British Journal of Anaesthesia 1998; 80: 270–274 Tracheal intubation in trauma

Sir,—The article by Nolan and Parr1 depicted in-line cervical stabilization and cricoid pressure during tracheal intubation in the trauma patient (fig. 2). In figure 2, in-line cervical stabilization is demonstrated as if it were a single-handed technique. It is accepted practice, however, to perform this manoeuvre as a double-handed technique (although we are sure this is the effect of the line drawing rather than the authors’ practice). The same figure also depicted single-handed cricoid pressure. There has been some controversy in the literature regarding the practice of cricoid pressure in the trauma patient with potential cervical spine injury. Some authors have claimed that there is no difference in the view obtained of the larynx2 whereas other assert that bimanual cricoid pressure enhances the view of the larynx.3 There is debate on the safety and efficacy of either technique on the stability of the cervical spine during tracheal intubation. In a recent investigation,4 Gabbott examined movement of the cervical spine with single-handed cricoid pressure in subjects in whom the trachea was intubated, although unfortunately he did not compare it with bimanual cricoid pressure. In the discussion that follows, he makes recommendations that we would agree with in the management of the potentially unstable cervical spine during intubation. We would suggest that if a hard cervical collar (particularly the two-piece collar) has been applied before tracheal intubation, then the posterior piece provides adequate support for the back of the neck and single-handed cricoid pressure may then be applied. Indeed, to remove the collar may risk additional movement of the cervical spine.5 If a hard collar is not in place then bimanual cricoid pressure is probably the safer practice.