Why is the jaw-thrust maneuver indicated for a patient with a possible spinal injury?

Box 3-1   Potential Adverse Effects of Oxygen Administration during Adult and Neonate Resuscitation

Overview of Post-Cardiac Arrest Care and the Use of Supplemental Oxygen

Although 100% oxygen may have been used during initial resuscitation, providers should titrate inspired oxygen to the lowest level required to achieve an arterial oxygen saturation of ≥94%, so as to avoid potential oxygen toxicity. It is recognized that titration of inspired oxygen may not be possible immediately after out-of-hospital cardiac arrest until the patient is transported to the emergency department or, in the case of in-hospital arrest, the intensive care unit (ICU). The optimal FIO2 during the immediate period after cardiac arrest is still debated. The beneficial effect of high FIO2 on systemic oxygen delivery should be balanced with the deleterious effect of generating oxygen-derived free radicals during the reperfusion phase. Animal data suggests that ventilations with 100% oxygen (generating PaO2 > 350 mm Hg at 15 to 60 minutes after ROSC) increase brain lipid peroxidation, increase metabolic dysfunctions, increase neurological degeneration, and worsen short-term functional outcome when compared with ventilation with room air or an inspired oxygen fraction titrated to a pulse oximeter reading between 94% and 96%.82–87* One randomized prospective clinical trial compared ventilation for the first 60 minutes after ROSC with 30% oxygen (resulting in PaO2 = 110 ± 25 mm Hg at 60 minutes) or 100% oxygen (resulting in PaO2 = 345 ± 174 mm Hg at 60 minutes).88* This small trial detected no difference in serial markers of acute brain injury, survival to hospital discharge, or percentage of patients with good neurological outcome at hospital discharge but was inadequately powered to detect important differences in survival or neurological outcome.

Once the circulation is restored, monitor systemic arterial oxyhemoglobin saturation. It may be reasonable, when the appropriate equipment is available, to titrate oxygen administration to maintain the arterial oxyhemoglobin saturation ≥94%. Provided appropriate equipment is available, once ROSC is achieved, adjust the FIO2 to the minimum concentration needed to achieve arterial oxyhemoglobin saturation ≥94%, with the goal of avoiding hyperoxia while ensuring adequate oxygen delivery. Since an arterial oxyhemoglobin saturation of 100% may correspond to a PaO2 anywhere between ~80 and 500 mm Hg, in general it is appropriate to wean FIO2 when saturation is 100%, provided the oxyhemoglobin saturation can be maintained ≥94% (Class I, LOE C)

If a cervical spine injury is suspected, try to open the airway using a jaw-thrust. The Resuscitation Council (UK) stresses that maintaining an airway and sufficient ventilation is the overriding priority in caring for a person with a suspected spinal injury (Resuscitation Council (UK) 2015). In a patient with no evidence of head or neck trauma, use the head tilt-chin lift method to open the airway.

Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.

Based on Mosby Nursing Skills
Adapted by: Chris Brooker BSc MSc RGN SCM RNT
Updated by: Katy Elliott BH Hons RN
Last updated: April 20

Head tilt-chin lift – adult. (From Sanders M J 2006 Mosby’s Paramedic Textbook, 3rd edn. Mosby, St Louis.)

Jaw-thrust – adult. (From Emergency Nurses Association 2007 Trauma Nursing Core Course: Provider Manual, 6th edn. Emergency Nurses Association, Des Plaines.)

Head tilt-chin lift – child. (From Trigg E, Mohammed T A 2010 (eds) Practices in Children’s Nursing. Guidelines for Hospital and Community, 3rd edn. Edinburgh, Churchill Livingstone.)

Learning Objective

After reading the skill overview, watching the video, following up some of the references/web sites and completing the self-test quiz you should be ready to be assessed in practice in the skill of opening the airway.

Introduction

The head tilt-chin lift and jaw-thrust methods are indicated for conscious and unconscious patients who do not have an adequate airway. The purpose of these methods is to open and maintain a patent (clear) airway or to relieve a partial or total airway obstruction. The most common causes of airway obstruction are displacement of the tongue into the posterior pharynx and displacement of the epiglottis at the level of the larynx. This may be due to head injury, seizure activity, medications (especially opiates and sedatives), hypotension and other causes (Palmer 2014). 

Opening the airway is usually done as part of the assessment of an unconscious person. It is important to ensure the airway is patent before assessing whether the patient is breathing. Obstruction of the airway may affect the effectiveness of the person’s ability to breathe.  If the patient is not breathing, the relevant basic life support algorithm should be commenced (Resus Council UK 2015).

An occluded airway, whatever the cause is considered a medical emergency and without an open and patent airway the patient is unable to breathe and will have a respiratory arrest which may also lead to a cardiac address.  It is therefore important that the local emergency procedures should be undertaken at the same time as the clinical skill.  This may include calling for help by shouting, pulling an emergency buzzer or phoning the emergency number.  Ensure that you are familiar with these policies.

The patient may regain consciousness if their airway is opened effectively so ensure that you are aware of this and observing for changes in conscious level, offering reassurance to the patient throughout.

Preparation and safety

• Assess patency of airway.
• Place the patient in a supine position if it is safe to do so (this may require additional people to ensure the safety of the patient).

Procedure

Adult patients

1. Perform hand hygiene (if time) and put on gloves.
   Rationale – This is usually an emergency situation and so hand hygiene may not be possible but gloves should be worn.
2. For the head tilt-chin lift – adult method, place the fingertips under the mandible (chin). Lift the chin forward to displace the mandible anteriorly while tilting the head back with the other hand on the forehead (Figure 1).
   This manoeuvre results in hyperextension of the neck and therefore is NOT used when a head or neck injury is suspected or known to be present.
3. If the head tilt-chin lift – adult method is unsuccessful or contraindicated, use the jaw-thrust. With a hand on each side of the patient’s jaw, lift the mandible forward with your index and middle fingers while pushing against the zygomatic arches (cheek bones) with your thumbs (Figure 2).
   Rationale – Your thumbs provide counter pressure to prevent movement of the head when the mandible is pushed forward.
4. Reassess airway patency after either method is used to open the airway.
   Rationale – Positioning alone may be insufficient to achieve and maintain an open airway. Additional interventions such as suctioning, oral or nasal airway insertion, or endotracheal intubation may be indicated. Additional, expert help will be required at this point if not already present.
5. Remove gloves and perform hand hygiene.
6. Document the procedure in the patient’s record.

Child and infant

In this situation a ‘child is defined as a person aged 1 year and up to the age of puberty and an infant as being less than 12 months old’ (Resus Council UK 2015, Fiadjoe et al. 2016). If the child or infant is conscious, support them in a position they find comfortable as they will naturally try and maintain their own airway, but ensure that they are continually observed and not left.  If the child or infant is unconscious then the following considerations should be made:

• ‘In children and infants the head tilt-chin lift is used but without over-extension because this can cause the airway to close (Figure 3). Jaw thrust is used if head/neck injury is present or suspected but this time only the index finger on the lower jaw is used' (Resus Council UK 2015, Fiadjoe et al. 2016).
• In a child the neck should be slightly extended. This is known as the sniffing position.
• In an infant, the occiput of the head and the small neck means that the head needs to be in a neutral position (Resus Council UK 2015)
  
• Padding, such as a towel or small blanket, placed under the shoulders of a child may facilitate positioning of the patient’s airway
• Make small adjustments to the position of the airway if you are unable to adequately open the airway as there may be a partial obstruction and a small movement may be enough to open the airway.
  

Because maintaining a patent airway and providing adequate ventilation is vital in paediatric cardiopulmonary resuscitation (CPR), careful use of head tilt-chin lift – child method without over-extension can be used if the jaw-thrust does not open the airway (Figure 3).

All children without suspected or known head or neck injury should be allowed to maintain a position of comfort. This is particularly important in children presenting with symptoms of epiglottitis, such as high fever, drooling, and respiratory distress. Forcing them into a supine position could obstruct the airway. Allow the conscious child to maintain a position of comfort until definitive airway management is available.

Ongoing care, monitoring and support

• Having opened the airway, it is important to keep it open by maintaining the chin lift if the patient is unable to maintain this themselves.
• Continually reassess the patient for airway patency using:
  
  • observation – skin colour, signs of distress
  • respiration rate, rhythm and depth, noisy breathing sounds, oxygen saturation, pulse, and blood pressure
  • movement of the chest and abdomen taking care to observe that air is shifting in and out of the mouth/nose.
• Anticipate the need for definitive airway management, such as endotracheal intubation, and have supplies readily available.
• Anticipate the need for additional, specialist support if not already present.

Documentation and reporting

Document all relevant information including:

• Airway patency.
• Methods used to open the airway and their success or failure.
• Patient’s condition including physical observations.

Why is the jaw

What is the purpose for using the jaw

What maneuver is used to check for airway patency for patient with spine injury?

Why is it important not to use the neck tilt technique when spinal or neck injury is suspected?