Trendelenburg's Position in field

[Lamiae]

In my AEMT class, the instructor stated that the Trendelenburg's Position was not commonly used in the field. Instead, fluids were given. Could someone tell me why, please?
Thank you.

 

[DesertMedic66]

Because there has been no evidence that it has any benefit to the patient. It is falling out of favor in many protocols.

 

[Jason]

DesertEMT66 is correct. There is no evidence that it helps the Pt. I ride in VA, and we're not doing it here.
Fluids can be given, but even that can be tricky - as you don't want to turn your Pt's blood volume to kool-aid.
Keep in mind that some things you learn this year ... next year, 3 years, or 5 years from now will be considered wrong. Its a part of practicing medicine.

 

[Akulahawk]

Any benefit that Trendelenburg gives is transient at best and it fools the body into believing that it has more fluid than it actually does and that's also just temporary. If you do see any change in vitals, those changes won't last long. At this point, you're better off thinking "add fluids" if you're at a point where you'd start thinking "Trendenlenburg is a good idea..." You're going to want to follow your protocols on this, but generally you're going to want to keep the amount of fluids added fairly low, and literally just enough to maintain perfusion or you risk turning the patient's blood into kool-ade. Kool-ade doesn't clot well. This also helps avoid popping clots that have formed as popping those clots is a bad thing due to this little problem of bleeding...

 

[Carlos Danger]

Trendelenburg actually does work. It increases mean arterial pressure, cardiac output, cerebral perfusion pressure, and coronary perfusion pressure, and it does so without diluting hemoglobin or clotting factors.

Yes the effects are transient (the effects of passive leg raise are similar and last longer), but in profound hypotension it can be potentially useful as a bridge to other therapies.

The studies that show "it doesn't improve outcomes" were probably done on trauma patients who presumably were going to keep bleeding - and die or not - regardless of almost anything that was done in the field. It may be worth pointing out that prehospital IV fluids rarely improve outcomes either; all things being equal if you had to choose between one or the other, I don't think it can be said in most cases that IV fluids would result in better outcomes than t-burg.

 

[gnosis]

I've been told that one of the main reasons trendelenburg is going out of vogue is that it tends to increase intracranial pressure over time. It's not that it doesn't increase MAP and perfusion, it's just that the increase is temporary and the increase in ICP can end up being detrimental to the Patient. As for adding the fluids, it really depends on why they were hypotensive in the first place. Neurogenic shock can be temporary, and if you pump them full of fluids to bring them up to a normal BP while it's low, when they rebound it'll get ugly.

I've found kicking the legs up for a few seconds can help get a tricky IV sometime, though

 

[VFlutter]

T-burg is great...for pulling heavy patients up in bed and placing lines. I tend to just use the CPR lever on our beds to lay people flat instead of actual trendelenburg.

 

[avdrummerboy]

T-burg as far as I know is out of style because as usual, 'legislation by catastrophe' people would put legs up for every patient in shock, and someone with internal bleeding in the abdominal area doesn't necessarily need to have the blood from the legs forced in to also bleed out, that'll happen anyway, no need to hurry it along. That's why fluids are a somewhat better consideration (aside from surgical interventions)

 

[johnrsemt]

Trendelenburg is also a problem when people are having problems breathing. With me it makes my respiratory effort harder, but does raise my blood pressure (but that is probably due to the increased resp distress)

 

[Carlos Danger]

Trendelenburg is also a problem when people are having problems breathing. With me it makes my respiratory effort harder, but does raise my blood pressure (but that is probably due to the increased resp distress)

It makes it harder to breath because your diaphragmatic excursion is inhibited. Definitely a concern in obese people.

The increase in BP has nothing to do with that, though. It is a result of increased preload and afterload.

 

[Wheel]

Well like everyone else has said, the evidence for it isn't great. It was originally created by a German surgeon (Trendelenburg) in order to help visualize pelvic and abdominal organs for surgery.

 

[Handsome Robb]

Random side note, sorry didn't read the whole thread so I apologize if someone already pointed this out, but we don't place people in true Trendelenburg position in EMS. It's not possible with our equipment. Ok, on a backboard yes if you elevate the foot end of the board but in patients who aren't in spinal motion restriction we actually place them in a the modified Trendelenburg position or the shock position since we only elevate their legs rather than placing their pelvis above their head.

Also, fluids aren't always the answer either. Research "permissive hypotension".

 

[epicEMT]

Not much evidence that supports it, yet some people swear by it.