I Hate Trendelenburg

Once again, I need to point out that I am not your boss, not your medical director, not your QA Coordinator, and not your protocol author.  But enjoy anyway.

I was working with one of my favorite partners and a student of some sort recently when we ran a patient with a low systolic blood pressure – something like 80 mmHg.  I don’t remember the patient specifically, but I think it was a GI bleed that we thought was causing hypovolemia, resulting in hypotension and tachycardia.  When I loaded the patient into the bus, I noticed that the legs were elevated in the Trendelenburg position.  I did what I always do – lower the legs so that the patient is lying flat.  We farted around for a few minutes on scene, starting IVs and such, and transport was initiated.  I noticed that the patient’s legs were up in the air again.  I put them back down.  Again.

I hate Trendelenburg.  More specifically, I hate the Trendelenburg position*.  To me, this is a sign that EMS providers simply copy the medics who taught them who copied the medics who taught them, ad infinitum back to the 60s and 70s.  This is no way to improve the provision of prehospital care.  If medicine followed that model, we would still be leeching the bad humors away.

I was taught that gravity would help pull the blood in the lower extremities superiorly, thus increasing cardiac filling, stroke volume, and cardiac output, helping to perfuse the brain.  Unfortunately, there is no proof of this.  It is close to the same logic that went into MAST pants.  Even more unfortunately (and like with MAST pants), there is some indication that the Trendelenburg position makes patients worse off.

In 2004, Johnson and Henderson published a meta-analysis that found “…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.”  In 2005, a literature review of Trendelenburg position articles stated: “The literature on the hemodynamic effects of the effectiveness of use of the Trendelenburg position in treating hypovolemic shock is small and does not reveal beneficial or sustained changes in systolic blood pressure, preload, afterload, or cardiac output.”  A 2008 Best Bets meta-analysis found adverse consequences associated with the position and does not recommend using the position.  Even friggin’ Wikipedia is not down with the Trendelenburg position!  Wikipedia!

I could keep going, and even get into the literature upon which the meta-analyses are based.  But I’m not sure most of you would read it.  If you’re interested, follow the links above and work your way through the literature on your own. 

What it comes down to is that the Trendelenburg position isn’t doing what you think it is doing.  It may cause venous pressure increases in the brain, probably interferes with immobilization, may cause nasal congestion that interferes with respiration, and can push abdominal contents against the diaphragm impeding its free movement.  In addition, there appears to be no effect on systolic blood pressure or cardiac output - so what we’re trying to accomplish is not being accomplished.  The best position for a shocky patient is probably supine, even with the head slightly elevated if the patient is more comfortable like that.  If you are a hardcore Trendelenburg proponent, it is on your shoulders to find evidence to support your position. 

Stop with the Trendelenburg position.  Spend your time doing something productive with these patients. 

*I have nothing against Friedrich Trendelenburg, the German surgeon who first described the position in 1873.  He used it to improve his view when performing abdominopelvic surgeries.  He also described the Trendelenburg gait, Trendelenburg’s sign, Trendelenburg’s test, Brodie-Trendelenburg percussion test, the Trendelenburg cannula, and Trendelenburg’s operation.  I’m always jealous of people who are badass enough to get something with their name on it and this nut throws at least seven of them.  Makes me feel like my life has been wasted.