# Low blood pressure call



## MattD (Sep 6, 2014)

I transported this lady being discharged from the hospital to a nursing home.  During transport her blood pressure was routinely 75 / 46 77/ 49 etc on her forearm which was the only place I could get a B/P other than her leg.  I automatically assumed it was falty reading because all of her other vitals were normal. She was oriented x3, pulse 85, RR 20, SPO2 99 on O2, 2 second cap refill and a normal peripheal pulse. She had no pain other than her ulcer and warm and dry to the touch. After not getting a read on her leg  I readjusted to a new smaller cuff to her forearm and it read 95 / 63 which i was ok with but as we began to arrive to the nursing home her B/P dropped back to 75.  I then told my paramedic partner about the situation and he said it was probably due to her beta blockers but I dont recall her receiving any medication upon leaving. I know I should have taken a manual after we arrived but I took my partners word on it and dropped her off. She still seemed fine after moving her and when i said my goodbyes to her.  I also called about 4 and half to 5 hours later and the home said she is alert and ok. I am still worried that i made the wrong decision by leaving her and wonder if I should have taken her to the E.R. There is nothing I can do about it now and the fact that the home said she is fine gives me some relief. I am only 8 months into being an EMT and definitely learning as much as I can every shift I work I guess I am afraid of this coming back to bite me later.


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## Ewok Jerky (Sep 6, 2014)

Medical Hx?
Med list?
Admit/discharge Dx?

If she was asymptomatic then what would you expect for treatment?  What would you be treating for? Not trying to be an butt but in medicine you have to ask yourself sometimes.

Also, BBs can be a once daily med, and hypotension is a common side effect.


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## Underoath87 (Sep 6, 2014)

What were her initial vitals? (the ones your partner should have obtained immediately upon making pt contact)
With routine discharges, I always get a full set (including temp), look at the trends on the monitor, and bring it to the nurse's attention if anything stands out. 

Most times, they will agree to postpone the discharge (by putting the pt on will-call and allowing us to leave) until the issue is resolved without me having to twist their arm too much. 
If they insist that the pt is stable and can be discharged (and I feel differently), I will politely request that the pt's attending physician and SNF charge nurse verbally sign off on the discharge so that everyone is covered and on the same page.

If her bp actually dropped dangerously low during transport, I would have returned to the ER.


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## MattD (Sep 6, 2014)

She has had an MI before and does have a beta blocker on her list of daily medications. My initial was the 77 / high 40's as we were pulling onto the road. i noticed the cuff was the long one and after i readjusted and put the small adult one on the pressure jumped back up to 95 / 63 and like I stated before all her vitals were normal I kept talking to her and she had no pain.  I thought I had solved the problem but when it went down again towards the end of the run I told my partner that it dropped and he told me not the worry about it and I just took his word on it but I'm just beating myself up about it for not doing little things like taking the manual one upon arrival and just taking my partner's word on it because he is a paramedic.


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## J B (Sep 6, 2014)

I can count on 1 hand the number of times I've seen someone take a manual pressure at the bedside for a routine transport.  If you did that at my company all your partners would laugh and think you were crazy.  It's a hassle and you'll probably get tired and give up that habit quickly.  I think a more realistic goal would be to aim to always get a set of vitals using the facility's machines, and then another set with your own equipment once you're in the truck if you want.  You don't need to bring anything extra in, and it's very easy to do while talking to the pt, making sure they have all their stuff ready, etc.

Also, you're taking BPs on her forearm and her leg in the back of a moving truck... Pt is asymptomatic... Occam's razor says that the most likely scenario is that your BPs just weren't accurate.  That's probably the real reason your partner wasn't worried about it.  If she actually had a BP of 75/46... Well, that'd be a wee bit concerning.

Another thing - we don't care so much if she has pain or not.  The question you should be asking is whether she is perfusing adequately.  Is she confused/showing signs of AMS?  Calls like this get a lot more interesting with patients who are demented at baseline...

Don't beat yourself up over this.  Just always do your best, learn as much as you can from everything, and don't make the same mistake twice.  You have a lot of things that you learned from this call that will make you a better EMT going forward, and nobody got hurt.  Seems like a win to me.


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## Akulahawk (Sep 6, 2014)

MattD said:


> She has had an MI before and does have a beta blocker on her list of daily medications. My initial was the 77 / high 40's as we were pulling onto the road. i noticed the cuff was the long one and after i readjusted and put the small adult one on the pressure jumped back up to 95 / 63 and like I stated before all her vitals were normal I kept talking to her and she had no pain.  I thought I had solved the problem but when it went down again towards the end of the run I told my partner that it dropped and he told me not the worry about it and I just took his word on it but I'm just beating myself up about it for not doing little things like taking the manual one upon arrival and just taking my partner's word on it because he is a paramedic.


This is one such occasion that just highlights (as a learning moment, w/o hazard to a patient) why you should always obtain a full set of vitals while on scene, even when the call is _just_ an interfacility or d/c home. This is _also_ an instance where actually obtaining a manual BP first is an excellent idea. You want to be able to get a baseline (for yourself) set of vitals and compare that to the patient's trend, if known. 

One of the things I do (did) if my patient was on the hospital's monitor is look for the most recent set of vitals and grab another set if more than about 30 minutes old. While I'm still on scene (in the nice quiet room) is obtain my own manual BP. If I have a monitor with the NIBP function (not common back then) I would then goes on my monitor and off we go. I do this so that I know what the in-hospital trend is, how that compares to my baseline, and so now I can report that "the patient's vitals were stable and normal for her at.... and the trend continued with me during transport. My last vitals were..." 

Remember that most people "run" in the typical range that we're all familiar with. There are some people whose vital signs are significantly different from what we're used to seeing. I would expect that most folks won't bat an eye if they saw a hypertensive elderly patient but might flip out if we saw someone who would be considered hypotensive but is otherwise very asymptomatic. Sometimes it's just normal for _them _and out of the norm for us to see.


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## J B (Sep 6, 2014)

One more thing - some people will give you a hard time if you take a manual BP and come up with an odd number.  The notches on BP cuffs generally represent even numbers (110, 112, 114, 116, 118, 120), so some people would accuse you of making vitals up or being sloppy.  I think those people are stupid, but just fwiw.


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## MackTheKnife (Sep 6, 2014)

You didn't mention her size. Petite, thin, etc. Women generally have lower BP, especially older ones.


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## Underoath87 (Sep 6, 2014)

J B said:


> One more thing - some people will give you a hard time if you take a manual BP and come up with an odd number.  The notches on BP cuffs generally represent even numbers (110, 112, 114, 116, 118, 120), so some people would accuse you of making vitals up or being sloppy.  I think those people are stupid, but just fwiw.



Which is why we're taught to round up to an even number when taking a manual pressure.


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## Clare (Sep 7, 2014)

While you should *never *underestimate acute changes in vital signs you must keep them in context.  An elderly lady with a BP of 77 or 95 who has no symptoms and is known to be beta blocked is fine and there is absolutely no clinical significance of this other than it is fine.  

It doesn't matter if the person has a BP of 50 or a pulse of 20 ... if they are awake, alert and well perfused then don't worry about it.


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## joshrunkle35 (Sep 7, 2014)

If you are concerned:

1st, say something if you are concerned. Always go with your gut. If you are wrong and nothing's wrong, then you're merely wrong. If you are not wrong and something is wrong with the patient, they could crash and die. If you are worried, make a stronger case. You are a patient advocate. Think of yourself as the patient's voice.

2nd, the goal of blood pressure is to make sure that blood has enough pressure to carry oxygen throughout the body and remove co2. Specifically, enough to take oxygen to the brain. 

Remember, you can check cap refill. That checks if the extremities are being perfused. 

You can check a radial pulse. This gives a rough estimate that systolic is above 80. This also gives an idea of perfusion to the extremities.

You can check inside and around the mouth and check skin turgor (pinch) to check for dehydration. This gives you an idea about the container volume. 

Obviously, check mental status. If someone has no mental deficits, that is a good indication that their brain is receiving oxygen. On the other hand, mental deficit doesn't necessarily mean that their brain isn't getting oxygen.

Check for all types of shock. Does the patient have any other symptoms that would signal that she is in compensated or uncompensated shock?

Is hypotension normal for this patient?

What are the effects of meds she's taking, do they cause hypotension?

So, I know you got a lot of this info. Cap refill, peripheral pulse, etc. What's important here is to put all of that information together to form a complete picture of the wellness of the patient.

Then, if you still have doubts, even if you are worried you might be wrong, always say something.


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## Brandon O (Sep 7, 2014)

I second getting a set of vitals before you leave. It was always part of my routine when I was driving to find the patient, see how they're doing, and if possible throw them on a monitor to get vitals. Scribble 'em on a card for the tech while they're looking through the paperwork or getting a report. It's convenient for them, but more than anything, it lets you correlate findings with the staff who knows them while you still can.

One of the hardest parts of this job is figuring out when patients are deviating from their baseline and when their baseline is just chronically sketchy. One of the best methods is to ask folks who know. Hard to do that if you've already left.

However, I have on many occasions called back to the sending facility (on my phone) while en route to ask if something was known or normal. "Heart rate of 40? Oh yes, she's always like that." Ask for the floor and then for the nurse who was caring for them.

You can also look through the paperwork they sent for a vitals flowsheet or something similar. Or, in some cases, ask the patient.


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## MackTheKnife (Sep 7, 2014)

Clare said:


> While you should *never *underestimate acute changes in vital signs you must keep them in context.  An elderly lady with a BP of 77 or 95 who has no symptoms and is known to be beta blocked is fine and there is absolutely no clinical significance of this other than it is fine.
> 
> It doesn't matter if the person has a BP of 50 or a pulse of 20 ... if they are awake, alert and well perfused then don't worry about it.


Well said.


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## avdrummerboy (Sep 7, 2014)

"Read the patient not the monitor" whatever the monitor may be, even if it is manual. If you're getting screwy numbers but everything about the patient is fine, then in all likelihood, the patient is fine. If you're worried, speak up, the sending or receiving facility may have a reason that the pt bp is so low or at least be able to tell you that it is normal for the patient. 

Also, I don't remember exactly but doesn't bp go down just a little bit when taking off of the forearm?


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## NPO (Sep 9, 2014)

As others have stated, it was probably fine.

I make it a routine to collect vitals prior to transport, and more specifically, before the patient is on my gurney, including a look at the rhythm if available. 

I have taken a manual BP bedside twice. Both patients were transported code 3 BLS (within protocol) to an ER. Its no coincidence that I had the cuff with me on both of those transports, I had a pretty good idea I'd need it, given the facility they were coming from.


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## Carlos Danger (Sep 10, 2014)

MattD said:


> She has had an MI before and does have a beta blocker on her list of daily medications. My initial was the 77 / high 40's as we were pulling onto the road. i noticed the cuff was the long one and after i readjusted and put the small adult one on the pressure jumped back up to 95 / 63 and like I stated before all her vitals were normal I kept talking to her and she had no pain.  I thought I had solved the problem but when it went down again towards the end of the run I told my partner that it dropped and he told me not the worry about it and I just took his word on it *but I'm just beating myself up about it for not doing little things like taking the manual one upon arrival and just taking my partner's word on it because he is a paramedic*.



If I were transporting a patient and got that low of a BP, the first thing I would do is recyle the pressure. Then maybe try another site. Then look in the chart or transfer form to see what her last BP was at the sending facility. Assuming the BP's I'm getting are similar (+/- 10% or so) to what the sending had and there don't seem to be any associated changes in her clinical presentation then she's fine, even if the value is outside of normal ranges.

But if her last BP at the hospital was 128/76 and now she's 75/44 and I can't identify a good reason, then yeah, we'd be probably be calling someone.

More than anything, this highlights the importance of getting a good report. At a minimum they should be telling you (and/or giving you a transfer form with) pertinent history, reason for this admission and a quick overview of the clinical course, and describing her normal VS / mental status / general clinical condition. I believe EMTALA requires all this for transfer, as well as a set of VS within 30 minutes of discharge.

Taking the BP yourself before leaving is not a horrible idea, but as long as you can document a recent one from the facility, that'll do just fine.


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## johnrsemt (Sep 12, 2014)

If the patient is alert enough; ask them.  I have walked into the blood center to donate and was refused due to my BP being 72/30.  taken 11 times by 3 different people with 3 different cuffs.  I felt fine, not dizzy, or tired;  kind of cold.


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## ZombieEMT (Sep 19, 2014)

I never understood the mentality of always rounding a manual BP up when the number falls in between an even number. If you fall between 142 and 144, wouldn't a more accurate number be 143? Also, is the individual number completely relevant to the situation. Do you treat a patient different if the BP was 142 vs 144, or in the same case 143? No.


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## JPINFV (Sep 19, 2014)

ZombieEMT said:


> I never understood the mentality of always rounding a manual BP up when the number falls in between an even number. If you fall between 142 and 144, wouldn't a more accurate number be 143? Also, is the individual number completely relevant to the situation. Do you treat a patient different if the BP was 142 vs 144, or in the same case 143? No.


On one hand, I agree completely, on the other hand, it's simply not a battle worth having... especially once you consider that the margin of error for most cuffs are +/-3mmHg. So, in the end, you need a change of 6mmHg to actually prove a change in BP (since 120 and 126 could both be, in reality, 123).


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