hi everyone this is Lahiru from abc's anesthesia so today i'm going to be talking about the
recovery positions for various problems in medicine and various deteriorating patient
conditions so what happened is i gave it to yesterday for junior doctors and we
had a really good question which is what is the recovery position and i mentioned the v position
but i'm going to go into a little more detail in this particular video so let's get started
i'm here with greg now greg is one of our new interns and he's very kindly volunteering to be
my little guinea pig here so he's now laying down as a patient a deterring patient and we're going
to demonstrate the recovery position there's so there's pretty much two situations here now the
first situation is a cardiovascular problem and the second situation is a respiratory problem
and i'll make some arguments as to why you know a different position is relevant for each problem so
here we go so often with a cardiovascular problem one of the main problems will be a lack of preload
or afterload so there's a lack of volume in the system so you'll notice that often patients who
have a slow heart rate from a vasovagal or some kind of collapse they'll have their feet
up so we call a trendelenburg position so kind of head down feet up that's really to take the
volume from the legs all the way down and you know bring it back into the central part of the body so
what does that look like that looks like the legs going up so i'm just going to raise the legs now
and that way you can see that this positioning here is going to have the legs raised you might
also see this kind of angle here so here we have greg in the recovery position i've got the legs up
which means that most of that volume that of blood that's in the legs will be going back down towards
the heart towards the central area of the body and that will help aid the blood pressure and you know
hopefully bring the patient back to consciousness so that's a really effective way of doing this
now notice that i haven't got the head all the way down now the advantage of that is there's a lot of
problems that can happen when your head is all the way down for example your airway management
is difficult if the patient's unconscious you'll get passive regurgitation of gastric contents into
the airway so i'm trying to prevent that so i've just got the legs up in the air
and the head pretty much level so i hope that made sense if i've got a cardiovascular problem i
really just want to improve the blood supply back to the heart therefore legs up is a really good
way to go so that's the first situation imagine someone who's fainted so they've got a low heart
rate maybe they need that extra volume to increase the heart rate pumping as well maybe they've
got you know they're having an ethyl anaphylactic shock and they're slowly losing consciousness
because of the lower blood pressure or they're having a bleed and you just need to prop that
blood pressure up rapidly sometimes i don't even use the controls on the bed literally i'll just
get someone to raise the legs and that provides an immediate resuscitative effort to provide
volume back centrally now the next problem is someone who's got a respiratory issue so
imagine someone in who's deteriorating because they're hypoxemical have difficulty breathing
so what we say is that we want to increase the mechanical advantage of having the patient
head up so what this means is i just put the head of the bed up
and this allows the lungs to have their best mechanical advantage now i'll demonstrate what i
mean by that now let's say greg's having a problem with his respiration his ventilation or his
oxygenation there's a number of things that happen when i put the patient at 30 to 45 degrees head
up now the first thing there's this thing called frc or functional residual capacity and what that
means is that when the head is up that frc this space in the lungs at the end of a normal tighter
volume or when the patient is at rest so they're not inspiring or expiring they're just at rest
that volume is going to be greatest with the head up at supine or head down that reserve of oxygen
in the frc is going to be less so i want to really maximize the frc it's got lots of really major
functions but pretty much to go through them specifically it provides a big oxygen reserve
at frc of the highest compliance of the lungs so that's really good mechanical advantage that
aids the respiration lowest pulmonary vascular resistance it aids preventing adelectosis and
buffers all the variations of your oxygen so this is some intense physiology just believe me when i
say that frc and maximizing frc in a patient deteriorating from a respiratory cause is a
really good thing as i was mentioning it provides a really good mechanical advantage imagine if
you're lying down or your head is down you've got the weight of gravity and it's very difficult to
breathe but when your compliance is maximal when you're you know having 45 degrees or even elevated
a bit more you're able to breathe more effectively you don't have the weight of your stomach or you
know say you have an obese patient the weight of their stomach and chest impairing their breathing
so if i have anyone with a respiratory issue i get them in this kind of 45 degree or 30
degree head up position now aside from increasing the frc and improving the mechanical function
of the lungs when you have the patient at a 30 degree or 45 degree head up position you improve
the positioning of the airway and you'll notice that a lot of time we talk about the sniffing the
morning air position you can which really is your mastoid process lining up with your certain angle
when you have a patient head up that is already optimized therefore the conduit the passage of air
going through from the mouth down into the trachea has improved because you automatically put
the head in the right position and also it's much easier to manage the airway do jaw thrust chin
lifts head tilt if the patient was head down with the head quite low this is more difficult to do
it's far easier to intubate bag mask lma ventilate with the patient has having with a 30 degree
head up type position so that's pretty much it that's the way i think of deterring patients
and recovery positions and now that sometimes you'll have a patient with an unknown issue
maybe they've got some cardiovascular problems and some hypoxemia respiratory problems in which
case i might combine those methods and put the legs up and the head slightly up so i'm
improving venous return to the heart but i'm also allowing the opportunity to maximize the patient's
respiratory function ventilation as well as airway intervention and that position is kind of this v
position which i'll show you now so this this position here you can see that the bottom of the
patient is the lowest position i've got the legs going up and then i've got the head slightly up
as well that's a reasonable recovery position for any patient when you're not really sure exactly
what's going on or they've got cardiovascular and respiratory issues so i hope you enjoy that video
just gone through the recovery positions for a deteriorating patient the cardiovascular best
recovery position the respiratory function best recovery position and then the combined approach
and yeah thank you very much greg for joining us and helping us to educate see you next time