# Manual BP



## LoneStarSoldier (Jul 30, 2011)

I had several calls where I needed to get the blood pressure of a patient using the BP cuff and a stethescope. However, on the majority of my patients (90% Geriatric) I just couldn't get a good reading. I attribute this somewhat to the noisy environment in the back of a moving ambulance but mostly to the fact that I'm rusty in this skill. Are there any tips anyone could share with me as to how to make this a little simpler for me? Also, I want to learn how to do it manually and I'm sure that the more I practice with people the better at it I'll get but is using one of the automated blood pressure devices acceptable or are they less accurate? Like I said, I want to learn how to get a good BP manually but when you need the BP you need the BP ASAP and until I get better at it the automated method may be better.


----------



## Shishkabob (Jul 30, 2011)

Practice.

Heck,k do a palpated BP if you have to.


If after plenty of practice you still can't auscultate a BP... buy a better steth.


----------



## LoneStarSoldier (Jul 30, 2011)

Thanks, and what of the automated BP?


----------



## Shishkabob (Jul 30, 2011)

They have the ability to be wrong.  I won't say "less accurate" because some people just suck, but like all technology it can be wrong.  I've seen it give a bp of 120/80 on a can of soda...


Best practice is to do a manual, then use the automated cuff as a trending BP every few minutes.  Compare your manual to the first automated one, then you can know if it's in the ballpark for the subsequent ones.


----------



## Aprz (Jul 30, 2011)

Taking a manual blood pressure v. an automated one (even though a manual blood pressure is still an non invasive blood pressure (NIBP), people usually write NIBP instead of automated) have their own pros and cons. Some people may say that you should take a manual blood pressure before using a NIBP to watch for trending, or they'll take a manual blood pressure to confirm what they got by NIBP, but in my opinion, it doesn't really matter. You should consider everything. If you get something way different from manual, or something way different from NIBP, you should consider that you're doing one of them wrong, not automatically assume that the manual blood pressure is right, which seems to be what most people assume.

I assume you already know the motion to do it even though you said you'd like to learn how to do it. 

Things that help in my opinion is palpating the brachial pulse above the antecubital fossa (above the bend of the elbow), and place the diaphragm/bell of the stethoscope there.

I believe the AHA still recommends using the bell, the part people confused to be "the pedriatric side", of the stethoscope instead of the diaphragm. The bell is used for low pitch sounds like blood pressure and bowel sounds. The diaphragm is used for high pitch sounds like breath sounds.

In a moving vehicle, people have recommended putting your feet on the gurney, and don't let the patient rest their arm on the gaurd rail.

If you put the diaphragm/bell under the cuff, you might hear a lot of extraneous sounds side as the vehicle moving. It can also cause the patient unnecessary discomfort.

Also when you are listening, you could try closing your mouth. I think mycrofft mentioned that on another blood pressure post, and he was talking about how if you stick your fingers in your ears while your mouth is open, and then you closed it, you can feel it narrow. Dunno if he was just seeing if we would be dumb enough do it or not, haha! I think it makes sense. ^_^

I would link you to several other good blood pressure post, but my searching skills failed me. We had one massive one, but the problem is, trying to search "blood pressure" in EMTLife gives you just about every post, haha! We do have other good posts though so definitely search around. There was one really massive one that had a bunch of goodies in it that I think I mostly covered. One good one on how to do it, one one NIBP v. manual, and then JPINFV wrote a little thing that included about taking into consideration of what the machine says.... 

Good luck.


----------



## Aprz (Jul 31, 2011)

Oh, one more thing I can think of is with the gaurd rail part have the patient put their arm on your lap instead.


----------



## bigbaldguy (Jul 31, 2011)

Aprz said:


> I believe the AHA still recommends using the bell, the part people confused to be "the pedriatric side", of the stethoscope instead of the diaphragm. The bell is used for low pitch sounds like blood pressure and bowel sounds. The diaphragm is used for high pitch sounds like breath sounds.



Wow this is the first I've heard of this. Can't wait to try it. It never occurred to me that BP would be a low pitch sound till I read this.


----------



## Aprz (Jul 31, 2011)

Well, I found some of those pages I was talking about for you.

http://emtlife.com/showthread.php?t=22749
http://www.emtlife.com/showthread.php?t=22781

And the part that I felt that was relevant to this post is...



> *4 Phrases That Should Never Be Said on an Ambulance*
> 
> 1. Treat the patient, not the machine.  With the exception of automated blood pressure cuffs (technically auscultation is a form of NIBP), essentially all of the machines EMS uses in our assessment are to give us information that we can’t otherwise obtain. You can’t look at a patient and see if they’re mildly hypoxic. You can’t look at a patient and see if they’re hypoglycemic. You can’t look at a patient and tell if they’re having a STEMI. I think it takes great hubris to say, “My history and physical is perfectly done and 100% correct every time.” As such, diagnostic tests shouldn’t be discarded simply because they disagree with our assessment. *As one of the actual useful Ayn Rand quotes from Atlas Shrugged goes, “Contradictions do not exist. Whenever you think that you are facing a contradiction, check your premises. You will find that one of them is wrong.” We need to troubleshoot both the test itself as well as our assessment.* Did I miss something? Is there some preexisting condition that I’m missing? Am I assuming that there is only one new condition?


https://emtmedicalstudent.wordpress...es-that-should-never-be-said-on-an-ambulance/

The important part to me with the NIBP v. manual is the part I bolded (except the title). If you take a manual blood pressure and you take one by machine, and they are completely different, don't discard what the machine has to say. Maybe you're doing a manual incorrectly.  Of course, it seems like this was aimed more at things like pulse ox, EKGs, etc, but I think it still applies.


----------



## guttruck (Jul 31, 2011)

I guess this comes from working in the ER but I'm a fan of doing it manual. The only time I dont do manual BP's,Pulse,SPO2,and Resp is during an emergency. To me it seems useless to to have someone hooked up to god and everything and everytime they need to pee having to unhook them.^_^


----------



## MSDeltaFlt (Jul 31, 2011)

If you are having a difficult time hearing a manual BP in the back of a moving ambulance, remember this one option.  The ambulance can always pull over.


----------



## Sasha (Jul 31, 2011)

guttruck said:


> I guess this comes from working in the ER but I'm a fan of doing it manual. The only time I dont do manual BP's,Pulse,SPO2,and Resp is during an emergency. To me it seems useless to to have someone hooked up to god and everything and everytime they need to pee having to unhook them.^_^



How do you do a manual spO2?


----------



## LoneStarSoldier (Jul 31, 2011)

MSDeltaFlt said:


> If you are having a difficult time hearing a manual BP in the back of a moving ambulance, remember this one option.  The ambulance can always pull over.



That would be nice, but that's a no-go in my area. We don't delay transport for ANYTHING. By the time the patient is secured in the back of the ambulance and the driver is strapped in, has reported on the radio that we're en route to the receiving facility, and has recorded the times on the time sheet you should already have a BP, SPO2, Pulse, and be well into filling out your patient care form. Of course if the call isn't an emergency there can be a little deviation from this.


----------



## adamjh3 (Jul 31, 2011)

LoneStarSoldier said:


> That would be nice, but that's a no-go in my area. We don't delay transport for ANYTHING. By the time the patient is secured in the back of the ambulance and the driver is strapped in, has reported on the radio that we're en route to the receiving facility, and has recorded the times on the time sheet you should already have a BP, SPO2, Pulse, and be well into filling out your patient care form. Of course if the call isn't an emergency there can be a little deviation from this.




So... in your area, proper care is less important than getting the patient to the hospital? Why don't you just call them a taxi instead of an ambulance, then?


----------



## guttruck (Jul 31, 2011)

Sasha said:


> How do you do a manual spO2?



sry its not manual its a little digital clip I put on the end of their finger. I call it "manual" because its not all hooked up to the monitor


----------



## Sasha (Jul 31, 2011)

guttruck said:


> sry its not manual its a little digital clip I put on the end of their finger. I call it "manual" because its not all hooked up to the monitor



So by your definition a wrist cuff could be considered manual?

Sent from LuLu using Tapatalk


----------



## LoneStarSoldier (Jul 31, 2011)

adamjh3 said:


> So... in your area, proper care is less important than getting the patient to the hospital? Why don't you just call them a taxi instead of an ambulance, then?



Well that's the whole point. You're 'supposed' to be able to do everything right WITHOUT delaying anything. More than likely this is more geared towards an emergency situation where every second counts.


----------



## JPINFV (Jul 31, 2011)

LoneStarSoldier said:


> where every second counts.



In an emergency where every second counts, precision is more important than speed.


----------



## guttruck (Jul 31, 2011)

Sasha said:


> So by your definition a wrist cuff could be considered manual?
> 
> Sent from LuLu using Tapatalk



IMO no its not manual due to its digital and you slap it on and let it rip. The only reason I use the little digital SPO2 is because I have no other quick way to take SPO2. Ide rather not admit a avid drug seeker who has had 10 ER visits in the last month on the monitor.


----------



## usalsfyre (Jul 31, 2011)

guttruck said:


> IMO no its not manual due to its digital and you slap it on and let it rip. The only reason I use the little digital SPO2 is because I have no other quick way to take SPO2. Ide rather not admit a avid drug seeker who has had 10 ER visits in the last month on the monitor.



Wow...hope one of your drug seekers never presents with something that could cause them to code...


----------



## usalsfyre (Jul 31, 2011)

LoneStarSoldier said:


> Well that's the whole point. You're 'supposed' to be able to do everything right WITHOUT delaying anything. More than likely this is more geared towards an emergency situation where every second counts.



The problem with the policy is that I would wager "every second counts" in less than 0.1% of a percent of cases.


----------



## guttruck (Jul 31, 2011)

Thing is I dont do the triage due to I'm not an RN. However if they are assesed for SOB,CP,or any what is deamed emergent we hook them up. If they are just there to try and get an old script filled they see the PA and are put in what we call the "fast track" area.


----------



## usalsfyre (Jul 31, 2011)

Taking a manual B/P is a vital skill. The biggest help? A good stethoscope. I'm not sure you can beat the Maxiscope for the price. 

Two word phrase EMS needs to learn with regards to technology. "Correlate clinically". I had a patient with a automated pressure of 68/46 yesterday. I didn't go tearing off to get a manual because it fit the clinical picture. Look at the patient and the value. If they don't go together, figure out why, don't just discard the B/P. Your assumptions about the PATIENT may be wrong, which can be life threatening.


----------



## Sasha (Jul 31, 2011)

usalsfyre said:


> The problem with the policy is that I would wager "every second counts" in less than 0.1% of a percent of cases.



And in those cases an accurate set of vitals are pretty important.

Thats barring arrest, though.

Sent from LuLu using Tapatalk


----------



## usalsfyre (Jul 31, 2011)

guttruck said:


> Thing is I dont do the triage due to I'm not an RN. However if they are assesed for SOB,CP,or any what is deamed emergent we hook them up. If they are just there to try and get an old script filled they see the PA and are put in what we call the "fast track" area.



I see your point, in my area medics actually triage and get countersigned by an RN. I wouldn't be worried so much about the chest pains and SOBs those pretty well get handled well. It's the abdominal pains, back pains and psychs that get blown off and come back to bite you.


----------



## MSDeltaFlt (Jul 31, 2011)

LoneStarSoldier said:


> That would be nice, but that's a no-go in my area. We don't delay transport for ANYTHING. By the time the patient is secured in the back of the ambulance and the driver is strapped in, has reported on the radio that we're en route to the receiving facility, and has recorded the times on the time sheet you should already have a BP, SPO2, Pulse, and be well into filling out your patient care form. Of course if the call isn't an emergency there can be a little deviation from this.



Really?  Are you kidding me?  Do me a favor.  Next time you're on shift time your pulling over to a complete stop and take a manual BP then keep timing getting back up to speed.  I guarantee you it won't be nearly as long as you're afraid it might be.

Doing the right thing is what's important.  When you are balls to the wall, somebody somewhere will miss something and something important.  That's when your pts die.


----------



## guttruck (Jul 31, 2011)

usalsfyre said:


> I see your point, in my area medics actually triage and get countersigned by an RN. I wouldn't be worried so much about the chest pains and SOBs those pretty well get handled well. It's the abdominal pains, back pains and psychs that get blown off and come back to bite you.



in our are we have sitters that have to wach the psychs the whole time they are in our care. Now the Abdominal pains are required by our rules to be sceen by the MD's. Now back pains depend it just depends. I do see where you are coming from


----------



## LoneStarSoldier (Aug 1, 2011)

usalsfyre said:


> Taking a manual B/P is a vital skill. The biggest help? A good stethoscope. I'm not sure you can beat the Maxiscope for the price.



I've looked at the Maxiscopes, is there anything particularly special about them? The description says they make it easier to hear in noisy environments but have you actually used one? You're right about the price through, pretty good.


----------



## LoneStarSoldier (Aug 1, 2011)

Aprz said:


> Well, I found some of those pages I was talking about for you.
> 
> http://emtlife.com/showthread.php?t=22749
> http://www.emtlife.com/showthread.php?t=22781
> ...



Thanks for those links, they were heplful. After traversing those two lengthy threads, as well at the Stethescope mega-thread of 15 pages, I have come to the realization that opinions on stethescopes are like opinions of cars, firearms, movies, etc. (they're inconclusive). I do believe that there is a stethescope suited for every situation, but more often than that, there are more than one stethescope suited for every situation. I know what to steer clear of in terms of scopes, but the general consensus seems to be that of Littman, ADH, and a couple others. One of my partners has a Littman that I tried out and I liked the feel of it. But for right now, I'm still back to square one in terms of what scope that would be best for me.


----------



## usalsfyre (Aug 1, 2011)

LoneStarSoldier said:


> I've looked at the Maxiscopes, is there anything particularly special about them? The description says they make it easier to hear in noisy environments but have you actually used one? You're right about the price through, pretty good.


I don't know what's special about them, BUT, I can hear better with mine than any of the Littmans or ADCs I've owned.


----------



## Leafmealone (Aug 2, 2011)

One thing I have found to be invaluable for taking BP's in a moving ambulance is quite simple actually. First place the patients arm that you have the cuff on one of your legs and let it rest there. Then place your other leg on the folded legs of the gurney, this helps reduce road noise because your dispersing a lot of the bumps throughout the gurney. Also, if you have a double tubed stethoscope, try looking for a single tube one, as the two tubes can bump into each other and cause more noise than wanted.

Just something I picked up from one of our senior medics.


----------



## jjesusfreak01 (Aug 3, 2011)

Leafmealone said:


> One thing I have found to be invaluable for taking BP's in a moving ambulance is quite simple actually. First place the patients arm that you have the cuff on one of your legs and let it rest there. Then place your other leg on the folded legs of the gurney, this helps reduce road noise because your dispersing a lot of the bumps throughout the gurney. Also, if you have a double tubed stethoscope, try looking for a single tube one, as the two tubes can bump into each other and cause more noise than wanted.
> 
> Just something I picked up from one of our senior medics.


This plus palpate for a (brachial) pulse and place the head of the scope over that spot. Otherwise, that is exactly how I take BPs.


----------



## Leafmealone (Aug 3, 2011)

jjesusfreak01 said:


> This plus palpate for a (brachial) pulse and place the head of the scope over that spot. Otherwise, that is exactly how I take BPs.



Yes, forgot to mention that. Makes hearing sounds a lot easier.


----------

