• Akira Nishisaki, Louis Scrattish, John Boulet, Mandip Kalsi, Matthew Maltese, Thomas Castner, Aaron Donoghue, Roberta Hales, Lisa Tyler, Peter Brust, Mark Helfaer, and Vinay Nadkarni.
• Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA. nishisaki@email.chop.edu
• Pediatr Emerg Care. 2008 Nov 1;24(11):749-56.

ObjectiveCurrent guidelines recommend cervical spine immobilization during orotracheal intubation when traumatic injury is suspected in infants. We evaluated the effect of cervical spine immobilization techniques on orotracheal intubation performance with a high-fidelity infant simulator.MethodsA randomized control study with repeated measurement. Nonanesthesia pediatric practitioners certified for intubation performed 6 intubations with 3 different cervical spine immobilization techniques (no physical protection, manual in-line immobilization, and cervical collar: C-collar). Time to accomplish key actions, cervical extension angle, and observed intubation associated events such as mainstem intubation, esophageal intubation with or without immediate recognition were recorded.ResultsTwenty-six practitioners performed 156 successful orotracheal intubation. Time to intubation from end of mask assist ventilation was 29.0 +/- 12.2 seconds in no physical protection, 33.0 +/- 17.4 seconds in C-collar, and 33.0 +/- 17.1 seconds in manual in-line immobilization (P = 0.39). Maximal cervical extension angle in no physical protection (2.39 +/- 2.56 degrees ) and C-collar (2.65 +/- 1.79 degrees ) were significantly greater compared with 0.85 +/- 1.05 degrees in manual in-line immobilization (P < 0.0001). The number of intubation attempts and intubation associated events were not different among 3 techniques. Laryngeal visualization measured by Cormack-LehaneScale was more difficult in C-collar compared with other 2 techniques (P< 0.001).ConclusionsIn this high-fidelity infant simulator model, cervical spine immobilization technique affected cervical extension angle and laryngeal visualization. Tracheal intubation associated events occurred in 33% of intubation attempts but were not different by technique. Time to achieve tracheal intubation, number of intubation attempts needed to succeed, and intubation-associated events were not affected by immobilization techniques. These results support Advanced Trauma Life Support recommendations to perform manual in-line immobilization in infants.

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