BLS scenerio time

sabbymedic

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I am not sure what your standards are but over here in Canada and in Ontario we follow the BLS patient care standards. Trendellenburg does work I am not sure what studies say it does not but it does work to bring up a pt's BP. When you have a hypovelimic pt it is one of the only things you can do to elevate BP. This procedure has been around for years and would not have been if it did not work to some degree. I agree it is not the best method but if you don't have any other options you need to do something. The pt does not always read the book. Scientifically proven or not proven studies are not always right that is why medicine is called a practice.
 

skyemt

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I am not sure what your standards are but over here in Canada and in Ontario we follow the BLS patient care standards. Trendellenburg does work I am not sure what studies say it does not but it does work to bring up a pt's BP. When you have a hypovelimic pt it is one of the only things you can do to elevate BP. This procedure has been around for years and would not have been if it did not work to some degree. I agree it is not the best method but if you don't have any other options you need to do something. The pt does not always read the book. Scientifically proven or not proven studies are not always right that is why medicine is called a practice.

if you like, you can go to the website of Dr. Bryan Bledsoe... he opines that it is something in EMS that was anecdotally based, and he cites studies showing no improvement in the position.

so to say it "does work"... what is that based on?
 

sabbymedic

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That would be based on experience. I have used it on pt's and it does have positive effects. Hospital beds, ambulance stretchers all have Trendelumburg positions and have for years but what you are saying is that all that is there for the heck of it. Our doctors that run our base hospitals still say that it can be used if you are not worried about ICP. I personally have used it several times and have go an increase in BP which is what you want to keep oxygenated blood going to the heart and lungs and brain. Not trying to argue but saving a pt's life is not based on case studies it is doing what you can to save a life.
 

JPINFV

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Link to Bledsoe's reveiw
http://www.merginet.com/index.cfm?pg=trauma&fn=TrendelenburgPosition


WISE-2005: orthostatic tolerance is poorly predicted by acute changes in cardiovascular variables.

Twenty-four (24) healthy women from 25-40 years of age underwent orthostatic tolerance tests consisting of passive tilt and lower body negative pressure before and after completing 60-days of continuous -6 degree head down tilt bed rest (HDBR). Prior to HDBR, participants were assigned to one of three groups: control, exercise or nutrition. We aimed to identify any acute head up tilt changes in mean arterial pressure, pulse pressure, total peripheral resistance, cardiac output, stroke volume, or heart rate, which might predict tolerance or changes in tolerance with HDBR. Generally, these attempts were largely unsuccessful. The results indicate that the mechanisms of orthostatic failure are not strongly related to the way in which the body responds to the initial challenge. Additionally, the observation that some variables were predictive of tolerance before and not after tilt may indicate a change in the strategies used to maintain blood pressure, or differential adaptations to HDBR.
http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Myth: The Trendelenburg position improves circulation in cases of shock


Conclusion

The Trendelenburg position is taught in schools and on the wards as an initial treatment for hypotension. Its use has been linked to adverse effects on pulmonary function and intracranial pressure. Recognizing that the quality of the research is poor, that failure to prove benefit does not prove absence of benefit, and that the definitive study examining the role of the Trendelenburg position has yet to be done, evidence to date does not support the use of this time-honoured technique in cases of clinical shock, and limited data suggest it may be harmful. Despite this, the ritual use of the Trendelenburg position by prehospital and hospital staff is difficult to reverse, qualifying this as one of the many literature resistant myths in medicine.

http://www.caep.ca/template.asp?id=DF61785B363D4460835A593243E70058

to note, that last one is from Canada.

Not trying to argue but saving a pt's life is not based on case studies it is doing what you can to save a life.
How is your anecdotal evidence any different than a case study? Do you still use massive amounts of fluids, or are they practicing permissive hypotension in trauma patients in Canada? I bet there are plenty of medics who have seen patients walk out of a hospital after maintaining a blood pressure in the 120s due to fluids alone. That doesn't mean that fluid resuscitation is still the standard of care. Personally, I prefer to practice evidence based medicine as much as possible instead of emotion based medicine.

Protip: Most BP cuffs have a standard of error of +/-3 mmHg. Therefore, any true change has to be at least 6 mmHg difference. (100+3= 103 106-3=103. Hence the BP could have been both 103 both times.
 
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sabbymedic

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Like I said before I was not trying to start an argument. I mentioned that there were potential risks in the use of this position especially in ICP. If you don't use it, well that is up to you. I have used it in pt's with low BP due to blood loss and it has worked. I am not talking about huge leg elevation here I am only talking about 6-8 inches with pt laying flat. This job is teaches you a lot about what you learn by experience and what you learn in class and out of books. If something works for you and helps the pt then at the end of the day as long as you are not breaking any of your Base Hospitals rules then we are doing our jobs as medics. That is my opinion anyway.
 

JPINFV

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Psuedotreatments (treatments that have failed to prove effect despite clinical trials) have no place on an ambulance.


Just for kicks, another review article (not case study, not anecdotal evidence)
Use of the Trendelenburg Position as the Resuscitation Position: To T or Not to T?

American Journal of Critical Care. 2005;14: 364-368
• Conclusion The general "slant" of the available data seems to indicate that the Trendelenburg position is probably not a good position for resuscitation of patients who are hypotensive. Further clinical studies are needed to determine the optimal position for resuscitation.

So, I ask again, does anyone have any evidence, scientific evidence, that shows that Trendelenburg is useful for combating hypotension? Especially the foot lift/non-body tilt one that is used on prehospital stretchers?
 
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Arkymedic

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Psuedotreatments (treatments that have failed to prove effect despite clinical trials) have no place on an ambulance.


Just for kicks, another review article (not case study, not anecdotal evidence)
Use of the Trendelenburg Position as the Resuscitation Position: To T or Not to T?
American Journal of Critical Care. 2005;14: 364-368


So, I ask again, does anyone have any evidence, scientific evidence, that shows that Trendelenburg is useful for combating hypotension? Especially the foot lift/non-body tilt one that is used on prehospital stretchers?

What does your protocol say to do? If it says to use then its in your best interest to do so, despite your personal feeling. Your personal feeling and research does not stand up in court like a protocol book does.
 

JPINFV

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Well, to be purely technical, the only written protocol for the basic level is to achieve rapid advanced care for critical patients, including transport if paramedic ETA is longer than transport time. Crazy, I know, but that's the system. As far as paramedic protocols are concerned, trendelenburg is not addressed in either the trauma or non-traumatic shock protocols. Mind you, this is the same system that feels that a written protocol is needed for paramedics to use a pulse ox and that the paramedics are too stupid to interpret a 12-lead. So I'm sure if the medical director thought that the trendelenburg position was worthy of pursuing then it would be included.

Your also assuming that all systems require cookbook style systems. Some systems treat their protocols as guidelines, not an automatic treatment. So 'deviating' is not always a bad thing guaranteed to get a provider in trouble.

*note: All links lead to a .pdf file.
 

sabbymedic

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In Ottawa were I work we have protocals that we follow set out by a Base Hospital. We are trained to be clinitians not technitions. Can we deviate from our protocols? You better be sure that you can cover yourself before doing so because you are betting your mortgage if you do. As Paramedics we practice under a doctors lisence and I don't know too many doctors that would be willing to lose it because of Paramedics who don't know how to work in their scope of practice. Yesterday I referred to the BLS Patient care standards and those are set out in Ontario Canada by the Ministry of Health. If we do not practice within those guidelines this is where we will lose in court. As far as Trendelenburg I read some of the studies you spoke of or read some of it I did not have time to finish all and I find it very interesting. Our Base Hospital states that the use of raising the legs should be used at the Paramedics discretion but use carefully due to possible complications with SOB and ICP this I already knew and have for years. After all do we take respiratory pt's and lift their legs above the heart? No!! Why because it makes it harder to breath common sense. Same applies for persons with a head injury raise the legs increase blood flow to the head possibly causing further increase in ICP then we get into the old seizure coma death scenario. You asked if people had scientific evidence and a couple of times I mentioned that I have used the position with persons with low BP and had a successful outcome an increase in BP. Not scientific in a book but real life. I may not be a medical student or have a university degree but I am also not stupid. I have been a medic for a while now and have to rely on my training and my experience. That was the point I was trying to make. The whole scenario that was on here was fantastic that is why I replied to it because that is what I thought the point was, for people to reply to it giving their view on what they would do. So once again if I offended I am sorry.
 

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