Rescue airway maneuvers after jaw-thrust failure in suspected cervical spine injury: a prospective post-guideline observational cohort study.

BACKGROUND

Effective ventilation is a priority during resuscitation, but clinicians may hesitate to use head tilt-chin lift after jaw-thrust failure when cervical spine injury is suspected. We evaluated rescue ventilation pathways and clinical outcomes in this setting.

METHODS

We conducted a prospective, single-center observational cohort study between 22 January 2026 and 10 June 2026, after institutional ethics approval had been obtained. Adults requiring bag-mask ventilation with suspected cervical spine injury were included if an initial jaw-thrust attempt with appropriate airway adjunct use failed to achieve effective ventilation and a subsequent rescue airway action was required. The primary outcome was time from jaw-thrust failure to effective ventilation. Secondary outcomes included hypoxemia, escalation to intubation, 28-day functional outcome, and new neurological deficits.

RESULTS

Among 218 patients, head tilt-chin lift was used in 64 patients (29.4%). Median time to effective ventilation was 58 s with head tilt-chin lift and 138 s in non-head tilt-chin lift pathways. Hypoxemia occurred in 21.9% of head tilt-chin lift patients versus 57.6% of patients managed with prolonged bag-mask ventilation. At 28 days, unadjusted favorable functional outcome was more frequent after head tilt-chin lift, whereas new neurological deficit rates were similar across pathways. Cervical collar application showed complete separation with head tilt-chin lift non-use, while resident physician status and manual in-line stabilization were independent predictors in the adjusted non-use model.

CONCLUSIONS

In this post-guideline prospective cohort, head tilt-chin lift use after jaw-thrust failure was associated with faster effective ventilation and less hypoxemia. These observational associations do not establish superiority over other rescue strategies. New neurological deficit rates were similar across pathways, but the study was not powered to establish neurological safety or exclude rare cervical-spine-specific harm.