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Optimal position for shock victim

Question Type:
Intervention
Full Question:
Among adults and children who receive First Aid for shock  (P), does does positioning of the patient (I), compared with not positioning the patient  (C), change overall mortality, complications, incidence of cardiac arrest, vital signs, hospital length of stay (O)?
Consensus on Science:
After application of inclusion and exclusion criteria, 1 RCT and 5 observational trials were included in evidence evaluation. For the critical outcome of vital signs, we identified 1 RCT and 5 observational trials.In Normotensive Subjects (P), Passive Leg Raising to 60° for 5 Minutes (I) Compared With Supine Position (C)We identified very-low-quality evidence (downgraded for inconsistency, indirectness, and imprecision) from 1 observational study(Kyriakides 1994, 288) enrolling 43 subjects (12 healthy subjects and 31 subjects with heart disease) showing no significant changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), or heart rate (HR).In Normotensive Subjects With Blood Loss (P), Passive Leg Raising to 45° for 5 Minutes (I) Compared With Supine Position for 5 Minutes (C)We identified low-quality evidence (downgraded for inconsistency, indirectness, and imprecision) from 1 observational study(Wong 1989, 979) enrolling 27 normotensive subjects with 500 mL blood loss, showing no benefit from passive leg raising (PLR) with a nonsignificant change in mean arterial blood pressure (MAP) but a benefit from PLR, with a significant• Increase in thoracic bioimpedance cardiac index (MD, 0.8; 95% CI, 0.75–0.85) • Increase in stroke index (SI) (MD, 15.00; 95% CI, 14.46–15.54) • Decrease in HR (MD, −3; 95% CI, −3.56 to −2.44)Subjects without blood loss showed a significant increase in cardiac index with PLR (MD, 0.3; 95% CI, 0.12–0.72) but no significant change in MAP or difference in HR. In Normotensive Subjects With Blood Loss (P), Standing for 5 Minutes (I) Compared With Supine Position (C) for 5 MinutesWe identified low-quality evidence (downgraded for inconsistency, indirectness, and imprecision) from 1 observational study(Wong 1989, 979) enrolling 27 normotensive subjects with 500 mL blood loss, showing a nonsignificant increase in MAP.The standing position showed a statistically significant decrease in cardiac index compared with supine position (MD, −0.3; 95% CI, −0.38 to −0.22), and an increase in HR (MD, 22; 95% CI, 20.84–23.16).In Normotensive Subjects (P), Supine Position for 3 Minutes Followed by PLR to 60° for 20 Seconds (I) Compared With Supine Position (C) for 3 MinutesWe identified very-low-quality evidence (downgraded for inconsistency, indirectness, and imprecision) from 1 observational study(Gaffney 1982, 190) enrolling 10 normotensive subjects showing a benefit from the supine position plus PLR, with a significant increase in both cardiac output (CO) (MD, 0.6; 95% CI, 0.48–0.72) and stroke volume (SV) (MD, 7; 95% CI, 2.93–11.07). In Normotensive Subjects (P), Supine Position for 3 Minutes Followed by PLR to 60° for 7 Minutes (I) Compared With Supine Position for 3 Minutes (C)We identified very-low-quality evidence (downgraded for inconsistency, indirectness, and imprecision) from 1 observational study(Gaffney 1982, 190) enrolling 10 normotensive subjects showing no significant difference in MAP, CO, or HR. Thus, improvements in CO and SV seen with PLR at 20 seconds disappeared by 7 minutes.In Normotensive Subjects (P), PLR to 60° for 1 Minute (I) Compared With Supine Position (C)We identified very-low-quality evidence (downgraded for inconsistency, indirectness, and imprecision) from 1 observational study(Kamran 2010, 284) enrolling 125 normotensive subjects. No cardiovascular benefit was shown for PLR to 60° for 1 minute.In Hypotensive Patients (P), PLR to 45° (I) for 2 Minutes Compared With Semirecumbent (Head at 45°) for 2 Minutes (C)We identified low-quality evidence (downgraded for inconsistency, indirectness, and imprecision) from 1 RCT(Jabot 2009, 85) enrolling 35 hypotensive subjects. No difference was found in HR, but a statistically significant benefit with PLR was demonstrated with• An increase in MAP (median difference 7 higher, CI not estimable)• An increase in SBP (median difference 12 higher, CI not estimable)• An increase in central venous pressure (CVP) (median difference 2 higher, CI not estimable) In Hypotensive Patients (P), Supine Position (C) for 2 Minutes Compared With Semirecumbent (Head at 45°) for 2 Minutes (I)We identified low-quality evidence (downgraded for inconsistency, indirectness, and imprecision) from 1 RCT(Jabot 2009, 85) enrolling 35 hypotensive subjects. Placing patients in the supine position for 2 minutes compared with a semirecumbent 45° position failed to show any benefit for MAP, SBP, or HR. A significant increase in CVP was reported with transfer from semirecumbent to supine position (median difference 1 higher, CI not estimable).In Hypotensive Patients (P), PLR to 45° for 2 Minutes (I) Compared With Supine for 2 Minutes (C)We identified very-low-quality evidence (downgraded for inconsistency, indirectness, and imprecision) from 1 RCT(Jabot 2009, 85) enrolling 35 hypotensive subjects. No difference was noted for HR, but a statistically significant benefit with PLR was shown with • An increase in MAP (median difference 5 higher, CI not estimable) • An increase in systolic arterial pressure (SAP) (median difference 8 higher, CI not estimable) • An increase in CVP (median difference 1 higher, CI not estimable) In Hypotensive Patients (P), Supine Position for 4 Minutes (C) Compared With PLR to 45° for 4 Minutes (I)We identified very-low-quality evidence (downgraded for inconsistency, indirectness, and imprecision) from 1 observational study(Boulain 2002, 1245) enrolling 15 hypotensive subjects. No statistically significant difference in MAP or HR was shown between the supine position and PLR to 45° for 4 minutes. A statistically significant decrease in SAP was found for change in position from PLR to supine (MD, −4; 95% CI, −16.88 to 8.88) and for diastolic arterial pressure (DAP) (MD, −3; 95% CI, −14.81 to 8.81).In Hypotensive Patients (P), PLR to 45° for 4 Minutes (I) Compared With Supine for 4 Minutes (C)We identified very-low-quality evidence (downgraded for inconsistency, indirectness, and imprecision) from 1 observational study(Boulain 2002, 1245) enrolling 15 hypotensive subjects. There was no statistically significant difference in MAP or HR between PLR to 45° for 4 minutes and the supine position for 4 minutes. Statistically significant benefit with PLR was found for SAP (MD, 7; 95% CI, −10.89 to 24.89) and DAP (MD, 3.0; 95% CI, −8.47 to 14.47). We did not identify any evidence to address the critical outcomes of complications, incidence of cardiac arrest, overall mortality, or length of hospital stay.
Treatment Recommendation:
We suggest first aid providers place individuals with shock in the supine position as opposed to the upright position (weak recommendation, low-quality evidence).Values, Preferences, and Task Force Insights In regard to other positions studied, a review of the evidence suggests clinical equipoise in the first aid setting. For individuals with shock who are in the supine position and with no evidence of trauma, the use of PLR may provide a transient (less than 7 minutes) but statistically significant improvement in HR, MAP, cardiac index, or stroke volume. The clinical significance of this transient improvement is uncertain; however, no study reported adverse effects due to PLR. Because improvement with PLR is brief and its clinical significance uncertain, this position is not recommended, although it may be appropriate in some first aid settings as a temporizing measure while awaiting more advanced emergency medical care. Studies included used PLR ranging between 30° and 60° elevation. An optimal degree of elevation was not identified. • Categories of hypotensive shock in studies included with this review were septic shock, cardiogenic shock, and hypovolemic shock.• In making these recommendations, we place increased value on the potential but uncertain clinical benefit of improved vital signs and cardiac function by positioning an individual with shock in the supine position or supine with PLR position over the risk of movement to effect a change in position. • The Trendelenburg position was excluded from evaluation in this review due to the inability or impracticality of first aid providers to place a person into the Trendelenburg position in an out-of-hospital setting.
CoSTR Attachments:
Data Collection Position for ShockNS 12-16-14.xls    
GRADE table Shock position 01-18-15_n.docx    

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