# Tips on getting a better BP reading in the back of an Ambulance



## Noel (Jan 22, 2016)

This might be a noobie question since I just started out as an EMT a couple days ago, but do you guys have any good tips or tricks on finding a PT BP while the ambulance is in motion using a BP Cuff and Stethoscope. I obviously can get one regularly if the pt is sitting in place with no further motion involved, but when the rig is moving, it gets abit hard. I just want the best and most accurate VS notes for my PT.


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## StCEMT (Jan 22, 2016)

If it is that bad/noisy and you need to have a general idea, just palp it.


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## Qulevrius (Jan 22, 2016)

Either palp it or wait til the rig stops @ a traffic light and do not let the pt's arm (the one w/ the cuff on) touch the gurney. I won't suggest watching the needle bounce because it's a losing game if you don't know what to look for/don't have baseline v/s + general impression to kick off from.


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## Ensihoitaja (Jan 22, 2016)

Palpate a brachial pulse and put your stethoscope right on top of it. Also, do what you can to isolate the patient's arm- rest it on your leg or something.


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## Chewy20 (Jan 22, 2016)

Ensihoitaja said:


> Palpate a brachial pulse and put your stethoscope right on top of it. Also, do what you can to isolate the patient's arm- rest it on your leg or something.



Brachial on an adult? Better off putting on the BP cuff, find a radial pulse, inflate cuff until you cannot feel the radial anymore. Then deflate the cuff, once you feel a pulse again, thatch your systolic. Wait until you come to a stop, or buy a better stethoscope.


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## Aprz (Jan 22, 2016)

I usually put my feet on the gurney (the left foot on the undercarriage and right foot on the back part of the gurney). I'll then rest the patient's arm extended on my leg with the palm facing up towards the ceiling of the ambulance.

I've failed to auscultate a blood pressure because the cuff wasn't tight enough around the patient's arm. Make sure the cuff fits their arm like yoga pants or whatever, lol. It's not too tight, but it is pretty much attached or form fitting.

I put the diaphragm/bell of my stethoscope where I would palpate the brachial artery. I notice that there seems to be two to three different ways people palpate the brachial artery.

I often see people palpating it near the mid shaft of the humerus like in this image. On an adult patient in a moving ambulance, I imagine that would be absurd or insane to try to palpate.

I palpate the brachial artery distal to that around the antecubital area (the bend of the arm, opposite side of the elbow) and medial (the part that is closest to the attached body when in the anatomical position / palm up). Here is an image of what I am describing (also taken from Google. The image link goes to this website).







Some images/books I've seen show it in the center of the antecubital (example is this), but I have never felt it in the center.

If you're going to palpate it, it is easiest while the arm is extended with the palm faced up.

I've always successfully palpated the brachial artery in the antecubital area and medial part of the arm. The bell or diaphragm of the stethoscope covers such a large part of that arm that any variation in where the brachial artery is easiest to palpate doesn't really matter. For this reason, I skip palpating the brachial artery and just place the bell or diaphragm at the antecubital and medial part of the arm.

Another issue I've notice people doing is tucking part of the stethoscope under blood pressure cuff. Some cuffs are even made with stethoscopes already attached doing this. Here and here is an image of what I am talking about. To me, it seems like you'll hear a lot more extraneous sounds like people talking, the ambulance vibrating, etc. when you do it this way. I avoid putting the bell or diaphragm of the stethoscope under the cuff as much as possible. The two are rarely touching. Here is an example of what it should look like to me (the image is taken from this website).






A lot of people buy fancy stethoscopes. I didn't buy my first fancy stethoscope until I started my paramedic clinicals (if I were actually a paramedic, lol). I had the hardest time getting a blood pressure with them. Turns out that some of them are so fancy that whether it is easier to hear low or high pitch sounds depends on how hard you are pressing the bell or diaphragm. On a normal cheap-o stethoscope, you'll hear low pitch sound like blood pressures, heart tones, and bowel sounds using the smaller side called the bell (it's not actually for pediatrics like most people mistakenly believe) and high pitch sounds like breath sounds using the larger side of the stethoscope called the diaphragm.






Image is taken from this website.

Anyhow, I was probably pressing pretty hard initially when trying to get a blood pressure. I'd press harder and harder trying to hear something thinking maybe I didn't have a good seal. Nope. Pressing harder was a bad idea.

In my opinion, although you should technically hear the Korotkoff sounds better using the bell of the stethoscope, which is what the AHA recommends, I don't think it really makes a difference with the cheap-o stethoscope. I usually use the diaphragm still because I don't personally hear a difference and people thought I was clueless for using the "pediatric" side. Got tired of being called out and then explaining it (if they even allowed me to explain it). I did find a significant difference with the fancy stethoscopes pressing harder. Be careful too cause some of them look like the standard bell/diaphgram, but they are actually pressure sensitive (eg Littmann Cardiology III, the one I bought).

Hope some of that helps.


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## NomadicMedic (Jan 22, 2016)

Get your feet off the floor of the ambulance. If you're sitting on the bench, put your feet on the bottom rail of the stretcher and rest the patients arm on your legs. It acts as a vibration/noise dampener.


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## Ensihoitaja (Jan 22, 2016)

Chewy20 said:


> Brachial on an adult? Better off putting on the BP cuff, find a radial pulse, inflate cuff until you cannot feel the radial anymore. Then deflate the cuff, once you feel a pulse again, thatch your systolic. Wait until you come to a stop, or buy a better stethoscope.



I do it like it shows in *Aprz*'s picture.


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## Chewy20 (Jan 22, 2016)

Ensihoitaja said:


> I do it like it shows in *Aprz*'s picture.




 Fair enough. I'll stick with thto radial!


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## Jim37F (Jan 22, 2016)

I've personally found when palpating for a pulse (radial or brachail) I get much better results using 3 or 4 fingers with the pads of my finger tips spread out over a wider area applying moderate pressure vs. Digging in with the tips in one spot....the wider area helps me feel it better vs having to hunt for it (helps both finding the pulse in the AC to properly place the steth for BP and for counting the pulse rate)


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## OCemt86 (Jul 4, 2016)

Palp or red light or remind your partner he's driving an ambulance not a medcaid sponsored NASCAR.


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## Hold My Beer (Jul 15, 2016)

Obviously experience taking blood pressures with help you when knowing what to listen for.  Some day you will be able to distinguish a korotkoff while in the middle of a rock concert.  Until that day I'll offer you some tips which helped me become the superior mediocre provider I am today.  I'll try auscultating once and if that is a no go then I'll palp it.  Now with my palpated blood pressure I have an idea of where I should be really listening (about 10mmHg higher).  When I go to listen again I will watch for the bouncing needle that usually precedes the first thump, wish, or tic.  With the palpated pressure and the bouncing needle I usually can distinguish the systolic reading.  If I still cant auscultate the BP then whatever, I at least have a palpated pressure.  Also please give the patient a few minutes between each attempt to relax their arm or you will get a skewed pressure, but I'm sure you already knew that.  Also remember that the second you become really good at taking blood pressures you will have just graduated paramedic school and BPs become the work of your EMT.


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