The art of patient positioning
EMS providers must skillfully assess the needs of the patient, any mechanism of injury, and the risks of immobilization
By James Augustine
Our first job as emergency providers is to "do no harm." This is a particular priority when it comes to making decisions on the way to care for a patient on scene, and then in transport to a health care facility. There are a broad range of very important devices that are now available for emergency patient packaging, but it is our earliest days of medic training that will often be critical to patient outcome.
Proper positioning of patients allows quality care and safe transport, by all levels of EMS providers, in a wide variety of medical and traumatic conditions. Appropriate positioning can maintain an airway, prevent aspiration or further injury, and facilitate treatment.
Traditional medic training begins with the basic instruction to "put the patient in his or her position of comfort," and we are wise to always begin in that fashion. The supine position — flat on the back, face up — is then employed for most adults with major medical or trauma emergencies. This is considered the "conventional" position for packaging and transporting most adult patients.
In situations where possible spinal column or cord injuries have occurred, the patient is secured on a long backboard, and the board and patient is laid supine on a moving cot.
There are a growing number of studies that raise concerns about the poor outcomes of patients who are managed on a long backboard, particularly in victims of penetrating trauma. The act of strapping and taping a victim flat on the back leads to potential danger to the patient's ability to maintain an airway and breathe effectively.
How did this practice come to be used so widely? The risk of spinal-cord injury is viewed as so potentially devastating, and so difficult to predict in the immediate time after an injury, that the American EMS system has evolved to utilize packaging techniques for essentially all injured persons being transported to hospitals. The terminology has evolved, first being called spinal traction, and then spinal immobilization, and now spinal motion restriction.
Most EMS systems now employ a full range of options for positioning patients for care and transport. EMS education and protocols now call for spine clearance of many trauma patients, and the use of various other extremity splints and some European-style flexible spine packaging devices . Some patients require no splinting, and can be cared for in a seated position of comfort on a stretcher and belted for safe transport to a hospital.
Soft tissue injuries associated with collars and spine board immobilization
Every device used in EMS has the potential to cause harm to some patients . Packaging a patient in a cervical collar can cause injury through compromise of the airway; compressing swollen tissues in the neck; directly injuring or pinching tissues in the neck, scalp, ears, and chin; and causing pain in patients who already have bone or skin injuries that will be in direct contact with the collar.
There is greater potential for harm when a poorly sized collar is used, or when a collar is used incorrectly. There is less flexibility with one-piece collars then older two-piece devices. At the extremes of age, small children and older, arthritic patients may not be able to fit safely into any collar in the first-in bag, and must have cervical immobilization provided by blanket or towel rolls.
Rigid long backboard and long extrication devices have the potential to pinch and compress tissue. Over time, the patient lying on an inflexible board will compromise skin because of poor blood supply and the shearing motion of the skin and any irregular layers of clothing or the device itself.
Every EMS provider should take the opportunity to be strapped onto a board, moved in an ambulance, and left in place for 30 minutes to simulate the experience of a patient. It is uncomfortable to the skin and scalp, and often to the bony and muscle structures of the lower back and pelvis, even in the person who had no injury to begin with!
The use of positioning to improve care
There are predictable traumatic and medical situations that result in the need for unconventional patient positioning. Patients with severe blunt or penetrating injuries to the face and head, and medical patients who have critical shortness of breath, are at risk for life threatening complications when strapped supine on a board.
These already traumatized patients cannot be placed in a position that compromises the airway. Subsequent struggling of the patient may result in a number of complications including further blood loss, lack of oxygen, loss of spinal column immobilization with secondary injury to the spinal cord, or injury to the rescuers.
Blunt and penetrating injuries to the face and neck, especially with active bleeding, will require positioning of the patient at an angle where the patient is able to maintain his/her airway. The initial intervention is to perform manual cervical immobilization. This may be loosely supplemented by some type of cervical collar or cervical immobilization device.
The patient's head, chest and pelvis or upper legs are secured to a backboard. Once secured to the board, the patient can be moved to a lateral decubitus, face down, or face down with Trendelenburg position.
The airway can be subsequently suctioned using standard suctioning technique, which will be facilitated by gravity assistance. Control of airway can be maintained for a long time in this manner. If injuries are isolated to one side of the face or neck, it is usually appropriate to put the injured side down.
This allows bleeding or swelling to occur in the most gravity dependent position, and leaves the uninjured side in an uppermost position. Positioning so that the airway is stabilized will also help to control patient apprehension and combativeness. Once advanced-level care is available, either by paramedics or physicians, these patients will require further airway control by intubation or surgical methods.
In extreme circumstances, even the "face down" positioning on the backboard may not provide adequate airway management. This occurs with most extensive blast or gun shot wounds injuries to the face or neck. With active bleeding, the patient may not be able to control their airway even in the face down position.
In these circumstances, manual cervical immobilization is maintained and the patient is allowed to stabilize themselves in their position of "airway management." This may be in a kneeling position supporting their upper body with their hands. These patients must be rapidly transported, as their blood loss will soon produce a shock state with decreased level of consciousness and ultimate need for full airway control and shock treatment. The emergency department may need to intubate the patient while the patient is still in the upside down position.
Traumatic injuries with impalement of foreign objects in the body will create serious problems with conventional positioning, and a flexible approach. Impalement injuries cannot be dealt with in a single manner because of the unique incident and patient.
Depending on the size of the object that is impaled and the place it is impaled, the patients may need to be immobilized in any position. The common management priorities: some type of manual immobilization of the spine; stabilization of the object so that it does not inflict further damage on any internal body structure, and movement on some type of long backboard device.
For many medical patients, placing the patient in a standard reclining position on the long backboard may result in increasing shortness of breath. For patients with heart failure and pulmonary edema, slight changes in position can result in dramatic changes in their cardiac and respiratory function.
Typically, these patients are already found in a sitting or standing position, and do not tolerate any attempt to place them in a reclining position. The patient must be transported in a sitting position, sometimes even strapped in the captain's chair in the ambulance.
For certain other medical diseases, such as an enlarged thyroid gland, bleeding from mouth, neck, throat, or lung tumors, the lateral decubitus positional may be lifesaving. In general, patients are placed with the tumor side down. A patient with a left-sided tumor is placed into a left side down position to restore optimal expansion and oxygenation of the "good" right lung.
If the patient is uncertain which side is affected by the disease, the patient should be placed on the side which produces the maximum degree of patient comfort and relieves shortness of breath. As in trauma patients, prompt notification of the emergency department will enhance the care of these critical patients.
Do's and Don'ts of immobilization
There are certain emergency patients where unconventional positioning may be a life-saving technique necessary to maintain an airway and prevent serious complications. There are circumstances where special patient positioning has been a part of emergency practice for many years: pregnancy (rolled onto left side), pediatrics (in a car seat, or belted in a parent's lap for children in severe respiratory distress), isolated head or eye injuries (head elevated), severe nosebleeds (head forward), or uninjured medical patients who prefer the sitting position.
Considering the risks of our packaging devices, the EMS provider must know all the situations where patient positioning will be life-saving, and when not to use a cervical collar for trauma and immobilization. Spinal-cord injury is a devastating and life-threatening result of modern trauma.
The management of patients with high energy injuries requires continuous vigilance for injuries to the spinal canal and to the spinal cord, and restricting the movement of the spinal column using proper packaging devices.
EMS personnel must skillfully assess the needs of the patient, any mechanism of injury, and the risks of immobilization to make the best decision as to provide safe and appropriate care and movement. This begins with an appropriate history, a structured physical assessment, and knowledge of the protocols and packaging options. Then the devices will be used properly to enhance care of the patient, provide safe transport, and prevent any injury to the spinal cord or column.