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Listserv Discussions - archives

• Shock/Trendelenburg Position (posted October 15th, 2003)
• Ventilation Rates in TBI (posted December 12th, 2002)
• Scoop Stretchers (posted September 30th, 2002)

-------- Original Message --------
Subject: Scientific data shock position
Date: Wed, 15 Oct 2003 20:11:37 +0200
From: Florian Kuehl <Florian@tolafloka.de>
To: <phtls2maryann@telus.net>

hello,
i´ve read in the phtls 5th edition that the shock position is no longer
taught. on what scientific data did you make that decision? can you send
me any studies about that?
thanks,
florian

Thanks for your inquiry about the Trendelenberg / shock positions.

Our primary source for no longer recommending this position in PHTLS 5th edition was: Marino PL: The ICU Book, ed 2, Baltimore, 1998, WIlliams and Wilkins. See the dicussion on pages 217-218.

We are aware of no published data showing efficacy FOR the Trendelenberg position, despite the fact that this is a popular methodology.

Marino cites 4 references showing a LACK of efficacy:

-Amoroso P, et al. Posture and central venous pressure measurements in circulatory volume depletion. Lancet 1989;i;258-260.

- Weil MH, et al. Cardiac output and end tidal carbon dioxide. Crit Care Med 1985; 13:907-909.

- Stamler KD. Effect of crystalloid infusion on hematocrit in non bleeding patients. Ann Emerg Med 1989;18:747-749.

- Buchman TG, et al. Strategies for trauma resuscitation. Surg Gynecol Obst 1991; 172: 8-12.

Marino concludes, and we concur, that "this maneuver should be abandoned for the management of hypovolemia. It remains axiomatic tha tthe effective treatment for hypovolemia is volume replacement."

I hope this helps.

Jeff Salomone, MD
Associate Medical Director

------- Original Message --------
Subject: Scoop stretchers
Date: Mon, 30 Sep 2002 20:32:13 -0400
From: Jeffrey Salomone <jsalomo@emory.edu>
To: RICEA@ci.hoover.al.us
CC: atls@facs.org

Allan Rice, EMT-P, RN wrote:
I am compiling information from major trauma educational organizations
regarding the use of a "scoop"-type stretcher for spinal immobilization of
trauma patients. I am interested in determining if any recognized trauma
curriculum addresses the use of these devices, either as a recommendation
or a contraindication. I would appreciate a response detailing your
organization's position, if any, on the use of "scoop" stretchers for
patient management in these situations. Thank you in advance for your
assistance.

Your inquiry was forward to me by the ATLS office.

The Prehospital Trauma Life Support program was developed by the National Association of EMTs and is taught in cooperation with the Committee on Trauma of the American College of Surgeons.

We believe that patients with an indication for spinal immobilization should be immobilized to a rigid back board- either metal, plastic or wood. We do not believe that the scoop
stretcher is equivalent to a backboard for immobilization. If picked up from either end, it tends to bow in the middle, somewhat defeating the purpose of spinal immobilization. It is also difficult to strap a person to a scoop stretcher and obtain adequate immobilization.

We do feel that a scoop stretcher can be used as an interim device, because it is convenient to pick up a patient as an alternative to logrolling. When used in this fashion, it must be lifted form the sides (and not the ends) and only high enough for a rigid backboard to be placed underneath. The scoop streatcher is then placed on the rigid backboard and removed, leaving the patient on the backboard. It is not ideal to try to immobilize a patient on a scoop to a long backboard.

I hope this answers your question.

Jeff Salomone, MD, FACS, NREMT-P
Associate Medical Director, PHTLS

Ventilation Rates in TBI:
<snip>My question was if there is any evidence that a ventilatory rate of 10 used in the prehospital setting is enough not to get an increase in carbondioxide in the blood.<end snip>

------- Original Message --------
Subject: Ventilation Rates in TBI
Date: Mon, 09 Dec 2002 9:36AM
From: Jeffrey Salomone <jsalomo@emory.edu>

Anna:

Norm McSwain has forwarded your question regarding our recommended ventilation rates for patients with TBI.

In the prehospital setting, ventilation the patient with TBI can be very challenging. The reference for the ventilation rates are from "Guidelines for Prehospital Management of Traumatic Brain Injury", published by the Brain Trauma Foundation in New York, NY. You can access these guidelines on the internet at:

http://www.braintrauma.org/index.nsf/Pages/Guidelines-main

I think the expert panel selected a rate of 10 because they felt that the natural temptation of EMS providers was to ventilate too quickly resulting in a respiratory alkalosis that could cause cerebral vasoconstriction and further impair cerebral blood flow and aggravating the brain injury. And , as you note ventilating at a rate that is too slow with cause verebral vasodilation, possibly increasing intracranial pressure.

As we all know, blood pCO2 is related to alveolar ventilation, which is the result of both ventilation rate and tidal volume. So, while we can recommend a rate to squeeze a bag-valve-mask device, its hard to recommend how hard to squeeze it to produce a certain tidal volume.

In the hospital blood pCO2 is maintained in the desired range by using a mechanical ventilator and by monitoring blood gases. The venitlator allows one to control both the ventilation rate and the tidal volume. Few EMS services in the United States have transport ventilators. And even fewer can check blood gases in the prehospital setting.

My feeling is that in the absence of blood gases in the prehospital setting, using capnography is probably the best guide to maintaining CO2 in a desired range. If capnography isn't available, then we opted to go with the recommended ventilation rates in the prehospital guidelines published by the Brain Trauma Foundation (it is at least Class III evidence-- expert opinion of a consensus panel).

I dont know of any evidence that shows that the "average" paramedic venitlating an adult patient at this rate, will keep a patient eucapneic. Obviously, if he squeezes too little, the patient will be hypercarbic, and if he squeezes too much, the patient will be hypocapneic. So, he has to squeeze "just right."

I hope this helps as an explanation.

Jeff Salomone, MD, FACS