# CVAs and taking BPs



## Foxbat (Oct 7, 2009)

I recently was on an interfacility transport; the patient was a female who was having a stroke and was being transferred to a stroke center. As I started to put BP cuff on her left hand she told me I couldn't use that hand because years ago she had stroke and two aneurysms which affected that side. So we ended up using her right hand.
Medic I was working it said the pt. was right but couldn't explain me why. I tried to search for info but all I was getting are articles about connections between CVA and HTN and such, not about BP measurements.
I read that aneurysms can lead to unequal BP readings on opposite hands, but patient's aneurysms were in the past and I think they were taken care of; also, what does her past stroke have to do with it?


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## Summit (Oct 7, 2009)

Foxbat said:


> I recently was on an interfacility transport; the patient was a female who was having a stroke and was being transferred to a stroke center. As I started to put BP cuff on her left hand she told me I couldn't use that hand because years ago she had stroke and two aneurysms which affected that side. So we ended up using her right hand.
> Medic I was working it said the pt. was right but couldn't explain me why. I tried to search for info but all I was getting are articles about connections between CVA and HTN and such, not about BP measurements.
> I read that aneurysms can lead to unequal BP readings on opposite hands, but patient's aneurysms were in the past and I think they were taken care of; also, what does her past stroke have to do with it?



I would assume that if the stroke affected muscular control on that side, it might also affect involuntary control to some extent leading to a loss in vascular tone and artificially low pressures... but that would be a guess...


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## Epi-do (Oct 7, 2009)

Summit said:


> I would assume that if the stroke affected muscular control on that side, it might also affect involuntary control to some extent leading to a loss in vascular tone and artificially low pressures... but that would be a guess...




I'm with him. * ↑*


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## Foxbat (Oct 7, 2009)

That was my guess, but then I thought what are the odds of having medulla damage so localized that just some of vasomotor function would suffer.


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## twinstar_ca (Oct 7, 2009)

i had a hemmoraghic cva in 2003 and triple bypass in 2008... bp's remain the same bilaterally...


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## el Murpharino (Oct 8, 2009)

Also, don't take BP's in the arms of patients with masectomies on the affected side, or shunts in the affected arm.  

In regards to CVA's, you'll find the BP in the hemiplegic arm is less than that in the non-affected side.

http://www.anesthesia-analgesia.org/cgi/reprint/82/2/437a.pdf


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## Akulahawk (Oct 8, 2009)

While you might still have good vasomotor tone in all extremities after a CVA, if a limb is completely flaccid because of it, there's not going to be any skeletal muscle tone. That loss of support could allow the vasculature in the limb to increase their lumen size. That would result in a larger pipe to push fluid through. Same volume of fluid in a larger pipe... less pressure you're going to see. Firefighter Engineer types know this. If they need to move a lot of water at a constant rate, they can choose a larger pipe at a lower pressure or a smaller pipe at a higher pressure. 

In a person, you're going to see lower BP numbers compared to an unaffected limb... but if the person is doing OK... you'll want to watch the trend anyway.

With mastectomies, the patient usually loses lymphatic drainage... and taking a BP (or a few) can ultimately lead to edema in the arm. With dialysis shunts, you could damage the shunt if you take a BP on that side...


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## SurgeWSE (Oct 9, 2009)

The aneurysms you're thinking of which could cause differential upper extremity blood pressures is Thoracic Aortic Aneurysm or an aneurysm in other thoracic vasculature.


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## firetender (Oct 9, 2009)

Take the time (if the patient can spare it) to compare BPs L arm vs. R with every stroke patient you can. Experience will be your teacher.


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## Akulahawk (Oct 9, 2009)

SurgeWSE said:


> The aneurysms you're thinking of which could cause differential upper extremity blood pressures is Thoracic Aortic Aneurysm or an aneurysm in other thoracic vasculature.


A dissecting TAA can be of the ascending, transverse, or descending aorta. The location and direction that they can extend can cause the Right Common Carotid, Left Carotid, or Left Subclavian Artery to be tamponaded. If the right Common Carotid or the Left Subclavian Artery is tamponaded, you'll likely see a marked BP difference between the arms. With a fresh CVA, if you see that BP differential, your patient needs a surgeon...


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## Number1Monkey (Oct 27, 2009)

firetender said:


> Take the time (if the patient can spare it) to compare BPs L arm vs. R with every stroke patient you can. Experience will be your teacher.



Well put...


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## daedalus (Oct 27, 2009)

For some reason, my old co-workers think that taking a blood pressure on the side of a mastectomy is against some proverbial EMS law. I personally have never been able to find evidence of such damming proportions. It is my opinion is that while we must first do no harm, we must also first hasten to help. If you _need_ a blood pressure in a critical situation and for some reason can only take one on the side of a mastectomy due to an amputation, limited access in an accident or nursing home bed, etc, by all means do so. When you can avoid it however, you should use the other arm. For bilateral mastectomy you have no choice to suck it up and take one, unless the leg if possible (although this may be very difficult in obese patients, and patients with peripheral vascular disease)



> Treatment of breast cancer now typically involves a modified mastectomy, which removes only the sentinel lymph nodes — those closest to the cancer. Lymphedema of the arm is uncommon in women who have had this type of surgery. If swelling does occur, it's typically mild and short-term, resolving within a year after surgery. As a result, constriction of the arm is unlikely to cause swelling.
> 
> If you have only had your sentinel nodes removed, it is safe to have blood pressure readings taken — as well as blood drawn — on the side of the surgery. However, it's better to use the unaffected arm when possible


-Mayoclinic.com


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## daedalus (Oct 27, 2009)

Also OP, hypertension is a risk factor for stroke. Chronic damage to blood vessels results from chronically elevated pressures. High blood pressure is a common finding in patients with a history of stroke or who are experiencing ischemic neurological events. The stroke does not cause the HTN, rather it is a common risk factor and co-morbidity in CVA. 

Other risk factors for stroke include diabetes, atrial fibrillation, advanced age, family history, previous CVA, smoking, poor diet, hyperlipidemia, and obesity.


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