Actions for patient going into shock

[brochocinco]

I'm touching up on my material and reading through the Brady book...This book has so many inconsistencies and errors, it's frustrating. Maybe someone can help clarify..

For steps to Emergency Medical Care, it says
"If the patient has injuries to the pelvis, lower extremities, head, chest, abdomen, neck or spine, or if the shock may be due to cardiac compromise, keep the patient supine; do not elevate the feet"

Now in the chapter review's case study follow-up, you respond to a teenager thats been stabbed in the LUQ..."Although the external bleeding was profuse, you know that because the wound site is the abdomen, the patient is most likely bleeding internally as well as suffering from shock. You elevate the patients feet approximately 8-12 inches..."

Can someone tell me what I am supposed do in that situation?

 

[Giddi]

Trendelenburg maybe?

 

[jjesusfreak01]

I'll agree I have found an alarming number of errors and inaccuracies in the Brady EMT-B book (you can tell when it starts to contradict itself).

Since basics usually can't use full body anti-shock suits, this does pose an interesting problem. I think the question is, "Will putting the patient in the Trendelenburg position aggravate the abdominal injury?"

It appears that the book is placing the emphasis on preventing shock rather than worrying about aggravating the abdominal wound. That would seem to be the right course of action, since shock is going to be the thing that kills them in the end.

 

[Smash]

Trendelenburg position was used to allow better view of the abdominal contents during surgery. It is of no use in preventing or treating hypovalemic shock. Nor are PASG/MAST suits. Leave them flat, control bleeding as best you can, control pain, avoid cyclic crystalloid resuscitation, drive fast to top tier trauma center.

 

[CAOX3]

Trendelenburg position was used to allow better view of the abdominal contents during surgery. It is of no use in preventing or treating hypovalemic shock. Nor are PASG/MAST suits. Leave them flat, control bleeding as best you can, control pain, avoid cyclic crystalloid resuscitation, drive fast to top tier trauma center.

What he said.

Trendelenburg is useless in EMS.

We havent had MAST trousers on a truck since we had the EOA/EGTA.

 

[lightsandsirens5]

What he said.

Trendelenburg is useless in EMS.

We havent had MAST trousers on a truck since we had the EOA/EGTA.

We have 'em! They are a PAIN to put on, but they worked in the case I have used them. I think the key is proper use. I do agree with you on Trendellenburg (or however the h**l you spell it) though.

My insturtor used to say "The best way to control traumatic hypovolemic shock is surgery. Since you cant do that on an ambulance, you tell me what you should do. If you can't figure it out, it is: Stop dinging around on scene or in the rig and GET THE PATIENT TO A TRAUMA CENTER AS SOON AS POSSIBLE. Yesterday if you can."

But standard proceedures at my service? Control bleeding before moving on to any other steps. (Well DUH!) Trendeleburg position (However useless it may be. Our hospital likes it.......) IV fluid resuscetation (or IO if indicated) PASG (maybe, like once in a blue moon), and a Diesel and Wheelen combo special.

 

[CAOX3]

If I remeber correctly PASG were removed because there was no scientific data on hand to prove they were effective.

I havent seen a pair in a long time.

 

[Smash]

If I remeber correctly PASG were removed because there was no scientific data on hand to prove they were effective.

I havent seen a pair in a long time.

We ditched ours some time in the late 1980s.

 

[lightsandsirens5]

If I remeber correctly PASG were removed because there was no scientific data on hand to prove they were effective.

Really, I am going to have to look innto that. I assumed that some of it was based on the g-suit concept. Pilot goes into high G situation essentially causing hypovolemic shock in his upper body, but g-suit inflates and blood is forced back up into his upper body since the legs are no longer able to hold as much blood.

 

[Smash]

Really, I am going to have to look innto that. I assumed that some of it was based on the g-suit concept. Pilot goes into high G situation essentially causing hypovolemic shock in his upper body, but g-suit inflates and blood is forced back up into his upper body since the legs are no longer able to hold as much blood.

It's a nice idea, but like so many ideas in medicine, particularly prehospital medicine, the reality doesn't match the theory. It's like fluid resus for penetrating trauma. Back in the day we saw that circulating volume had been lost, resulting in poor perfusion, so we restored circulating volume with crystalloids (and colloids) to improve perfusion. And we certainly improved some numbers. Patients got to hospital with superb blood pressure and we all felt good. All of us except the patients who died horribly as a result of our nice idea.

From the Cochrane plain English summary: About one third of injury deaths are due to shock from blood loss. Preventing shock in people with uncontrolled bleeding is therefore vital. Treatment aims to maintain blood pressure, so that tissue damage is minimised. Medical anti-shock trousers (MAST) are believed to increase blood pressure and blood flow to the heart and brain, helping to stabilise the person until they receive further treatment. The review of trials found no evidence that MAST application decreases deaths, with some suggestion that it may even do harm. More research is needed.

 

[Veneficus]

I'm touching up on my material and reading through the Brady book...This book has so many inconsistencies and errors, it's frustrating. Maybe someone can help clarify..

For steps to Emergency Medical Care, it says
"If the patient has injuries to the pelvis, lower extremities, head, chest, abdomen, neck or spine, or if the shock may be due to cardiac compromise, keep the patient supine; do not elevate the feet"

Now in the chapter review's case study follow-up, you respond to a teenager thats been stabbed in the LUQ..."Although the external bleeding was profuse, you know that because the wound site is the abdomen, the patient is most likely bleeding internally as well as suffering from shock. You elevate the patients feet approximately 8-12 inches..."

Can someone tell me what I am supposed do in that situation?

Forget elevating the feet. It is not going to help.

These type of inconsistencies are relatively normal when you have a textbook written by multiple authors.

 

[EMSLaw]

Forget elevating the feet. It is not going to help.

These type of inconsistencies are relatively normal when you have a textbook written by multiple authors.

I think the textbook answer for EMT-B is still that the treatment for hypovolemic shock includes high flow O2, keeping the patient warm, and placing the patient in the modified Trandelenberg position (feet raised).

Of course, since the textbook also tells us that we should be backboarding almost every trauma patient, I'm not entirely sure how we accomplish this. We need to carry a phone book to prop the foot end of the board up, I guess.

This is what happens when two useless EMS interventions collide!

 

[Veneficus]

I think the textbook answer for EMT-B is still that the treatment for hypovolemic shock includes high flow O2, keeping the patient warm, and placing the patient in the modified Trandelenberg position (feet raised).

Of course, since the textbook also tells us that we should be backboarding almost every trauma patient, I'm not entirely sure how we accomplish this. We need to carry a phone book to prop the foot end of the board up, I guess.

This is what happens when two useless EMS interventions collide!

in the 10th edition book i have it says to elevate the feet, but I will call my NR friend and see if it is still tested there for basic.

 

[dudemanguy]

I've heard of PASG pants working when transfering a patient with a AAA. You put the pants on and in the event the patient starts crashing you inflate them to buy some time en route. I talked to a paramedic who told me about this situation being the only time he's ever seen a patient have a AAA rupture and still live.

I did see a pair and practiced applying them in my Basic class, although we were told we werent likely to see them.

 

[EMSLaw]

The plural anecdote is not data. The fact that someone, somewhere used MAST pants and they seemed to work provides no evidence of their clinical efficacy.

EMS as a whole is far to dependent on anecdotal "evidence" for why we do what we do.

 

[JPINFV]

I think the textbook answer for EMT-B is still that the treatment for hypovolemic shock includes high flow O2, keeping the patient warm, and placing the patient in the modified Trandelenberg position (feet raised).

Of course, since the textbook also tells us that we should be backboarding almost every trauma patient, I'm not entirely sure how we accomplish this. We need to carry a phone book to prop the foot end of the board up, I guess.

This is what happens when two useless EMS interventions collide!

For a backboarded patient you can go full on trendelenburg by raising the feet end of the gurney, thus tilting the entire backboard and body.

Of course this doesn't change the fact that I still haven't seen a single study that supports trendelenburg as an intervention for shock.

 

[LondonMedic]

EMS as a whole is far to dependent on anecdotal "evidence" for why we do what we do.

The problem of course is that it's very hard to do any form of ethical RCT in emergency cases.

 

[Veneficus]

the great MAST debate

Here are a few links for your perusal.


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1875765/

http://www.annemergmed.com/article/S0196-0644(81)80158-8/abstract

Which of course have links to other links.

I have heard of the research about MAST helping with aortic bleeds, but it was years ago and I honestly dismissed it when I read it as extremely impractical in EMS. (Read I have no idea where to find a copy anymore)

From what I understood, if memory serves me, was that inflating the abd. compartment could basically "cross clamp" the aorta if the bleed was low enough. I also recall something about the BP having to be <50 systolic but I am not sure what exactly it pertained to.

Unfortunately, most of the MAST studies are done by people who have a position for or against them. I see the middle road. MAST definitively does not do what it was supposed to do in theory. It may have some occasional uses which it will benefit a patient by a different mechanism.

But consider... How often are these events? I have read that applying MAST in patients not requiring, results in an average of +1.7 ICU days. That means they do harm if not used properly. So we cannot simply advocate to use these on every patient or under broad painted protocols.

How are EMS providers going to recognize when MAST will be useful? Does the environment (rural, wildernes, military) play an important factor? If you are using MAST in desperation, while you may make it to the hospital alive, how many people are going to leave the hospital?

Let's say you do successfully crossclamp an aorta by inflating them, once at the hospital, now what? The patient is going to have to be opened up to fix it. Forget about acidosis, how is the abd. going to be accessed for surgical correction?

I have had the honor of speaking with what could be described as the leading "pro" and "anti" surgeons about MAST. I find the Anti argument more compelling in this case.

I think that since there will be no definitive studies on this. (ethcally it might not be possible) It will come down to the judgement of medical directors and protocol.

 

[MonkeySquasher]

Let's say you do successfully crossclamp an aorta by inflating them, once at the hospital, now what? The patient is going to have to be opened up to fix it. Forget about acidosis, how is the abd. going to be accessed for surgical correction?

Not to mention when you get them to the hospital, you have to in-service the ER staff and surgeons on them. Otherwise, ER staff who don't know what they are will either:

A) Attempt to cut off the pressurized pants. Which I hear is a bad idea.

or

B.) Depressurize the pants to get them off, and you'll watch your patient's BP go from 90/palp to 40/crap and they die.

 

[Veneficus]

Not to mention when you get them to the hospital, you have to in-service the ER staff and surgeons on them. Otherwise, ER staff who don't know what they are will either:

A) Attempt to cut off the pressurized pants. Which I hear is a bad idea.

or

B.) Depressurize the pants to get them off, and you'll watch your patient's BP go from 90/palp to 40/crap and they die.

Actually, surgeons are educated on them. Most just don't have any respect for MAST. I suspect that most EMs are educated on them too.

I live for the day i get to cut a set off of a patient. Even better if it is in a trauma bay in front of the person who put them on. Then they will go tell all of their EMS buddies how stupid I am.