# Leg injury and shock position



## bigdude (Aug 7, 2011)

Let's say a patient has a laceration mid femur with profuse bleeding.  After bleeding is controlled and assuming the patient is showing signs of shock, would you transport in shock position or supine?

From what I can remember the only contraindiction for shock position is a suspected spinal injury, correct?


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## crazycajun (Aug 7, 2011)

bigdude said:


> Let's say a patient has a laceration mid femur with profuse bleeding.  After bleeding is controlled and assuming the patient is showing signs of shock, would you transport in shock position or supine?
> 
> From what I can remember the only contraindiction for shock position is a suspected spinal injury, correct?



Just elevate the legs above the level of the head, cover, O2 and transport


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## Amber (Aug 7, 2011)

Would it not depend on how the laceration happened? And if there was enough MOI to think possible femur injury? Say there was a broke femur, depending how that happened, you might be able to suspect spinal injury. So I guess this question could go both ways, because not enough info is presented.


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## crazycajun (Aug 8, 2011)

Amber said:


> Would it not depend on how the laceration happened? And if there was enough MOI to think possible femur injury? Say there was a broke femur, depending how that happened, you might be able to suspect spinal injury. So I guess this question could go both ways, because not enough info is presented.



OK so what is more important to your PT? Stabilizing the spine or treating for shock that can become irreversible and you PT dies?


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## Amber (Aug 8, 2011)

Ive been taught that treating for shock as a EMT-B we can only provide O2, cover, and watch for breathing. I recently learned that you can immobilize and still elevate feet?

So I guess in a perfect world we could do both? 



crazycajun said:


> OK so what is more important to your PT? Stabilizing the spine or treating for shock that can become irreversible and you PT dies?


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## G00CH 53 (Aug 11, 2011)

Cover and dress the wound first. During Medic practicals, if it was lets say an open femur fx, you obviously can't splint that. Place a gloved hand over it to provide pressure, then bandage. You still need to splint the injury because of susprected fracture. Aircast or air splint. As the bascis go, ABC's and you've covered your bleeding control.


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## tickle me doe face (Aug 11, 2011)

bigdude said:


> Let's say a patient has a laceration mid femur with profuse bleeding.  After bleeding is controlled and assuming the patient is showing signs of shock, would you transport in shock position or supine?
> 
> From what I can remember the only contraindiction for shock position is a suspected spinal injury, correct?



I think you should transport in the shock position. 

From my reading, the shock position is really helpfull, and can greatly improve the patients appearance and bp.


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## lightsandsirens5 (Aug 11, 2011)

Amber said:


> Ive been taught that treating for shock as a EMT-B we can only provide O2, cover, and watch for breathing. I recently learned that you can immobilize and still elevate feet?
> 
> So I guess in a perfect world we could do both?



Yea. Just lift the whole LSB. Same thing is accomplished. 

Of course if you actually believe in science, Bryan Bledsoe has a good article on this issue: http://www.ems1.com/ems-products/ed...-Current-Slant-on-the-Trendelenburg-Position/

So actually tilting the whole LSB really doesn't accomplish anything. I have personally only ever put one person in the Trendellenburg positions and that was because it made it easier for me to put in an IO. 


Sent from a small, handheld electronic device that somehow manages to consume vast amounts of my time. Also know as a smart phone.


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## usalsfyre (Aug 11, 2011)

tickle me doe face said:


> From my reading, the shock position is really helpfull, and can greatly improve the patients appearance and bp.



Hmmmm, that's the problem with reading EMT text....

Supine, yes, it can improve patient condition over them being upright. I've yet to see elevating the patient's legs provide any sort of improvement though.


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## tickle me doe face (Aug 11, 2011)

usalsfyre said:


> Hmmmm, that's the problem with reading EMT text....



I don't have any real world experience yet, so that's pretty much all i gots


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## JPINFV (Aug 11, 2011)

LSB and trendelenburg? Have we considered if adding crystal therapy or aroma therapy to help out?


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## tickle me doe face (Aug 11, 2011)

JPINFV said:


> LSB and trendelenburg? Have we considered if adding crystal therapy or aroma therapy to help out?



I don't understand how either of these would work, but am very interested to learn!

link!


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## JPINFV (Aug 11, 2011)

tickle me doe face said:


> I don't understand how either of these would work, but am very interested to learn!
> 
> link!



Here's a better idea. Look for research showing the efficacy of spinal immobilization or trendelenburg.


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## crazycajun (Aug 11, 2011)

JPINFV said:


> Here's a better idea. Look for research showing the efficacy of spinal immobilization or trendelenburg.



You can argue the point but I have personally seen leg elevation and trendellenburg improve a PT vitals and general condition in shock.


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## JPINFV (Aug 11, 2011)

crazycajun said:


> You can argue the point but I have personally seen leg elevation and trendellenburg improve a PT vitals and general condition in shock.




Just that? You mean it couldn't have been simply because of a bunch of strangers manhandling, questioning a patient, and doing several other things that cause an increase in stress past the fact that the patient is sick?


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## McGoo (Aug 11, 2011)

crazycajun said:


> You can argue the point but I have personally seen leg elevation and trendellenburg improve a PT vitals and general condition in shock.



Legs up will help improve vitals (too tired for more details) but trendellenburg will do zip. Look at the situation in another way: a fractured femur can lose a lot of blood, so it needs to be splinted for pain, long term recovery and also to reduce blood loss. Combine this with the need for spinal precautions as enough trauma to snap a femur is also likely to damage the spine, and you have a patient who needs to be supine with legs flat. How would you elevate a splinted leg anyway?


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## JPINFV (Aug 11, 2011)

McGoo said:


> Legs up will help improve vitals (too tired for more details) but trendellenburg will do zip.




...and how will legs up increase blood pressure that wouldn't be contributed by trendelenburg? After all, increasing venous return is increasing venous return...


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## tickle me doe face (Aug 11, 2011)

JPINFV said:


> Here's a better idea. Look for research showing the efficacy of spinal immobilization or trendelenburg.



My EMT book says both are good, and has detailed instructions with pictures for each.


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## JPINFV (Aug 11, 2011)

tickle me doe face said:


> My EMT book says both are good, and has detailed instructions with pictures for each.



I've got science. While the studies are small, small consistent studies are significantly more evidence than no evidence at all. My bar for accepting trendelenburg (or spinal immobilization for that matter) are rather low, but there evidence for them are simply not there. 

http://journals.lww.com/ccmjournal/...nburg_position__hemodynamic_effects_in.2.aspx (No increase in MAP in either hypotensive or normotensive cardiac patients)

http://www.sciencedirect.com/science/article/pii/S0196064485808787  (1.8% auto transfusion... wee)

http://ajcc.aacnjournals.org/content/14/5/364.short (Review paper that came to the conclusion that there simply is no evidence to support trendelenburg). 

...oh, and sorry, there aren't any pictures involved.


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## Aidey (Aug 11, 2011)

McGoo said:


> Legs up will help improve vitals (too tired for more details) but trendellenburg will do zip. Look at the situation in another way: a fractured femur can lose a lot of blood, so it needs to be splinted for pain, long term recovery and also to reduce blood loss. *Combine this with the need for spinal precautions as enough trauma to snap a femur is also likely to damage the spine,* and you have a patient who needs to be supine with legs flat. How would you elevate a splinted leg anyway?



That is assuming the same force that was applied to the femur was applied to the spine. I can think of a few patients off the top of my head who had mid-femur fractures and none of them got back boarded because they were all isolated injuries.  



tickle me doe face said:


> My EMT book says both are good, and has detailed instructions with pictures for each.



We're considering EMT books accurate sources of peer-reviewed scientific information now?


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## tickle me doe face (Aug 11, 2011)

Aidey said:


> We're considering EMT books accurate sources of peer-reviewed scientific information now?



I bet there was a team of peers writing it, yes.

Since when are textbooks considered not accurate?

it wasn't an outdated edition or anything


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## tickle me doe face (Aug 11, 2011)

McGoo said:


> Legs up will help improve vitals (too tired for more details) but trendellenburg will do zip.



what's the difference between legs up and trendellinberg, i think those sound alot alike


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## JPINFV (Aug 11, 2011)

"Shock position" is just the legs while "trendelenburg" is technically an entire body tilt and generally can't be done on ambulance stretchers without a backboard.


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## Aidey (Aug 11, 2011)

Peer reviewed and several EMTs and Paramedics each writing a couple of chapters are not the same thing. And they are considered not accurate since they continue to teach the automatic, unquestioning use of backboards, high flow O2, trendelenburg, lights and sirens, urban helicopter response, MAST pants...etc. 

Spend some time searching those topics on Pubmed. I promise what you find will not be what your EMT book says.


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## tickle me doe face (Aug 11, 2011)

JPINFV said:


> "Shock position" is just the legs while "trendelenburg" is technically an entire body tilt and generally can't be done on ambulance stretchers without a backboard.



ok. but is there really a difference between the two, like physiologically?


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## tickle me doe face (Aug 11, 2011)

Aidey said:


> Spend some time searching those topics on Pubmed. I promise what you find will not be what your EMT book says.



I;m finding this out quickly.

Why is there such a discrepancy?

Shouldn't science always agree with itself, no matter who, or where it is done?

Why does the science in my EMT book and class, not agree with the science in the rest of the world?


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## McGoo (Aug 12, 2011)

tickle me doe face said:


> ok. but is there really a difference between the two, like physiologically?



Yes there is. Trendellenburg raises the feet a few inches above the body and also creates a low point of the head. Legs up raises the feet and legs by the length of the femur, creating a larger head of pressure, without the drain of the head.


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## tickle me doe face (Aug 12, 2011)

McGoo said:


> Yes there is. Trendellenburg raises the feet a few inches above the body and also creates a low point of the head. Legs up raises the feet and legs by the length of the femur, creating a larger head of pressure, without the drain of the head.



are we talking legs up like 90 degrees???


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## Aprz (Aug 12, 2011)




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## systemet (Aug 12, 2011)

tickle me doe face said:


> ok. but is there really a difference between the two, like physiologically?



Both positions risk reducing vital capacity by allowing the viscera to compress the diaphragm, limiting lung expansion.  I'm not sure if would be worse to be head down, or to have your hips flexed.  I'm not feeling energetic enough to search Pubmed right now, but I wouldn't be suprised if someone's studied the difference.  I'd assume this would be a bigger issue in the obese patient.

I think the amount of blood redistributed to the core by Trendelenburg versus modified-Trendelenberg, versus spine position is likely to be fairly trivial.

In the situation described, if the extremity hemorrhage is controlled, and there's no suspicion of abdominal / chest trauma, I'd be happy to administer a fairly large amount of crystalloid, provided there's no CHF / renal failure issues to be worried about.


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## systemet (Aug 12, 2011)

tickle me doe face said:


> I;m finding this out quickly.
> 
> Why is there such a discrepancy?



I'm not sure if you're trolling, but...

Most of the people writing EMS textbooks lack a scientific background.  Most EMTs and Paramedics lack an understanding of research methodology, statistics, epidemology, and all the other things necessary to understand evidence-based medicine.  As a result we're not critical consumers of information.  We tend to believe what we believe because (i) some instructor told us, (ii) a senior medic told us, (iii) some random MD told us, or (iv) we read it in some textbook.  We don't tend to demand to look at the source material and critically evaluate what we're being told.  The textbooks reflect this.



> Shouldn't science always agree with itself, no matter who, or where it is done?



In essence, yes.  The underlying physiology of the human body doesn't change because a different researcher is evaluating the response to a given experimental therapy.  The same way that pi remains a constant, and that the circumference of a circle is always going to be 2 * pi * r.

The problem with the human body is that it's a very complex system, and the responses aren't always easy to measure.  Our understanding of this system changes with time, and as we gather more information what appears to be a beneficial or promising therapy often turns out to be harmful.  For reference see any of the ACLS / CPR guideline changes.  

It's also hard to study.  There's ethical limitations on what we can do to human subjects.  Animal data doesn't always transfer.  A lot of experimental research is performed on small rodents, due to the expense and ethical concerns with working with large mammals.  

A consequence is that treatments are often introduced on the basis of limited data that seems neutral or slightly positive.  When newer data is produced that brings a practice into question it takes time for a therapy to be withdrawn.  Some practices are common place today because they were used historically, but are now considered to be of questionable efficacy.



> Why does the science in my EMT book and class, not agree with the science in the rest of the world?



I'm going to suggest that the people writing your EMT textbook were probably largely ignorant of the science.  I imagine the people teaching your EMT course probably are too.  That's not to say they're not good people.

Are you being taught physiology by a physiologist?  Pharamacology by a pharmacologist?  Is a board-certified emergency physician teaching you emergency treatment?

There's also a limit to how much information you can put into a short course without academic prerequisites.  In some cases you're being taught procedures and therapies without what you might consider is an adequate scientific background.


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## Akulahawk (Aug 12, 2011)

systemet said:


> Both positions risk reducing vital capacity by allowing the viscera to compress the diaphragm, limiting lung expansion.  I'm not sure if would be worse to be head down, or to have your hips flexed.  I'm not feeling energetic enough to search Pubmed right now, but I wouldn't be suprised if someone's studied the difference.  I'd assume this would be a bigger issue in the obese patient.
> 
> I think the amount of blood redistributed to the core by Trendelenburg versus modified-Trendelenberg, versus spine position is likely to be fairly trivial.
> 
> In the situation described, if the extremity hemorrhage is controlled, and there's no suspicion of abdominal / chest trauma, I'd be happy to administer a fairly large amount of crystalloid, provided there's no CHF / renal failure issues to be worried about.


If the hemorrhage is controlled... I would probably stick with small amounts of crystalloid, judiciously administered so as to not pop clots. From what I've read, any effect you get from Trendelenburg or Modified Trendelenburg in terms of BP improvement is transient, and not much better, if at all, than supine positioning. With a Modified Trendelenburg, you may see some gravity induced autotransfusion of about 3-500 mL of blood to the central circulation though. That autotransfusion effect will disappear as soon as the legs are lowered back to supine, which limits it's practical use to showing if someone needs more fluid.

In the urban prehospital environment, it's going to be of little use.


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## systemet (Aug 12, 2011)

Akulahawk said:


> If the hemorrhage is controlled... I would probably stick with small amounts of crystalloid, judiciously administered so as to not pop clots



I think I'd be less worried about this, if it's an isolated extremity injury.




> With a Modified Trendelenburg, you may see some gravity induced autotransfusion of about 3-500 mL of blood to the central circulation though. That autotransfusion effect will disappear as soon as the legs are lowered back to supine, which limits it's practical use to showing if someone needs more fluid.



Is it that much?  Because I think only about 500 ml of blood redistributes to the core when you go from standing to supine.



> In the urban prehospital environment, it's going to be of little use.



Agreed.


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## systemet (Aug 12, 2011)

This reference suggests that the redistribution of blood volume with a 15 degree full Trendelenburg versus supine is around 2% (of around 5.5 L, so about 110ml).  When you read the article it seems like there's a lot of intersubject variability, e.g. changes in lower compartment blood volume of  - 7.3% to + 0.2%, and it's just 10 subjects.

[This is also in healthy volunteers.  I'd expect a hypovolemic trauma patient to already have substantial redistribution of blood from the extremities to the core, suggesting a lesser benefit.  But that's just an opinion.]


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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## Stingray91 (Aug 12, 2011)

My book says the shock position is no longer recommended basically because the abdomen organs can be pushed up toward the diaphragm, making breathing more difficult, and increasing pressure inside the skull in pts with a head injury and of course, defiantly contraindicated in a pt. with suspected spinal injury. But the trendelenburg and shock are good to use for a pt who just suffered a simple faint.:deadhorse:


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## medichopeful (Aug 12, 2011)

tickle me doe face said:


> Why does the science in my EMT book and class, not agree with the science in the rest of the world?



Because it's such an entry-level class that they literally teach the bare minimum.


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## Meursault (Aug 12, 2011)

I was hoping this thread would die quietly after a few people confirmed the textbook answers, this being the NREMT forum. Eh, into the fray.



tickle me doe face said:


> I;m finding this out quickly.
> 
> Shouldn't science always agree with itself, no matter who, or where it is done?



Science is not a substance one extracts by doing research and then sprinkles on textbooks. Science is a set of methods/ontological framework for describing and interpreting the real world. Part of that involves learning to deal with conflicting _research findings_ and opinions that conflict with each other or with research findings. In the case of your textbook, its opinion probably conflicts with the existing evidence because it was never based on any evidence at all, just a plausible idea.


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## Meursault (Aug 13, 2011)

And I just checked my email and found an article in EMS World that cites the same handful of studies we've all been talking about:
http://www.emsworld.com/features/article.jsp?id=17918&siteSection=5

The author equivocates a bit, but so did some of the study authors.


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