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Use of the McCoy laryngoscope in patients with suspected cervical spine fracture
  1. Simon Carley,
  2. John Butler
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL

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    Report by Simon Carley, Specialist Registrar Search checked by John Butler,Specialist Registrar

    Clinical scenario

    A 24 year old man is brought to the emergency department after a fall. He has reduced conscious level and requires intubation to secure his airway. As a cervical injury cannot be excluded you attempt intubation in the neutral position with manual in-line cervical spine stabilisation. At laryngoscopy using a size 4 Macintosh blade you are unable to visualise the cords (grade 3 view) but manage to intubate the patient using a gum elastic bougie. Later, when discussing the case with an anaesthetist, you hear that the McCoy laryngoscope is said to give a better view than a conventional laryngoscope when patients are intubated in the neutral position. You wonder is there is any evidence to back this up before you go and buy some more equipment for the emergency department.

    Three part question

    In [patients requiring intubation with the neck in the neutral position] is [a McCoy laryngoscope better than an Macintosh laryngoscope] at [optimising the view of the laryngeal inlet]?

    Search strategy

    Medline 1966–06/00 using the OVID interface. ({McCoy.mp} AND {exp intubation, intratracheal OR exp laryngoscopy OR “laryngoscope”.mp}) LIMIT to human AND english.

    Search outcome

    Altogether 27 papers found of which 25 were irrelevant or of insufficient quality. The remaining two papers are shown in the table 1.

    Table 1

    Comments

    Failure to intubate a trauma patient because the larynx cannot be visualised is a feared sce-nario, yet in-line cervical stabilisation makes the view at laryngoscopy difficult. These studies demonstrate a clear advantage to the McCoy blade as compared with the Macintosh blade. In particular the incidence of grade 3 views markedly reduces with the McCoy blade. Both studies fail to assess the ability to actually intubate the patient, rather they just analyse the view of the cords. However, visualising the cords is a useful proxy marker for ease of intubation.

    Clinical bottom line

    A McCoy laryngoscope is a useful aid in difficult intubation, and should be available when rapid sequence induction is attempted in the patient in whom a cervical spine injury is suspected.

    Report by Simon Carley, Specialist Registrar Search checked by John Butler,Specialist Registrar

    References

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