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Recovery position

Recovery position

Overview
The recovery position refers to one of a series of variations on a lateral recumbent or three-quarters prone position of the body, in to which an unconscious
Unconsciousness
Unconsciousness is the condition of being not conscious—in a mental state that involves complete or near-complete lack of responsiveness to people and other environmental stimuli. Being in a comatose state or coma is a type of unconsciousness. Fainting due to a drop in blood pressure and a...

 but breathing casualty can be placed as part of first aid
First aid
First aid is the provision of initial care for an illness or injury. It is usually performed by non-expert, but trained personnel to a sick or injured person until definitive medical treatment can be accessed. Certain self-limiting illnesses or minor injuries may not require further medical care...

 treatment.

An unconscious person (GCS <8) in a supine position
Supine position
The supine position is a position of the body: lying down with the face up, as opposed to the prone position, which is face down, sometimes with the hands behind the head or neck. When used in surgical procedures, it allows access to the peritoneal, thoracic and pericardial regions; as well as the...

 (on their back) may not be able to maintain a patent airway as a conscious person would. This can lead to an obstruction of the airway, restricting the flow of air and preventing gaseous exchange, which then causes hypoxia
Hypoxia (medical)
Hypoxia, or hypoxiation, is a pathological condition in which the body as a whole or a region of the body is deprived of adequate oxygen supply. Variations in arterial oxygen concentrations can be part of the normal physiology, for example, during strenuous physical exercise...

, which is life threatening.
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Encyclopedia
The recovery position refers to one of a series of variations on a lateral recumbent or three-quarters prone position of the body, in to which an unconscious
Unconsciousness
Unconsciousness is the condition of being not conscious—in a mental state that involves complete or near-complete lack of responsiveness to people and other environmental stimuli. Being in a comatose state or coma is a type of unconsciousness. Fainting due to a drop in blood pressure and a...

 but breathing casualty can be placed as part of first aid
First aid
First aid is the provision of initial care for an illness or injury. It is usually performed by non-expert, but trained personnel to a sick or injured person until definitive medical treatment can be accessed. Certain self-limiting illnesses or minor injuries may not require further medical care...

 treatment.

An unconscious person (GCS <8) in a supine position
Supine position
The supine position is a position of the body: lying down with the face up, as opposed to the prone position, which is face down, sometimes with the hands behind the head or neck. When used in surgical procedures, it allows access to the peritoneal, thoracic and pericardial regions; as well as the...

 (on their back) may not be able to maintain a patent airway as a conscious person would. This can lead to an obstruction of the airway, restricting the flow of air and preventing gaseous exchange, which then causes hypoxia
Hypoxia (medical)
Hypoxia, or hypoxiation, is a pathological condition in which the body as a whole or a region of the body is deprived of adequate oxygen supply. Variations in arterial oxygen concentrations can be part of the normal physiology, for example, during strenuous physical exercise...

, which is life threatening. Thousands of fatalities occur every year in casualties where the cause of unconsciousness was not fatal, but where airway obstruction caused the patient to suffocate. The cause of unconsciousness can be any reason from trauma
Physical trauma
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...

 to intoxication from alcohol.

It is not necessarily used by health care professionals, as they may have access to more advanced airway management techniques, such as intubation
Intubation
Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic or rubber tube into the trachea to maintain an open airway or to serve as a conduit through which to administer certain drugs...

.

Purpose


The recovery position is designed to prevent suffocation through obstruction of the airway, which can occur in unconscious supine
Supine position
The supine position is a position of the body: lying down with the face up, as opposed to the prone position, which is face down, sometimes with the hands behind the head or neck. When used in surgical procedures, it allows access to the peritoneal, thoracic and pericardial regions; as well as the...

 patients. The supine patient is at risk of airway obstruction from two routes:
  • Mechanical obstruction - In this instance, a physical object obstructs the airway of the patient. In most cases this is the patient's own tongue, as the unconsciousness leads to a loss of control and muscle tone
    Muscle tone
    In physiology, medicine, and anatomy, muscle tone is the continuous and passive partial contraction of the muscles, or the muscle’s resistance to passive stretch during resting state. It helps maintain posture, and it declines during REM sleep.-Purpose:Unconscious nerve impulses maintain the...

    , causing the tongue to fall to the back of the pharynx
    Pharynx
    The human pharynx is the part of the throat situated immediately posterior to the mouth and nasal cavity, and anterior to the esophagus and larynx. The human pharynx is conventionally divided into three sections: the nasopharynx , the oropharynx , and the laryngopharynx...

    , creating an obstruction. This can be controlled (to an extent) by a trained person using airway management
    Airway management
    In cardiopulmonary resuscitation, anaesthesia, emergency medicine, intensive care medicine and first aid, airway management is the process of ensuring that:# there is an open pathway between a patient’s lungs and the outside world, and...

     techniques.
  • Fluid obstruction - Fluids, usually vomit, can collect in the pharynx, causing the person effectively to drown. The loss of muscular control which causes the tongue to block the throat can also lead to the stomach contents flowing into the throat, called passive regurgitation. Fluid which collects in the back of the throat can also flow down into the lungs. Another complication can be stomach acid attacking the inner lining of the lungs, causing aspiration pneumonia
    Aspiration pneumonia
    Aspiration pneumonia is bronchopneumonia that develops due to the entrance of foreign materials into the bronchial tree, usually oral or gastric contents...

    .


Placing a patient in the recovery position gives gravity assistance to the clearance of physical obstruction of the airway by the tongue, and also gives a clear route by which fluid can drain from the airway.

The International Liaison Committee on Resuscitation
International Liaison Committee on Resuscitation
The International Liaison Committee on Resuscitation was formed in 1992 to provide an opportunity for the major organizations in resuscitation to work together on CPR and ECC protocols...

 (ILCOR) does not recommend one specific recovery position, but advises on six key principles to be followed:
  1. The victim should be in as near a true lateral position as possible with the head dependant to allow free drainage of fluid
  2. The position should be stable
  3. Any pressure of the chest that impairs breathing should be avoided
  4. It should be possible to turn the victim onto the side and return to the back easily and safely, having particular regard to the possibility of cervical spine injury
  5. Good observation of and access to the airway should be possible
  6. The position itself should not give rise to any injury to the victim

History


The earliest recognition that placing an unconscious patient on their side would prevent obstruction of the airway was by Robert Bowles, a doctor at the Victoria Hospital in Folkestone
Folkestone
Folkestone is the principal town in the Shepway District of Kent, England. Its original site was in a valley in the sea cliffs and it developed through fishing and its closeness to the Continent as a landing place and trading port. The coming of the railways, the building of a ferry port, and its...

, England. In 1891 he presented a paper title 'On Stertor, Apoplexy, and the Management of the Apoplectic State' in relation to stroke
Stroke
A stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...

 patients with noisy breathing from airway obstruction (also known as stertor).

This paper was taken up by anaesthetist Frederick Hewitt from the London Hospital
Royal London Hospital
The Royal London Hospital was founded in September 1740 and was originally named The London Infirmary. The name changed to The London Hospital in 1748 and then to The Royal London Hospital on its 250th anniversary in 1990. The first patients were treated at a house in Featherstone Street,...

 who advised a sideways position for postoperative patients. This thinking was, however, not widely adopted, with surgical textbooks 50 years later still recommending leaving anaesthetised patients in a supine position.

First aid
First aid
First aid is the provision of initial care for an illness or injury. It is usually performed by non-expert, but trained personnel to a sick or injured person until definitive medical treatment can be accessed. Certain self-limiting illnesses or minor injuries may not require further medical care...

 organisations were similarly slow in adopting the idea of the recovery position, with 1930s and 1940s first aid manuals from the British Red Cross
British Red Cross
The British Red Cross Society is the United Kingdom branch of the worldwide impartial humanitarian organisation the International Red Cross and Red Crescent Movement. The society was formed in 1870, and is a registered charity with over 31,000 volunteers and 2,600 staff. At the heart of their work...

 and St John Ambulance both recommending lying a patient on their back. The 1938 British Red Cross First Aid Manual goes so far as to instruct "place the head in a such as position that the windpipe is kept straight, keeping the head up if the face is flushed, and in line with the body if it is pale". By contrast, the St. John manual advocated turning the head to the side, but it was not until the 1950 40th edition of the St John Manual that it was added "if breathing is noisy (bubbling through secretions), turn the patient into the three-quarters prone position", which is very similar to a modern recovery position.

A large number of positions were experimented with, mostly in Europe, as the United States did not widely take up the recovery position until its adoption by the American Heart Association
American Heart Association
The American Heart Association is a non-profit organization in the United States that fosters appropriate cardiac care in an effort to reduce disability and deaths caused by cardiovascular disease and stroke. It is headquartered in Dallas, Texas...

 in 1992. Positions included the 'Coma Position', 'Rautek's Position' and the 'HAINES (High Arm IN Endangered Spine) position'.

In 1992, the European Resuscitation Council
European Resuscitation Council
The European Resuscitation Council is the European Interdisciplinary Council for Resuscitation Medicine and Emergency Medical Care. It was established in 1989....

adopted a new position where the arm nearest the floor was brought out in front of the patient, whereas it had previously been placed behind the patient. This change was made due to several reported cases of nerve and blood vessel damage in the arms of patients.

ILCOR made its recommendations on the basic principles for recovery positions in 1996, but does not prescribe a specific position, and consequently, there are several in use around the world.

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