Podcast 1: The Myth of Pulse Palpate (Discussion)

[medicRob]

Feel free to discuss the topic of episode 1 here.

You can listen to the podcast here!

 

[Tommerag]

We actually just went over the pulse palpate in class and 1 of the questions in on our test asked "What does being able to feel a carotid pulse, but not radial mean the mmHg is atleast" or something to that effect. I can say I've never done this on a patient probably never will. As it is pointed out it is not exactly reliable. If something isn't reliable why use it?

 

[JPINFV]

If something isn't reliable why use it?

 

[Tommerag]

True, but also notice that every year that happens people are either killed and/or seriously injured. Shows how well some traditions work.

 

[medicRob]

As it is pointed out it is not exactly reliable. If something isn't reliable why use it?

Well, here is the thing. EMS doesn't exactly have the best track record for moving from practices that fall by the wayside to those which have new evidence supporting them (Just look at 15 lpm O2 for proof on that). The Deakin study was published in 2000 (strangely 3 years after the ATLS Guidelines were changed to no longer endorse pulse palpate as it had since the 1985 curriculum). As such, other professions moved away from the use of pulse palpate as well. EMS, as you just proved, is still teaching this practice. Now, there are arguments against the Deakin study, and of course no 1 study, especially not 1 evaluating only 20 patients should be relied upon in most cases to dismiss the use of a practice. However, if this is true in just 20 out of 100 patients, that means that you are in effect not getting the correct data on 20 patients.

Then again, if you are a good provider, you are NEVER going to rely on one thing alone, especially not a number. You are going to use your critical thinking skills to put several pieces of information together to come to a conclusion. Some examples include:

The patient's color, does the extremity feel cold, are Resps increased? Are they experiencing difficulty with breathing?

A medic who depends solely on 1 number for treatment is as bad as one who doesn't give a cyanotic patient oxygen because his/her SpO2 is 95%.

If you are going to use pulse palpate, at least understand that it isn't synonymous with a TRUE systolic pressure and try to assess some of the things I mention above.

 

[bigbaldguy]

Didn't they just have an article in JEMS about this. I swear I just read it somewhere.

 

[medicRob]

Didn't they just have an article in JEMS about this. I swear I just read it somewhere.

There have been a couple of posts on the topic here in the past few weeks. In fact, I thought my Podcast notes were being spyed on at one point.

 

[Aprz]

Great job with the podcast. I didn't like that it sounded like you were moving away and close up to the mic in the beginning though.

I think the only good thing about this method isn't estimating a number, but just establishing a hierarchy of pulses.

In the local EMT programs here, they teach it as radial > brachial > carotid instead of radial > femoral > carotid. I wonder if the femoral would be about the same brachial.

 

[medicRob]

Great job with the podcast. I didn't like that it sounded like you were moving away and close up to the mic in the beginning though.

I think the only good thing about this method isn't estimating a number, but just establishing a hierarchy of pulses.

In the local EMT programs here, they teach it as radial > brachial > carotid instead of radial > femoral > carotid. I wonder if the femoral would be about the same brachial.

This one was quick and dirty due to a deadline and mitigating factors. The next one will be more properly recorded as my new podcasting mic should be here by then.

 

[Combat_Medic]

Well I've looked all over. Where can I find this podcast at?

 

[Aprz]

Well I've looked all over. Where can I find this podcast at?

http://emtlife.com/podcast/?category_name=dispelling-common-ems-myths

 

[Sandog]

20 patients is a pretty small number for a study.

 

[BEorP]

A medic who depends solely on 1 number for treatment is as bad as one who doesn't give a cyanotic patient oxygen because his/her SpO2 is 95%.

In your experience, have you seen a cyanotic patient who is satting this high? Other than a problem with the SpO2 reading, what would cause this?

 

[HotelCo]

In your experience, have you seen a cyanotic patient who is satting this high? Other than a problem with the SpO2 reading, what would cause this?

Carbon monoxide poisoning.

 

[Sandog]

In your experience, have you seen a cyanotic patient who is satting this high? Other than a problem with the SpO2 reading, what would cause this?

Carbon monoxide poisoning, blood loss.

 

[Combat_Medic]

Sometimes in my line of work palpating for a pulse is the only option. Per TC3 guidelines: absent radial pulse = 500ml hextend.

 

[Aprz]

The point he's making is that this method of estimating the systolic blood pressure usually overestimates the true systolic, and that you should consider other sign and symptoms when considering treatment. The analogy to a cyanotic patient with a high SpO2 is the high SpO2 is probably overestimating as palpating the pulse site is overestimating.

By the way, cherry red skin (not cyanotic) is usually associated with carbon monoxide poisoning, and pallor is usually associated with hemorrhages.

But I just noticed... if the sample size was only 20, then this isn't consistent with the central limit theorem. ^_^ Y'know what would make this interesting is if the next couple of calls you guys get, you report back the correlation of the patient's blood pressure and their palpateable pulses (if it doesn't interfere with patiet care and you can remember it/write it down of course). It would be like our own EMTLife study!

 

[MrBrown]

20 patients is a pretty small number for a study.

That is true, Brown thinks the point is still very well taken and this should be read in context with the notion that blood pressure is a poor indicator of perfusion.

In your experience, have you seen a cyanotic patient who is satting this high? Other than a problem with the SpO2 reading, what would cause this?

Personally Brown has not but again, the generic concept it that a critically thinking person will look at the sat metre and say oh look it says 100% but this bloke is smurf blue, hmmmm?

 

[BEorP]

Carbon monoxide poisoning, blood loss.

As another poster has already mentioned, cyanosis is not typical in CO poisoning since the Hb is bound to something... it just isn't O2. My understanding is that cyanosis is caused by deoxygenated Hb so blood loss on its own would not be expected to lead to cyanosis since the Hb that is present will still be relatively saturated.

I have read that patients with anemia may not ever become cyanotic because they cannot have a high enough concentration of deoxygenated Hb in their blood to display the blue colour. The other extreme is patients with polycythemia who could have cyanosis under normal conditions since they have so much available Hb that it may not all be saturated.

I would still be quite curious to hear of any experience of patients with a reliable high SpO2 with cyanosis or suggestions of a clinical condition that would cause this. I can't seem to think of anything still.

 

[Veneficus]

True, but also notice that every year that happens people are either killed and/or seriously injured. Shows how well some traditions work.

It's people like that who will be paying my student loans back.

I cheer for the bull in any sport they partake in.