Transporting AAA pt?

[usalsfyre]

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

 

[usalsfyre]

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.

 

[Anjel]

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.

 

[Anjel]

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.

 

[usalsfyre]

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.

 

[systemet]

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.

 

[8jimi8]

Do people still use Trendelenberg?

For a minute until we put a central line in

 

[ArcticKat]

If signs of shock are present, trendelenberg.

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

 

[abckidsmom]

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.

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

 

[Akulahawk]

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...

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

 

[Voodoo1]

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.

 

[Handsome Robb]

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.

 

[bstone]

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

 

[LondonMedic]

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.

 

[rmabrey]

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)

 

[LondonMedic]

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

Even then does it actually add any tangible benefit?

 

[rmabrey]

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"

 

[medichopeful]

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.

 

[usalsfyre]

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.

 

[Akulahawk]

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...