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Cervical spine protection in airway management (not a substitute for formal training)

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DR. MAHADEVAN: Hi, this is Dr. Mahadevan of Stanford University School of Medicine. I'm here with my good friend-- SAL KHAN: Sal. DR. MAHADEVAN: --Sal Khan. And we're following up to our earlier discussions about cervical spine injuries, or neck injuries. And we're going to talk about some of things you might do to manage a patient who might have a cervical spine injury in the case that you had to do something invasive, like manage their airway. SAL KHAN: Right. When you say manage their airway, there might be something stuck in their airway, or blocking their airway. DR. MAHADEVAN: Usually the tongue falls back and blocks the airway. But you're right. If your airways blocked, you can't get air to your lungs. And if you can't get air to your lungs, you die. SAL KHAN: Right. And when you said, usually your tongue falls back, that's normal-- wait, what are you talking about? DR. MAHADEVAN: When you're unconscious, the musculature, or the muscles that control your tongue, relax. Because you're unconscious, your tongue falls back exactly. And it falls back into your pharynx, which is a posterior part of your throat, there, and that blocks the air from either going either through your mouth or your nose into your trachea, and then into your lungs. SAL KHAN: Really? So if someone's just unconscious, and they fall back like that, that might cause them to stop breathing? DR. MAHADEVAN: That would obstruct their ability to breathe, and so even if they were trying to breathe, they wouldn't be able to move as much air into their lungs. SAL KHAN: OK. So it could be literally something as simple as moving the tongue out of the way. DR. MAHADEVAN: Exactly. And that's really what these first two diagrams show. The one with the young boy, there, is showing a technique called the head tilt-chin lift. SAL KHAN: Head tilt. OK, so he's laying down, they're pushing on his-- OK, they're pushing on that hand, down on the top of his head, and then lifting up there. DR. MAHADEVAN: Exactly. And in doing so, in sort of tilting the head and pulling the chin up, what you're effectively doing is pulling that tongue out of the way, and opening the airway so air can get into your lungs. SAL KHAN: I see. And this is a little off topic, but where did you get these pictures? DR. MAHADEVAN: These are actually pictures of my children. SAL KHAN: Yeah, I thought he was joking, because they're clearly drawings. I thought he lived in some type of animated reality. But no, apparently they are your children. DR. MAHADEVAN: That's my son, [? Auditya, ?] on the left, and my daughter, [? Lavinya, ?] on the right. SAL KHAN: OK, so someone traced them afterwards. They aren't-- DR. MAHADEVAN: Absolutely, a very excellent medical illustrator changed them from pictures into illustrations. SAL KHAN: Very cool. So sorry, that was off topic. DR. MAHADEVAN: And so the head tilt-chin lift. But as we talked about earlier, if you had a spine injury, moving the neck, or tilting the head, could potentially cause an injury. And so in trauma victims, we tend to avoid using this particular technique. And we use the one there on the right. SAL KHAN: I see, I see. Because something might have happened to their spine or their neck. DR. MAHADEVAN: And the last thing you want to do is turn their neck, or flex or extend their neck. SAL KHAN: I see. Right, because this is going to put a little pressure on the neck around that area. DR. MAHADEVAN: Exactly. Exactly. And the bones can move, and if the bones move, they can injure the spinal cord. SAL KHAN: This is, whoever this person who's hands these are-- DR. MAHADEVAN: My wife's hands. SAL KHAN: Oh, these are your wife's hands? Really? It's a family affair. And so what is it she doing exactly? DR. MAHADEVAN: She's doing a maneuver which we would use in someone who potentially could have an injury to the neck, called the jaw thrust. And essentially what she's doing is, she's grasping the angle of the mandible, exactly right there, kind of like a little 90 degree angle that we have, and pulling that mandible forward. And in doing that, what she's doing is, she's doing the same thing as the head tilt-chin lift, just she's not flexing the neck or extending the neck. SAL KHAN: So you're just kind of just moving the jaw as opposed to everything else. DR. MAHADEVAN: And in moving the jaw, you're pulling that tongue forward, and opening the airway. SAL KHAN: I see, because the tongue's in there. OK. That makes sense. DR. MAHADEVAN: And so this is the technique that we use for trauma victims. And the reason that this is important is really shown in the x-rays. And what you see is, the same person. And in the first x-ray, you can see, as we talked about earlier, their spine is well aligned. So if you were to check their alignment, anterior vertebral body line-- SAL KHAN: Yeah, I'm an expert at this, now. DR. MAHADEVAN: --posterior vertebral body line, spinolaminar line, and spinous process line all look fine in this particular circumstance. But what you can see, is if you remove the lines, you can see that there is a small fracture-- SAL KHAN: Right here. DR. MAHADEVAN: --right there. Exactly. And right in front of that fracture, there's a bunch of swelling. All that stuff right there is your soft tissues, and so they're swollen. And what you can't see is that your whole cervical spine is held together by ligaments. And sometimes they can be torn, and you may not be able to see them on the x-ray. SAL KHAN: I see. How did you know there was swelling here? DR. MAHADEVAN: If you look at the x-ray, you can see that the distance between the front of the spine, and the front of the soft tissues, is widened. SAL KHAN: Than what you would normally see. DR. MAHADEVAN: Exactly. SAL KHAN: I see DR. MAHADEVAN: Exactly. It's usually very small, very narrow in that part of the cervical spine. SAL KHAN: I see. It makes sense. DR. MAHADEVAN: And what you realize is, if a person were to come and try to open the airway, what happens on the next radiograph could occur. So if I were to-- SAL KHAN: So if they used this technique right over here. DR. MAHADEVAN: Exactly if they were to use the head tilt-chin lift, and were to tilt that head back-- SAL KHAN: Oh, yeah, put that pressure right there. DR. MAHADEVAN: Exactly. What could happen, the next x-ray shows-- SAL KHAN: They push the-- I wanted to use magenta, It's easier to see. So they push that back-- DR. MAHADEVAN: Exactly. SAL KHAN: And then [? wow. ?] OK. DR. MAHADEVAN: And now if you were to draw your lines again, specifically, the anterior you might get away with-- SAL KHAN: Yeah, but this one right-- [INTERPOSING VOICES] DR. MAHADEVAN: Definitley the posterior line is abnormal. And again, the key fact here is that, right behind that line that you drew is your spinal cord. SAL KHAN: Yes, which is important. Right. DR. MAHADEVAN: And so one of the tenets of Emergency Medicine, and medicine in general, is do no harm. And here, in an attempt to open the air way, by this head tilt-chin lift maneuver, we potentially could do harm to the patient. SAL KHAN: Yes. Wow, wow. Do no harm. It's a good first rule of thumb. Right, right. DR. MAHADEVAN: The next step that we would take, if just simply opening the airway wasn't adequate to get someone breathing again, potentially would be to actually intubate them, or insert a plastic breathing tube into their trachea, and allow them to breathe. What you can see there is the act of intubation. SAL KHAN: So yeah, I've heard this word intubate a lot. My wife is a physician, and I always hear-- so this is literally you're inserting a tube to clear things? DR. MAHADEVAN: You're inserting a tube to create a passageway from the oxygen-rich atmosphere, and directly into your lungs. And again, if your tongue has fallen back, and you can't keep it out of the way, or you vomited and you're unconscious, this would be something that would help you breathe. SAL KHAN: How far does this tube go? DR. MAHADEVAN: It starts right at your mouth, and it goes all the way down-- SAL KHAN: It's a flexible tube, I'm assuming. DR. MAHADEVAN: It's a flexible tube, and it would go right in between this cartilage right here. So it would kind of go right there, exactly. Right through the larynx, and right there where you've got the pointer, there, is where your vocal cords are. And it would go just beyond the vocal cords, right into your trachea. SAL KHAN: I see. DR. MAHADEVAN: Exactly, exactly. SAL KHAN: And that's because that's where you normally have something blocking. DR. MAHADEVAN: That is the connection between the oxygen-rich environment-- SAL KHAN: Oh, yeah. After that, then the oxygen can get to you, at least some part of your lungs. DR. MAHADEVAN: You've got a tube now. You've got an airway, and you can give, deliver oxygen to a patient through that tube. SAL KHAN: I see. I see. And what are they doing here? What are they pinching? DR. MAHADEVAN: In this particular diagram, what they're doing is a couple things. There's actually three people there. One person who looks like they're pinching is actually putting pressure on your cartilage, your cricoid cartilage. And they're doing that to push back and occlude your esophagus. SAL KHAN: Occlude the esophagus. What is occlude? DR. MAHADEVAN: They want to close off the esophagus because the esophagus connects to the stomach. The stomach is full of whatever you had to eat. SAL KHAN: Oh, I see. So you might be continuing to-- fluid could be coming out and all of that. I see. So there could be stuff coming out from the stomach. DR. MAHADEVAN: Right and that tube. The esophagus runs right back here, and it could come up. SAL KHAN: Sorry. Shows how much I know about [INAUDIBLE]. DR. MAHADEVAN: Exactly. Running right behind your airway, right there, and by pushing back, you collapse the esophagus and prevent any of what we call passive regurgitation or-- SAL KHAN: I see. So they're pushing this-- and let me do this in another color-- they're actually pushing back, and the esophagus is likely to get closed, then-- DR. MAHADEVAN: Exactly. SAL KHAN: So something can't come from the stomach. That doesn't close-- the trachea's more rigid? DR. MAHADEVAN: The trachea is a rigid structure. And this is actually, the first ring of the trachea is a cricoid cartilage, and that's what they're pushing on right there. SAL KHAN: I see. So this is rigid there, so when you push, it closes the esophagus, trachea can still stay open. DR. MAHADEVAN: Exactly. SAL KHAN: That makes sense. DR. MAHADEVAN: Exactly. So there's three people. One person that we talked about is giving cricoid pressure, and that would be that gentleman right there, or a young lady. The second person is actually holding the head, as you can see. And the reason that they're doing that is for what we showed earlier. They don't want that head to extend or flex. So they're actually holding the person in the neutral position to prevent those bones, potentially, from moving. SAL KHAN: Right, because they're going to be jiggling this thing through, and if there wasn't someone holding it, it could do that same damage. DR. MAHADEVAN: Absolutely. [INTERPOSING VOICES] DR. MAHADEVAN: And when you're that guy at the top who's trying to see the vocal cords, and pass the tube, you don't care about anything else except for seeing the vocal cords. So you might inadvertently flex the neck or extend the neck. SAL KHAN: Right, that makes sense. It makes sense. Is that also why they say at an accident, no, don't move the person and that type of thing? DR. MAHADEVAN: That's exactly why. Again, do no harm. In trying to help the person by lifting them up, or tilting their head, or flexing their neck, you potentially could cause a-- SAL KHAN: And that's why wait for the EMTs, or whoever, and then they'll-- DR. MAHADEVAN: Absolutely. SAL KHAN: --do it right. I see. DR. MAHADEVAN: And if you really had to open their airway, you could use the jaw thrust maneuver. SAL KHAN: Right. Just pull their jaw forward. DR. MAHADEVAN: Exactly. SAL KHAN: And hold on to the-- DR. MAHADEVAN: Exactly. SAL KHAN: We touched on right before this, there's other ways of doing this? Or there's other methods that people talk about? DR. MAHADEVAN: This cricoid pressure is quite controversial, because one of the things is it's supposed to help you with this procedure, and some people feel that it may not be proven to help you. Or it potentially can cause injury. But for those of us that are older, have used this technique for a long time, still stand by it. SAL KHAN: OK, this is what y'all teach it at the med school. DR. MAHADEVAN: Exactly. SAL KHAN: OK. DR. MAHADEVAN: Exactly. SAL KHAN: Well, thank you. This is very, very useful. DR. MAHADEVAN: You bet.