carefully removed Helmet removal, if possible, should involve at least two people to avoid potential neck motion Occasionally, mechanical bivalving of the helmet may be required for safe removal Caution must be exercised when applying airway maneuvers to a child with a possible cervical spine injury Airway interventions, however, often cannot wait until the cervical spine is cleared The clinician must prioritize and proceed with lifesaving airway maneuvers while minimizing motion of and risk to a potentially unstable cervical spine Hyperextension of the neck to facilitate intubation should be avoided A vigorous chin lift or jaw thrust may also inadvertently hyperextend the unstable cervical spine Gentle cricoid pressure should not cause excessive movement to the cervical spine; however, if applied vigorously, it may cause flexion of the spine When inline neck immobilization is used to assist with airway maneuvers, the clinician should be careful to avoid applying traction to the spine because this pressure can also stress the unstable cervical column Tracheal intubation in a patient with a potential cervical spine injury ideally requires at least two providers to perform the procedure safely and efficiently One provider should maintain inline immobilization of the neck while another performs the intubation The immobilization is often best accomplished from below, allowing the intubator as much room as possible to maneuver ( Fig 112.11 ) The hard cervical collar should be opened anteriorly, or removed It is difficult to intubate a child unless the reduction in mouth opening and jaw immobilization afforded by the collar is temporarily removed, as the trachea is more anterior than in an adult Oral intubation is the preferred method because of the child’s airway position and the usual experience of providers Adjunctive airway techniques that not require vigorous laryngoscopy, such as video fluoroscopy and optical stylets, may be useful in managing the airway of these patients The collar should be resecured after the airway intervention is complete