Actions for patient going into shock

[EMTinNEPA]

I have had anecdotal success with the Trendelenburg position, and while that does not prove that it is effective, is does not improve it either. I know we're supposed to be practicing evidence-based medicine, but I haven't seen anything suggesting that it causes harm, and if there's even a chance it may help keep my patient alive for a bit longer while I haul @$$ to the hospital, I'm going to do it. It's one of the few tools I have at my disposal, effective or not.

 

[Smash]

I have had anecdotal success with the Trendelenburg position, and while that does not prove that it is effective, is does not improve it either. I know we're supposed to be practicing evidence-based medicine, but I haven't seen anything suggesting that it causes harm, and if there's even a chance it may help keep my patient alive for a bit longer while I haul @$$ to the hospital, I'm going to do it. It's one of the few tools I have at my disposal, effective or not.

You could dance an Irish Jig in the corner as well. No evidence that it helps, but it's probably not harmful, so that is one more tool at your disposal, effective or not. Who knows, it may even make you patient laugh, and we know that laughter is the best medicine.

Bridges and Jarquin-Valdivia do a reasonable review in AJCC, there is a good plain summary at BestBETS and numerous papers that can be perused to show the complete lack of any evidence for the use of trendelenburg positioning.

 

[MrBrown]

What to do? ... it depends what type of shock

We no longer teach raising the legs, but it is taught to the lay first aider.

Large volumes of crystalloid are no longer infused in uncontrolled hypovalemia e.g. triple A or penetrating trauma. For controlled hypovolaemia I have seen blood pressure cuffs wrapped around bags and two to three litres given.

M*A*S*H pants were thrown out here about 10 years ago, I know we still had them in 1998.

 

[EMTinNEPA]

You could dance an Irish Jig in the corner as well. No evidence that it helps, but it's probably not harmful, so that is one more tool at your disposal, effective or not. Who knows, it may even make you patient laugh, and we know that laughter is the best medicine.

Bridges and Jarquin-Valdivia do a reasonable review in AJCC, there is a good plain summary at BestBETS and numerous papers that can be perused to show the complete lack of any evidence for the use of trendelenburg positioning.

An Irish Jig in the corner is still better than nothing, which is exactly what I can do for hypovolemic shock. Every other treatment we used to use has been shown to be ineffective or harmful... Aggressive fluid therapy? Nice pretty blood pressure, too bad crystalloids don't carry oxygen. MAST suit? Looks cool, but doesn't work, and good job wasting the time to put it on. Trendelenburg? Maybe not effective, but it takes what, half a second to perform? Supplemental oxygen? Great! Too bad he has no hemoglobin in his blood syst- er, saline system now, to carry it. Until they give us whole blood, packed RBCs, of FFP, there's not gonna be anything especially effective we can do about hypovolemic shock other than a rapid diesel infusion WFO, so we should at least do the things that we haven't shown to be harmful yet, instead of nothing at all just because it's ineffective.

 

[JPINFV]

I know we're supposed to be practicing evidence-based medicine, but I haven't seen anything suggesting that it causes harm,

Off the top of my head, increased ICP and increased incidences of difficulty breathing.

 

[EMTinNEPA]

Off the top of my head, increased ICP and increased incidences of difficulty breathing.

Ok. Do you have a source?

 

[mycrofft]

Just lay down in Trendellenburg and experience it.

Some of us lose our airway if you do that.

A coworker in 1978 was a volunteer to wear the trousers for a class. They just opened the stopcocks to let him out. He said later it was as close to an orgasm, or dying, as he ever wanted to experience in front of an audience.

Combat aviators wearing their suit also do a conrolled Valsalva and are in very good shape, albeint occasionally a little hung over. Not bled out, shot or dissecting.

 

[Akulahawk]

Some of us lose our airway if you do that.

A coworker in 1978 was a volunteer to wear the trousers for a class. They just opened the stopcocks to let him out. He said later it was as close to an orgasm, or dying, as he ever wanted to experience in front of an audience.

Combat aviators wearing their suit also do a conrolled Valsalva and are in very good shape, albeint occasionally a little hung over. Not bled out, shot or dissecting.

Those anti-G suits provide at MOST about 1-1.5 G's above what the Pilot can achieve without one. They train to perform essentially a massive valsalva maneuver, and is one BIG reason why they do strength training over cardio alone. A lot of people can handle 6 G's without too much effort. Older fighters were limited to about 7.5 G's because of that. Once it was figured out what helps the aviators fight G-LOC, training was adapted and now it's commonplace for aviators to achieve 9-10 G's without G-LOC with assistance of the suit. There have even been improvements in the suits and other life-support systems. The most visually apparent of those is the Oxygen Mask.

 

[LucidResq]

Ha. Accidentally researched spinal immobilization and increased ICP / respiratory problems. Will update with info on TRENDELENBURG'S and aforementioned physiological effects.

 

[Akulahawk]

For the OP:
Your patient who is stabbed in the LUQ, the MAST won't help. MAST suits normally don't extend much beyond the lower quadrants of the abdomen. The suit just won't tamponade the wound. Treatment should include: IV (with blood tubing) at a KVO rate, with boluses to maintain SBP at about 90 mmHg or just enough to maintain a detectable radial pulse. Oxygen. Diesel. Get the patient to a surgeon. Your time on scene? As close to zero as you can make it. Scoop and run. Make the patient naked and search for additional wounds. It's just not that complicated.

 

[LucidResq]

It was surprisingly hard to dig up literature on the use of Trendelenburg's in emergency or prehospital medicine. Here's a start...

Use of the Trendelenburg position in the treatment of shock has been common practice on the assumption that it can divert blood into the central circulation and improve the systemic hemodynamics. The literature on the hemodynamic effects of the effectiveness of use of the Trendelenburg position in treating hypovolemic shock is small and does not reveal beneficial or sustained changes in systolic blood pressure, preload, afterload, or cardiac output.

Bridges, N. and Jarquin-Valdivia, A. A. 2005. Use of the Trendelenburg position as the resuscitation position: to t or not to t? American Journal of Critical Care : an official publication, American Association of Critical-Care Nurses 14:364-368.


I'll post more as I find it.

 

[Smash]

Reuter DA, Felbinger TW, Moerstedt, Kilger E, Lamm P, Goetz AE Trendelenburg Positioning After Cardiac Surgery: Effects on Intrathoracic Blood Volume Index and Cardiac Performance Eur J Anaesthesiol 2003;20:17-20.

Transient and non-significant rise in BP and MAP with trendelenburg followed by significant deterioration in cardiac index when returned to supine position. There is also the potential for respiratory distress and decreased tidal volume, agitation from the uncomfortable position making the patient harder to manage, increased ICP from venous congestion.

We all want to be seen to be doing something for out patients, but sometimes there really isn't anything to do. Stop the bleeding that you can, stop the pain that you can, keep them warm and drive to hospital.

 

[JPINFV]

Well... errr... I see my job here is done.

 

[LucidResq]

Well... errr... I see my job here is done.

I see that DO training is getting to you... already letting your underlings do your dirty work eh?

 

[JPINFV]

I see that DO training is getting to you... already letting your underlings do your dirty work eh?

Leading by inspiration! ::cackles::

 

[usafmedic45]

blood is forced back up into his upper body since the legs are no longer able to hold as much blood.

You have it backwards. The "anti-G suit" (can't remember the technical term for it) is designed, not to push blood back up, but to limit the amount of blood being forced into the capitance vessels of the legs in the first place.

Combat aviators wearing their suit also do a conrolled Valsalva and are in very good shape, albeint occasionally a little hung over.

Actually fighter pilots (at least modern ones) are not nearly as frequently hung over or "Tom Cruise style mavericks" as we are led to believe. Those who are find themselves kicked out of training programs or 'flying a desk' very quickly.

Those anti-G suits provide at MOST about 1-1.5 G's above what the Pilot can achieve without one.

Quick point. It's G, not "Gs". 8 G, 10 G, etc. Just a friendly reminder from your local injury epidemiologist in training.

It adds that little bump in tolerance mostly because it limits the amount of blood squeezed into the legs and abdomen by the Valsalva.

They train to perform essentially a massive valsalva maneuver, and is one BIG reason why they do strength training over cardio alone.

Well, that and the fact that your arm weighs about 200 lbs at 8 G.

Older fighters were limited to about 7.5 G's because of that.

The wings or horizontal stabilizers will come off most propeller-driven warbirds somewhere around 8 G. That's another major reason (the major reason) for it.

 

[Akulahawk]

Anti-G Garment.

That's the name for the suit. There's a "few" different designs in use. One type requires essentially CPAP or BiPAP to overcome counter pressure put on by a chest piece. That system is called COMBAT EDGE.

Oh, and I was referring to more modern aircraft designs from the late '60's and newer. The F-16 is a great design... capable of much more stress that pilots can handle. The F-14 can handle greater stress than 7.5 G, same with the F-15. Wonder why they limited max G loads on the F-14 and 15 to about 7.5 G...

The older WW2 warbirds can turn inside modern jets at lower G loads. Why? They fly slower...

 

[usafmedic45]

The F-16 is a great design... capable of much more stress that pilots can handle.

It's a great design....right up until it develops electrical or engine problems. Then it turns into what one of my friends (a LTC who flew them and who was the pilot when I got my incentive ride in one) eloquently described as "the world's most expensive lawndart".

Wonder why they limited max G loads on the F-14 and 15 to about 7.5 G...

According to a friend of mine (retired F-14 crew chief) it was over concerns about how the wing and tail structures would handle repeated high G loading and unloading. This is one of the reasons why the F-15s had safety stand down days a couple of years back after several broke apart in mid-air due to metal fatigue of structural members. There was a question of whether the failure was due to "overload fatigue" (to quote a friend who was on the investigation board for the incidents in question) or simply due to the standard wear and tear all aircraft encounter.

The older WW2 warbirds can turn inside modern jets at lower G loads. Why? They fly slower...

Right, and they have a much prettier sound to them as well.

That's the name for the suit. There's a "few" different designs in use. One type requires essentially CPAP or BiPAP to overcome counter pressure put on by a chest piece. That system is called COMBAT EDGE.

Were you aircrew life support or something?

 

[Akulahawk]

usaf: Not even close... you could say that I developed a nearly unhealthy knowledge of (primarily) USN flight gear at a very young age. When your Dad flies combat aircraft for a living, you kind of get real curious what keeps him alive and how the aircraft and is' systems work... Plus I read pretty much whatever I could get my hands on.

The G limitations were mostly in place prior to many of those crashes.

The original engine was an OK design. At least they didn't use the TF-30 in it... those had some sensitivity to airflow inlet disturbances. The F110 engine was a better design. FCS problems will be a problem for any FBW aircraft... There aren't any direct connections to the flight control surfaces and in an aircraft with relaxed static stability or even negative static stability, controlled flight is basically impossible without the computers.

Any very modern aircraft will turn into a lawn dart if the computers die and no longer can control the flight control surfaces... at which point the pilot can only hope to reach the ejection handles...

Oh, and I got one detail slightly incorrect about COMBAT EDGE. The O2 mask increases pressure in the thoracic cavity during higher G loads and the chest piece provides counter pressure to prevent barotrauma.

 

[usafmedic45]

The G limitations were mostly in place prior to many of those crashes.

Correct. I didn't not mean to imply that those particular crashes were the reason for the regulations. For example, there was a F-89 (?; the Scorpion) that broke up during an airshow in the 1950s due to structural failure after an excessively high G performance the previous day. I don't believe they ever definitively linked that to the crash, but that was one source of the regulations (they are "written in blood" as the saying goes) according to some sources including a friend of mine who was a civilian researcher and temporarily found himself persona non grata for suggesting it was improper for the miltary to be investigating its own crashes.

Any very modern aircraft will turn into a lawn dart if the computers die and no longer can control the flight control surfaces... at which point the pilot can only hope to reach the ejection handles...

Pretty much, but the regularity of F-16 crashes is what earned it that nickname. The other moniker it is saddled with is the "disposable jet".