Ustun E, et al. Awake tracheal intubation through the intubation laryngeal mask airway in a patient with halo traction. Can J Anaesth 2002;49:610–3.[Web of Science][Medline]
4. Mercer M. Respiratory failure after tracheal extubation in a patient with halo frame cervical spine immobilization–rescue therapy using the Combitube airway. Br J Anaesth 2001;86:886–91.[Abstract/Free Full Text]
5. Shantha TR. Retrograde intubation using the subcricoid region. Br J Anaesth 1992; 68:109–12.[Abstract/Free Full Text]

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				K. Maruyama, T. Yamada, K. Hara, H. Nakagawa, and A. Kitamura Tracheal intubation using an AirWay Scope(R) in a patient with Halo-Vest Fixation for upper cervical spine injury Br. J. Anaesth., April 1, 2009; 102(4): 565 - 566. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (3) Citing Articles via Google Scholar Google Scholar Articles by Bhardwaj, N. Articles by Makkar, S. Search for Related Content PubMed PubMed Citation Articles by Bhardwaj, N. Articles by Makkar, S.