Key takeaway: In suspected cervical spine injury, use a jaw thrust first to open the airway; if ineffective, perform a head tilt–chin lift because airway patency supersedes spine motion restriction.
A 13 yo boy is carried into the ED by his friends after falling from a tree. He is unresponsive. There is bruising over his face and chest. The team places a c-collar. The resuscitation team attempts to ventilate with bag-mask, but they are unable to effectively ventilate the patient. As you prepare to perform endotracheal intubation, what is the preferred first method for opening the airway?
Answer Options:
A. Cricoid pressure
Keyed as correct: C. Jaw thrust
The keyed answer is correct and aligns with current standards. AHA Pediatric Life Support (2020) and ATLS (2018/2023) recommend a jaw thrust (without head tilt) as the initial airway-opening maneuver in trauma with suspected cervical spine injury to minimize cervical motion. If the airway cannot be opened or ventilation remains ineffective with a jaw thrust alone, a head tilt–chin lift is acceptable because oxygenation and ventilation take precedence. Routine cricoid pressure is not recommended as it does not reliably prevent regurgitation and may hinder ventilation and intubation. A shoulder roll risks neck hyperextension and should be avoided when cervical spine injury is suspected.
- Examinees over-apply the “no neck movement” rule and forget that airway patency overrides motion restriction when jaw thrust fails.
- Persistent belief that cricoid pressure prevents aspiration and is part of airway opening.
- Confusion between positioning aids (e.g., shoulder roll) versus airway-opening maneuvers in suspected C-spine injury.
| Option | What It Tests / Implies | Why It’s Wrong Here |
| Cricoid pressure | Knowledge of aspiration prevention maneuvers | Not an airway-opening technique; routinely not recommended and may impede ventilation/intubation. |
| Head tilt-chin lift | Basic airway opening in non-trauma | Acceptable only if jaw thrust fails; first choice in suspected C-spine is jaw thrust. |
| Jaw thrust | Correct application of trauma airway principles | Correct: preferred first method with suspected cervical spine injury. |
| Shoulder roll | Positioning to optimize airway alignment | Risks neck hyperextension; avoid in suspected C-spine injury. |
In trauma with suspected cervical spine injury, start with jaw thrust; if ventilation is still inadequate, proceed to head tilt–chin lift—airway beats spine.
Boards test whether you prioritize airway patency over theoretical cervical motion restriction: jaw thrust first—then head tilt–chin lift if necessary—while rejecting outdated practices like routine cricoid pressure.
A 15-year-old with suspected C-spine injury is apneic with poor chest rise during BVM despite an oral airway. Best initial airway-opening maneuver?
A. Head tilt–chin lift
B. Shoulder roll
C. Cricoid pressure
D. Jaw thrust
Jaw thrust fails to open the airway in a 12-year-old with suspected C-spine injury. Next best step?
A. Apply cricoid pressure
B. Perform head tilt–chin lift
C. Place shoulder roll
D. Proceed directly to surgical airway
During RSI in pediatric trauma, which statement is most accurate regarding cricoid pressure?
A. It reliably prevents aspiration
B. It improves visualization of the glottis
C. It may impede ventilation and intubation; routine use is not recommended
D. It is necessary when using a BVM
In a 10-year-old with facial trauma and suspected C-spine injury, which positioning is preferred prior to BVM?
A. Neutral head position with jaw thrust
B. Sniffing position with shoulder roll
C. Hyperextension with chin lift only
D. Lateral recovery position
Which principle best guides airway maneuvers in suspected C-spine injury?
A. Immobilization is absolute and supersedes ventilation
B. Cricoid pressure should be applied first
C. Airway patency and oxygenation take precedence; escalate from jaw thrust to head tilt–chin lift if needed
D. Surgical airway is first-line in pediatric trauma
Compare the approach to airway opening in: (1) an unresponsive pediatric trauma patient with suspected C-spine injury and ineffective BVM, and (2) a non-trauma child with obstructive apnea. Discuss the sequence of maneuvers, when to accept head tilt–chin lift, and the role of adjuncts (OPA/NPA).
- Q: Do boards still expect routine cricoid pressure?
A: No. AHA/ILCOR (2020) do not recommend routine cricoid pressure; recognize it can impede ventilation/intubation.
- Q: If jaw thrust doesn’t work, will I be penalized for using head tilt–chin lift in trauma?
A: No. Boards expect you to prioritize airway/ventilation; head tilt–chin lift is appropriate if jaw thrust fails.
- Q: Should I place a shoulder roll to optimize view in trauma?
A: Not with suspected C-spine injury; avoid maneuvers that extend the neck.
- Q: Is jaw thrust always required in trauma?
A: It’s the preferred first maneuver with suspected C-spine injury; if no spine concern, head tilt–chin lift is fine.
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