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Correct pt position for vomiting pt going into shock - PUD hemorrhage

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jonorato has 2 years experience and specializes in CICU.

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Currently studying Peptic Ulcer Disease. In discussing priority interventions for a hemorrhage complication where the pt is actively vomiting large amounts of blood and starting to go into shock my prof. said to put the pt. into the trendelenburg position.

My thought was that this would not be the "best" position for the pt based on the ABC's.

Trendelenburg would be contraindicated d/t risk for aspiration. I could see doing a modified trendelenburg (elevate legs only), or side lying/recovery position. I could see putting a pt's HOB down slightly if you were to stay there with suction ready to go. My thought is the priority is to keep that airway patent!

Plus won't the physician be coming in and placing an NGT STAT? are they able to do that when the pt is in trendelenburg?

I don't know, maybe I"m over thinking this...wouldn't be the first time! ;)

Thanks for the responses in advance.

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Here.I.Stand has 16 years experience as a BSN, RN and specializes in SICU, trauma, neuro.

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I wonder if your instructor has ever tried vomiting w/ her body tilted upside down? What was her rationale for this suggestion?

You're right, pt should NOT be in trendelenburg, unless you want him to drown in his vomit. HOB should elevated at least 30 degrees to minimize aspiration risk, or else turned on their side. You can elevate their legs if you want, but if the pt is losing that much blood that they're becoming hemodynamically unstable (i.e. shock), they're probably going to order a blood transfusion.

Not sure if you're in the U.S. or not, but generally the RN inserts the NG (unless they have esophageal varices or other anatomic issue). But yes, it would be more difficult to do w/ their head/trunk upside down. If the pt is alert and following commands, we encourage them to swallow to help it down.

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jonorato has 2 years experience and specializes in CICU.

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Thank you so much for the response! My program is in the US and we learned how to place NGT our first semester...so I was also confused why she said the provider would place it. I would've thought that I, or another RN, would be placing it instead of standing around waiting for the provider to show up.

Sometimes it's hard as a nursing student when prof's say stuff and you're like, "wait, what?" Then I go home and start thinking about what they said and how it doesn't make any sense at all...but I'm a nursing student and they are a seasoned 40 yr + RN. But I'll at the very least ask her for her rationale and see where she goes with it. Maybe she just misspoke or something.

Her actual quote on the pt positioning was "reverse tendelenburg" with their "head down & feet up" which is trendelenburg. It's ok though, i knew what she meant. I can't imagine having to say the correct thing every time for 3 hrs. with all those students ready to pounce if you say the wrong thing!

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Here.I.Stand has 16 years experience as a BSN, RN and specializes in SICU, trauma, neuro.

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No problem! This is reverse trendelenburg-- 🙂 Which you could do if they're on spinal precautions or something, but otherwise I'd just elevate the HOB. True enough, she could have just misspoke.

reverse-trendelenburg_1339876119266.jpg

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Here.I.Stand has 16 years experience as a BSN, RN and specializes in SICU, trauma, neuro.

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Yikes, not sure why it came out so huge! Sorry about that!

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CT Pixie has 10 years experience as a BSN, RN.

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Wouldn't a reverse trendelenburg be head up feet down? :yes:

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jonorato has 2 years experience and specializes in CICU.

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yes, reverse trendelenburg is head up feet down.

trendelenburg (aka "shock" position) is head down feet up.

pretty sure my prof. just misspoke.

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Esme12 has 40 years experience as a ASN, BSN, RN and specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

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I am very confused....Trendelenberg (supine with the head of the bed tilted 45 degrees downward)it is not encouraged as a viable option in hypotension especially when someone is vomiting....http://www.medscape.com/viewarticle/780771_4

as far back as the 1960s, researchers found undesirable effects of the Trendelenburg position, including decreased blood pressure, engorged head and neck veins, impaired oxygenation and ventilation, increased aspiration risk, and greater risk of retinal detachment and cerebral edema. Evidence shows that while this position shifts fluid, it adversely engorges the right ventricle, causing it to become dilated, which further reduces cardiac output and blood pressure. It also impairs lung function by compromising pulmonary gas exchange. Abdominal contents shift upward, increasing pressure on and limiting movement of the diaphragm and reducing lung expansion. Lung compliance, vital capacity, and tidal volumes decrease while the work of breathing increases. The result is impaired gas exchange—hypercarbia and hypoxemia.
I have believed that the Trendelenburg position has little, if any, positive effect on cardiac output and blood pressure. It impairs pulmonary gas exchange and increases the aspiration risk.

If you are talking evidence based medicine...The evidence doesn't support its use to treat hypotension. However, evidence-based practice does support elevating the lower extremities—without using a head-down tilt position—to mobilize fluid from the lower extremities to the core during hypotensive episodes. Sometimes called a modified Trendelenburg position, this position has been found to support blood pressure without the negative consequences of the traditional Trendelenburg position

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Esme12 has 40 years experience as a ASN, BSN, RN and specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

6 Followers; 4 Articles; 20,908 Posts; 149,595 Profile Views

Thank you so much for the response! My program is in the US and we learned how to place NGT our first semester...so I was also confused why she said the provider would place it. I would've thought that I, or another RN, would be placing it instead of standing around waiting for the provider to show up.

Sometimes it's hard as a nursing student when prof's say stuff and you're like, "wait, what?" Then I go home and start thinking about what they said and how it doesn't make any sense at all...but I'm a nursing student and they are a seasoned 40 yr + RN. But I'll at the very least ask her for her rationale and see where she goes with it. Maybe she just misspoke or something.

Her actual quote on the pt positioning was "reverse tendelenburg" with their "head down & feet up" which is trendelenburg. It's ok though, i knew what she meant. I can't imagine having to say the correct thing every time for 3 hrs. with all those students ready to pounce if you say the wrong thing!

There are "NGT" that needs to be placed by the MD. The one for GI bleeds...mostly esophageal varicies bleeds...is called a Blakemore and it must be placed by the MD.

A Sengstaken–Blakemore tube is a medical device inserted through the nose or mouth and used occasionally in the management of upper gastrointestinal hemorrhage due to esophageal varices (distended and fragile veins in the esophageal wall, usually a result of cirrhosis). The use of the tube was originally described in 1950,[1] although similar approaches to bleeding varices were described by Westphal in 1930.[2] With the advent of modern endoscopic techniques which can rapidly and definitively control variceal bleeding, Sengstaken–Blakemore tubes are rarely used at present.[3]
Although I am not always a Wiki fan they have a great explanation...http://en.wikipedia.org/wiki/Sengstaken%E2%80%93Blakemore_tube..
The device consists of a flexible plastic tube containing several internal channels and two inflatable balloons. Apart from the balloons, the tube has an opening at the bottom (gastric tip) of the device. More modern models also have an opening near the upper esophagus; such devices are properly termed Minnesota tubes.[3][4] It is passed down into the oesophagus and the gastric balloon is inflated inside the stomach. A traction of 1 kg is applied to the tube so that the gastric balloon will compress on the gastroesophageal junction to reduce the blood flow to esophageal varices. If the use of traction alone cannot stop the bleeding, the esophageal balloon is also inflated to help stop the bleeding. The esophageal balloon should not remain inflated for more than six hours, to avoid necrosis. The gastric lumen is for aspirating stomach contents.

Generally it is used only in emergencies where bleeding from presumed varices is impossible to control by administration of medication. It may be difficult to position, particularly in an unwell patient, and may inadvertently be inserted in the trachea, hence endotracheal intubation before the procedure is strongly advised to secure the airway. The tube is often kept in the refrigerator in the hospital's emergency department, intensive care unit and gastroenterology ward. It is a temporary measure: ulceration and rupture of the esophagus and stomach are recognized complications.[4][5]

A related device with a larger gastric balloon capacity (about 500 ml), the Linton–Nachlas tube, is used for bleeding gastric varices. It does not have an esophageal balloon.

I would ask her to explain it one more time.

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jonorato has 2 years experience and specializes in CICU.

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Oh my gosh! I love you for posting that journal article & the added info! I saw the same thing on medscape. I'm such a hound for medscape and additional info. My clinical classmates always laugh and roll their eyes when I start talking about a "journal article I read last night" or "new evidence based practice says". It's a good thing they love the nerd in me so much!

Edited by jonorato
typo

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136 Posts; 5,099 Profile Views

comment deleted. i was wrong

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MunoRN has 10 years experience as a RN and specializes in Critical Care.

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It's a moot point since since the use trendelenburg for hypotension/shock hasn't been considered good practice for some time now, and has instead become synonymous with bad nursing myths. As Esme pointed out, there are numerous adverse effects of trendelenburg in these patients, but most importantly there are no beneficial effects to balance these risks with; when the body is experiencing hypotension/shock, it relies on this state being sensed by baroreceptors which are mainly in the upper body. Trendelenburg can potentially 'trick' this baroreceptors into thinking they don't need to tell the body to compensate for hypotension, which is last thing you want to do.

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