more BP questions

[monkeyfeet]

while i'm starting to feel pretty skookum on the actual process of taking bps, i do have some bp-related questions i was hoping some of you folks could help me out with...

if a pt has a distal iv, can you still take a bp on that arm so long as the line is closed/capped?

how about if the pt has an iv/picc in thier upper arm -- can you inflate the cuff right over it?

is it ever ok to take a bp on the same side on which a pt has had a mastectomy? (i've heard both no and yes so long as the mastectomy was more than 2 yrs ago.)

i know if a pt has hemiparesis not to take the bp on the flaccid side, but i'm curious as to why not. there's still blood flow to the limb... is there an issue c the neurological process that controls vasodilation/constriction being affected? or something?

are there any other medical conditions that would make taking bp on a particular arm ill-advised?

and finally, if neither arm is an option, how the heck to you take bp on a leg?

thanks much!

 

[MICU]

About the IV case, I'm allways taking BP from the second hand, the only one time I didnt, blood was getting to the Saline bag, not recomended at all...

The leg case, as much as I remember you take it just above the ankle, but I'm not entirely sure:wacko:

 

[Asclepius]

if a pt has a distal iv, can you still take a bp on that arm so long as the line is closed/capped?

No, just take it on the other arm. If not the arm, then the bottom half of the leg.

how about if the pt has an iv/picc in thier upper arm -- can you inflate the cuff right over it?

is it ever ok to take a bp on the same side on which a pt has had a mastectomy? (i've heard both no and yes so long as the mastectomy was more than 2 yrs ago.)

Again, there is no good reason to attempt either of these. You can seriously mess up a pt. in your attempt. Stay clear of both of these.

and finally, if neither arm is an option, how the heck to you take bp on a leg?

Place your cuff on the bottom half of the leg. Now feel for a pulse on the top of the foot. Once you find the pulse, inflate the cuff until you no longer feel it. Then bring down your pressure until you feel it again. That is your systolic by palpation.

 

[VentMedic]

Women (and becoming more common in men) who have had mastectomies should have their BP taken on the opposite or leg due to lymph node removal. In a few cases such as the Simple mastectomy where just the breast tissue is removed, the lymph nodes may not have been dissected. Unless I a totally positive about that, I use another site. Any procedure with the word radical will have lymph node involvement. Compression on the affected arm will set them up for Lymphedema. Lymphedema may become a life long battle for them

 

[VentMedic]

No BP over a PICC line.

 

[eggshen]

Also you should not take a B/P in an arm containing an active shunt, i.e. one used for dialysis. You can bugger up the shunt requiring placement of a new one. Now this is a good thread on b/p taking. ALL legitimate questions and useful answers.

Egg

 

[BossyCow]

Now this is a good thread on b/p taking. ALL legitimate questions and useful answers.

Egg

We couldn't have done it without you!

 

[eggshen]

Rhiiiight not sure how to take that one.

Egg

 

[MedikErik]

how about if the pt has an iv/picc in thier upper arm -- can you inflate the cuff right over it?

I almost had a heart attack when I read that. Most definitely do NOT do it directly over an iv/pic, and just to be on the safe side I don't do it on that limb if I don't absolutely have to.

 

[monkeyfeet]

thanks for the replies, everyone! i got a lot of inconsistent answers from ppl at work, so i'm reassured by the general sense of agreement here.

 

[Ridryder911]

Not just being able to obtain an accurate blood pressure is essential, knowing what it means and as well understanding the physiological occurrence of what is occurring is just as essential. How many actually understands the mean pressure and reports it ? [(2 x diastolic)+systolic] / 3)

Just obtaining the numbers is only one part of the equation..

 

[eggshen]

Just out of curiosity, how does the MAP affect how you run your call?

Egg

 

[Ridryder911]

Just an FYI:
Yes, we all are taught to watch our patients blood pressure, and then to take it at least every 5-10 minutes on critical patients. But very few if any pay enough attention to the mean arterial pressure (MAP)? Many see it as that tiny innocent little number that is usually placed in brackets or hiding off to one side of the monitor screen of electronic blood pressure cuffs or on the cardiac monitors.
.
So what the heck is that number? Is it important? Should I record it?
YES !

MAP is defined as the average arterial blood pressure during a single cardiac cycle. The amount of stroke volume (blood ejected from the ventricle) cardiac output (blood perfusion).

The reason that it is so important is that it reflects the hemodynamic perfusion pressure of the vital organs. In other words how much blood supply is reaching or going through your patient.

So what if we do not have a electronic B/P cuff, can we still obtain a MAP reading ? YES !

If so, how can we calculate it?
The simple way to calculate the patients MAP is to use the following formula:
MAP = [ (2 x diastolic) + systolic ] divided by 3. (i.e. 155/85 the MAP would be 108)

The reason that the diastolic value is multiplied by 2, is that the diastolic portion of the cardiac cycle is twice as long as the systolic. Or in other words, it takes twice as long for the ventricles to fill with blood as it takes for them to pump it out….. that is at a normal resting heart-rate.

In bradycardia or tachycardia conditions; in a patient this relationship between systolic and diastolic values may have some changes, and the formula may not be as always accurate, but still is an important.

One may see the use of invasive monitoring of BP (using an arterial line) in the ER and especially in ICU/CCU settings. This gives a true and only real accurate blood pressure reading (single digit). This uses a complex formula and real time value, very few understand the formula for this method.
Okay, if you want to know ...it is obtained via Fourier analysis of the arterial waveform, or as the time-weighted integral of the instantaneous pressures derived from the area under the curve of the pressure-time.
Understand it ?.. me neither....LOL okay a little bit...

Does EMT's need to watch it MAP?
Definitely. I would describe MAP as that as the RPM or oil pressure in an automobile.
A MAP of at least 40-60 is necessary to perfuse the coronary arteries, brain, and kidneys. The normal range is around 70 - 110 mmHg.

This should be taught as another vital sign for all EMT'sto monitor. It should be monitored anytime the patient has a potential problem with perfusion of their organs. For example (and there are many more):

Shock : especially pt.'s with septic shock and are on vasopressors (Levophed, Dopamine, etc).
CHI :head injured patients, and those with suspected ICP.
Cardiac patients on vasodilator med.s such as NTG, Nipride drips
Patient with a suspected dissecting abdominal aneurysm (AAA)> They need to have their BP controlled within a narrow range so as not to cause increased bleeding or tear.
In the head injured patient, the brain is at risk of ischemia injury if there is insufficient blood flow if the MAP falls below 50. On the other hand, a MAP above 160 reflects excess cerebral blood flow and may result in raised intracranial pressures (ICP).

So, one can see obtaining a blood pressure is important but just getting the numbers is not the real purpose. What those numbers reflect is the main importance. This is why, I am so picky of my blood pressure readings. It is much more than just pumping up a sphygmometer up and listening to some lubb.. dubbs... Any idiot can do that!... Being able to distinguish the true sounds, having the knowledge of what is going on inside your patient is the whole point.

How will this affect my call.. this can lead to a more accurate diagnosis as well as knowing how well my patient is being perfused .... What kills most patients is multiple end organ perfusion.. being secondary to shock, sepsis, post arrest.. what ever. Having a knowledge of thorough assessment, just by understanding the basics of numbers ... can make one understand the "big picture".

Hopefully this answered your question + some...

 

[RedZone]

while i'm starting to feel pretty skookum on the actual process of taking bps, i do have some bp-related questions i was hoping some of you folks could help me out with...

if a pt has a distal iv, can you still take a bp on that arm so long as the line is closed/capped?

how about if the pt has an iv/picc in thier upper arm -- can you inflate the cuff right over it?

is it ever ok to take a bp on the same side on which a pt has had a mastectomy? (i've heard both no and yes so long as the mastectomy was more than 2 yrs ago.)

i know if a pt has hemiparesis not to take the bp on the flaccid side, but i'm curious as to why not. there's still blood flow to the limb... is there an issue c the neurological process that controls vasodilation/constriction being affected? or something?

are there any other medical conditions that would make taking bp on a particular arm ill-advised?

and finally, if neither arm is an option, how the heck to you take bp on a leg?

thanks much!

PERIPHERAL, VENOUS IV: No problem, take it on that arm. Put the damn cuff over the line if you have to. Sure, blood's gonna back up if it's open, but just keep an eye on it in a real situation. Blood doesn't back up into the IV bag. Or, yes, you can close it (or it's a saline lock). But you technically must understand the minute risk of losing IV patentcy.

Common sense: Trauma patient gets two IV's. Probably one in each arm. Would you even think of not getting a BP? And if his BP is 70/P, a leg won't do.

PICC Line: Personally, I can't think I've ever seen one that wasn't proximal to the biceps. The catheter terminates in, or close to the thorax. What is the contraindication to taking a BP???

Dialysis access: If the WORKING dialysis access is in the arm.... that arm is off limits to anyone but a licensed dialysis tech or a nephrologist.

Hemiparesis: PREFEREBLY use the working arm. I look at this as a relative contraindication unless it would cause severe pain to the patient.

A BP is only a tourniquet for a few seconds with good technique.

 

[RedZone]

Oh yeah, the mastectomy thing:

The last ruling I got was NO BP on that side if it is a recent one. I don't know how recent that is... I don't do it at all unless it would be a matter of life or death.

Like rid said, WHY are you taking the BP??? Stable pt on a non-emergency? Well, there's plenty of signs besides BP to give you an indication of perfusion status.

Post-arrest of a bilateral mastectomy? Guess what, in that unlikely event, where's my BP cuff going?

 

[VentMedic]

Oh yeah, the mastectomy thing:

The last ruling I got was NO BP on that side if it is a recent one. I don't know how recent that is... I don't do it at all unless it would be a matter of life or death.

Lymph node removal is permanent. It doesn't matter the length of time. Any compression or trauma (including needle sticks) to that arm at any time during that person's (male or female) life will cause potential damage.

 

[Ridryder911]

Both of you brought up some very important basic points in obtaining blood pressures. What many think of is okay or the opposite of being taboo may not be the case.

Usually, one can obtain a blood pressure in the other extremity. Yes, even over burned areas.. etc. Personally, I attempt to stay away from line site areas especially PICC lines since the do usually originate in the A/C area and are pretty thin catheters. But, as Vent described.. use common sense and if need has to be; outweigh the consequences and use it.

As well many are not familiar with taking radial pressures in lieu of brachial ones. I do this often on obese patients that you cannot find a cuff large enough to circumference the upper arm. Thigh cuffs are great, just remember the accuracy may be altered or need adjusted do to the distal location (don't alter the numbers) and be sure to document location as well.

True mastectomy patients should not receive peripheral sticks, B/P, and IV since the thoracic duct is usually removed and circulation is altered. It is not okay to do this.... as I have heard many medics describe. This just shows their ignorance by proceeding.

For the A/V shunts or dialysis grafts, avoid if possible as others stated. Yes, very few times I have cannulated one for emergency procedures, but would never recommend it to ones not educated and specially trained to do so. However; you might see it performed in severe crisis situations.

I realize we in EMS usually go for the biggest and most easiest vein. If possible though, and the situation allows, attempt to initiate IV''s more distally. It is not just a "nurse" thing. The patients will appreciate the IV location, leaving other potential sites. Yes, in severe emergencies one has to do what they can.

There are so many associated things to blood pressure. The same could be stated about pulses, respiratory and yes... even temperatures. This is why they do call it vital signs for a reason.

I do not believe most EMS personal understand the need of obtaining and reporting vital signs, and a brief H & P. Yes, I will judge you upon certain things. Give me inaccurate vital signs, and poor history, assessment, one looses creditability with me from then on. Simplistic things like vital signs should be a "give me". If one has trouble obtaining, then inform me of such.. .. there maybe a reason. However; you give me a very false reading...
now, that's a different story. Honesty is a big part of being a professional as well as possibly affecting the patients treatment and outcome.

Remember, blood pressures as well are one of the last vital signs to change. Awaiting for the numbers to drop or increase will increase your patients risks. Become educated and learn other symptoms to inform you of potential problems before relying upon the decompensation of the patient.

Be safe,
R/r 911

 

[VentMedic]

There are so many things about blood pressure that still have not been discussed indepth which Rid mentioned by example in his previous posts.

Orthostatic Blood Pressure
Pulse Pressure
Pulsus Paradoxus
Bilateral Systolic Blood Pressure Significance

Getting proficient at taking BP and all other vital signs is a must.

Paying attention to the medications and how they can skew the whole picture concerning BP and HR is also important.

 

[Ridryder911]

Do you know how to stop a topic in EMT Life? Add more general education to it...

R/r 911

 

[RedZone]

Do you know how to stop a topic in EMT Life? Add more general education to it...

R/r 911

I think this topic was actually covered pretty thoroughly. The original and very specific concerns were debated, and several opinions were offerred. I'll send you a pm.