Does Trendelenburg belong in the EMS toolkit?

Trendelenburg is taught to all EMS students, but does it still have a place in prehospital care?

For many years, EMS relied on the Trendelenburg position  elevating the patient's feet higher than the head  was a vital treatment for shock, and would raise blood pressure, and perhaps cause blood to flow from the legs to the trunk.

German surgeon Friedrich Trendelenburg first described Trendelenburg position in 1873. He would tilt his patients at a 45-degree angle during pelvic surgeries to get a clearer view of their abdominal organs.

Trendelenburg was also used on the battlefields of World War I when wounded soldiers were tilted in hopes of increasing blood pressure and drawing blood to the heart and brain.

Trendelenburg position, once believed to reduce shock symptoms has potential contraindications in EMS.
Trendelenburg position, once believed to reduce shock symptoms has potential contraindications in EMS. (Photo/Wikipedia)

EMS providers and nurses have held Trendelenburg as the standard shock position for over 100 years, but new research shows that it has limited use and might even harm certain patients.

So EMS providers and educators must ask: Is Trendelenburg position still used? And should we still use Trendelenburg position for EMS patients?

Can Trendelenburg help patients in shock?

Despite its wide use on early 20th century battlefields, there is little evidence that the Trendelenburg position actually helps patients recover from shock.

A 2012 study published in the Journal of Clinical Anesthesia by Geerts BF, van den Bergh L, Stijnen T, et al, found that while Trendelenburg position slightly improved cardiac output, it only worked for a short period of time. Even raising the patient’s legs was more effective at countering hypovolemia, and the effect lasted slightly longer.

A 2012 study published in the American Journal of Critical Care by Margo Halm found the increase in cardiac output and blood pressure was so minimal that the position was “probably not useful in rescue efforts.”

Another group of clinicians was even more skeptical of Trendelenburg, insisting that patients should “never” be tilted to treat shock except in specific, closely-monitored situations.

Is Trendelenburg position indicated in EMS?

While Trendelenburg position does very little to lessen the effects of shock, there are many cases where tilting a patient head-down could cause harm.

EMS providers in particular must consider the risks of Trendelenburg position and how it can affect patients who have suffered head trauma or spine injuries.

Trendelenburg position contraindications

Repositioning a patient may complicate spinal injuries, which is not worth the negligible shift in blood pressure and blood volume.

Trendelenburg can also increase intracranial pressure, increase cardiac stress and reduce ventilation in vulnerable patients. Patients who have suffered rib injuries may find it more difficult to breathe while tilted head-down.

Where is Trendelenburg Position Useed?

Trendelenburg position may not be ideal for EMS, but it still has applications in hospital and surgical settings.

Almost 150 years later, surgeons still use Trendelenburg position to gain better access to a patient’s pelvis or lower abdomen. Central venous lines are easier to insert when a patient is tilted head-down, and the angle offers some relief from certain hernias and cysts.

Otherwise, Trendelenburg is minimally effective or not at all effective at increasing cardiac output, raising blood pressure and treating hypovolemia. In prehospital situations involving spinal injury, head trauma or dyspnea, the risks of Trendelenburg position outweigh its minimal benefits.

This article, originally published on Sept. 12, 2016, has been updated. 

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