# Patient positioning



## Ediron (Dec 2, 2009)

Im quite skeptical about which patients should be positioned in such manner.

For example a diabetic patient, AMS, chest pain , stroke, etc.
can anyone help please.

The only thing that isnt confusing to me is when a patient has
a possible spinal injury, you place the patient in a supine position 
immobilized.


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## usafmedic45 (Dec 2, 2009)

If they are conscious, you put them in whatever position makes them most comfortable.  If in doubt, ask the patient.  

If they are not or are unstable, you either roll them lateral recumbent ("recovery position") or if you need to work on them lay them supine to allow you to work on them. 

The major exception is in a CHF/pulmonary edema patient (unless receiving assisted ventilations) where you want to keep them sitting up to allow gravity to help keep the fluid down in the lower parts of the lungs which makes oxygenation and ventilation easier.  In a conscious CHF patient, trying to lay them flat is going to worsen their condition and make that patient very upset.  One of my instructors told me about being punched in the face by an old lady when he did this as a student himself. 

This is the two-dollar commentary since I have to get ready for work. 

BTW, I don't think you meant to say "skeptical".  I think you were looking for "unsure" or "confused".


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## Ediron (Dec 2, 2009)

Thanx very much. 

How bout Oro- and nashopharyngeal adjuncts???

Only on occasions where the patient has a severe altered mental status
or just altered??

when you are assessing for ABC's, do you place a NRB or BVM as soon as you get to B (breathing)??


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## EMSLaw (Dec 2, 2009)

I agree with USAFMedic.  Your decision is going to depend on the situation.  Many patients will be transported in a position of comfort - sitting up on the cot, usually, though they might straddle it and tripod if they're having breathing difficulties, and you'll want to position, say, pregnant women in a left lateral recumbent.   Patients in shock get their feet raised in a modified Trandelenberg position.  Stroke patients are often positioned on their side, with the afflicted side down.  Another option for breathing difficulty is a Fowler's position, sitting up with a blanket roll under the knees.  

If you need to work on a patient, they generally need to be supine for you to do it, whether sitting up or lying flat.  C-Spine precautions require the patient to be flat, because they should be on a back board, but again, you're going to prop up one side for pregnant women, because you want to avoid pressure on the inferior vena cava.  I can't really think of any situation in which you'd transport a patient prone, except maybe a pending delivery with a prolapsed cord (and that's not entirely prone, either).


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## EMSLaw (Dec 2, 2009)

Ediron said:


> Thanx very much.
> 
> How bout Oro- and nashopharyngeal adjuncts???
> 
> ...




You can only put an OPA in an unconscious patient with no gag reflex.  You could theoretically put an NPA in anyone without a head injury, but I don't know if I'd try it.  

If your general impression is that the patient is not breathing adequately, you would address that right then, because it is a life threat.


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## medichopeful (Dec 3, 2009)

Ediron said:


> Thanx very much.
> 
> How bout Oro- and nashopharyngeal adjuncts???
> 
> ...



Give them oxygen as soon as you can, usually during the breathing part of the initial assessment.  So yes, you are correct on that part.

As far as when an OPA or NPA is indicated, it is basically whenever the patient is unable to protect their own airway.  This would be done during the airway (A) portion of the ABCs (if indicated), BEFORE any oxygen is administered.  Because if they don't have a patent airway, all the oxygen in the world is not going to do the patient any good.  This could be when they have an AMS, but that is not the only situation.  Anytime the airway is endangered, an OPA or NPA should be used.  Remember, an OPA will only work if they do NOT have a gag reflex.  If they have a gag reflex, they could very easily vomit and aspirate it, which could end up with them dying.  If they have a gag reflex, though, you may still be able to insert an NPA, as long as it is not contraindicated (for example, head trauma, cerebrospinal fluid present, etc.).  

Basically, the ABCs works like this:
Airway: See if it's patent.  If not, open it and if necessary, insert an OPA.  If they will not tolerate an OPA, try to use an NPA, unless contraindicated
Breathing: once the airway is open and clear, make sure they are moving oxygen.  This is when you would administer oxygen via NRB, nasal cannula, or BVM
Circulation: Make sure it's happening, and that the stuff circulating is going where it's supposed to.

I hope this is clear (I'm tired, so it may make no sense).  If it isn't, let me know.


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## medichopeful (Dec 3, 2009)

EMSLaw said:


> You could theoretically put an NPA in anyone without a head injury, but I don't know if I'd try it.



Only use an NPA if their airway is endangered.



> If your general impression is that the patient is not breathing adequately, you would address that right then, because it is a life threat.



Correct.  Otherwise it could and will lead to cardiac arrest.


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## Brandon O (Dec 9, 2009)

I just want to say that the question about "when" to use BLS airways is not necessarily an obvious one. In my experience this is generally glossed over in BLS training material, especially when you're working through the formal AHA CPR flow or anything similar. Quite aside from the issue of how you're interacting with any ALS that's present or may arrive later, exactly when you stick in your OPA or NPA, on a patient that can't protect their own airway -- but has no obstruction when properly positioned -- is probably worth discussion.


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## medicdan (Dec 9, 2009)

Brandon Oto said:


> I just want to say that the question about "when" to use BLS airways is not necessarily an obvious one. In my experience this is generally glossed over in BLS training material, especially when you're working through the formal AHA CPR flow or anything similar. Quite aside from the issue of how you're interacting with any ALS that's present or may arrive later, exactly when you stick in your OPA or NPA, on a patient that can't protect their own airway -- but has no obstruction when properly positioned -- is probably worth discussion.



An interesting, and very informative article/post on the proper use of NPAs, from generally an excellent resource

http://theemtspot.com/2009/12/08/the-art-of-the-nasopharyngeal-airway/


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## mycrofft (Dec 9, 2009)

*As always, watch the pt.*

Supine is the traditional position, also that which autopsies are performed in...
I've seen a few pts' airways go west when placed supine and no airway was placed, or was unplaceable.


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## emtzach03 (Dec 9, 2009)

having gone throught army training now i would tell you that if im concious and you try craming an npa into my nose you will be the one that may actually need it ive had it done ten times in training with npa's that were to big to begin with, lol. any way for testing i would always "consider" opa npa where applicable. if your breathing for them then start with npa and what for als cuz im sure there rsi and drop a tube anyway


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## NomadicMedic (Dec 9, 2009)

This has been an interesting discussion so far. 

I've found that most EMTs are scared to place an NPA and will often just bag a patient with no adjunct in place. Let me tell you... anytime you are bagging a patient, you better have an airway adjunct in place!

Through lack of training and poor understanding for indications of use I feel that the NPA is one of the most under utilized items in the BLS airway toolbox.

As for when you place the Oxygen on a patient, in the National Registry check sheet, it's during the "B" portion of your assessment, following the initial assessment. 

You can see the NREMT-B skill sheet to get a good idea for the flow, and how it's scored when you test. http://www.nremt.org/nremt/downloads/patientassessmentmanagementmedical.pdf


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## gamma6 (Dec 15, 2009)

Ediron said:


> Thanx very much.
> 
> How bout Oro- and nashopharyngeal adjuncts???
> 
> ...



depends on their breathing and A&O situation really as far as the nrb and bvm are concerned....can they tolerate a bvm, can they tolerate a nrb...if they are hyperventilating most won't tolerate the bvm cause they are already freaking out. coach the breathing to slow down, fix underlying problem. plus co2 is being blown off when breathing is to fast and now you have an issue of resp. alkalosis. true o2 never hurts anyone but.....

if you do put a nrb on em i would start around 10 and go up from there unless the pt is not breathing or is cyanotic, now you are dealing with resp. acidosis. again fix underlying problem. in the instance of asthma it's mostly a broncho spasm problem and clossing up, air going in but not much air coming out. that's why a cpap is kinda bad in this area. putting a butt load of air in but it can't come out. i'm not saying you can't use em but be aware of the issue.

as far as a npa is concerned i don't use em and actually have never used one. most of the time the pt is out and i stick an opa in. why screw around with the npa, grab the opa and go at it, plus the opa moves the tongue out of the was and gives you an open airway for the most part.


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## VentMedic (Dec 15, 2009)

gamma6 said:


> depends on their breathing and A&O situation really as far as the nrb and bvm are concerned....can they tolerate a bvm, can they tolerate a nrb...if they are hyperventilating most won't tolerate the bvm cause they are already freaking out. *coach the breathing to slow down, fix underlying problem. plus co2 is being blown off when breathing is to fast and now you have an issue of resp. alkalosis*. true o2 never hurts anyone but.....


 
How do you know they are "hyperventilating" as opposed to being tachypneic due to an underlying acidosis from sepsis or some metabolic issue like DKA or they have impending respiratory failure where their PaCO2 is rising and they must breathe fast to maintain an acceptable pH? Do you tell your DKA patients who may have a clinical definition of "hyperventilation" with a low PaCO2 but are still acidotic with a pH of 6.98 to "slow down"? Are you prepared to treat a patient with a pH of 6.5? That is a death situation and the body will fight to recover homeostasis and will continue that struggle until exhausted or interfered with rather than assisted or until assisted in its fight against death. 





gamma6 said:


> as far as a npa is concerned i don't use em and actually have never used one. most of the time the pt is out and i stick an opa in. why screw around with the npa, grab the opa and go at it, plus the opa moves the tongue out of the was and gives you an open airway for the most part.


 
The NPA and the OPA are two very different devices with different uses. The OPA can NOT be used on someone with a gag reflex. The NPA can be used for someone with a gag and can also give better access to NT suctioning someone with lung congestion such as the scrambled eggs and oatmeal that the patient aspirated and made worst by improper assessment and use of CPAP.  Or, used for NT suctioning of patients who have aspirated vomit from an OPA placed with a gag reflex.


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## gamma6 (Dec 15, 2009)

so not going to get into a pissing match with you man....

i've never used an npa in the 8 yrs of being on the street, yes you are correct they do have different uses.... as far as the breathing: dka is whole nother set of issues to deal with. i've been in situations were the pt is hyperventilating and have refused the bvm, some will some won't. if the ph is that bad then some other questions need to be asked or head another direction as far as what the problem is in why they are breathing fast. some are freaking out secondary to some mental problems some aren't (i'm not implying that all pt's are having anxiety issues at all, it was more of an example). i've always been told to calm some one down in that situation. the only way to tell a ph balance is from labs really (kinda like hyperkalemia) , well that and end title volume through the monitor. and if the range is horrible then yes fix it. 

i did run a call a few weeks ago where we slapped a cpap on a pt and it helped but the dude died an hour later from basically his body giving out. his sats did improve for a bit. 

i guess the npa is like a k.e.d. some people use em some don't. the k.e.d. is great for kids. 

you are very correct in what you said, different situations call for different strategies.


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## VentMedic (Dec 16, 2009)

gamma6 said:


> i've been in situations were the pt is hyperventilating and have refused the bvm


 
Again, how do you know the patient is "hyperventilating"?  Do you know the PaCO2 at scene?   If you do carry the iSTAT for confirmation then I apologize.  

Hyperventilation is a clinical condition or syndrome where the the PaCO2 os lowered.  However as I mentioned before, impending respiratory failure with an increased PaCO2 will cause a patient to be tachypneic and definitely not to be confused with hyperventilation. 

Not all patients need to be bagged and an NPA can open an airway.   As well, "out" or unconscious does not always mean the patient is without a gag.   Too many have fallen into that trap and have inserted an OPA only to watch the vomit erupt. 

ETCO2 is whole other discussion where V/Q mismatch and deadspace ventilation needs to be understood.


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## gamma6 (Dec 16, 2009)

VentMedic said:


> Again, how do you know the patient is "hyperventilating"?  Do you know the PaCO2 at scene?   If you do carry the iSTAT for confirmation then I apologize.
> 
> Hyperventilation is a clinical condition or syndrome where the the PaCO2 os lowered.  However as I mentioned before, impending respiratory failure with an increased PaCO2 will cause a patient to be tachypneic and definitely not to be confused with hyperventilation.
> 
> ...


i do agree with you and yes i do understand what you are saying. i have been through paramedic and have been on the street for 8 yrs. my point was look at the underlying problem in certain situations. if the pt is gonna fight ya don't push the issue. if the pt needs it and will tolerate it great, do it.


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## VentMedic (Dec 16, 2009)

BTW, welcome to the forum.


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## gamma6 (Dec 16, 2009)

thanks....


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## redcrossemt (Dec 16, 2009)

gamma6 said:


> i've never used an npa in the 8 yrs of being on the street



Wow, that's pretty amazing. I use an NPA at least once every month on a fairly slow 911 car. I'm surprised that in your 8 years of working the road that you've never had a patient gag on the OPA you placed. Or did you just choose to use no adjunct at all then, even though you had already decided the patient's airway wasn't patent?



gamma6 said:


> the only way to tell a ph balance is from labs really (kinda like hyperkalemia) , well that and end title volume through the monitor. and if the range is horrible then yes fix it.



What was your point about hyperkalemia?

How would you "fix" an EtCO2 of 5 mmHg? ... of 100 mmHg?



gamma6 said:


> i guess the npa is like a k.e.d. some people use em some don't. the k.e.d. is great for kids.



Oh man, don't make me get out the soapbox! To those who choose not to use the KED or another similar device, can I tell your medical director and your operations manager about how you think that it's optional?? You can't just choose to rapid extricate patients because you are lazy and don't want to take the time to apply a short board or KED.

I'm not here to start a pissing match either, but Gamma, I would just be careful what you're getting yourself into. It seems like you are talking about things that you don't really know much about. When you say things like "end title" it gives people the idea that you really don't know what you're talking about, and they won't respect or listen to you.


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## gamma6 (Dec 16, 2009)

redcrossemt said:


> Wow, that's pretty amazing. I use an NPA at least once every month on a fairly slow 911 car. I'm surprised that in your 8 years of working the road that you've never had a patient gag on the OPA you placed. Or did you just choose to use no adjunct at all then, even though you had already decided the patient's airway wasn't patent?
> 
> 
> 
> ...



ok not going to argue with you....because i choose not to use a K.E.D. and can get the pt out safely doesn't make me an idiot.....and yes you can talk to my boss about it. there are a thousand ways to do something, think outside the box. 

end tidal, my bad.

a few things didn't come out the way i wanted to respond, my apologies. i'm not an idiot i swear.


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## MrBrown (Dec 16, 2009)

gamma6 said:


> ...true o2 never hurts anyone but.....



There's a whole gammet of stuff coming out about reperfusion injury and hyperoxygenation, especially in patients with ischemic injury (heart, brain, bowel, anything really), is bad.  

Nothing is magic about oxygen and it's often given to patients who do not require it, in concentrations far & above what is required.



gamma6 said:


> if you do put a nrb on em i would start around 10 and go up from there



Why ten litres? Why not .... 6 or 8, again, there is nothing magic about oxygen and if the normal inspired volume is (from memory) about 5 litres who says that this huge amount of oxygen is not doing harm?



gamma6 said:


> unless the pt is not breathing or is cyanotic, now you are dealing with resp. acidosis



I think what you have here is a false positive.  Cyanosis and hypoxygenation go hand in hand, whereas respiratory acidosis and cyanosis do not.  One is high PaCO2 and the other low PAO2.  

*stops squishing Vent's toes 



gamma6 said:


> as far as a npa is concerned i don't use em and actually have never used one. most of the time the pt is out and i stick an opa in. why screw around with the npa...



What if you cannot use an OPA?  NPA's do have their place.



VentMedic said:


> How do you know they are "hyperventilating" as opposed to being tachypneic due to an underlying acidosis from sepsis or some metabolic issue like DKA or they have impending respiratory failure where their PaCO2 is rising and they must breathe fast to maintain an acceptable pH? Do you tell your DKA patients who may have a clinical definition of "hyperventilation" with a low PaCO2 but are still acidotic with a pH of 6.98 to "slow down"? Are you prepared to treat a patient with a pH of 6.5? That is a death situation and the body will fight to recover homeostasis and will continue that struggle until exhausted or interfered with rather than assisted or until assisted in its fight against death.



Basically what she said!



gamma6 said:


> i have been through paramedic and have been on the street for 8 yrs.



Then why are you still practicing as a Basic?  Sounds to me like you've got "just enough syndrome" and I see it a bit in my US EMS friends; they have "just enough" knowledge (because that's all they were taught) and end up with false positives or false negatives because they get two things mixed up (which we all do, not saying I'm fantastically awesome or anything) and go off on a tangent .... 



gamma6 said:


> ...if the pt is gonna fight ya don't push the issue. if the pt needs it and will tolerate it great, do it.



So by your statement, I am a critical asthma patient, I can't speak more than one word a breath, my PACO2 is going through the roof and my respiratory centre is legging it out of town, I'm freaking out and don't want you to smother me with a nebuliser mask .... what, you're just gonna go "don't push it?"


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## EMSLaw (Dec 16, 2009)

gamma6 said:


> ok not going to argue with you....because i choose not to use a K.E.D. and can get the pt out safely doesn't make me an idiot.....and yes you can talk to my boss about it. there are a thousand ways to do something, think outside the box.
> 
> end tidal, my bad.
> 
> a few things didn't come out the way i wanted to respond, my apologies. i'm not an idiot i swear.



Like it or not, the KED is the standard of care.  Yes, there are situations where the safety of the scene, or the injuries to the patient, require a rapid extrication.  But when those circumstances don't exist, you should use the KED (or another "vest-type upper spinal immobilization device")  or short board.

Why?  Well, when you do a rapid takedown of the patient, and the patient ends up a quadraplegic, and you are hauled into court, the plaintiff is going to put an expert - probably an EMT instructor - on the stand.  And that expert will be asked what the standard of care is for removing someone from a crashed motor vehicle.  Then the expert replies that one should use a KED in that situation.  Pan to the Doctor who says that had the KED been used, little Johnny would be walking and playing baseball in the bright sunshine today.  Pan to the Jury, awarding lots and lots of money.  

The KED is a pain.  We all know it's a pain - especially when it's the middle of the night, and it's cold, and you want to go back to bed.  But if the situation calls for it, it should be used.  The extra ten minutes won't hurt as much as the potential consequences.


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## MrBrown (Dec 16, 2009)

EMSLaw said:


> ...Pan to the Jury, awarding lots and lots of money.



Ah I do like that notion, how much of it do I get?


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## redcrossemt (Dec 16, 2009)

gamma6 said:


> ok not going to argue with you....because i choose not to use a K.E.D. and can get the pt out safely doesn't make me an idiot.....and yes you can talk to my boss about it. there are a thousand ways to do something, think outside the box.
> 
> end tidal, my bad.
> 
> a few things didn't come out the way i wanted to respond, my apologies. i'm not an idiot i swear.



If you have been through paramedic, why aren't you a paramedic? Going through paramedic means nothing unless you can retain the knowledge, pass the test, and go through a few CEU's a year to keep your license. And even then, being a paramedic doesn't mean much... Nor does CCEMTP these days.

If you are not concerned about violating the accepted standard of care, please PM me with your organization and operations manager's contact information so him/her and I can talk. Imagine when the lawyers find out you bragged about getting the patient out safely without the KED!!!

Still waiting to hear how you are going to fix their EtCO2 and the comparison you were making about hyperkalemia and pH...?


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## redcrossemt (Dec 16, 2009)

EMSLaw said:


> Pan to the Jury, awarding lots and lots of money.



Do the lawyers roam EMTlife looking for easy prey??

Defendant: Well, I never said I wouldn't use a KED.
Prosecutor: Actually, we have the conversation from EMTlife right here. Will you read it to the jury?


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## redcrossemt (Dec 16, 2009)

MrBrown said:


> There's a whole gammet of stuff coming out about reperfusion injury and hyperoxygenation, especially in patients with ischemic injury (heart, brain, bowel, anything really), is bad.
> 
> Why ten litres?
> 
> ...



+1

10 liters because it gets you in the high flow area, dontcha know? And obviously we do that because they said "HIGH FLOW O2 for all sick patients" in MFR/EMT/P school.

J.E.S. - I like it. Very popular in medics nowadays. No one thinks they need to learn.

Why would you push it? If they're conscious and they're not breathing well enough, it's their fault.


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## Brandon O (Dec 16, 2009)

MrBrown said:


> Why ten litres? Why not .... 6 or 8, again, there is nothing magic about oxygen and if the normal inspired volume is (from memory) about 5 litres who says that this huge amount of oxygen is not doing harm?



Well... actually the rest of it's just getting wasted. You get what you breathe with the NRB.

I suspect that on issues like the KED, IF your protocols do not demand specific treatment or at least allow wriggle room -- Mass. protocols, for instance, are written loosely -- a ballsy EMS provider could sit in that courtroom and argue the clinical side based on the available evidence. I don't know who would pay for that trial, though. Maybe Bledsoe has some extra dough. And your employer might be done with you waaaay before a jury ever heard thing.


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## EMSLaw (Dec 16, 2009)

MrBrown said:


> Ah I do like that notion, how much of it do I get?



Get your NREMT-P, write a bunch of articles, become well known, and then prostitute yourself as an expert witness for a few thousand dollars a pop.  Welcome to America, land of opportunity! 



redcrossemt said:


> Do the lawyers roam EMTlife looking for easy prey??
> 
> Defendant: Well, I never said I wouldn't use a KED.
> Prosecutor: Actually, we have the conversation from EMTlife right here. Will you read it to the jury?



I don't practice that kind of law, so I wouldn't know.  The longer I'm a lawyer, the more kinds of practice I think I wouldn't be interested in.  But personal injury, insurance defense (which are two sides of the same coin), matrimonial, and real estate are on the list at the moment.

But I wouldn't put it outside the realm of possibility.


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