# BLS Shock



## AMF (Feb 15, 2011)

According to the NR, we're supposed to lift the legs of shock patients.  As I understand, the logic is that it tricks the body into thinking that it doesn't have to circulate as much blood, so the heart chills out (more or less).  We've been taught, though, that this is illegal in Maine (and I assume elsewhere) because when you lower the legs again the shock pretty much kills them.  Has this been your experience?


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## Shishkabob (Feb 15, 2011)

No, I have never heard of it being illegal and would be surprised if it was so.  The reason it really isn't done is because the amount of blood it 'returns' to central circulation is minuscule.  Not because it will kill someone when you lower their legs.


In reality, if your body is that shocky to begin with, it will have already shunted blood away from the legs.  Raising the legs, while technically making it harder for the body to pump blood in to them, the body would overcome that by vasoconstriction if it needed to.   Sit down and raise your legs-- You'll see there will be minimal change in blood pressure.  




Therefor making the whole move useless in both instances:  Either needed but already done, or not needed and your body will reverse what you just did by working harder.


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## JPINFV (Feb 15, 2011)

First off, what is shock? Shock is the inability to properly circulate blood throughout the body. A more appropriate term is "hypoprofusion." It's basically like losing fuel pressure in a car. Sure, the energy (oxygen) content of the fuel is fine, it's just not getting to where it needs to go. 

Hypoprofusion is, ultimately, severe hypotension. Blood pressure is determined by 3 major things. Stroke volume (how much is pumped per contraction), heart rate (these two, collectively, determines cardiac output), and systemic vascular resistance. Not enough of either of those will cause hypoprofusion if the other 2 factors are unable to compensate. So if the patient is in heart failure, the heart can only pump so much faster and the resistance can only go so high before cardiogenic shock sets in. In a patient with anaphylactic shock, the arterioles dilate and there's only so much that the heart can do to pump enough blood to keep the pressure up. 

In theory, lifting the legs allows gravity to help pull blood through the veins into the body, and ultimately back to the heart (called "venous return"). An increase in venous return increases the end diastolic volume (how much blood is in the ventricle immediately before contraction), which increases the distension of the ventricle. The more distended the ventricle (to a point) the harder it contracts (via a process known as Starling's Law), the more cardiac output, and the higher the blood pressure. 

While this all sounds good on paper, it isn't seen under laboratory conditions.


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## Veneficus (Feb 15, 2011)

AMF said:


> We've been taught, though, that this is illegal in Maine (and I assume elsewhere) because when you lower the legs again the shock pretty much kills them.  Has this been your experience?



Demand your money back from whoever taught that to you.


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## AMF (Feb 15, 2011)

Veneficus said:


> Demand your money back from whoever taught that to you.



Well it is illegal, and the reasoning is that of the lawmakers, not a medical professional


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## EMS49393 (Feb 15, 2011)

AMF said:


> Well it is illegal, and the reasoning is that of the lawmakers, not a medical professional



Wow, are we talking misdemeanor or felony illegal?  A mere citation, a fine, or full on prison time?  You might be confusing illegal with protocol.


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## Veneficus (Feb 15, 2011)

AMF said:


> Well it is illegal, and the reasoning is that of the lawmakers, not a medical professional



could you please post a citation to that, I cannot find one in my google or yahoo search. 

Additionally, Trendelenburg position is a legitimate surgical technique.


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## HotelCo (Feb 15, 2011)

AMF said:


> Well it is illegal, and the reasoning is that of the lawmakers, not a medical professional



Cite the law, please.


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## Handsome Robb (Feb 15, 2011)

Why would they teach it in your class if it was illegal? The one area I could see it being detrimental would be in a patient with increased ICP, seeing as you are trying to keep the ICP down and trendelenburg would theoretically be pushing more blood into the patient's head,  but I may be entirely wrong in that thought process.


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## BigPoppa (Feb 15, 2011)

JPINFV said:


> First off, what is shock? Shock is the inability to properly circulate blood throughout the body. A more appropriate term is *"hypoprofusion."*




Isn't it hypoPERfusion ?


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## lampnyter (Feb 15, 2011)

NVRob said:


> Why would they teach it in your class if it was illegal? The one area I could see it being detrimental would be in a patient with increased ICP, seeing as you are trying to keep the ICP down and trendelenburg would theoretically be pushing more blood into the patient's head,  but I may be entirely wrong in that thought process.



They would need to teach is because it is NREMT recognized. Like i had to learn about aspirin but EMTs in CT cant administer it.


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## JPINFV (Feb 15, 2011)

BigPoppa said:


> Isn't it hypoPERfusion ?




Yes, but we'll keep it between us...


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## Handsome Robb (Feb 15, 2011)

lampnyter said:


> They would need to teach is because it is NREMT recognized. Like i had to learn about aspirin but EMTs in CT cant administer it.



Fair enough. But I don't think they would teach a skill that is downright illegal...but i guess as a B administering ASA in CT would be illegal so I answered my own question :wacko:


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## usafmedic45 (Feb 15, 2011)

Veneficus said:


> Demand your money back from whoever taught that to you.



...and also surrender your certification for being that gullible and possessing of other traits that will endanger patients.


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## rwik123 (Feb 15, 2011)

I'm not too knowledgeable on the law, so someone correct me... Would lawmakers delve into such specific and legit medical procedure and out law it? This seems a bit odd. Seems more like a protocol issue than an actual piece of legislature.


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## MrBrown (Feb 16, 2011)

usafmedic45 said:


> ...and also surrender your certification for being that gullible and possessing of other traits that will endanger patients.



US EMS would collapse if such were required ... mega-super LOL


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## CAOX3 (Feb 16, 2011)

usafmedic45 said:


> ...and also surrender your certification for being that gullible and possessing of other traits that will endanger patients.



Wow very professional, maybe we could cut him some slack considering he is a student.


Or maybe thats expecting to much.


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## usafmedic45 (Feb 16, 2011)

CAOX3 said:


> Wow very professional, maybe we could cut him some slack considering he is a student.
> 
> 
> Or maybe thats expecting to much.




I think of it as the same kind of professionalism that USMC DIs adhere to when dealing with recruits...minus the screaming.  LOL


Apparently, so is expecting our students to have basic reasoning skills and the ability to admit their mistake when corrected.  Sorry...I dont think we help ourselves or our patients by cutting the slow, weak and stupid amongst us "some slack".  Are you willing to put your life or the life of your child in the hands of someone who passed because their instructors took pity on them?  I sure as hell am not.


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## AMF (Feb 16, 2011)

usafmedic45 said:


> ...and also surrender your certification for being that gullible and possessing of other traits that will endanger patients.



First of all, I'm not even half-way certified; second of all, by illegal, I mean grounds for revocation; and third of all, on what grounds would I not believe my instructor, my only source of medical knowledge (besides the internet)?  Because the law is ridiculous?  This from the same state the requires that your shotguns to be blessed in a Christian church and has regions where playing the violin outside is illegal.  As far as the National Registry vs State Protocol/Law goes, we are constantly learning contradicting information (Is a fall of the pt's height severe MOI, or does it have to be 3x his or her height or 15ft, whichever is less?  Is physical contact a part of Assault?  Does code 2 exist?).


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## usafmedic45 (Feb 16, 2011)

> second of all, by illegal, I mean grounds for revocation



Prove it.  Show us the documentation. If it's you should be able to find it somewhere because that sort of thing has one hell of a paper trail involved with it. 



> and third of all, on what grounds would I not believe my instructor, my only source of medical knowledge (besides the internet)?



Ever heard of "trust but verify"?  Extraordinary claims require extraordinary evidence.  I've never heard of a bunch of lawmakers making such a mandate so the logical assumption was that your instructor is either a bumbling moron with his head lodged pretty far up his *** or he was simply messing with you and you didn't pick up on it.


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## alphatrauma (Feb 16, 2011)

AMF said:


> ...This from the same state the requires that your shotguns to be blessed in a Christian church and has regions where playing the violin outside is illegal.



Whilst we _cannot_ choose where we are born, we most certainly _can_ decide where we live


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## usafmedic45 (Feb 16, 2011)

> This from the same state the requires that your shotguns to be blessed in a Christian church and has regions where playing the violin outside is illegal.



We also used to have a law banning the song '_Louie, Louie_' from the radio as 'obscene'.  Your point other than a failed attempt to discredit me after I pointed out your errors?


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## Veneficus (Feb 16, 2011)

I try to enable students, but in US EMS there is a huge problem.

An instructor meets that qualification by years in service. Not by knowledge or any special education. Students expect a teacher is knowledgable, some form of social contract actually. 

Personally I can never find fault with a student who doesn't know something that is beyond their level and the legal aspects of EMS are probably completely beyond Basic EMT class anyway as it is set up to be do as I say, do not ask questions. 

No instructor should ever be teaching local protocols in the original EMS education. Many protocols do not meet the modern standards of care and teaching them confuses the hell out of students because verified and credentialed tests are based on the EMS curriculum, not on local practice.

In this particular case I think the failure is on the agency and the instructor. 

While the instructor may have been sarcastic or joking, teachers have to be very aware that some jokes interefere with education. 

As advice to the OP, I would seriously hold in question the ability of your instructors and school. Get a copy of your state or national curriculum. Read the book very carefully, always go with the book answer. If a teacher fails you, you can argue a published source. They cannot do the same with their anecdotes.

I would still demand my money back. Even if you are dropped from the program, you are now armed with the knowledge of what makes a program and instructor substandard so you can better evaluate your next school.


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## Veneficus (Feb 16, 2011)

usafmedic45 said:


> I think of it as the same kind of professionalism that USMC DIs adhere to when dealing with recruits...minus the screaming.




While I recognize the effectiveness and value of the drill instructor method, it is simply not my way.

I like the senpai/kohai method.


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## AMF (Feb 16, 2011)

Veneficus said:


> I try to enable students, but in US EMS there is a huge problem...
> 
> As advice to the OP, I would seriously hold in question the ability of your instructors and school. Get a copy of your state or national curriculum. Read the book very carefully, always go with the book answer. If a teacher fails you, you can argue a published source. They cannot do the same with their anecdotes.
> 
> I would still demand my money back. Even if you are dropped from the program, you are now armed with the knowledge of what makes a program and instructor substandard so you can better evaluate your next school.



To be clear, what are you contesting?  That legs should be raised or that raising them shouldn't be malpractice?  If it's the former, that seems very similar to immediate release of a tk.


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## usafmedic45 (Feb 16, 2011)

> If it's the former, that seems very similar to immediate release of a tk.



How so?  I want to hear your reasoning on that one.


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## AMF (Feb 16, 2011)

usafmedic45 said:


> We also used to have a law banning the song '_Louie, Louie_' from the radio as 'obscene'.  Your point other than a failed attempt to discredit me after I pointed out your errors?



I'm saying that just because a law sounds crazy doesn't mean it isn't legit, especially since I assume legislation for public servant operation licensure is more lax than more traditional criminal/civil law.

I didn't mean to offend you or compare ME to wherever you're from.


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## usafmedic45 (Feb 16, 2011)

> I'm saying that just because a law sounds crazy doesn't mean it isn't legit, especially since I assume legislation for public servant operation licensure is more lax than more traditional criminal/civil law.



Yeah, but EMS related legislation are generally not spelled out that specifically.  They are written in pretty broad strokes by the state legislature and the specifics are worked out by the EMS cronies (usually docs and senior EMS personnel) at the state EMS agency.  It's not a matter of the "lawmakers" not knowing what they are talking about.  That's what we have been trying to get across and why we have been asking you to point us to the particular source of this information since it seems so exceptional and outlandish.


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## Veneficus (Feb 16, 2011)

AMF said:


> To be clear, what are you contesting?  That legs should be raised or that raising them shouldn't be malpractice?  If it's the former, that seems very similar to immediate release of a tk.



All of the research I have seen demonstrates that there is no benefit to raising the legs. There is no mention of demonstratable harm either.

In Surgery we put people in trendelenburg quite often. I have never witnessed some type of rebound hypotension upon righting them.

I would also like to point out from one of the most widely used EMT texts.

Step 2 of managing shock. "If there is no serious injury," (referring to the spine) "elevate the feet 8-12 inches."

I have not found any reference in any law on google or yahoo that states it is illegal or improper treatment anywhere.

All I did find about the legality of it was that it is not permitted during the interrogation of a prisoner in several states in laws referring to "aggresive interrogation techniques."

Some local protocols I have seen have removed trendelenburg position from their standing orders because of its lack of demonstratable effect in shock, but that doesn't make it illegal.

I doubt very much that there is any law on any book that states specifically legs may be elevated during surgical procedures where there is demonstratable benefit like moving anatomy to a more technically efficent position but not in the course of EMS treatment of shock.

Even saying it sounds stupid.

Not to mention every surgeon who performed a laproscopic procedure of the lower GI would be in violation. (along with some other specific procedures)

as for the tk, is there another way to release it I am unaware of?


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## AMF (Feb 16, 2011)

usafmedic45 said:


> How so?  I want to hear your reasoning on that one.



Sudden return of vascular volume.  Wouldn't you worry about de-oxygenation in the blood vessels?  Obviously the vascular volume is different and the return methods have different flow time-derivatives, which is why I asked.  From what I understand, extracorporeal oxygenation works similarly with refractory cardiogenic shock in acute MIs, specifically in reversing circulatory collapse without compromising (or maybe even improving) hemodynamic stability.  However, Linuss and another early commenter informed me that the reason this procedure fell out of practice was not because it did the wrong thing but because it didn't do enough of the right thing.


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## AMF (Feb 16, 2011)

Veneficus said:


> All of the research I have seen demonstrates that there is no benefit to raising the legs. There is no mention of demonstratable harm either.
> 
> In Surgery we put people in trendelenburg quite often. I have never witnessed some type of rebound hypotension upon righting them.
> 
> ...




EMTs (to my knowledge) do not remove tourniquets.  It's not so much criminally offensive as outside our scope of practice.  But it seems that the collective opinion is that it doesn't matter either way.


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## Veneficus (Feb 16, 2011)

AMF said:


> Sudden return of vascular volume.  Wouldn't you worry about de-oxygenation in the blood vessels?  Obviously the vascular volume is different and the return methods have different flow time-derivatives, which is why I asked.  From what I understand, extracorporeal oxygenation works similarly with refractory cardiogenic shock in acute MIs, specifically in reversing circulatory collapse without compromising (or maybe even improving) hemodynamic stability.  However, Linuss and another early commenter informed me that the reason this procedure fell out of practice was not because it did the wrong thing but because it didn't do enough of the right thing.



What the hell are they teaching you?

You are comparing ECMO to trendelenburg based on deoxyhemaglobin?

My head hurts now.


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## Veneficus (Feb 16, 2011)

AMF said:


> EMTs (to my knowledge) do not remove tourniquets.  It's not so much criminally offensive as outside our scope of practice.  But it seems that the collective opinion is that it doesn't matter either way.



Performing procedures outside of your scope constitutes the practice of medicine without a license. In every country I know of it is a felony offense. That makes it against the law.


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## AMF (Feb 16, 2011)

Veneficus said:


> What the hell are they teaching you?
> 
> You are comparing ECMO to trendelenburg based on deoxyhemaglobin?
> 
> My head hurts now.



The motivation is the same (AMI vs idiopathic, but really...) and the end result is the same, only the mechanism differs.

My question now is why would surgeons (I presume you at least work with them) use a procedure that EMS personel found ineffective (See the first couple of responses)?


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## AMF (Feb 16, 2011)

Veneficus said:


> Performing procedures outside of your scope constitutes the practice of medicine without a license. In every country I know of it is a felony offense. That makes it against the law.



I know you people love citations, so I'm sorry I can't provide any, but somewhat famously some european dude performed cardioversion on a police officer without a certification.  I'm just saying that good samaritan can make some legal gray areas.


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## Veneficus (Feb 16, 2011)

AMF said:


> The motivation is the same (AMI vs idiopathic, but really...) and the end result is the same, only the mechanism differs.
> 
> My question now is why would surgeons (I presume you at least work with them) use a procedure that EMS personel found ineffective (See the first couple of responses)?



Because EMS providers know more about medicine than surgeons? (pay no attention to the sarcasm)

In surgery it is not used for shock, it is used for the optimal placement of anatomy as well as things like aiding in the reduction of indirect inginal hernias or to increase vascular volume in the neck and thorax for the placement of invasive catheters.

Trendelenburg as a treatment of shock is based off of venous compliance and volume in regards to CVP, not oxyhemaglobin concentration.


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## AMF (Feb 16, 2011)

Veneficus said:


> Because EMS providers know more about medicine than surgeons? (pay no attention to the sarcasm)
> 
> In surgery it is not used for shock, it is used for the optimal placement of anatomy as well as things like aiding in the reduction of indirect inginal hernias or to increase vascular volume in the neck and thorax for the placement of invasive catheters.
> 
> Trendelenburg as a treatment of shock is based off of venous compliance and volume in regards to CVP, not oxyhemaglobin concentration.



I was indicating that maybe said EMS providers were wrong.  So now I really don't know if your "pay no attention to the sarcasm" was sarcastic or not.

But apparently (^) it doesn't matter anyways.


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## Veneficus (Feb 16, 2011)

AMF said:


> I was indicating that maybe said EMS providers were wrong.  So now I really don't know if your "pay no attention to the sarcasm" was sarcastic or not.
> 
> But apparently (^) it doesn't matter anyways.



It looked to me like you were accusing surgeons of using an ineffective practice that EMS providers discovered the truth about.


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## cw15321 (Feb 16, 2011)

Veneficus said:


> In Surgery we put people in trendelenburg quite often. I have never witnessed some type of rebound hypotension upon righting them.
> 
> I would also like to point out from one of the most widely used EMT texts.
> 
> Step 2 of managing shock. "If there is no serious injury," (referring to the spine) "elevate the feet 8-12 inches."



If you read Prehospital Emergency Care, 9th edition by Joseph Mistovich, in Chapter 6 on Lifting and Moving Patients, it does mention that Trendelenburg is no longer a treatment for shock due the fact that it causes abdomen organs to compress the diaphram and increase the pt's difficulty breathing. In addition for pt's with head bleeds it makes the situation worse for them.


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## usalsfyre (Feb 16, 2011)

I'm gonna take a stab here and say the fact that any CHI patient your thinking about trendelenburging likely has no CPP is a FAR, FAR bigger issue than any harmful effects of the position itself...


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## Veneficus (Feb 17, 2011)

cw15321 said:


> If you read Prehospital Emergency Care, 9th edition by Joseph Mistovich, in Chapter 6 on Lifting and Moving Patients, it does mention that Trendelenburg is no longer a treatment for shock due the fact that it causes abdomen organs to compress the diaphram and increase the pt's difficulty breathing. In addition for pt's with head bleeds it makes the situation worse for them.



I was not referring to the Mistovich book.

Compression of the abdominal organs is one of the points of using it. A patient in shock is sufferering from a fluid perfusion problem, not primarily from a breathing problem. I couldn't find a study, but from my experience I would be willing to bet there is considerably more breathing restirction from immobilization than from trendelenburg. In the event that the position has a significant effect or the breathing effort, the patient is likely to have issues that are bigger than can be managed without invasive techniques anyway.

Just as a thought, if you were concerned about an intraabdominal bleed, compression of the compartment would be a good thing.

You are right,Trendelenburg has been a contraindication in CHI for sometime, but we are speaking about valcular volume and movement for the prupose of central perfusion as far as I can tell.


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## tao (Feb 17, 2011)

Long story short, trendelenburg is generally not useful as a treatment for shock.  You aren't missing out on not being allowed to use it.  My local protocols don't allow it either, and if they did, I would probably contact med control to bypass it.

The best BLS treatment for shock is call ALS.


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## jjesusfreak01 (Feb 19, 2011)

tao said:


> Long story short, trendelenburg is generally not useful as a treatment for shock.  You aren't missing out on not being allowed to use it.  My local protocols don't allow it either, and if they did, I would probably contact med control to bypass it.
> 
> The best BLS treatment for shock is call ALS.



No, the best BLS treatment for shock is to get the patient to the hospital ASAP. There are 6+ types of shock, and while some can be treated in the field, some cannot. Raised the legs of a cardiogenic shock pt on a call last month, doesn't hurt them if they can breathe well when their BP is dropping through the floor, even with a 1L fluid bolus.


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