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WORKSHEET for Evidence Based Review of Science for First Aid

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					Worksheet No. FA-2301B                                                                                                          Page 1 of 5



                             WORKSHEET for Evidence-Based Review of Science for First Aid
Worksheet author(s)
Hong Shen                                                           Date Submitted for review: Nov 26. 2009


Clinical question.
Question:Which position might be the best for victims of possible head injury if they are unconsciousness?

Hypothesis: The lateral recovery position might be the best for victims of possible head injury if they are unconsciousness .
Conflict of interest specific to this question
Director of Emergency Department, Chinese PLA General Hospital, Board Member of Chinese RC First Aid Committee
This question addresses an intervention/therapy.
The author doesn’t have any conflict of interest disclosures relevant to this worksheet
Search strategy (including electronic databases searched).
Search terms (key words) as MESH and Google Headings::
("craniocerebral trauma"[MeSH Terms] OR ("craniocerebral"[All Fields] AND "trauma"[All Fields]) OR "craniocerebral
trauma"[All Fields] OR ("head"[All Fields] AND "injury"[All Fields]) OR "head injury"[All Fields]) AND position[All Fields]
AND ("unconsciousness"[MeSH Terms] OR "unconsciousness"[All Fields]) (up to January, 2010).

• State inclusion and exclusion criteria
Limitiations: Search was limited to include studies which involved head injury, unconsciousness and position.
We also reviewed the references of the above pertinent publications to obtain further potential articles.
The exclusion criteria are animal studies, abstract only studies and studies that do not specifically answer the question.

• Number of articles/sources meeting criteria for further review:
Cochrane database (0 hits), Medline (70 hits), Embase (0 hits)
Specific searches:
Final number of articles reviewed = 6
6 studies met criteria for further review. Of these one was LOE 2, five were LOE5.
Worksheet No. FA-2301B                                                                                   Page 2 of 5




                                        Summary of evidence
                             Evidence Supporting Clinical Question

                              Schneider 1993
    Good                           (E)
                                                                                      Davis 2004 (E)
    Fair                                                                              Gunn, 1995(E)
                                                                                      Jantzen 2007 (E)
                                                                                      Blake 2002(E)
                                                                                      Feldmen,1992(E)

    Poor

                         1          2                     3               4                      5
                                               Level of evidence

Outcomes – Please define outcomes for this question, place them after letters below and use letters to identify
studies which evaluate this outcome
A = Return of spontaneous circulation B = Survival of event C = Survival to hospital discharge D = Intact
neurological survival E = Other endpoint
Worksheet No. FA-2301B                                                                           Page 3 of 5




                             Evidence Neutral to Clinical question


    Good


    Fair


    Poor

                         1     2           3                    4                  5
                                         Level of evidence

Outcomes – Please use the same outcomes as defined for the Evidence Supporting table above
                             Evidence Opposing Clinical Question


    Good


    Fair


    Poor

                         1         2                   3               4                     5
                                            Level of evidence

Outcomes – Please use the same outcomes as defined for the Evidence Supporting table above
Worksheet No. FA-2301B                                                                                                 Page 4 of 5



REVIEWER’S FINAL COMMENTS AND ASSESSMENT OF BENEFIT / RISK: (please include implementation considerations including
at a minimum training, environment and availability:
There are mainly three dangerous conditions which can cause devastating consequences for victims of possible head injury.
These are asphyxia, intracranial pressure (ICP) increase and neck spinal-cord damage.
The evidences suggest that all of the recovery position share basic principles. The mouth is downward so that vomit or blood
can drain from the patient; the chin is well up to keep the airway opened. Arms and legs are locked as to stable position of the
patient. The recovery position, more technically the lateral recovery position, is an airway management technique for assisting
victims who are unconsciousness, or nearly so, but are still breathing.
Elevation of the head as a common practice to reduce intracranial pressure (ICP) has been discussed. Some investigators were
able to show that besides lowering ICP head elevation may also reduce cerebral perfusion pressure (CPP). For a new
evaluation of optimal head position in this condition, it would be of importance to know the influence of body position on
cerebral perfusion. Jantzen JP (2007 LOE 5) argue ICP may be controlled by correcting the patient's position. Schneider( 1993
LOE2) therefore employed continuous jugular venous oximetry, monitoring cerebral oxygenation, to study the effect of 0
degrees, 15 degrees, 30 degrees, and 45 degrees head elevation on ICP, CPP and jugular venous oxygen saturation (SJVO2) in
25 comatose patients with reduced intracranial compliance. As expected, head elevation significantly reduced ICP from 19.8
+/- 1.3 mmHg at 0 degrees to 10.2 +/- 1.2 mmHg at 45 degrees. Already at 30 degrees 92% of the possible effect on ICP was
detected. There was no statistically significant change in CPP and SJV O2 associated with varying head position. Individual
reactions of CPP to changes in head position, however, were quite unpredictable. The data suggest that an individual approach
to head elevation is to be preferred. A moderate head elevation between 15 degrees and 30 degrees significantly reduces ICP
and, in general, does not impair cerebral perfusion. Feldmen data (1992 LOE5) also indicate that head elevation to 30 degrees
significantly reduced ICP in the majority of the 22 head- injured patients without reducing CPP or CBF.
How should an unconscious person with a suspected head and neck injury be positioned? Gunn (1995 LOE5) aware of the risk
of spinal-cord damage in moving an unconscious person with a suspected neck injury into the "lateral recovery position,"
coupled with the even greater risk of inadequate airway management if the person is not moved, has resulted in a suggested
modification to the lateral recovery position for use in this circumstance. It is proposed that the modification to the lateral
recovery position reduces movement of the neck. In this modification, one of the patient's arms is raised above the head (in full
abduction) to support the head and neck. The position is called the "HAINES modified recovery position." HAINES is an
acronym for High Arm IN Endangered Spine. Neck movements in two healthy volunteers were measured by the use of video-
image analysis and radiographic studies when the volunteers were rolled from the supine position to both the lateral recovery
position and the HAINES modified recovery position. For both subjects, the total degree of lateral flexion of the cervical spine
in the HAINES modified recovery position was less than half of that measured during use of the lateral recovery position
(while an open airway was maintained in each). So an unconscious person with a suspected neck injury should be positioned in
the HAINES modified recovery position. 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. Blake (2002 LOE5) also
suggests that the modified HAINES position results in a more neutral position of the spine making it preferable to the lateral
recovery position in the management of patients when trauma may have occurred.
 Acknowledgements:
Worksheet No. FA-2301B                                                                                              Page 5 of 5




                                                        Citation List
Blake        Blake WE, Stillman BC, Eizenberg N, Briggs C, McMeeken JM. The position of the spine in the recovery
2002         position*/an experimental comparison between the lateral recovery position and the modified HAINES
             position. Resuscitation 53 (2002) 289_/297
             (LOE 5, quality fair ,supportive to hypothesis)

Davis        Davis DP, Dunford JV, Poste JC,et al. The impact of hypoxia and hyperventilation on outcome after
2004         paramedic rapid sequence intubation of severely head-injured patients. J Trauma. 2004 Jul;57(1):1-8;
             (LOE 5, quality fair ,supportive to hypothesis)

Feldme       ZEEV FELDMAN, MALCOLM J. KANTER, CLAUDIA S. ROBERTSON, et al. Effect of head elevation on
n,1992       intracranial pressure, cerebral perfusion pressure, and cerebral blood flow in head- injured patients. J
             Neurosurg 76:207-211, 1992
             (LOE 5, quality fair ,supportive to hypothesis)


Gunn         Gunn BD, Eizenberg N, Silberstein M, et al. How should an unconscious person with a suspected neck injury be
1995         positioned? Prehosp Disaster Med. 1995 Oct-Dec;10(4):239-44.
             (LOE 5, quality fair ,supportive to hypothesis)


Jantzen      Jantzen JP. Prevention and treatment of intracranial hypertension. Best Pract
2007         Res Clin Anaesthesiol. 2007 Dec;21(4):517-38.
             (LOE 5, quality fair ,supportive to hypothesis)


              Schneider GH, von Helden GH, Franke R, et al. Influence of body position on jugular venous oxygen saturation,
Schneid      intracranial pressure and cerebral perfusion pressure. Acta Neurochir Suppl(Wien), 1993;59:107-12
er 1993
             (LOE 2, quality good ,supportive to hypothesis)

				
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