Editing Recovery position

{{Short description|First aid technique}}
{{Infobox interventions |
  Name        = Recovery position |
  Image       = Recovery position.svg|
  Caption     = All forms of the recovery position share basic principles. The mouth is downward so that fluid can drain from the patient's airway; the chin is well away from the throat to keep the [[epiglottis]] opened. Arms and legs are nested to stabilize the position of the patient |
  ICD10       = |
  ICD9        = |
  MeshID      = |
  OPS301      = |
  OtherCodes  = |
  HCPCSlevel2 = 
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In [[first aid]], the '''recovery position''' (also called '''semi-prone''') is one of a series of variations on a lateral recumbent or three-quarters [[Prone position|prone]] position of the body, often used for [[unconsciousness|unconscious]] but breathing casualties.

An unconscious person, a person who is assessed on the [[Glasgow Coma Scale|Glasgow Coma Scale (GCS)]] at eight or below, in a [[supine position]] (on the back) may not be able to [[airway management|maintain an open airway]] as a conscious person would.<ref>{{cite web|publisher=Merck Online Manuals: Critical Care Medicine|title=Airway Establishment and Control|url=http://www.merck.com/mmpe/sec06/ch066/ch066b.html|author1=Bartle, C |author2=Levitan, R |date=January 2010}}</ref>  This can lead to an obstruction of the airway, restricting the flow of air and preventing gaseous exchange, which then causes [[Hypoxia (medical)|hypoxia]], 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.<ref>{{cite news|publisher=BBC News|title=First aid 'could save thousands'|date=2010-04-12|url=http://news.bbc.co.uk/1/hi/health/8612194.stm}}</ref><ref>{{cite news|publisher=GMTV|title=Be the difference|url=http://www.gm.tv/lifestyle/health/save-a-life/47641-be-the-difference.html|date=2010-04-11|url-status=dead|archiveurl=https://web.archive.org/web/20100417224103/http://www.gm.tv/lifestyle/health/save-a-life/47641-be-the-difference.html|archivedate=2010-04-17}}</ref> This is especially true for unconscious pregnant women; once turned on to their left side, pressure is relieved on the [[inferior vena cava]], and venous return is not restricted.  The cause of unconsciousness can be any reason from [[Physical trauma|trauma]] to [[Alcohol intoxication|intoxication from alcohol]].

It is not necessarily used by health care professionals in an institutional setting, as they may have access to more [[advanced airway management|advanced airway management techniques]], such as [[tracheal intubation]].

==Purpose==
The recovery position is designed to prevent suffocation through obstruction of the airway, which can occur in unconscious [[supine position|supine]] 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,{{cn|date=November 2017}} as the unconsciousness leads to a loss of control and [[muscle tone]], causing the tongue to fall to the back of the [[pharynx]], creating an obstruction.{{cn|date=November 2017}}  This can be controlled (to an extent) by a trained person using [[airway management]] techniques.
*'''Fluid obstruction''': Fluids, usually vomit, can collect in the pharynx, effectively causing the person 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]] burning the inner lining of the lungs, causing [[aspiration pneumonia]].

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]]    (ILCOR) does not recommend one specific recovery position, but advises on six key principles to be followed:<ref name=aha/>
#The casualty should be in as near a true lateral position as possible with the head dependent{{clarify|date=October 2018}} to allow free drainage of fluid.
#The position should be stable.
#Any pressure of the chest that impairs breathing should be avoided.
#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.
#Good observation of and access to the airway should be possible.
#The position itself should not give rise to any injury to the casualty.

==History==
The earliest recognition that placing unconscious patients on their side would prevent obstruction of the airway was by Robert Bowles, a doctor at the Victoria Hospital in [[Folkestone]], England.<ref name=aha>{{cite journal|publisher=American Heart Association|journal=Currents in Emergency Cardiovascular Care|volume=12|number=3|year=2001|title=A brief history: The Recovery Position|last=Handley|first=Anthony J|url=http://www.americanheart.org/downloadable/heart/1054148696790fall2001.pdf}}</ref> In 1891 he presented a paper with the title ''<nowiki>'</nowiki>On Stertor, Apoplexy, and the Management of the Apoplectic State<nowiki>'</nowiki>'' in relation to [[stroke]] patients with noisy breathing from airway obstruction (also known as [[stertor]]).

This paper was taken up by anaesthetist Frederick Hewitt from the [[Royal London Hospital|London Hospital]] 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.<ref name="aha"/>

[[First aid]] organisations were similarly slow in adopting the idea of the recovery position, with 1930s and 1940s first aid manuals from the [[British Red Cross]] 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".<ref>{{cite book|title=British Red Cross Society First Aid Manual No. 1|author=St. J.D. Buxton|year=1938|publisher=Cassell and Company Ltd|edition=Eight}}</ref> 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",<ref name=aha/> 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]] in 1992.<ref name=aha/>  Positions included the "Coma Position", "[[Franz Rautek|Rautek's Position]]" and the "HAINES (High Arm IN Endangered Spine) position".

In 1992, the [[European Resuscitation Council]] 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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[http://circ.ahajournals.org/cgi/content/full/112/22_suppl/III-115]
===If spinal or neck injuries are possible===
When the injury is apparently the result of an accidental fall, collision or other trauma, the risk of spinal or neck injuries should be assumed. Movement of spinal-injured victims runs the risk of causing permanent paralysis or other such injuries, and is best left to trained medical personnel.[http://circ.ahajournals.org/cgi/content/full/112/22_suppl/III-115] They should be moved to a recovery position only when it is necessary to drain vomit from the airway, or when it's obvious the patient has lost their Coug/Swallow reflex due to the increased risk of a silent aspiration.

In such instances, the correct position is called the "HAINES modified recovery position" (High Arm IN Endangered Spine.) In this modification, one of the patient's arms is raised above the head (in full [[Abduction (kinesiology)|abduction]]) to support the head and neck.[http://www.australianfirstaid.com/hains.html][http://circ.ahajournals.org/cgi/content/full/112/22_suppl/III-115] There is less neck movement (and less degree of lateral angulation) than when the lateral recovery position is used, and, therefore, HAINES use carries less risk of spinal-cord damage and is the only recovery position with clinical evidence to support its use. The two clinical studies benchmarked the HAINES Recovery Position against the Lateral Recovery Position, which the latter was clearly proven to be inappropriate for use in "Unconscious, suspected spinal injured" patients.[http://www.medscape.com/medline/abstract/10172477]

If an individual has suffered a fall or injuries that suggest damage to the spine, as a first aider the priority is to keep the airway open.  If breathing, position should not be changed.  If breathing has stopped, regardless of possible injury to the person, perform standard checks: DR & ABC (Danger, Response, Airway, Breathing, Circulation) and then move them into the recovery position to open the airway.  If they do not start breathing, begin CPR. If they begin to breathe, keep them in that position.

===Pregnant victims===
A pregnant woman should always rest on her left side, as lying on the right side may cause the uterus to compress the [[Inferior vena cava]], possibly resulting in death.

===Victims with torso wounds===
A victim with torso wounds should be placed with the wounds closest to the ground to minimize the possibility of blood affecting both lungs, resulting in [[asphyxiation]]. -->

== See also ==

* {{annotated link|Basic airway management}}
* {{annotated link|Basic life support}}
* {{annotated link|Human positions}}

==References==
{{Reflist}}

==External links==
{{Wikibooks|First Aid|Primary Assessment & Basic Life Support}}
{{commons}}
*[http://www.nhs.uk/conditions/accidents-and-first-aid/pages/the-recovery-position.aspx NHS Direct – The recovery position] (includes a video)
*[https://www.health.harvard.edu/staying-healthy/emergencies-and-first-aid-recovery-position The Recovery Position] – step-by-step description with diagrams, from Harvard Medical School

{{First aid topics}}

{{DEFAULTSORT:Recovery Position}}
[[Category:Emergency medicine]]
[[Category:First aid]]
[[Category:Human positions]]