• First aid providers should regularly check the person’s breathing while maintaining an open airway.
• First aid providers should always access emergency medical services (EMS) for an unresponsive person who is breathing normally, as this may indicate a serious condition.
Chain of survival behaviours
Prevent and prepare
• Follow instructions from your healthcare provider to manage any pre-existing health conditions.
• Wear and use appropriate safety equipment when working or participating in leisure and work activities.
Early recognition
Check for a response by gently shaking the person’s shoulders or if they are a baby, tap their foot. Speaking loudly and clearly, ask a question such as, “Are you alright?”.
If the person responds, continue with your assessment. (See General approach.) If the person is unresponsive, they will not move or respond to any noise or touch.
If the person does not respond:
1. Open their airway: Gently tilt their head back (or into a neutral position for a baby) until their mouth falls open and lift their chin. (You may need to turn the person onto their back to do this.) The jaw thrust manoeuvre might result in less cervical spine movement than the head tilt, which may be useful to consider when you suspect a Spinal injury.
2. Check for breathing: Keeping their airway open, look, listen and feel for normal breathing for up to ten seconds. Look for chest or abdominal movement; listen for breathing sounds; feel for air on your cheek.
First aid steps
If the person is breathing normally:
1. Move them onto their side and tilt their head back (or into a neutral position if it is a baby) to maintain an open airway. This is called the recovery position. A baby can be held in this position in your arms.
2. Access emergency medical services (EMS).
3. Monitor the person for any changes in their breathing or level of response. If possible, try to establish why the person is unresponsive.
• If it is impractical to move the person onto their side, the head-tilt-chin-lift or jaw thrust manoeuvres (or neutral position if it is a baby) can be used to maintain an open airway.
CAUTION
• If you suspect a spine injury, maintain an open airway by using the head-tilt-chin-lift or jaw thrust manoeuvres only and access emergency medical services (EMS).
• If medical care is some time away and if there is more than one first aid provider present, you can turn the person into a side-lying position while maintaining spinal alignment.
Access help
• When speaking to EMS, specify that the person is unresponsive and breathing normally. If you know what caused the person to become unresponsive, communicate this to EMS too.
Self-recovery
After a first episode of becoming unresponsive due to an existing health condition, the person should try to quickly recognise any warning signs of it occurring again. This may enable them to get into a comfortable position and call for help.
Education considerations
Context considerations
• The management of an unresponsive person who is breathing normally is dependent on the environment of the incident and availability of EMS. Management of a traumatic context must take account of the local recommendations, regulations and authorities.
• Programme designers should use the recovery position technique advised by the context’s medical authorities.
Learner considerations
• When practising how to put an unresponsive person on their side, consider the learner group’s needs and sensitivities regarding gender and culture (particularly to touching). Ask the learners how they would like to practise this manoeuvre.
• Talk to learners who have disabilities that prevent them from moving a person onto their side about how they might instruct another person to do this, or what other methods they might use to maintain an open airway.
• Consider teaching learners who might come in contact with spinal injuries about recognition of a Spinal injury and how to apply the head-tilt-chin-lift or jaw thrust manoeuvres. Ensure they understand that this manoeuvre results in the least amount of movement of the spine.
Facilitation tips
• Run relevant and realistic scenarios that allow learners to practise their general approach, recognition and first aid skills to care for an unresponsive person who is breathing.
• When facilitating learning about putting someone in the recovery position, focus on the desired outcome of the person (they are on their side and their airway is open) and keep the steps to achieving this as simple as possible.
• Discuss the mechanics of the tongue with regards to keeping an open airway. When a person is unresponsive, their muscles relax, which can cause the tongue to block the airway. Emphasise the importance of tilting the head back as that will pull the tongue forward and keep the airway open.
Moving the person onto their side maintains an open airway as the tongue will fall forward and any blood or vomit can drain out.
• Identify that a person can suddenly become unresponsive (due to a stroke, electrocution, head injury, etc.) or gradually (by certain poisonings or a diabetic emergency).
NOTE
If the person is breathing abnormally (gasping, taking irregular breaths or not breathing), start CPR immediately.
See Unresponsive and abnormal breathing (baby and child) or (adolescent and adult).
• Identify that while an altered mental status is frequently a separate issue, the person may display signs before becoming unresponsive. First aid providers may be able to intervene before the person becomes unresponsive.
Facilitation tools
The AVPU responsiveness scale may be useful for some learners, particularly those who use their first aid skills often and have a regular refresh of knowledge. The AVPU check is carried out as follows:
• A= alert: means that the person is aware of their environment, opens their eyes spontaneously and can follow instructions.
• V= verbal: means that the person does not open their eyes spontaneously, and only responds to a verbal cue when it is said directly to them.
• P= pain: means that the person does not open their eyes spontaneously, nor respond to verbal cues and only reacts directly to painful stimuli (like squeezing the fingers or pinching the back of the hand). The person may cry, moan or move.
• U= unresponsive: means that the person does not react, either to verbal or painful stimuli.
Learning connections
• Explore some conditions which could cause unresponsiveness: Head injury, Stroke, Diabetic emergency and Seizure.
• Differentiate between someone feeling faint and someone unresponsive and breathing normally.
Someone who faints should be unresponsive only for a very short amount of time.
Scientific foundation
Systematic reviews Recovery 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.
Use of the AVPU scale
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.
Feasibility
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.
Non-systematic reviews
New lateral (side-lying) trauma position for cases of cervical spine injury
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 HAINES positions 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.)
Clinical practice guideline
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.
AVPU (alert, verbal, pain, unresponsive)
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.