A 50 year old man is brought into the Emergency Department after acute flexion injury to the neck while surfing.  He is unable to move both arms or legs and has a sensory level at C4·5.   He ls a heavy smoker with a history of chronic bronchitis.

(b) His breathing is laboured with a  rate of 40 and with a paradoxical movement   What will you do?

[Click here to toggle visibility of the answers]

College Answer

Paradoxical movement in this setting suggests paralysed intercostals and residual diaphragm function. This produces at least 30% loss of FVC and will mean a poor cough in a supine patient. If he is struggling to breathe, he has no hope of effectively coughing. If the candidate had intubated the patient in (a) that was OK. The waverers should put the tube in and explain their technique in detail. There is limited place for non-invasive ventilation in this setting.

Discussion

As the college points out, paradoxical movement here demonstrates that only the diaphragm is moving the lungs. This is bad.

Thus: the patient needs to be intubated.

  • ensure the presence of skilled assistants and standby airway-skilled staff
  • ensure the rapid sequence induction drugs are prepared and checked
  • ensure the intubation equipment is prepared and checked, and that difficult intubation equipment is ready (videolaryngoscope, McCoy blade, bougie)
  • Ensure a Plan B is available (LMA)
  • Ensure inline stabilisation of the C-spine to prevent any further injury
  • Consider decompressing the stomach with an NGT before the intubation attempt to reduce the risk of aspiration
  • Intubate the patient with rapid sequence induction, using cricoid pressure