A 20-year-old man is brought to the emergency department after falling off a trampoline. He had been drinking alcohol with some friends and began jumping on a trampoline in his neighbor's backyard. The patient tried to do a backflip and landed on his head. Paramedics were called and found him confused but able to follow commands. However, he was unable to move his legs or his hands. The patient was placed in spine immobilization and transported to the emergency department. On arrival, his vital signs are within normal limits, but he has increasing shortness of breath and requests to sit up to help his breathing. Chest x-ray is normal, and ECG reveals sinus tachycardia. Over the next 30 minutes, his respirations become faster and shallower with more use of accessory muscles. The patient becomes sleepier and has difficulty responding to commands. Which of the following is the most appropriate next step in management?

Question

A 20-year-old man is brought to the emergency department after falling off a trampoline.  He had been drinking alcohol with some friends and began jumping on a trampoline in his neighbor's backyard.  The patient tried to do a backflip and landed on his head.  Paramedics were called and found him confused but able to follow commands.  However, he was unable to move his legs or his hands.  The patient was placed in spine immobilization and transported to the emergency department.  On arrival, his vital signs are within normal limits, but he has increasing shortness of breath and requests to sit up to help his breathing.  Chest x-ray is normal, and ECG reveals sinus tachycardia.  Over the next 30 minutes, his respirations become faster and shallower with more use of accessory muscles.  The patient becomes sleepier and has difficulty responding to commands.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

This patient who fell onto his head resulting in an inability to move his legs and hands likely has cervical spine trauma. In addition, his tachypnea, use of accessory muscles, and increasing somnolence are concerning for hypercapnic respiratory failure due to diaphragmatic paralysis. After a high cervical spine injury, patients are at risk for immediate diaphragmatic paralysis because the diaphragm is innervated by cervical nerve roots from C3-C5. However, if the spinal cord is injured lower than C5, a delayed diaphragmatic paralysis may occur (as in this patient) due to ascending edema. As in all trauma patients, primary survey includes assessment of the airway (in addition to breathing and circulation). In patients with impending respiratory failure, the best next step in management is orotracheal intubation, even with evidence of an unstable cervical spine injury, because this procedure can be rapidly performed and is relatively noncomplex. Typically, this is done with manual stabilization of the cervical spine to minimize neck movement during intubation. (Choice A) Nasotracheal intubation may be performed over a fiberoptic laryngoscope, or more often, the endotracheal tube is blindly passed through the nose and then direct laryngoscopy is performed to visualize the tube passing through the larynx. However, this adds unnecessary complexity (and increased time) to this patient's management, does not decrease neck extension, and does not result in a safer airway than orotracheal intubation. (Choice B) Needle cricothyroidotomy can be performed when other, less invasive techniques of airway management have failed (or are likely to fail). It is used only temporarily until a more secure airway can be placed because it offers no airway protection from secretions, may lead to CO₂ retention (and is particularly inappropriate in patients with hypercapnic respiratory failure), and gives less feedback about respiratory function (eg, ventilatory volumes, pressures, gas exchange). (Choice C) Noninvasive positive pressure ventilation (continuous positive airway pressure) is used primarily to improve oxygenation. This patient is likely hypercapnic due to diaphragm paralysis and requires improved ventilation rather than simply oxygenation. Noninvasive positive pressure ventilation also does not provide airway protection. (Choice E) Orotracheal intubation carries less risk (eg, bleeding, tracheal stenosis) and can be performed quicker than surgical tracheostomy; therefore, it is first-line management. In addition, the neck is often extended during tracheostomy, so this procedure would not necessarily prevent cervical spine movement. Educational objective: Patients with cervical spine injuries are at risk of respiratory compromise. Orotracheal intubation with manual stabilization of the cervical spine is recommended for initial airway management. References: Potential cervical spine injury and difficult airway management for emergency intubation of trauma adults in the emergency department-a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/16373795)

A 20-Year-Old Man Is Brought to the Emergency Department After