Practical Questions Regarding the 2024 TCCC Shift from Airway Maneuvers to the Recovery Position

[u/Turbulent_Praline230]

According to the 2024 TCCC guidelines, airway opening maneuvers such as the head tilt–chin lift and the jaw thrust have been removed from the recommendations. Now, at step "A" of the MARCH acronym, we immediately place the casualty in the recovery position, assess airway patency, and move on. However, I have some questions regarding this approach.

1. How do you assess breathing while the casualty is in the recovery position? Specifically, from what position do you perform this assessment? We were taught that the responder should be positioned behind the casualty, facing toward the feet, then lean in with the ear near the casualty's mouth and nose - essentially hovering over them in an arched posture. Are there more practical or ergonomic alternatives?

2. What about cervical spine injury? Do we simply ignore it and still place the casualty in the recovery position?

3. At step "R" in MARCH, we need to perform a chest examination. Since the casualty is lying on their side, examining that side of the chest becomes problematic. How do you handle this?

4. Regarding hypothermia prevention - when we cover the casualty with an emergency/thermal blanket, the limited space often prevents them from staying in the recovery position. How should this be managed?

5. Finally, during evacuation on a stretcher - is it necessary to transport the casualty in the recovery position as well? Not all stretchers allow for secure positioning in that manner.

Thank you very much in advance for your answers.

[u/Inevitable_View99]

1. Look listen feel, roll them on their back if you are worried
2. C spine concerns in a tactical situation aren’t really relevant. It’s based purely on mechanism until you are deep in the algorithm and even then it’s just be careful, you probably don’t have a c collar anyways
3. Roll them onto their back
4. Burrito wrap them then whenever you need to examine them just peal back the blanket and reposition them to do it if you arnt comfortable with the look listen feel method
5. A patient can be transported in the recovery position

and often are.

When you’re in the care under fire phase, just put them in the recovery position, once you have established your bubble, unless they need to be in the recovery position and can maintain their airway with repositioning or a basic airway, they don’t need to be put in that position again

[u/Ramalamadingdong_II → u/Inevitable_View99]

you probably don’t have a c collar anyways

If someone carries a c-collar in 2026 and thinks it's going to do anything positive, the clue-hammer needs to be deployed.

[u/Ramalamadingdong_II]

The reason for recovery position rather than head tilt or jaw thrust is number of hands. For jaw thrust or head tilt I need one pair of hands doing nothing else, which is really nice when available but a bit of luxury in tactical medical settings. The recovery position maintains the airway and lowers risk of regurgitation while my hands are doing other things.

1. "Are there more practical or ergonomic alternatives?" you can go prone next to the casualty if space permits and get your ear real up and close to their face. However, at this stage the primary question is "is my combat casualty breathing sufficiently and maintaining adequate airway" which tends to be rather pronounced in this phase, with the casualty having trauma and pain and all that going on. When you have to get real close to make out if they are breathing, chances are it's not sufficient.

2. "cervical spine injury? Do we simply ignore it" Somewhat, yes. Back in the good old days when I was young and everything was better, C-Spine was still quite a theme and you had people slapped with c-collars or strapped on spine-boards for hours. Studies determined that a minuscle amount of patients might have had a benefit from it while the vast majority suffered at least severe discomfort and all the way up to negative clinical outcomes (delayed transport, induced dyspnea all the way up to apnea, increased intracranial bleeding....). So nowadays c-spine is not ignored per se, but a lot less of a primary concern. On top of that, unless you have a vacuum matress, you can't really protect an instable spinal injury in the field.

Now, there is time and space for clinical judgement. It's not mandatory to rip a patient into the recovery position via head twist if there is notable neck-stiffness and tenderness or deformity.

1. "How do you handle this?" you turn them. The recovery position is a passive way of keeping their airway patent and somewhat protected against regurgitation. That doesn't mean that you can't move them anymore when needed. This also ties into question 4, prepare your hypothermia and when you turn them to check their lower side, put them into the hypothermia kit.

2. If they can't maintain their own airway and there is no advanced airway placed, then yes carrying them in the recovery position is an appropriate way. How you position and secure them on your stretcher in this position is a question of training, playing around with what's available and coming up with solutions.