How would you treat an unresponsive person who is breathing normally and has a suspected spinal injury?

Summary

• Always call triple zero (000) for an ambulance in an emergency.
• The presence or absence of blood isn’t a reliable indicator of the seriousness of the head injury.
• Symptoms of serious head injury can include clear fluid leaking from the nose or ears, altered consciousness or a period of unconsciousness, skull deformities, vision changes, bruised eyes and ears, nausea and vomiting.
• A person who has sustained a head injury may also have injured their spine.

This page has been produced in consultation with and approved by:

This page has been produced in consultation with and approved by:

Related information

• The type of pain felt in the abdomen can vary greatly.

• Children may feel stomach pain for a range of reasons and may need treatment

• The long-term effects of brain injury will be different for each person and can range from mild to profound.

• A person with alcohol related brain impairment (ARBI) might experience problems with coordination, thinking, planning and memory.

• If a person with alcohol related brain impairment is aware of their memory limits, they can learn how to deal with them.

From other websites

Content disclaimer

Content on this website is provided for information purposes only. Information about a therapy, service, product or treatment does not in any way endorse or support such therapy, service, product or treatment and is not intended to replace advice from your doctor or other registered health professional. The information and materials contained on this website are not intended to constitute a comprehensive guide concerning all aspects of the therapy, product or treatment described on the website. All users are urged to always seek advice from a registered health care professional for diagnosis and answers to their medical questions and to ascertain whether the particular therapy, service, product or treatment described on the website is suitable in their circumstances. The State of Victoria and the Department of Health shall not bear any liability for reliance by any user on the materials contained on this website.

Systematic reviewsRecovery position

The International Liaison Committee on Resuscitation (ILCOR) did a scoping review in 2020 about the recovery position for people with a decreased level of consciousness of non-traumatic cause, not requiring rescue breathing or chest compressions (Singletary 2020). The review includes 31 studies, a case report and two letters to the editor, including people with a decreased level of responsiveness due to medical conditions (e.g. stroke), overdose or sleep-disordered breathing, or including healthy participants, participants with medically induced unconsciousness, or cadaveric models of spine instability. In these studies, several recovery positions were studied. One study, where a decreased level of responsiveness was the result of an overdose, suggested that lying down in a semi-raised position may be preferable to a side-lying position, however, additional studies need to confirm this finding. For the other medical causes of decreased mental status (e.g. stroke), the side-lying position was reported as associated with beneficial outcomes. The studies on sleep-disordered breathing found that side-lying positioning improved apnoea, hypopnea , and oxygen desaturation. However, they may not be directly applicable to the use of the recovery position for people with a decreased level of responsiveness from a medical, toxicological, and non-traumatic cause.

A Centre for Evidence-Based Practice (CEBaP) evidence summary from 2019 identified three experimental studies, including one study with healthy volunteers and two studies with human cadavers, comparing the Haines position (with both legs bent at the knee), modified HAINES position (with one leg bent at the knee) or side-lying trauma position (which requires two rescuers and the use of a cervical collar) to the side-lying recovery position. It was shown that the HAINES position resulted in a statistically significant decrease of movement in the cervical region and a decrease of the spinal range of linear motion, compared to the side-lying recovery position. However, the HAINES position resulted in a statistically significant increase of movement in the thoracolumbar region, compared to the side-lying recovery position. It was shown that the modified HAINES position resulted in a statistically significant decrease of the spinal range of linear motion, compared to the side-lying recovery position. It was shown that the side-lying trauma position resulted in a statistically significant decrease of the spinal range of angular motion, compared to the side-lying recovery position. A statistically significant difference in a range of other motion outcomes could not be demonstrated for any of these alternative positions. No other outcomes were measured, and evidence with people with a spine injury is not available. Evidence is of very low certainty and results of these studies are imprecise due to the small number of participants, the large variability of results and lack of data.

A second CEBaP evidence summary from 2019 compared the recovery position to only doing the jaw thrust, but no studies could be identified.

A CEBaP evidence summary from 2018 identified five diagnostic accuracy studies on the use of the AVPU scale, showing limited evidence in favour of using the AVPU scale as a tool to assess the level of consciousness.

In a first study, children with pre-hospital emergencies were classified according to AVPU and the Glasgow Coma Scale (GCS) by paediatric emergency physicians at the scene of the emergency. This study showed that AVPU category ‘A’ corresponds to a paediatric GCS score greater than 12 (clinical indication of non-critical neurologic condition). Moreover, categories ‘P’ and ’U’ corresponded to a paediatric GCS score less than 8 (neurologic impairment with the need of more invasive treatment).

A second study with a large set of 20,000 participants over the age of five who were assessed by ambulance crews using the AVPU and GCS scales, and transported to the emergency department, also demonstrated that AVPU category ‘A’ corresponds to a GCS score greater than 12, and that categories ‘P’ and ‘U’ correspond to a GCS score less than 8. In addition, this study showed that categories ‘A’ and ‘V’ corresponded to a GCS score greater than 8.

Similarly, a third study in people over the age of 13 who were admitted to hospital due to deliberate or accidental drug overdose, and were assessed using the AVPU and GCS scales, demonstrated that categories ‘P’ and ‘U’ corresponded to a GCS score less than 8.

Finally, a fourth study in adults with acute drug poisoning confirmed that categories ‘P’ and ’U’ corresponded to a GCS score less than 8.

However, the results of a fifth study, in which the AVPU scale is used during the initial assessment of consciousness at the emergency department in children presenting with a head injury classification, do not support the correlation between the AVPU categories and GCS scores found in studies mentioned above. In this study, classification in the AVPU categories ‘VPU’ was not clinically helpful to correctly detect the presence or the absence of head injury or depressed fractures in children older than one year of age. Similarly, the study showed that the’ VPU’ categories can be considered as not clinically helpful to detect the absence of head injury or depressed fractures in babies (less than one-year-old). In other words, this study does not favour AVPU scale use to assess the level of consciousness.

One possible explanation for these diverging results are potential differences in how the AVPU assessment is conducted across the different studies. The AVPU scale is a rapid and very simple method that does not require training, and is, therefore, suitable for use by first aid providers. This simplicity is accompanied by a lack of defined stimuli and responses, making the scale vulnerable to user interpretation. Some studies above report the use of a fixed algorithm on how to use the scale (including which stimuli the assessor should give), some do not. Hence, the AVPU assessment and therefore classification into one of the AVPU categories may have been variable. Evidence is of low certainty.
 

There is limited evidence neither in favour of AVPU scale use nor GCS scale use. When comparing the level of agreement between the final ratings of two emergency physicians, who independently scored the level of consciousness in adults with altered levels of consciousness from traumatic and non-traumatic causes using the GCS and subsequently the AVPU scale, no statistically significant differences could be demonstrated. In other words, use of the AVPU scale should be as feasible as use of the GCS scale. Evidence is of very low certainty and results of this study are imprecise due to limited sample size.
 

Hyldmo, Horodyski, Conrad et al. (2016) investigated the safety of the new side-lying trauma position in cervical spine injuries in a cadaver model study and found that in the standard recovery position, the range of motion for lateral bending was 11.9°. While both   caused a similar range of motion, the new side-lying trauma position resulted in 2.6° less (P = 0.037). The range of motion of the head, neck and upper body in the standard recovery position was 13.0 mm. In comparison, the HAINES positions showed significantly less motion (5.8 and 4.6 mm, respectively), while the side-lying trauma position showed even less (4.0 mm, P = 0.067). The authors concluded that in unresponsive trauma people, the side-lying trauma position or one of the two HAINES techniques is preferable to the standard recovery position in cases of an unstable cervical spine injury.

In a cadaver study, the new side-lying trauma position and the well-established log-roll manoeuvre resulted in comparable amounts of motion in an unstable cervical spine injury model. (Hyldmo et al., 2020.)

In a guideline based on a systematic review, Rehn et al. (2016) could not identify any evidence suggesting that placing a person with a spine injury in a side-lying position (including the use of a log roll) causes harm. Although the guideline was intended for professional responders, it can also apply to first aid providers. The guideline recommends the recovery position for all unresponsive people, where there is no suspicion of trauma and where advanced airway management is not immediately available.

For unresponsive people with trauma, the recommendation is to turn them into a side-lying position while maintaining spinal alignment (strong recommendation, limited evidence). This move would require two first aid providers. When spinal precautions are necessary, providers should use the head-tilt/chin-lift or jaw thrust manoeuvre in addition to manual in-line stabilisation to reduce the risk of worsening any spinal injuries.

Romanelli and Farrell (2020) underlined that the AVPU scale is a quick and simple way of detecting altered mental status in a person. No formal training is necessary to use this score. First aid providers can use the tool in any pre-hospital setting as anything less than “A” is considered abnormal, indicating they should access medical care. 

What technique should you use to open the airway of an unresponsive victim with spinal injury?

Is it preferable to turn an unconscious breathing person with suspected spinal injury in to the recovery position?

What is the first step in caring for an unresponsive victim with signs and symptoms of a brain injury?

When should someone with a spinal injury be placed in the recovery position?