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Why Do We Teach Leg Elevation in Shock?

Why Do We Teach Leg Elevation in Shock?

We continue to teach leg elevation as a tool to manage shock, despite hearing “leg elevation in shock is no longer recommended….no significant auto transfusion…..may compromise breathing and increase intracranial pressure.”   "It's medical folklore."  Are we wrong?  Are we stubborn old medics longing for the days of bleeding, blisters and purges? 

There are many things in medicine without science to support the practice.  Leg elevation in shock (the modified Trendelenburg position) is one.  The technique has been around forever, but no one has been able to show it treats profound shock.  At the same time no one has shown it compromises breathing or increases intracranial pressure (ICP), often cited as reasons to abandon the technique.  I suspect these would only be a problem if someone exaggerated the leg elevation or tilted the patient head down.

When we do something out of habit, or simply want something to work, there is temptation to explain when there is no explanation.  It's an especially dangerous trap for an instructor in front of a class.  The role of gravity in pulling blood from the legs to the core is the common explanation for leg elevation in shock.  It's interesting and plausible, but unproven.

When a patient is in profound shock we have very limited tools in the wilderness.  The patient needs IV fluid resuscitation, correction of the underlying problem and perhaps a surgeon.  We only offer oral fluids, maintaining temperature and leg elevation.

WMI teaches to, ideally, place the shock patient on their back with their legs elevated no more than 12 inches (30 cm); to look for and treat the underlying cause; reassure the patient; keep the patient warm; consider administering oral fluids in an extended care situation and if available, administer O2.  Leg elevation is not indicated for cardiogenic shock or possible head injury.  It may not be appropriate if there are lower extremity injuries. 

We have our eyes wide open with no illusions that leg elevation in shock is effective, but we don't see the harm in trying.  There is another simple piece to wilderness medicine we sometimes forget.  Lying on one’s back with straight legs for hours is uncomfortable.  Whether we are treating for shock or simply providing patient comfort, keep leg elevation in your toolkit.

Tod Schimelpfenig

Curriculum Director

NOLS Wilderness Medicine

April 2013

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