Airway management in an unconscious person is the first priority in emergency care. When a person is unresponsive, the muscles of the jaw and tongue relax, often causing the tongue to fall backward and block the airway. Securing this passage is immediately necessary to ensure oxygen reaches the brain and lungs. However, when a head injury is suspected, the approach to opening the airway must be carefully adapted to prevent further harm. A specialized technique is required to open the airway without moving the head or neck.
The Risk of Moving the Neck
In cases of significant trauma, such as car accidents or falls from a height, a person may have sustained an unstable injury to the cervical spine (C-spine). The C-spine comprises the seven vertebrae in the neck that protect the spinal cord. Moving a fractured or unstable C-spine can cause fragments of bone or tissue to damage the spinal cord itself, leading to a secondary injury. This movement can result in permanent neurological deficits, including paralysis.
The standard technique for opening an airway in a non-trauma scenario is the Head-tilt/Chin-lift maneuver. This technique involves tilting the head backward and lifting the chin forward to displace the tongue. This action requires hyperextension of the neck, which must be avoided when a neck injury is possible. Therefore, the Head-tilt/Chin-lift is contraindicated in any patient with suspected head or neck trauma. Maintaining the head and neck in a neutral, inline position is paramount to prevent worsening a potential spinal cord injury.
Identifying the Proper Technique
The technique specifically designed to open the airway while minimizing movement of the cervical spine is the Jaw Thrust maneuver. This maneuver clears the airway obstruction by lifting the lower jaw (mandible) forward. Displacing the mandible anteriorly pulls the tongue away from the back of the throat, clearing the passage for air. The Jaw Thrust is favored over the Head-tilt/Chin-lift because it allows the head and neck to remain in a stable, neutral alignment.
The Jaw Thrust is commonly referred to as the modified Jaw Thrust in a trauma setting, emphasizing the need for minimal head movement. This action directly addresses the most common cause of airway obstruction in an unconscious person: the tongue relaxing against the posterior pharyngeal wall. Performing this technique requires more skill and physical effort than the standard maneuver but is necessary in any situation involving a potential spinal injury.
Step-by-Step Execution of the Jaw Thrust
To begin the Jaw Thrust maneuver, the rescuer must first kneel at the patient’s head. The patient should be lying flat on their back on a firm surface. The rescuer places their elbows on the ground and positions their hands on either side of the patient’s head to maintain a neutral position. This hand placement provides manual in-line stabilization to prevent any lateral or rotational movement of the neck.
The rescuer next places the index and middle fingers of both hands under the angles of the lower jaw (the bony part near the ears). The thumbs are placed gently on the patient’s cheekbones or chin for support and leverage. The fingers are then used to firmly and steadily lift the jaw straight up and forward (anteriorly). This movement must be strong enough to pull the mandible forward, opening the mouth slightly and clearing the tongue from the airway.
Fingers must only apply pressure to the bony parts of the jaw, avoiding the soft tissue under the chin which could worsen the obstruction. The lifting force is applied with the fingers, while the thumbs act primarily as a fulcrum to stabilize the head. The rescuer must maintain this upward and forward pressure constantly to keep the airway open until professional medical personnel can take over.
What to Do If Airflow Remains Blocked
If the Jaw Thrust maneuver does not immediately result in adequate airflow, the rescuer should first try to slightly adjust the position or increase the forward pressure on the angles of the jaw. Sometimes a minor repositioning is all that is required. The rescuer should also visually check the patient’s mouth for any visible foreign objects, such as dentures, blood clots, or debris, that may be causing a mechanical blockage. Any visible object that can be safely swept out with a finger should be removed.
If the Jaw Thrust fails to open the airway after careful attempts, securing the airway becomes the absolute priority, even over the theoretical risk of spinal injury. The rescuer must then carefully switch to the Head-tilt/Chin-lift maneuver as a last resort, as a patent airway is necessary for survival. If the patient begins to vomit, they must be log-rolled onto their side while maintaining strict manual stabilization of the head and neck to prevent aspiration. The Jaw Thrust should be reapplied immediately after any necessary repositioning.