Practical approach

1. Call for help and prepare
   • Assign roles: airway operator, person providing manual in-line stabilization (MILS), medication/monitoring clinician.
   • Prepare suction, bag-mask ventilation, video laryngoscope, bougie/stylet, supraglottic airway, and a front-of-neck access kit.
   • Continuously monitor SpO₂, ECG, blood pressure, and capnography.
2. Maintain spinal precautions
   • Keep the patient supine and neutral. Do not apply traction.
   • Remove or open the front/anterior portion of the rigid collar for intubation, while a trained assistant holds the head and neck in neutral alignment with MILS.
   • Avoid head-tilt/chin-lift. Use jaw thrust to open the airway.
3. Preoxygenate thoroughly
   • Use high-flow oxygen and a well-fitting mask.
   • Gentle positive-pressure ventilation is appropriate if required to prevent desaturation. Avoid unnecessarily high pressures and excessive tidal volumes.
   • Hypoxia is more immediately harmful than the small amount of unavoidable neck movement during a careful airway attempt.
4. Use a first-pass-success strategy
   • Video laryngoscopy is preferred where available and the operator is skilled, often with a bougie or stylet.
   • Limit lifting force and avoid repeated attempts.
   • An experienced operator using direct laryngoscopy may be appropriate if video laryngoscopy is unavailable or they are more proficient with it.
   • A 2024 guideline recommends videolaryngoscopy where possible and consideration of a bougie/stylet in cervical spine injury. It also notes that MILS can worsen the laryngeal view. Association of Anaesthetists guideline
5. If the view is poor or intubation is difficult
   • Do not persist with repeated traumatic laryngoscopy attempts.
   • Optimize oxygenation, suction blood/vomit, reposition external laryngeal manipulation as appropriate, and use a bougie.
   • Because MILS can substantially impair laryngoscopy, consider reducing or temporarily releasing it if it is preventing life-saving intubation, while maintaining as neutral a position as feasible.
   • Place a supraglottic airway as a rescue oxygenation device if needed.
   • If unable to intubate and unable to oxygenate, proceed promptly to emergency front-of-neck access per local difficult-airway protocol.
6. Confirm and secure
   • Confirm tracheal placement with continuous waveform capnography.
   • Secure the tube without moving the neck, then reapply full cervical immobilization.
   • Document neurologic status when feasible before and after airway management.

Awake fiberoptic intubation

Key points

• Protect the neck, but do not let immobilization cause failed oxygenation or delayed airway control.
• Remove the anterior collar piece for the attempt and use neutral-position MILS rather than traction.
• Aim for one well-planned attempt by the most experienced available clinician.
• Video laryngoscopy generally improves first-pass success in immobilized patients. A recent meta-analysis found it faster and more successful on the first attempt than flexible fiberoptic intubation in simulated cervical immobilization, though most evidence is not from actively bleeding, unstable trauma airways (2024 systematic review). Another 2025 meta-analysis found C-MAC video laryngoscopy improved first-pass success compared with direct laryngoscopy (study abstract).