# Transporting AAA pt?



## Voodoo1 (Sep 20, 2011)

Just for my own reference, but what is the best position to transport a AAA pt?


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## LondonMedic (Sep 20, 2011)

In what context?

To their clinic appointment?
To the ER?
To the morgue?


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## Voodoo1 (Sep 20, 2011)

Sorry, should have been more specific. To the ER.


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## LondonMedic (Sep 20, 2011)

Voodoo1 said:


> Sorry, should have been more specific. To the ER.


With a presumed diagnosis of ruptured AAA?

If they're conscious I'd be tempted to say leave them in whatever position they find comfortable.

If they're not, then whatever position best allows you to control their airway.

Arguably Fowler's position but I don't think that there's going to be much in the way of evidence.


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## Voodoo1 (Sep 20, 2011)

LondonMedic said:


> With a presumed diagnosis of ruptured AAA?
> 
> If they're conscious I'd be tempted to say leave them in whatever position they find comfortable.
> 
> ...



That's what I had thought. I had it as a scenario and when I said I was going to place the pt in a semi fowler's, the examiner looked at me like I had two heads. Thank you.


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## Katy (Sep 20, 2011)

LondonMedic said:


> With a presumed diagnosis of ruptured AAA?
> 
> If they're conscious I'd be tempted to say leave them in whatever position they find comfortable.
> 
> If they're not, then whatever position best allows you to control their airway.


This, there isn't anything you can do for AAA pre-hospital besides get them to the hospital as quickly as possible.


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## Voodoo1 (Sep 20, 2011)

Katy said:


> This, there isn't anything you can do for AAA pre-hospital besides get them to the hospital as quickly as possible.



Yeah, I know. It was just the look on the examiners face, it kinda threw me off. I was wondering if I had done something wrong or if there was a better position to transport the pt.


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## Katy (Sep 20, 2011)

Voodoo1 said:


> Yeah, I know. It was just the look on the examiners face, it kinda threw me off. I was wondering if I had done something wrong or if there was a better position to transport the pt.


I wouldn't worry too much about it, but I wouldn't put the patient in any certain position that wasn't comfortable for them. Maybe fowlers will be comfortable, maybe not.


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## ArcticKat (Sep 20, 2011)

If signs of shock are present, trendelenberg.

If no signs of shock, position of comfort, likely semi fowlers with the knees elevated for comfort.


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## LondonMedic (Sep 20, 2011)

ArcticKat said:


> If signs of shock are present, trendelenberg.


Do people still use Trendelenberg?


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## Katy (Sep 20, 2011)

LondonMedic said:


> Do people still use Trendelenberg?


I believe it is standard first aid for shock. I'm not sure about anything past that.


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## LondonMedic (Sep 20, 2011)

Katy said:


> I believe it is standard first aid for shock. I'm not sure about anything past that.


I believed it was used until the evidence about respiratory, cerebral and occular risks became more widely received.


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## Katy (Sep 20, 2011)

LondonMedic said:


> I believed it was used until the evidence about respiratory, cerebral and occular risks became more widely received.


Yeah, I remember reading something about that on the interenet. I still think it is taught at the Red Cross in my area though, I'll have to check that out.


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## Yarbo (Sep 20, 2011)

What was the BP during your scenario? Maybe that had something to do with it?


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## Katy (Sep 20, 2011)

EMT 34 said:


> What was the BP during your scenario? Maybe that had something to do with it?


If the patient's blood pressure was elevated in a position that was comfortable, would you change there position just to lower the blood pressure and cause more pain which could also make the blood pressure rise?


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## Voodoo1 (Sep 20, 2011)

ArcticKat said:


> If signs of shock are present, trendelenberg.
> 
> If no signs of shock, position of comfort, likely semi fowlers with the knees elevated for comfort.



I thought that Trendelenberg is contraindicated for suspected AAA. If I'm wrong about that could you explain why?


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## Katy (Sep 20, 2011)

Voodoo1 said:


> I thought that Trendelenberg is contraindicated for suspected AAA. If I'm wrong about that could you explain why?


Your probably right, I was going off speculation.


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## Anjel (Sep 20, 2011)

I use trendelenburg. 

Especially for hypotension. It definitely works. And when I did use it. It drastically improved the BP.


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## Anjel (Sep 20, 2011)

Oh. ANd I would most likely transport in position of comfort if conscious. I don't want to me moving them around and them being uncomfortable.


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## Voodoo1 (Sep 20, 2011)

Anjel1030 said:


> I use trendelenburg.
> 
> Especially for hypotension. It definitely works. And when I did use it. It drastically improved the BP.



For a AAA pt with no pulse to the lower extremities? Wouldn't that just compound the aneurysm?


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## usalsfyre (Sep 20, 2011)

Whatever position allows you to work the futile cardiac arrest your soon to be involved in.


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## usalsfyre (Sep 20, 2011)

To be a little more helpful, I have no doubt your evaluator was looking for some baloney about "shock position" or "Trendelenberg". First off anyone who states EMS can transport in Trendelenberg has never seen a patient truly in the Trendlenburg position. Our stretchers don't do it. Secondly Trendelenberg was developed as a way to move organs around for surgery, and someone "thought" it may work for shock states as well. Quite simply, they were wrong, the auto-transfussion effect is negligible and any benefit is outweighed by the complications associated with standing people on their heads. Yet it persist in EMS culture because "I saw it work one time", neglecting to mention it was on a non-hemorrhaging patient (most often vasovagal or septicemia patients who have an issue with the vascular bed). It's another example of someone thinking education stops after medic school.


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## Anjel (Sep 20, 2011)

Voodoo1 said:


> For a AAA pt with no pulse to the lower extremities? Wouldn't that just compound the aneurysm?



No i was just stating in general that I use it. Because someone said no one uses it anymore. 

For the AAA... I said Position of comfort.


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## Anjel (Sep 20, 2011)

usalsfyre said:


> To be a little more helpful, I have no doubt your evaluator was looking for some baloney about "shock position" or "Trendelenberg". First off anyone who states EMS can transport in Trendelenberg has never seen a patient truly in the Trendlenburg position. Our stretchers don't do it. Secondly Trendelenberg was developed as a way to move organs around for surgery, and someone "thought" it may work for shock states as well. Quite simply, they were wrong, the auto-transfussion effect is negligible and any benefit is outweighed by the complications associated with standing people on their heads. Yet it persist in EMS culture because "I saw it work one time", neglecting to mention it was on a non-hemorrhaging patient (most often vasovagal or septicemia patients who have an issue with the vascular bed). It's another example of someone thinking education stops after medic school.



For hypotension I think it does work. 

For shock, trauma, hemorrhage, etc. I don't have any knowledge or experience with that, besides what is taught in the books.


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## usalsfyre (Sep 20, 2011)

Getting a patient supine works just about as well as lifting the legs. It works especially well when there's a loss of control in the vascular system.

One of the reasons you don't see a lot of effect in hemmorrhagic shock is that your dealing with a "tight" vascular bed, meaning much of the blood you would be moving around has already been shunted from the extremities.


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## systemet (Sep 21, 2011)

We discussed this a while back here:

http://www.emtlife.com/showthread.php?t=25294&highlight=trendelenburg


This paper (Bivins et al.) measured redistribution in a small number of healthy volunteers, found a wide range of variation in the response, but a mean value of about 2% of the blood volume redistributed.  So, somewhere around 100ml.

In healthy volunteers.  Who weren't already peripherally vasoconstricted and shunting due to a shock state.

Without trying to be rude, I'm going to suggest that if you've put a couple of people in (modified) Trendelenburg and the pressure's gone up, it's probably coincidental.



Bivins HG, Knopp R, dos Santos PA. Blood volume distribution in the Trendelenburg position. Ann Emerg Med. 1985 Jul;14(7):641-3.


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## 8jimi8 (Sep 21, 2011)

LondonMedic said:


> Do people still use Trendelenberg?



For a minute until we put a central line in


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## ArcticKat (Sep 21, 2011)

ArcticKat said:


> If signs of shock are present, trendelenberg.




Snicker, sorry, I couldn't resist.  Call it the Troll in me.


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## abckidsmom (Sep 21, 2011)

systemet said:


> We discussed this a while back here:
> 
> http://www.emtlife.com/showthread.php?t=25294&highlight=trendelenburg
> 
> ...



I would put it on anxiety.  If you stood me on my head in an ambulance, my pressure would go up for sure.


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## Akulahawk (Sep 22, 2011)

For a AAA? Supine if not conscious, position of comfort if conscious. Apply diesel quickly & quietly because I don't want to scare the AAA into rupturing... if it goes and it's big, I can only hope that someone with a scalpel and clamps is available in very short order... along with a direct to OR ticket. Otherwise, that AAA is going to buy the person a celestial escape ticket, and the ride will begin right before your eyes. Large bore IV's won't be able to keep up with the loss, even at max flow rates.

Which sets me up for...



usalsfyre said:


> Whatever position allows you to work the futile cardiac arrest your soon to be involved in.


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## Voodoo1 (Sep 22, 2011)

Akulahawk said:


> Apply diesel quickly & quietly because I don't want to scare the AAA into rupturing... if it goes and it's big, I can only hope that someone with a scalpel and clamps is available in very short order... along with a direct to OR ticket. Otherwise, that AAA is going to buy the person a celestial escape ticket, and the ride will begin right before your eyes.
> 
> Which sets me up for...



Which is exactly what happened in my scenario. I passed it, and it was an awesome learning experience for me.


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## Handsome Robb (Sep 22, 2011)

Akulahawk said:


> For a AAA? Supine if not conscious, position of comfort if conscious. Apply diesel quickly & quietly because I don't want to scare the AAA into rupturing... if it goes and it's big, I can only hope that someone with a scalpel and clamps is available in very short order... along with a direct to OR ticket. Otherwise, that AAA is going to buy the person a celestial escape ticket, and the ride will begin right before your eyes. Large bore IV's won't be able to keep up with the loss, even at max flow rates.
> 
> Which sets me up for...



Even if large bore IVs could keep up, isotonic solutions create volume for the pump to move, not oxygen transportation capabilities. Which I know you are more than aware of 

Ruptured AAA, welcome to losing a pt. From what I was told the mortality is ~98% if it blows on the OR table. (I was told that I don't know from experience and/or research.) I can look up a stat if you want me too, but I'm leaning towards we will all agree that a prehospital rupture of an AAA has an awful outcome.

Leaking or dissecting AAA, be quick but very gentle, along with cautious fluid resuscitation. No reason to jostle a delicate situation around more than necessary. They are technically in a state of hypovolemia/relative hypovolemia due to increasing the 'container size' along with losing blood volume internally. Overload the vasculature system and you create a higher pressure on the leaky parts, but a pump with no primer (think fluid) can't pump anything. 

If you suspect it, but have no confirmation I'd say transport in position of comfort, monitor vitals repetitively (ie more often than q 5 minutes) caution about fluid blouses, no dopamine or dobutamine, I would think it would make the situation worse. Then again it would be contraindicated in hypovolemic shock due to hemorrhage. Calm the patient, no reason to excite them and to increase the CO/BP past what is required. Respiratory/ventilatory support as needed and a quick but smooth transport to a hospital with adequate notification time for them to prep a team. I would classify this as a true emergency.

I don't see modified trendelenburg's creating a huge problem. It may temporarily boost the BP in the core and help perfusion to the vital organs but it wont last for long. We aren't dealing with a situation of increased ICP and I doubt the slight increase in BP would have an effect on the AAA, but that is from very limited education. I was taught that if the Pt's vitals warranted and they would tolerate it to try trendelenburg's and see if it helps, if there's no change, drop the legs and see what the pt wants for POC. Obviously if there is accompanying SOB don't lay them down. Make it easy on yourself by making it easy on the patient.


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## bstone (Sep 22, 2011)

With a AAA you might try a satinsky clamp. If you're a surgeon. In an OR.


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## LondonMedic (Sep 22, 2011)

NVRob said:


> Ruptured AAA, welcome to losing a pt. From what I was told the mortality is ~98% if it blows on the OR table. (I was told that I don't know from experience and/or research.) I can look up a stat if you want me too, but I'm leaning towards we will all agree that a prehospital rupture of an AAA has an awful outcome.


I was taught that 50% die before they reach hospital, 50% of the remainder die before they reach the operating theatre and 50% of the remainder die before they get home.

An anaesthetist I worked with was doing some research into individualised outcomes using various modified APACHE scoring systems, the upshot being that those likely to have large AAAs often have significant co-morbidities that will hinder their ability to leave hospital alive even if they are delivered to the table in a timely fashion.


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## rmabrey (Sep 22, 2011)

LondonMedic said:


> I believed it was used until the evidence about respiratory, cerebral and occular risks became more widely received.



And that its virtually ineffective outside of the rural setting (transport times)


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## LondonMedic (Sep 22, 2011)

rmabrey said:


> And that its virtually ineffective outside of the rural setting (transport times)


Even then does it actually add any tangible benefit?


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## rmabrey (Sep 22, 2011)

LondonMedic said:


> Even then does it actually add any tangible benefit?



No. That's just all I really remember about it from class. That and "you'll never use it"


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## medichopeful (Sep 22, 2011)

ArcticKat said:


> If signs of shock are present, Trendelenberg.



I'd argue heavily against this.  If they're actively bleeding from an AAA, I'd worry seriously about the hemorrhaged blood pooling in the thoracic cavity, throwing off the intrathoracic or intrapleural pressure.


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## usalsfyre (Sep 22, 2011)

medichopeful said:


> I'd argue heavily against this.  If they're actively bleeding from an AAA, I'd worry seriously about the hemorrhaged blood pooling in the thoracic cavity, throwing off the intrathoracic or intrapleural pressure.


Think about what "AAA" is an abbreviation for. I see what your saying, but your thinking of a different condition.


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## Akulahawk (Sep 22, 2011)

medichopeful said:


> I'd argue heavily against this.  If they're actively bleeding from an AAA, I'd worry seriously about the hemorrhaged blood pooling in the thoracic cavity, throwing off the intrathoracic or intrapleural pressure.


Minor point... if the AAA is in the abdomen, blood won't (and can't) pool in the thoracic cavity as there's this thing called the diaphragm that gets in the way...


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## medichopeful (Sep 22, 2011)

usalsfyre said:


> Think about what "AAA" is an abbreviation for. I see what your saying, but your thinking of a different condition.



Oops! That's what I get for posting on the fly without really thinking!


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## medichopeful (Sep 22, 2011)

Akulahawk said:


> Minor point... if the AAA is in the abdomen, blood won't (and can't) pool in the thoracic cavity as there's this thing called the diaphragm that gets in the way...



:rofl: See my response above!


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## LondonMedic (Sep 22, 2011)

Akulahawk said:


> Minor point... if the AAA is in the abdomen, blood won't (and can't) pool in the thoracic cavity as there's this thing called the diaphragm that gets in the way...


It can however, pool against the diaphragm and decrease respiratory compliance.


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## ArcticKat (Sep 22, 2011)

medichopeful said:


> I'd argue heavily against this.  If they're actively bleeding from an AAA, I'd worry seriously about the hemorrhaged blood pooling in the thoracic cavity, throwing off the intrathoracic or intrapleural pressure.



Read my other post.



LondonMedic said:


> It can however, pool against the diaphragm and decrease respiratory compliance.


Except that they'll be dead by then anyways.


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## Akulahawk (Sep 22, 2011)

LondonMedic said:


> It can however, pool against the diaphragm and decrease respiratory compliance.


Believe it or not, I was actually typing something very similar to that and had to go do something else...


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## Medicus (Sep 22, 2011)

For completeness, I just want to point out that AAAs are extremely common and you have all transported many patients with AAAs without even knowing it. The vast majority of patients are asymptomatic and will not require surgery.

When they start to become symptomatic, that is when you need to worry.

-Medicus


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## Voodoo1 (Sep 23, 2011)

Medicus said:


> For completeness, I just want to point out that AAAs are extremely common and you have all transported many patients with AAAs without even knowing it. The vast majority of patients are asymptomatic and will not require surgery.
> 
> When they start to become symptomatic, that is when you need to worry.
> 
> -Medicus



Interesting. Could you explain please? I wonder how an abdominal aneurysm would be asymptomatic and not require surgury. I would think that the pt would be in quite a bit of pain and most certainly be symptomatic if there was an AAA.


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## LondonMedic (Sep 23, 2011)

Voodoo1 said:


> Interesting. Could you explain please? I wonder how an abdominal aneurysm would be asymptomatic and not require surgury. I would think that the pt would be in quite a bit of pain and most certainly be symptomatic if there was an AAA.


A "AAA" is an abdominal aortic aneurysm, it is a vascular malformation, most of the time is not bleeding, leaking, tearing or rupturing, it is pain free, asymptomatic and bloody hard to diagnose on examination (outside of anorexics). Most of them are detected by chance and monitored until they are large enough to warrant the risk of surgery (currently 4.4cm in the UK). They rupture (or tear or bleed or leak) much less often.

What you, in the pre-hospital field, commonly refer to as an "AAA" is actually a ruptured aneurysm.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001215/


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## usalsfyre (Sep 23, 2011)

An aneurysm is simply a "ballooning" of the blood vessel due to weakness of the vessel wall. As such, AAA is very common in older patients, typically just above where the aorta bifurcates into the femoral arteries due to the natural area of high pressure this creates.

What we are concerned with in EMS are rupturing or dissecting aneurysms. This is when the wall of the vessel actually tears.


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## Voodoo1 (Sep 24, 2011)

Thank you both LondonMedic and Usalsfyre for the clairification.


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