Which of the following patients should you place in the recovery position

Positioning the Patient

Normally, a patient is left in the position in which he or she is found until the primary assessment is completed. However, if the patient is having difficulty breathing or there is no pulse, the patient must be positioned to do CPR. If the conscious patient is prone and in respiratory difficulty, the examiner, with assistance, shouldlog-roll the patient (Fig. 18.12) onto a spinal board so that an attempt can be made to restore the airway. During any movement of the patient, the examiner should apply traction of approximately 4.5 kg (10 lbs) to the cervical spine to maintain stability. The patient should be reassured that others are going to carefully move the patient while he or she remains still. Before any movement is attempted, the patient and those who are going to assist the examiner should know what the examiner plans to do and what their jobs are. This requiresfrequent practicing of emergency procedures. The sequence of movement and positioning of the extremities and body of the patient should be thought out beforehand so that everyone is aware of what is going to happen and in what order. The proper procedure for moving the patient should be practiced often to ensure competency.

To roll the patient, at least three assistants are needed. There should be two-way communication between the examiner and the patient at all times to continually evaluate the patient’s comfort level and neurological signs. The assistants should place the spinal board beside the patient and then kneel beside the spinal board and patient (seeFig. 18.12A). They should reach over the patient and hold the patient’s shoulder, hip, and knees (seeFig. 18.12B). On command from the examiner, the assistants roll the patient toward them while the examiner stabilizes the head (seeFig. 18.12C) until the patient is lying supine on the spinal board (seeFig. 18.12D). Only rolling—not lifting—should occur. With the patient in the supine position, proper CPR techniques may be applied, or the patient may be transported. The patient may also be covered with a blanket to provide warmth.

If a spinal injury is suspected and the conscious patient is in the prone position but has no difficulty breathing, the patient is log-rolled halfway toward the assistants while another assistant slides the spinal board as close as possible to the patient’s side. The patient is then rolleddirectly onto the spinal board in the prone position. Similarly, if a spinal injury is suspected and the patient is in the supine position and breathing normally, the patient is rolled toward the assistants while another assistant slides the spinal board under the patient as far as possible. The patient is then rolled back onto the spinal board in the supine position. If a spinal injury is suspected and the patient is in side-lying position, the patient is log-rolled directly onto the spinal board and into the supine position. In each of these cases, the examiner controls the head, applies traction, and instructs the assistants. The patient’s head is then stabilized and immobilized with sandbags, a head immobilizer, or triangular bandages, and the patient is strapped to the spinal board with restraining belts. If a collar is used to stabilize the spine, it must do so during movement and when the patient is stationary; it must not hinder access to the carotid pulse, airway, or performance of CPR; it must be easy to assemble and apply; it must be adaptable to patients of all ages and sizes; and it must allow radiological examination without removal.75,76 Any major injury (such as a head injury, a spinal injury, or a fracture) requires appropriate handling, slow and deliberate management, and proper transportation to provide a satisfactory outcome. These techniques must be practiced repeatedly.

Treatment of Anaphylaxis [6]

The patient is laid down in the recovery position. Cardiopulmonary resuscitation may be needed. Epinephrine (adrenaline) should be given immediately by intramuscular injection into the antero-lateral thigh: 0.1% (1 : 1000) (0.5–1 ml for adults; 0.01 mg/kg for children). If the patient is unconscious or pulseless, epinephrine diluted 1 : 100,000 is given by slow intravenous (IV) injection. In rare cases, blood pressure fails to respond to even large doses of adrenaline and plasma expanders and requires pressor agents, such as dopamine. Use of IV histamine H1 blockers such as chlorphenamine maleate (10 mg for adults; 0.2 mg/kg for children) and steroids are of unproven benefit, but may prevent relapses. People with known hypersensitivity should wear an identifying tag in case they are found unconscious after being stung. They should be trained to give themselves adrenaline using an “EpiPen” or “Ana-Pen”, but many of those who are prescribed these kits are unable to use them effectively because they have not been trained. Shock and airway obstruction are the main causes of death following insect sting anaphylaxis.

Operative Evaluation and Drainage

Surgical drainage remains the definitive treatment of anorectal abscesses. Bedside drainage in the left lateral decubitus (or Sims) position under local anesthesia using 1% lidocaine with dilute epinephrine often is well tolerated for perianal abscesses and small ischiorectal abscesses. If there is concern for patient intolerance, bedside drainage can be accompanied by light sedation when available (e.g., within the emergency department) where additional healthcare providers and a monitored setting are available.

After infiltrating the area with local anesthetic, the surgeon makes a radially oriented semilunar or cruciate incision over the abscess. A critical point of this procedure is the incision should be oriented over the side of the abscess closest to the anal verge without transgression into the sphincter complex. This is done so that the subsequent fistula (which forms up to 50% of the time) is more likely to have a simple, short tract that is easier to manage. A common mistake is to drain the area over the maximum site of fluctuance or farthest away from the anal verge, which can make the subsequent fistula longer and much more difficult to treat. A hemostat or blunt probe is used to explore the wound and ensure no pockets of undrained infection remain. Usually, the outermost wall of the abscess cavity is thick and well defined and can be used as a guide. If a thinner wall is encountered, or if bimanual examination reveals additional areas of cavernous extension, these should be entered. However, care should be taken not to spread or digitally break down all fibrous tissue within the abscess because this often represents nerves, which are oriented in a radial pattern spreading outward from the anal verge. Destruction of these can result in anorectal muscle dysfunction.

A segment of skin (either an ellipse or cruciate with corners excised) at least 1 cm in size is excised to prevent premature closure of the skin. The cavity is irrigated and dry gauze is applied externally with the expectation of ongoing drainage. Dense packing is unnecessary in most cases and may only serve to damage the internal nerve fibers. Hemostasis can be obtained with direct pressure overlying the pocket, silver nitrate, and the use of lidocaine with epinephrine.

Large abscesses (>5 cm), and those that must be approached transanally (e.g., intersphincteric, horseshoe, and deep postanal space infections) are most appropriately done in the operating room under monitored anesthesia care or general anesthesia. The anorectal region is best exposed with the patient in the prone jack-knife position and the buttocks taped widely apart, but high lithotomy is often adequate, particularly in multiple comorbidity patients or those with a difficult airway. A headlamp or other source of good lighting is recommended. Commonly used instruments are: Hill-Ferguson, Fansler, or Pratt bivalve retractors; fistula probes and curettes; and angiocath needles with dilute hydrogen peroxide. The perianal region is inspected, noting any induration, fluctuance, or dermatologic abnormalities. A digital rectal examination is performed followed by anoscopy, looking for mucosal bulging or other abnormality, including sphincter defects, function, and mucosal abnormalities. Biopsies should be performed on ulcerations, suspicious nodules, or perianal lesions to exclude neoplasia. Biopsies and/or culture should be performed on recurrent abscess or fistula tracts as well to diagnose underlying inflammatory bowel disease, infections (such as tuberculosis or actinomycoses), or the rare malignancy. If the site of purulence is not obvious or deep to the skin surface, an 18-gauge needle can be used as a finder to aspirate in suspected areas. Culture data are rarely required but may be insightful in patients with recurrent infections, a history of methicillin-resistantStaphylococcus aureus, or patients with underlying HIV infection in whom atypical microbes may be present.

Treatment

The barbed stings of Apidae remain embedded at the site of the sting and continue to inject venom, so they should be removed immediately by any possible means. Vespids can withdraw their stings, and sting repeatedly. Wasp stings may become infected because some species feed on rotting meat. Diluted domestic meat tenderizer (papain), ice packs, and aspirin relieve local pain in some cases. Systemic antihistamines can be used for more severe local reactions. Large local reactions may require treatment with antihistamines, non-steroidal anti-inflammatory agents, or even corticosteroids.

Lumbar Epidural Anesthesia

The lumbar epidural is usually performed in anesthetized patients via a midline route below the L2 to L3 interspace, which represents the lower limit of the conus medullaris (Fig. 76.6). The technique is essentially as in adults. A paramedian approach can be used instead in cases of spinous process anomaly or spine deformity. The child is positioned in the semiprone position, with the side to be operated lowermost and the spine bent to enlarge the interspinous spaces. The sitting position can be used in conscious patients.

Medium selection for the LOR technique has elicited considerable debate. Both air and saline are advocated for the LOR test to identify the epidural space. Saline is more popular, however air (or carbon dioxide) is perhaps more sensitive, especially in neonates and infants.

The distance from the skin to the epidural space is correlated with the patient’s age and size (seeFig. 76.1), but 1 mm/kg is a useful approximation for children between 6 months and 10 years of age.192 An ultrasound probe provides precise measurement of the distance from skin to the ligamenta flava and from skin to the posterior dura mater (Fig. 76.7).

When the tip of the needle penetrates the epidural space, the LOR technique syringe is disconnected, and no reflux of biologic fluid (blood or CSF) should appear at the hub. The next step consists of injecting the local anesthetic at a slow speed, either through the epidural needle or through a catheter. Progressive displacement of the dura mater can be visualized by placing an ultrasound probe in line with the spinous process line during injection in infants younger than 2 years of age.145 By using ultrasound, the anatomy of the spinal canal, the position of the spinal cord, visualization of the ligamentum flavum, and the space caudal spinous processes can actually be seen (seeFig. 76.7).193 When a catheter is inserted, it should not be introduced more than 3 cm, to avoid buckling, knotting, and lateralization of blockade or erratic migration. Tunneling the catheter reduces the incidence of accidental removal and bacterial contamination.194 Catheters inserted over a long distance have to be controlled in the same way as caudal catheters.

The volume of anesthetic solution depends on the upper level of analgesia required for completion of the surgery; approximately 0.1 mL/year of age is necessary to block 1 neuromere.195 Usual volumes of injectate range from 0.5 to 1 mL/kg (up to 20 mL), and the upper limit of sensory blockade ranges between T9 and T6 in more than 80% of patients.

Single-shot epidural blocks are appropriate for many pediatric surgeries, especially when adjuvants such as clonidine 1 to 2 μg/kg, and, in appropriate indications, morphine 30 μg/kg, or 10 μg /kg of hydromorphone are coadministered. Major operations resulting in long-lasting postoperative pain require placement of an epidural catheter and postoperative infusion of local anesthetics (Table 76.8).

Further instinctive sleep postures

Another posture that may be considered an instinctive sleep posture is the recovery position (which effectively stretches the pectoralis minor and anterior fibers of trapezius, using pressure on the coracoid process and/or zygomatic arch as the ultimate stimulus to move; see Figs 9.16A and 9.17).

A fully supine posture may also be considered an instinctive sleep posture, though will rarely be used to sleep in the natural environment, unless there is no perceived threat. Of course, this posture is mainly recognized as being either a complete relaxation posture or a complete surrender posture.

Hence it can be concluded that, in the functional state, pillows are props – props that propagate dysfunction.

Similarly, a forgiving, soft mattress not only allows biomechanical dysfunction to perpetuate but also may impair the body's inbuilt postural regulation system.

This is not to suggest that everyone should sleep without pillows on a firm surface, but that everyone with a functional spine should be able to, and would probably benefit from doing so.

Recovery position

When an unconscious athlete is breathing and shows a regular pulse, he or she should be placed into the recovery position (First Aid Manual, 1995, 2002). In this position, the chin is lifted forwards to keep the airway clear and open, the head is lower than the body so fluids will drain from the mouth, avoiding the possibility of them being inhaled. The athlete's hand supports the head and protects it from the ground, and the arm and leg are bent, increasing stability and preventing the body rolling forwards. The side-lying position avoids the chest compression of the prone position, making breathing easier.

The athlete is rolled into the recovery position in five stages (Fig. 6.7), making sure that the open airway remains a priority throughout the movement. In stage I, the practitioner kneels to the side of the athlete at waist level. The athlete's airway is opened (gum shield removed) by pulling the chin forwards and tilting the head back. If there is time, objects such as the athlete's spectacles, keys in the pocket, and any cord in or around the neck (stopwatch, whistle, etc.) should be removed. The nearest arm is bent to 90° at the elbow and shoulder, and supinated to bring the palm forward facing at the side of the head (‘oath’ position). For stage II, the athlete's other arm is brought across the chest and the hand held, palm outwards, against the near cheek throughout the remaining stages to support and protect the head. In stage III the far leg is grasped over the lower hamstrings to flex it and pull the bent knee towards the practitioner. The foot remains on the floor to take the weight of the limb and avoid lifting stress on the practitioner. In stage IV the knee is pulled towards the practitioner to roll the athlete onto the side. The practitioner's knees prevent the athlete from rolling too far. Finally, in stage V, the athlete's chin is pulled forwards to clear the tongue from the throat and assist drainage. Final adjustments are made to the hand beneath the cheek to maintain correct head alignment, and to the upper leg (flexed at 90° to both hip and knee) for maximum stability.

Treatment

1.

NPO.

Heimlich maneuver if patient is conscious. 3

If obstruction is relieved, place the patient in recovery position or position of comfort. 3

If patient becomes unconscious, lower patient to the ground and start CPR (no pulse check) until equipment is ready for intubation. 3

Avoid bag-mask ventilation as it can cause supraglottic foreign body to move below the vocal cords, making removal difficult. 3

Perform direct laryngoscopy and attempt removal of foreign body using Magill forceps, if you can see the foreign body. 3

If unable to remove the foreign body, intubate the right or left main stem bronchus, pushing the foreign body to enter the bronchus; then retract the tube to a proper depth, reinflate the cuff, and start invasive PPV. 3

One lung ventilation must be done carefully with low respiratory rates and low tidal volumes to avoid pneumothorax. 3

Pulmonology consultation for flexible bronchoscopy in OR, which has a 90% success rate for retrieval and allows a more comprehensive airway survey; grasping devices include forceps, baskets, or snares; rigid bronchoscopy is more optimal choice for patients with hemoptysis as the operator may use its barrel to mechanically tamponade the site of bleeding, and it also allows passage of the suction catheter; rigid bronchoscopy is preferred in patients with stridor or asphyxia.4

Postoperatively, chest physiotherapy may be used for patients with secretions.

Transport to medical care

Patients should be transported to hospital as quickly, but as passively, as possible. They should be placed on their left side in the recovery position to prevent aspiration of vomit. Persistent vomiting can be treated with chlorpromazine by intramuscular injection (25–50 mg in adults, 1 mg/kg in children) [intravenous (IV) injection risks hypotension] or chlorpromazine or prochlorperazine by intrarectal suppository. Syncope, shock, angio-oedema and other anaphylactic symptoms can be treated with 0.1% adrenaline (epinephrine) by intramuscular injection (0.5 ml for adults, 0.01 ml/kg for children) and an antihistamine such as chlorphenamine maleate, by IV injection (10 mg for adults, 0.2 mg/kg for children). Respiratory distress and cyanosis should be treated by clearing the airway, preventing obstruction by the tongue by jaw-lifting, inserting an oropharyngeal airway and by positioning, giving oxygen and, if necessary, assisted ventilation. If the patient is unconscious and no femoral or carotid pulses can be detected, cardiopulmonary resuscitation must be started immediately.

If the snake has been killed it should be brought to the hospital for identification, but it must be handled cautiously as even snakes that appear dead and severed heads can cause envenoming. They should be carried on a stick or maneuvered into a container.

Transport to Medical Care

Patients should be transported to a hospital as quickly, but as passively, as possible. They should be placed on their left side in the recovery position to prevent aspiration of vomit. Syncope, shock, angioedema, and other anaphylactic symptoms can be treated with 0.1% epinephrine by intramuscular injection (0.5 ml for adults, 0.01 ml/kg for children) and an antihistamine such as chlorphenamine maleate, by IV injection (10 mg for adults, 0.2 mg/kg for children). Respiratory distress and cyanosis should be treated by clearing the airway; preventing obstruction by the tongue by jaw-lifting, inserting an oropharyngeal airway, and positioning; giving oxygen; and, if necessary, assisted ventilation. If the patient is unconscious and no femoral or carotid pulses can be detected, cardiopulmonary resuscitation must be started immediately.

If the snake has been killed, it should be brought to the hospital for identification, but it must be handled cautiously, as even snakes that appear dead and severed heads can cause envenoming. They should be carried on a stick or maneuvered into a container.