# Asymptomatic hypotension?



## Mitchellmvhs (May 14, 2021)

Just started my ALS training with my new AMR ops, I’m a basic and with a medic and emt fto, I just ran this call and could use some input. One of the most intense calls I’ve run.

70 yo F who’s friend called 911 for falling out of her walker. Pretty extensive hx, chf, copd, db. We’re code 3 to call and get on scene before fire. Initially she said she felt fine and just needed help up to her walker. Lady was 280LBS, we help her sit on her walker. Fire medic and my medic convince her to let us check her out. I put her on the monitor and mind you our Large Adult BP cuff had a hard time fitting her. It didn’t get a BP, so we run it again and It’s coming back 60/20ish. We run it again and its continually not wanting to get a BP. We’re a little concerned now, so we load her up into ambulance, medic goes for IV and I try to get a manual, same issue, cuff doesn’t fit that great I can’t hear a BP, my EMT fto can’t hear it accurately. I was going to try for a Palp as wel, but I couldn’t get a radial or brachial. We decided to transport at this point Code 3. We get fluids going and medic gives epi. I try again for another manual and I still can’t hear **** (then again we were going c-3 as I try to take it) but i see the needle jumping around 100. We get the auto monitor cuff back on her and once we get to hospital it comes back around 110 systolic. We get to ER transfer care etc.

The biggest thing that confused me was SHES A/Ox4 SEEMS TOTALLY FINE but a little weak, but she’s got an extensive hx and pretty normally this way. Was her BP that low? can you really hear a manual BP that low? I’m questioning myself if I’m still **** at manual BPS. I even bought a Littman classic III to help awhile back, but still couldn’t hear ****. But at the same time our largest cuff didn’t fit that well.


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## mgr22 (May 14, 2021)

Without having been there, all I can say is I can't imagine giving epi to an A&O pt who feels fine -- especially one with her hx.


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## E tank (May 14, 2021)

EKG? Putting the cuff on the forearm and putting the index arrow thingy along the radial artery is a legit way to get a NIBP on a fat arm. Generally speaking, volume before pressor/inotrope in the setting of isolated, suspected hypotension.

SBP 110 after epi? Guess that's one way to do it....


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## Akulahawk (May 15, 2021)

I'm with E tank on this. Put the cuff on the forearm and let it run. Doing manual BPs that way can be a bit difficult but it's not impossible. Asymptomatic hypotension is certainly possible but not typically when you legitimately have an SBP of 60. If you stood the patient up and she became dizzy, that would make me worry... but otherwise, there are people that normally "live" at 90/60-ish, though none of the people I know that do are 200+ pounds...


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## medichopeful (May 15, 2021)

My money is on the BP not being accurate.  Like others have said, I would try the forearm.  I've seen an NIBP get a SBP in the 40s on a bedrail, so sometimes you have to evaluate the accuracy of them.

It's important to clinically correlate vitals and clinical presentation, and it doesn't really seem like that was done here.  I would go with a small fluid  bolus (maybe) if I was getting consistently low BPs, and I probably wouldn't go straight to epi.  If I did have to start a pressor on this patient for some really weird reason, I'd probably use levophed, not epi.

It seems like they were just treating a number in this case.  I'm not a fan of the whole "treat the patient, not the monitor" mantra because both the patient and the monitor will tell you important information, but I feel that this is one of those situations where the monitor was displaying false information.

I'm assuming "code 3" means L&S?  Curious why they did L&S on this one, any idea?


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## Comfort Care (May 15, 2021)

Accurate BPs are difficult to obtain in the obese patient. I had an obese septic,.intubated patient once, BP cuff could not get a pressure and was very labile 60s to 140s,.wtf.  How can I titrate pressors and sedation with an inaccurate pressure!?  Pain in the ***. I told MD to put in an A-line and CVC and we were solid. Love me my A-lines.


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## MackTheKnife (May 16, 2021)

Mitchellmvhs said:


> Just started my ALS training with my new AMR ops, I’m a basic and with a medic and emt fto, I just ran this call and could use some input. One of the most intense calls I’ve run.
> 
> 70 yo F who’s friend called 911 for falling out of her walker. Pretty extensive hx, chf, copd, db. We’re code 3 to call and get on scene before fire. Initially she said she felt fine and just needed help up to her walker. Lady was 280LBS, we help her sit on her walker. Fire medic and my medic convince her to let us check her out. I put her on the monitor and mind you our Large Adult BP cuff had a hard time fitting her. It didn’t get a BP, so we run it again and It’s coming back 60/20ish. We run it again and its continually not wanting to get a BP. We’re a little concerned now, so we load her up into ambulance, medic goes for IV and I try to get a manual, same issue, cuff doesn’t fit that great I can’t hear a BP, my EMT fto can’t hear it accurately. I was going to try for a Palp as wel, but I couldn’t get a radial or brachial. We decided to transport at this point Code 3. We get fluids going and medic gives epi. I try again for another manual and I still can’t hear **** (then again we were going c-3 as I try to take it) but i see the needle jumping around 100. We get the auto monitor cuff back on her and once we get to hospital it comes back around 110 systolic. We get to ER transfer care etc.
> 
> The biggest thing that confused me was SHES A/Ox4 SEEMS TOTALLY FINE but a little weak, but she’s got an extensive hx and pretty normally this way. Was her BP that low? can you really hear a manual BP that low? I’m questioning myself if I’m still **** at manual BPS. I even bought a Littman classic III to help awhile back, but still couldn’t hear ****. But at the same time our largest cuff didn’t fit that well.


Remember, treat the pt, not the numbers or machine. She was A/O X 4, and I assume she had good color, no diaphoresis? Did you try a leg BP? She didn't need fluids or epi. What was her HR by the way?


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## silver (May 16, 2021)

Just adding to what others have said with a reason why:

Some people with class II (BMI >35) and more so class III (BMI >40) have arms that are conically shaped and as a result have inaccuracies using a standard shaped rectangular BP cuff.


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## E tank (May 16, 2021)

silver said:


> Just adding to what others have said with a reason why:
> 
> Some people with class II (BMI >35) and more so class III (BMI >40) have arms that are conically shaped and as a result have inaccuracies using a standard shaped rectangular BP cuff.


"cone arm the Barbarian" we sometimes un-charitably refer to them as ..and, being rectangular, the thigh cuff (only ever have seen them used on these obese patients, never once on an actual thigh) don't help at all either.  I think probably the only way you'd get a reliable upper arm blood pressure on this kind of patient is with an antique sphygmomanometer with the 3 feet of velcro-less cloth you'd wrap around the arm a hundred times to get a snug fit. 

Lest anyone crack wise...those were long gone by the time I started....


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## DesertMedic66 (May 16, 2021)

medichopeful said:


> My money is on the BP not being accurate.  Like others have said, I would try the forearm.  I've seen an NIBP get a SBP in the 40s on a bedrail, so sometimes you have to evaluate the accuracy of them.
> 
> It's important to clinically correlate vitals and clinical presentation, and it doesn't really seem like that was done here.  I would go with a small fluid  bolus (maybe) if I was getting consistently low BPs, and I probably wouldn't go straight to epi.  If I did have to start a pressor on this patient for some really weird reason, I'd probably use levophed, not epi.
> 
> ...


I’ll answer your last question for you, the OP has a picture of Doctors ambulance for his profile picture. Doctors = Orange County in California. Orange County = Fire is in control of all aspects paramedic in the county, aside from one city. Orange County Fire is not known for being stellar in regards to medicine nor does the county as a whole.


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## MackTheKnife (May 16, 2021)

DesertMedic66 said:


> I’ll answer your last question for you, the OP has a picture of Doctors ambulance for his profile picture. Doctors = Orange County in California. Orange County = Fire is in control of all aspects paramedic in the county, aside from one city. Orange County Fire is not known for being stellar in regards to medicine nor does the county as a whole.


Curious as to what your comment means vis-a-vis the scenario?


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## DesertMedic66 (May 16, 2021)

MackTheKnife said:


> Curious as to what your comment means vis-a-vis the scenario?


The last question in the comment that I quoted is where my information is relevant. Pretty much anything and everything in LA/OC gets a code 3 transport.


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## Carlos Danger (May 16, 2021)

E tank said:


> "cone arm the Barbarian" we sometimes un-charitably refer to them as ..and, being rectangular, the thigh cuff (only ever have seen them used on these obese patients, never once on an actual thigh) don't help at all either.  I think probably the only way you'd get a reliable upper arm blood pressure on this kind of patient is with an antique sphygmomanometer with the 3 feet of velcro-less cloth you'd wrap around the arm a hundred times to get a snug fit.
> 
> *Lest anyone crack wise...those were long gone by the time I started....*


R I g h t......


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## medichopeful (May 16, 2021)

DesertMedic66 said:


> I’ll answer your last question for you, the OP has a picture of Doctors ambulance for his profile picture. Doctors = Orange County in California. Orange County = Fire is in control of all aspects paramedic in the county, aside from one city. Orange County Fire is not known for being stellar in regards to medicine nor does the county as a whole.


Ahh.  So the less time they have to spend with the patient, the happier they are.


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## DesertMedic66 (May 16, 2021)

medichopeful said:


> Ahh.  So the less time they have to spend with the patient, the happier they are.


Pretty much yeah. I’ve been on bed delay at hospitals out there multiple times and will hear a unit come in code 3, lights/sirens, to the hospital. I’ve asked the EMTs and their response is “anytime the fire medic rides in, they make us go code 3”.


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## E tank (May 17, 2021)

Carlos Danger said:


> R I g h t......


Ok...maybe not *long* gone....


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## Mitchellmvhs (May 17, 2021)

DesertMedic66 said:


> I’ll answer your last question for you, the OP has a picture of Doctors ambulance for his profile picture. Doctors = Orange County in California. Orange County = Fire is in control of all aspects paramedic in the county, aside from one city. Orange County Fire is not known for being stellar in regards to medicine nor does the county as a whole.


This was actually with AMR riverside. I just transfered out here from Doctors and going through my fto time. We Initially were code 2 to RCH but my medic wanted to upgrade. I probably didn’t grasp the whole situation entirely since it’s one of the first times I’ve been apart of such a stressful call, but it was definitely interesting and a good learning experience. The medic has also only been a medic for a little under 2 years I believe. IMO he’s a really solid medic, and pretty by the book with the calls I’ve run with him. He definitely is not lazy. I’d also like to add as a basic I’m only now starting to pick up on some of the ALS stuff since I’ve gotten to actually work a little more 1 on 1 with a medic, so my understanding of their protocols is not that great


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## Mitchellmvhs (May 17, 2021)

E tank said:


> EKG? Putting the cuff on the forearm and putting the index arrow thingy along the radial artery is a legit way to get a NIBP on a fat arm. Generally speaking, volume before pressor/inotrope in the setting of isolated, suspected hypotension.
> 
> SBP 110 after epi? Guess that's one way to do it....


12 lead was done nothing significant from my understanding, then again I’m a basic so I didn’t really look at the ekg I just put the leads on lol. We actually did try the Large cuff on her forearm, but it was the same thing, it was not giving us a BP


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## Mitchellmvhs (May 17, 2021)

MackTheKnife said:


> Remember, treat the pt, not the numbers or machine. She was A/O X 4, and I assume she had good color, no diaphoresis? Did you try a leg BP? She didn't need fluids or epi. What was her HR by the way?


I don’t remember the HR tbh but I don’t think it was anything super significant, maybe a little tachy. It was definitely a strange call for me, but this is my first time doing a lot more 911 lol I’ve learned more in 2 days I feel like than I ever did in my 10 months in Orange county


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## Mitchellmvhs (May 17, 2021)

Mitchellmvhs said:


> 12 lead was done nothing significant from my understanding, then again I’m a basic so I didn’t really look at the ekg I just put the leads on lol. We actually did try the Large cuff on her forearm, but it was the same thing, it was not giving us a BP. I also tried palping a BP with the manual. I was not able to feel any peripheral pulses. Idk if that’s bc I’m super incompetent at my job or if there really wasn’t any.


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## johnrsemt (May 18, 2021)

I weigh 275, and walk around 80/40 and I am asymptomatic, usually.  Except I am usually cold.
I have been as low as 62/24, when I walked in to donate blood (for some reason they wouldn't let me donate), but again no symptoms.
But I am weird


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## BobBarker (May 21, 2021)

As many have said, definitely questioning a code 3 response. Practically everything in LA here is code 3 transport. We held the wall the other day and LAFD comes blaring in the ER bay at 2AM with a homeless man C/C can't poop, nothing else acutely wrong, no treatments given. My buddy who works on a private ambulance with LA County Fire says anytime a medic jumps in it's automatically code 3, which completely goes against regulations but oh well.


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## E tank (May 21, 2021)

johnrsemt said:


> I weigh 275, and walk around 80/40 and I am asymptomatic, usually.  Except I am usually cold.
> I have been as low as 62/24, when I walked in to donate blood (for some reason they wouldn't let me donate), but again no symptoms.
> But I am weird.


Very broadly speaking, odd numbers like that, if accurate, merit further investigation. Doing stuff like checking both arms (subclavian artery stenosis will give erroneously low numbers) is a way to verify what you're seeing. Short that anything from endocrine to heart valve dz can be in play. Stuff like this may be tolerable the the 20-30 age range, but not in the 50-60's.


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## E tank (May 21, 2021)

BobBarker said:


> As many have said, definitely questioning a code 3 response. Practically everything in LA here is code 3 transport. We held the wall the other day and LAFD comes blaring in the ER bay at 2AM with a homeless man C/C can't poop, nothing else acutely wrong, no treatments given. My buddy who works on a private ambulance with LA County Fire says anytime a medic jumps in it's automatically code 3, which completely goes against regulations but oh well.


Sounds like the situation in Rhode Island...fire is in charge and and the EMS directors are eunuchs.


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## EpiEMS (May 21, 2021)

DesertMedic66 said:


> The last question in the comment that I quoted is where my information is relevant. Pretty much anything and everything in LA/OC gets a code 3 transport.



Wouldn’t that get flagged by QA? Seems dangerous without clinical benefit — assuming calls are verbally not beyond the scope of the provider on board to manage.


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## DesertMedic66 (May 21, 2021)

EpiEMS said:


> Wouldn’t that get flagged by QA? Seems dangerous without clinical benefit — assuming calls are verbally not beyond the scope of the provider on board to manage.


In a well established system yes it would. Let’s just say there are several systems in CA that are below standards.

For instance on my ground ambulance job, I can run lights and sirens all day long for every transport and nothing would ever be said as lights and siren transports aren’t a main thing that is tracked.


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## E tank (May 21, 2021)

DesertMedic66 said:


> In a well established system yes it would. Let’s just say there are several systems in CA that are below standards.
> 
> For instance on my ground ambulance job, I can run lights and sirens all day long for every transport and nothing would ever be said as lights and siren transports aren’t a main thing that is tracked.


No county policy? If you were to t-bone someone or take out a pedestrian in the course of a routine BLS transfer, what would the lawyer/liability fallout be? Seems the first thing an injury lawyer would do is subpoena the DR and ambulance records.


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## DesertMedic66 (May 21, 2021)

E tank said:


> No county policy? If you were to t-bone someone or take out a pedestrian in the course of a routine BLS transfer, what would the lawyer/liability fallout be? Seems the first thing an injury lawyer would do is subpoena the DR and ambulance records.


County policy only dictates what hospital we transport to. It doesn’t specify transport type or transport mode.


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## E tank (May 21, 2021)

DesertMedic66 said:


> County policy only dictates what hospital we transport to. It doesn’t specify transport type or transport mode.


That would make sense, as the county would not be wanting to dictate discretionary medical decisions but then there is the liability of the service itself which could be substantial, I'd think.


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## EpiEMS (May 22, 2021)

DesertMedic66 said:


> For instance on my ground ambulance job, I can run lights and sirens all day long for every transport and nothing would ever be said as lights and siren transports aren’t a main thing that is tracked.


Interesting -- and of course, if you don't chart it, harder to prove that you were running hot, I suppose.


E tank said:


> That would make sense, as the county would not be wanting to dictate discretionary medical decisions but then there is the liability of the service itself which could be substantial, I'd think.


Agreed from a liability perspective, would think that since consensus is that running hot, particularly from calls that can be managed well by EMS personnel, diverges from standard of care.


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## DesertMedic66 (May 22, 2021)

EpiEMS said:


> Interesting -- and of course, if you don't chart it, harder to prove that you were running hot, I suppose.
> 
> Agreed from a liability perspective, would think that since consensus is that running hot, particularly from calls that can be managed well by EMS personnel, diverges from standard of care.


It’s one of the mandatory things we have to chart, there is a button selection for it and the chart won’t lock if that is blank. So technically it is something that can easily be checked by QA/QI with a couple of mouse clicks however the QA/QI process we have for my ground agency is not the strongest and really only focuses on things paramedics have done that will kill patients.


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## RedBlanketRunner (May 25, 2021)

The OP would make an excellent training scenario. Thinking on your feet, coping when nothing is quite right. Very nice to hear the pros chime in here with their alternative dx methods.


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## johnrsemt (May 28, 2021)

E-Tank,  Back when I worked in a small Hospital ED, we where talking one night when it was relatively slow about 'freaky' patients that are normally hypotensive, and I mentioned that my BP is normally low.  The doctor on didn't believe, so we all (doctor, 2 nurses, and 2nd medic {left 1 nurse at nurses station) wandered into trauma room).
I was dressed as normal:  tech pants, and long sleeve shirt under scrub top, because I was cold in the AC.  Numbers may be off but I was basically 84/48 upper extremities:  upper and lower arms, automatic and manual cuffs.  I think I was 86/50 on the legs: thighs and calf's.  ED doc who was 29, and worked out every day was on HTN meds because of his BP.  

My BP 5 minutes ago was 82/50 left arm,  84/48 right arm automatic cuff, so normal.  At my annual physical in January it was approx the same which freaked out the Patient Care Tech.  My family doctor offers every year to put me on medication to increase my BP, but he just says that because he is Hypertensive.
Your comment about "Stuff like this may be tolerable in the 20-30 age range, but not in the 50-60's"?    I have been this way my entire life and oh yea  I am now 56:  so maybe some people can handle it their entire life (although I would give up another 20 points of BP to be warmer normally.  It is 72 degrees in the building at work and 80 deg out side and I am in a hoodie and freezing.


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## E tank (May 28, 2021)

johnrsemt said:


> E-Tank,  Back when I worked in a small Hospital ED, we where talking one night when it was relatively slow about 'freaky' patients that are normally hypotensive, and I mentioned that my BP is normally low.  The doctor on didn't believe, so we all (doctor, 2 nurses, and 2nd medic {left 1 nurse at nurses station) wandered into trauma room).
> I was dressed as normal:  tech pants, and long sleeve shirt under scrub top, because I was cold in the AC.  Numbers may be off but I was basically 84/48 upper extremities:  upper and lower arms, automatic and manual cuffs.  I think I was 86/50 on the legs: thighs and calf's.  ED doc who was 29, and worked out every day was on HTN meds because of his BP.
> 
> My BP 5 minutes ago was 82/50 left arm,  84/48 right arm automatic cuff, so normal.  At my annual physical in January it was approx the same which freaked out the Patient Care Tech.  My family doctor offers every year to put me on medication to increase my BP, but he just says that because he is Hypertensive.
> Your comment about "Stuff like this may be tolerable in the 20-30 age range, but not in the 50-60's"?    I have been this way my entire life and oh yea  I am now 56:  so maybe some people can handle it their entire life (although I would give up another 20 points of BP to be warmer normally.  It is 72 degrees in the building at work and 80 deg out side and I am in a hoodie and freezing.


So a MAP of about 60 mm Hg....that by strict definition is not hypotensive for a healthy individual. Hypotension is relative too. It just means organs are not being perfused. 130/80 could be hypotensive to someone.


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## mrhunt (Jun 7, 2021)

1: Epi was WAAY too agressive a treatment Imho.
2: She stood up and Remained asymptomatic which just screams inaccurate BP.  Likely would have DFO'd from + orthostatics or something.
3: Sure, I'd start a line and give a 250 bolus to be on the safe side, but def not lights and sirens. ESPECIALLY considering the pt literally has no complaints and Is presenting fine.


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