If you doubt the importance of this, read the story about local man, Will Clark, who was paralysed from the neck down  (published in the Westmorland Gazette). He says “A little stick got caught in my wheel and it stopped me dead. I was thrown forward and landed on my neck. I should have known to stay still, just to lie on my back but I didn’t realise what kind of injury I might have; that it would be spinal. I sat up and felt my arms and legs just lock up and that was it.”

How to apply Manual Inline Stabilisation

Place your hands on either side of the head and hold it still.

An alternative method is to grip the muscle between the neck and shoulder on each side, holding the head still between your forearms. This method is more effective if the casualty is restless.

A third very useful method is to place the head between your knees. This is very useful when you are on your own as it leaves your hands free to e.g. support the airway, check the pulse, etc. This method can be used when the casualty is lying on their back or face down.

Response: C-spine damage not expected

If the casualty is apparently unconscious as you approach but there is no reason to suspect a dangerous mechanism of injury, place your hand on their forehead and say – “Hello, can you hear me?”  If they respond either verbally or by opening their eyes, explain who you are, that you are going to assess them, what this involves and if possible get their consent to treat them.

If you don’t get an answer, then they are probably unconscious so an airway problem is very likely to be present. This is discussed further below.

Airway

Look for Airway Obstruction

If there is no or limited response, then look in the mouth for obstructions.  Consider the three most likely causes of obstruction: tongue (commonest), fluids (e.g. vomit) and objects (could be a tooth that has become dislodged by the injury).  This should be done under direct vision. If necessary, use a head torch or the pen torch to help you see.

Anaphylaxis is a cause of airway obstruction. Consider whether it may be the cause of airway problems.  If so, treat IMMEDIATELY with adrenaline. – see the anaphylaxis section for more details. 

Clear the Airway

Remove any foreign material (fluids or debris from the mouth) with suction, Magill forceps, a finger sweep or recovery position. Also consider removing loose fitting dentures.

Caution! Do not grope blindly in the mouth as this can push objects further down the throat. Only use suction, forceps or a finger sweep under direct vision. 

Remember – Fingers can be bitten or scratched by teeth so be careful and wear gloves.  Consider using the tip of an OP airway inserted side on (perpendicular) between the teeth as a bite block to protect yourself whilst doing a finger sweep.

The casualty may have to be rolled onto their side to clear the mouth/airway. Obviously don’t be unnecessarily heavy handed and try to protect the C-spine, but do not let concern over a risk of spinal injury compromise your airway management.

Maintain The Airway

Head Tilt Chin Lift
If there is no likelihood of C-spine damage, you can use a head tilt and chin lift or jaw thrust to maintain the airway.

Jaw Thrust
If there is potential for C-spine damage, or if in doubt, only use a jaw thrust to maintain the airway with minimal disturbance of neck stability. The tongue is a very large organ (see the diagram at the top of the page) and can easily cause airway obstruction. Jaw thrust is a very effective manoeuvre for moving the tongue forwards and away from the back of the throat to allow the unimpeded passage of air.

Notice the position of the operator’s thumbs. They are resting on the jawbone (mandible), not on the cheeks. If you attempt to make jaw thrust easier by applying counter pressure with your thumbs by pressing on the cheeks and there are fractures of the facial bones, the pressure from your thumbs will push the front of the face inwards. 

Once a second team member arrives on scene, one person takes responsibility for airway maintenance and C-spine stability.  This is their only role. They are in charge of and co-ordinate all movements of the casualty.

Practical Tip – the need for Airway Management and C-spine protection can be prolonged. Ensure you are in a comfortable position when you start.

Recovery Position
Sometimes the most effective way to maintain a clear airway is through the casualty’s body position e.g. if the jaw is clenched or locked, they have certain types of facial injuries or if they are repeatedly vomiting or bleeding in their mouth or nose.  For this we use the recovery position as it ensures the airway remains clear and open whilst allowing vomit or fluids to drain away.

As with moving them to clear their airway, obviously don’t be unnecessarily heavy handed, but do not let concern over a risk of spinal injury compromise your airway management.

A good way to remember the steps to get ready to turn someone into the recovery position is the saying ‘hello, cheeky, fancy a knees up’.

To place someone in the recovery position (the image shown here is the same for an adult):

• Kneel on the floor on one side of the person

• Place the arm nearest you at a right angle to their body with their hand upwards towards the head (‘hello’)

• Tuck their other hand under the side of their head, so that the back of their hand is touching their cheek (‘cheeky’)

• Bend the knee farthest from you to a right angle (‘fancy a knees up’)

• Roll the person onto their side carefully by pulling on the bent knee

• The top arm should be supporting the head and the bottom arm will stop you rolling them too far

• Open their airway by gently tilting their head back and lifting their chin, and check that nothing is blocking their airway

• Monitor closely

• If their injuries allow you to, turn the person onto their other side after 30 minutes

The diagram below illustrates the steps described above. Although it says Recovery Position for children, it works for adults too.

Secure the Airway

If the airway is not self-supporting, it will be necessary to insert a device or use body position to keep the airway open. We carry three types of artificial airway designed to keep the upper airway open. Which one you choose depends upon the level of consciousness, the presence of other injuries, and whether you will need to assist breathing.

Oropharyngeal Airway (OPA)

OP airways are the first choice in an unconscious casualty who is unable to maintain a clear airway but does not require assisted breathing.

OP airways should not be used in responsive casualties as they can cause vomiting (with risk of inhaling the vomit) or laryngospasm (mechanical irritation of the vocal cords causing them to go into spasm and block the airway).

 Inserting an OP airway
1). Size the airway. The appropriate size of the OPA is determined by measuring from the angle of the casualty’s jawbone to the centre of the incisors (see video below).

2). Look in the mouth under direct vision and clear any obstructions before inserting an OPA,. Consider removing loose fitting dentures.

3). Invert, insert (with care) & rotate (see video below). There is no need to invert an OPA for infants under 2 years old.

4). If seated correctly, the flange should be resting on either the lips or the front teeth.

If at any time, the casualty rejects the OPA, remove it immediately and consider a Nasopharyngeal Airway (NPA).

Nasopharyngeal Airway (NPA)

This is the most easily tolerated of the three airways, even by semi-conscious casualties. Most importantly, it can be used in a casualty with a clenched jaw. If inserted correctly, an NPA can be used in casualties with a suspected base of skull fracture.

1). Size: 6mm for female and 7mm for male.

2). Lubricate well using a water based lubricant.

3). Have suction available in case the nose bleeds.

4). If the casualty is lying on the ground, insert by pushing or twisting in a vertical direction towards the ground (as though you are nailing them to the ground). NEVER follow the angle of the nose towards the forehead. It doesn’t lead to the airway and if there is a skull fracture, the NPA might poke into the brain!

Do not force.  The nose can bleed profusely and this will cause major airway obstruction. If one nostril is blocked, try the other.

5). After inserting the airway look in the mouth again to check for bleeding.

Practical tip – OP and NP airways can be used together, for example one or two NP airways could be used at the same time as an OP airway.

Inserting an oversized NPA has two important disadvantages. (1) Greater likelihood of causing a nose bleed; (2) It will be too long for the casualty so can either go down the upper oesophagus (in which case, it won’t function as an airway device), or it will head towards the voice box and potentially provoke laryngospasm (see above).

i-gel Airway

i-gel airways are the preferred device in unconscious casualties who require assisted breathing.  They are much easier to use than attempting to breathe for the casualty using a bag-valve-mask. An i-gel is commonly used for cardiac arrest, drug overdose, head injury and respiratory insufficiency.

1). Size according to ideal body weight of casualty (written on the i-Gel). If the casualty is obese, consider the weight they are likely to be if they weren't over weight:

• Size 3 (yellow) for 30-60 kg or below 9 stone (children 8y old and older, and small men and women)

• Size 4 (green) for 50-90 kg or above 9 stone (men and larger women)

2). Lubricate using a water-based lubricant on the back and edges only. Ensure no lubricant gets into the bowl (front) of the device as this will obstruct it.

3). To insert an i-gel, ask a colleague to open the casualty’s mouth and move the jawbone (mandible) forwards by pulling on the angle of the jaw (jaw thrust). Remove loose fitting dentures.

4). Insert towards the hard palate then guide the device downwards and backwards along the hard palate with a continuous and gentle push until you feel a definitive resistance.

5). When fully inserted the incisors should rest on the body of the device near the black line.

6). Stabilise in position using tape fixed to one cheek, around the i-gel, and ending on the other cheek.

7). The i-gel can be attached to the bag and valve directly. Connect the bag to oxygen. Note: this does not need to be removed for defibrillation.

If inserted correctly an i-gel can reduce the likelihood of vomit being inhaled into the lungs.

If the casualty rejects the i-gel remove it and consider an alternative method of keeping the airway clear.

Below is a very comprehensive video made for hospitals by the manufacturers but shows all the essential relevant information that we need. Note: we will not be using the gastric channel in MR.

We have written a Standard Operating Procedure for the i-gel. This provides more information about the device and is a MREW requirement as the i-gel is a more complicated device than a OPA or NPA.

You can download a copy of the LAMRT SOP for the i-gel HERE or click on the download link below.

Recovery Position
As with maintaining the airway it may not always be possible or desirable to keep the airway secure using artificial airway devices.  Again this could because the jaw is clenched or locked, they have certain types of facial injuries or if they are repeatedly vomiting or bleeding in their mouth or nose.

In these instances the recovery position as described above should be used to secure the airway. This may include evacuating the casualty.

Complications Caused By Facial Injuries

Facial injuries are rare in MR, but could conceivably occur in a cyclist who flies over the handle bars, or in a climber whose face impacts on rocks as he falls. Mild facial injuries, such as superficial lacerations, do not generally cause airway problems. A nose bleed could be more problematic if the casualty is unconscious and lying on their back.

Major trauma to the face can lead to serious airway problems, and these can be exceedingly difficult to manage (even for experts). This is because an intact facial skeleton is necessary to keep the airway clear. Once that is disrupted, the tissues tend to collapse under the influence of gravity and cause life-threatening airway obstruction.

Anyone who has facial trauma is a good candidate for accompanying cervical spine injury. The principles outlined above are appropriate for managing the airway in casualties with facial trauma. Note that even a small amount of blood can cause significant airway obstruction, so suction will almost certainly be needed.

If the casualty is conscious, they will already be sitting or lying in the best position to keep their airway clear when you arrive. It is essential that you allow them to do that and not force them to lie down, in spite of concerns about the cervical spine. Airway takes priority over cervical spine.

A good example of this dilemma is someone with a fracture of both sides of the jawbone (mandible). In an intact, conscious person, muscle tone keeps the jaw and tongue in a suitable position to keep the airway clear. When the jawbone (mandible) is fractured in two places, the whole floor of the mouth including the tongue becomes mobile and will fall uncontrollably backwards to cause severe obstruction if the casualty lies down. In addition, blood will pool at the back of the throat and complete the obstruction. A person with this problem will only be able to keep their airway clear if they can sit up and lean forwards, and allow any blood to dribble out.

If you have to allow a casualty to be in a “non-ideal position” e.g. sitting up when there is a clear risk of cervical spine injury, then record on the Cas Card why you did that and make sure you inform the paramedics when you hand over the patient.

At this point, if you are on your own, consider whether it would be helpful to place the casualty in the recovery position.