Casualty Positioning

Once you've treated the injury or illness you are not quite out of the woods until further help arrives. In that time, correct positioning of the casualty can aid recovery in the same way that poor positioning can very easily aggrevate the injury or exacerbate the condition. Here are a few positions to consider.

Safe Airway Position
 

Without airway management equipment or techniques unconscious casualties will die on their back. We can open their airway with a simple head tilt but this does not prevent fluids (blood or saliva) draining down or coming up (vomit or blood) and entering the airway.

Any unconscious casualty (even with a suspected spinal injury) should be positioned onto their side because, quite simply, if you don't have an airway, you don't have a casualty.

Regardless of whether you call it the Safe Airway Position, Recovery Position, Drainage Position, Left lateral Recumbent or Three-Quarter Prone, we're going to flip them over.

How to do it

  • Remove the victim’s glasses, if present.
  • Kneel beside the victim and make sure that both his legs are straight.
  • Place the arm nearest to you out to you side – DO NOT place the shoulder and elbow at right angles. This is unnecessarily painful for people with limited range of movement and places pressure on the lower arm.
SAP Arms Wrong 1
SAP Arm Wrong 2
  • Bring the far arm across the chest, and hold the back of the hand against the victim’s cheek nearest to you.
  • With your other hand, grasp the far leg just above the knee and pull it up, keeping the foot on the ground.
  • Keeping their hand pressed against their cheek, pull on the far leg to roll the victim towards you on to their side.
  • Adjust the upper leg so that both the hip and knee are bent at right angles.
  • Tilt the head back to make sure that the airway remains open.
  • If necessary, adjust the hand under the cheek to keep the head tilted and facing downwards to allow liquid material to drain from the mouth.
  • Check breathing regularly.
  • If the victim has to be kept in the recovery position for more than 30 min turn him to the opposite side to releive the pressure on the lower arm.
Safe Airway Position

Left of Right?

The Safe Airway Position is often called Left lateral Recumbent, especially in the US.   There is sometimes milage in positioning the casualty on their left; the most cited reason - and most plausible - is significant for women in the later stages of pregnancy when positioning the casualty on their right will apply pressure from the foetus onto the superior vena cava (one of the two large vessels which return deoxygenated blood to the heart) impeding circulation.  Other reasons include:

  • Stomach curves to the left, so vomit would have an extra curve to overcome
  • Stomach curves to left, so contents won't be pushing against sphincter.
  • In the ambulance, attendant can watch him better facing toward him.
  • Improved ventilation given the right lung being slightly larger than the left and left main stem bronchus being at an angle


There is no real evidence for any of these justifications so it would seem that many of the reasons given are - as is often the way in First Aid - largely historical cliche's perpetuated because it is really easy to teach people what you have been taught rather than actually looking into what you are teaching.

In fact, positioning on the left can have adverse effects for some conditions, such as Congestive Heart Failure (1) or increase absorption of ingested poisons (2).

Lets be pragmatic.

Depending on the position your casualty is already found in and obstacles around them you may not have the luxury of this choice.  Practice positioning your casualties on either left or right and position them appropriately to 

  1. Maximize drainage without
  2. aggravating injuries or illnesses.
  3. Roll casualties with chest injuries onto the injured side to protect the unaffected lung.
Safe Airway Position Right

Safe Airway Position Right

Safe Airway Position Left

Safe Airway Position Left

Lying Down

Recumbent

Recumbent

Supine

Supine

Supine - Knees Bent

Supine - Knees Bent

Trendelenburg

Trendelenburg

Inclined

Inclined

If the causality is alert or we are able to manage their airway with suction and airway adjuncts, it is sometimes beneficial for the casualty to remain on their back.  Recumbent is a posh word for simply lying down with their head supported by a pillow and is the most common and appropriate position for someone who simply needs rest.  A slight modification for this would be to remove the pillow which would be appropriate for someone with a suspected spinal injury.  This position is now called Supine.  Neither of these positions are recommended for head injury (where the priority is to reduce intracranial pressure) or for casualties with breathing problems or chest pain.  In reality most conscious casualties with these conditions won't let you lay them flat

While we're on the subject of letting the casualty assume the most comfortable position, most people with abdominal pain will draw their knees in.  If that's what they want, let them do it.   Supporting under the knees is also meant to relieve pain from pelvic injuries - this is subjective so offer it, don't force it.

Sometimes a tilt can help; most ambulance trolleys will have this option but in the outdoors we have hills and slopes we can utilise.  With the legs elevated the Trendelenburg position can improve venous drainage from lower limbs and improve blood supply to the head but with pressure on the diaphragm from below, respiration can be reduced.  Inclining the whole body downhill can reduce intracranial pressure and without pressure on the diaphragm, easy respiration.  


Sat Up

We often have a tendency to force our casualty to lie down.   It's traditional.  Like a default position for poorly people.  Sometimes, allowing or encouraging your casualty to sit up will make their day.

 

An upright or semi-recumbent position is not just comfortable for some casualties it can greatly assist their recovery.  Upright positions will reduce intracranial pressure, essential for head injuries, and assist breathing.  

 

The W Position is one of the most common positions the conscious casualty will adopt and a safe bet for anyone with a reduced level of consciousness;  if they're on the floor they can't fall off it.  It's good for head injuries, chest pain, breathing problems and abdominal pain

 

Semi-recumbent

Semi-recumbent

Upright

Upright

W Position

W Position


Shock Position

The Shock Position

For years we have been told that the casualty who is in shock needs to lie down with their legs elevated because this will drain blood from the legs into the core to:

  • Improve cardiac output
  • Improve systemic vascular resistance
  • Improved mean arterial pressure
  • Improved systolic blood pressure

There is no evidence of any standard that this is of real benefit.  If you think about it, you know there is no available blood in the legs because the casualty is cold and pale - they are already shunting any available blood to the core by vasoconstriction.

And if they are going into shock we can expect their level of consciousness to drop.  How do unconscious casualties die?  Oh, that's right, on their backs.

After Schunder-Tatzber (2010) (3) and Epstein (2010) (4) A = Improved Cardiac Output C = Improved Systemic Vascular Resistance E = Other benefits B = Improved Mean Arterial Pressure D = Improved Systolic Blood Pressure

After Schunder-Tatzber (2010) (3) and Epstein (2010) (4)
A = Improved Cardiac Output C = Improved Systemic Vascular Resistance E = Other benefits
B = Improved Mean Arterial Pressure D = Improved Systolic Blood Pressure

Anaphylaxis

Several awarding bodies still teach this for the treatment of hypovolemic shock as well as the treatment of anaphylactic shock.  This position may be helpful for the anaphylactic casualty with low blood pressure but given 80% of cases present with skin rashes and 70% with difficulty breathing compared to the 10-45% who present with low blood pressure (5) elevating the legs could be the absolute worst thing you can do for them.  For the conscious casualty, they will adopt a comfortable position, probably the W Position or Semi Recumbent (6, 7).  Anyone unconscious is placed into the Safe Airway Position if airway management equipment and techniques are not available. 

Conclusions

Don't just leave them as you found them for fear of causing injury and neither flip them into a textbook position just because you were told to once.

Prioritise the airway - even with a spinal injury - a casualty without a clear and open airway will not last long.

If the casualty is conscious allow them to adopt the most comfortable position for them; they will know what relives pain or eases breathing much better than you and they will not appreciate being forced into an uncomfortable position just because it 'looks right'.

Be pragmatic:  Do the best you can based on the position they are found in and obstacles around them with as little movement as possible to avoid aggravating injuries.  More often than not the Real World is not Text Book.

References

  1. Palermo P, Cattadori G, Bussotti M, Apostolo A, Contini M, Agostoni P. "Lateral decubitus position generates discomfort and worsens lung function in chronic heart failure." Chest. 2005 Sep;128(3):1511-6.
  2. Vance MV, Selden BS, Clark RF. "Optimal patient position for transport and initial management of toxic ingestions." Ann Emerg Med. 1992 Mar;21(3):243-6. 
  3. Epstein JL.  (2010)  “What is the optimal position for a person in shock? Does elevating the legs improve outcome?” Worksheet for Evidence-Based Review of Science for Emergency Cardiac Care.  http://circ.ahajournals.org/site/C2010/FA-1601A.pdf  Accessed 8th November 2014
  4. Shunder-Tatzber S.  (2010)  “What is the optimal position for a person in shock? Does elevating the legs improve outcome?” Worksheet for Evidence-Based Review of Science for Emergency Cardiac Care.  http://circ.ahajournals.org/site/C2010/FA-1601C.pdf  Accessed 8th November 2015
  5. Simons FE (October 2009). "Anaphylaxis: Recent advances in assessment and treatment". J. Allergy Clin. Immunol. 124 (4): 625–36; quiz 637–8.
  6. Pumphrey RS. Fatal posture in anaphylactic shock. J Allergy Clin Immunol 2003;112(2):451-2.
  7. Soar J, Deakin CD, Nolan JP, Abbas G, Alfonzo A, Handley AJ, et al. European Resuscitation Council guidelines for resuscitation 2005. Section 7. Cardiac arrest in special circumstances. Resuscitation 2005;67 Suppl 1:S135-70.