Hyldmo PK, Vist GE, Feyling AC. Is the supine position associated with loss of airway patency in unconscious trauma patients? A systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med. 2015;23:50.
The mission, pleasure and curse of the research process is to question the status quo. In this manner we can critically analyze our practice and improve patient outcomes. We selected this month’s article because it challenges one of the simple unspoken truths: Most EMS providers have been taught to lay an unconscious trauma patient supine to manage their airway.
Background: Current EMS teaching includes the lateral or “recovery” body position, but it’s more common to train providers to insert adjuncts on manikins who are supine. In addition to rote skill memorization and repetition, it’s still true today that EMS immobilizes many traumatically injured patients, especially if the cause is unknown and the patient isn’t alert.
Methods: In this study, authors performed a systematic review of the current literature to see if the supine position is associated with reduced airway patency compared to lateral positioning.
Researchers reviewed a wide body of research, looking for outcome measures such as hypoxia, hypercapnia, hypoventilation, stridor, airway pressures and respiratory volumes, as well as previously utilized scores or indexes often used in sleep apnea. They ultimately included 43 full-text articles and 34 comparisons in the meta-analysis. Combined, these articles report the experiences of 4,614 patients.
The authors used surrogate indicators to indicate potential harm to the patient: desaturation, apnea and airway collapsibility. It’s unfortunate that no studies were found showing morbidity or mortality.
They weighed the evidence looking for airway obstruction of supine adults with sleep apnea (2,780/60.3%), airway compromise before and after surgery (1,448/31.4%), patients with stroke or transient ischemic attack (196/4.3%), and infants and small children (190/4.1%).
Results: The authors conclude that the supine position is associated with airway compromise. They also agree that concerns for spinal injury may strongly influence positioning and care of unresponsive trauma patients, but if it’s not necessary to lay the patients on their back, it may be best to leave them on their side.
Discussion: Ironically, as far back as 1959, findings by Peter Safar, MD, clearly showed this as well. So why do we still immobilize patients lying on their backs? This study shows yet another potential harm, and clearly there’s a need for an outcome-based randomized trial to help us safely package and transport patients while doing no harm.
What we already know: Immobilization in the supine position is often over-utilized and potentially harms patients.
What this study adds: The supine position compromises the airway in patients with altered mental status.
Learn more from David Page at the EMS Today Conference & Expo, Feb. 25—27, in Baltimore, Md. EMSToday.com
WATCH BOX: SUICIDE
Curtis J, Hodgson K, Wallis J. Suicide prevalence in Australian paramedics: A scoping review [conference poster]. Paramedics Australasia Conference 2015: Adelaide, South Australia, October 2015.
This group deserves kudos for their work looking into paramedic suicide. The authors of this conference poster, presented at the 2015 Paramedics Australasia Conference, compared the rates for suicide in the general population with that of EMS providers in Australia.
This retrospective database review yielded no studies about this topic prior to January 2015. The Australian Bureau of Statistics reports a standardized rate of suicide in the entire population as 11 per 100,000 people, and Australian media reports had indicated that paramedics were subject to a suicide rate 20 times the national average.
Investigators turned to 12 years of data retrieved from the National Coronial Information System (NCIS), an Internet-based data collection for mortality information in Australia and New Zealand. Although suicide rates weren’t standardized and couldn’t be directly compared, EMS suicide rates suggested a standardized rate of 35.6 per 100,000–the highest of all emergency workers.
Assuming this sample was representative of all emergency workers in Australia and New Zealand, the rate would actually be three to four times the national average. Although this isn’t 20 times higher as the news media suggested, it should still be considered a call to action for our profession.