# Hard time with BP in rig



## tnoye1337 (Mar 11, 2012)

Well I went on a call the other day and it was my first time teching along with the first time doing vitals without a life pack in the ambulance. I was feeling for a pulse and simple could not find it through all the bumps in the road. Along with that I couldn't get an accurate BP because I simply couldn't hear anything. The EMT that I was with said it would get better with time, but I feel like it won't.


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## Handsome Robb (Mar 11, 2012)

Take your vitals before you leave? 

Practice.

Practice.

Practice. 

Sometimes if you have too nice of a scope you hear too much background noise.

The pulse, I don't know what to tell you. Are you sure they had a radial? They'd be pretty sick if they didn't though...I've never had a problem finding a radial pulse in the ambulance, moving or not.


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## tnoye1337 (Mar 11, 2012)

Well that's why I didn't mention about vitals prior to getting into the rig. That's the easy part. Trust me the scope wasn't too nice. The other EMT on board was able to get her pulse. I guess it's something I have to work on.


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## medic308 (Mar 11, 2012)

I've had trouble getting a bp before but not a pulse. Practice is exactly what is needed.


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## tnoye1337 (Mar 11, 2012)

It could just be her age I guess. I'll make sure I practice every opportunity I get.


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## Handsome Robb (Mar 11, 2012)

tnoye1337 said:


> It could just be her age I guess. I'll make sure I practice every opportunity I get.



I doubt it unless she was morbidly obese. 

Age doesn't make a BP easier or more difficult to hear.


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## MedicBrew (Mar 11, 2012)

Try palpating the brachial pulse before you put your scope down. 

And try to not put the edge of you scope under the cuff, it may interfere with your ability to hear an accurate pressure as it will also put pressure over your pulse points.  Seen a few new folks do this recently. 

That and, Practice, practice, practice. It will come easier with time. 

You’re a professional now, bite the bullet and get you a good stethoscope. Whatever you hear best with, don’t just get the name brand everyone else has. Get one that works for you.


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## Tigger (Mar 12, 2012)

Practice is what will make this better, but you need to practice in the right environment. You will not get better at taking vitals in a moving ambulance if your practice in your living room. Be the one that takes vitals on every call. Eventually your ears will be conditioned to the sounds that they're looking for. As for pulses, try both hands and don't be afraid to firmly grasp their arms.


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## Steveb (Mar 12, 2012)

tnoye1337 said:


> Along with that I couldn't get an accurate BP because I simply couldn't hear anything.


I also can never hear anything. I recommend practice.


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## tnoye1337 (Mar 12, 2012)

NVRob said:


> I doubt it unless she was morbidly obese.
> 
> Age doesn't make a BP easier or more difficult to hear.



In that context I was talking about her pulse. Sorry if I wasn't specific.


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## MRSA (Mar 13, 2012)

It will get better! It'll take time ands practice. I remember it feeling the same way when I started but it does get better   if you can't get a radial auscultate or palpate the carotid just be gentle


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## BearChicago (Mar 16, 2012)

If the ambulance is in motion, ask your driver to let off the gas while you're getting the BP. I do this automatically if I see my partner trying to get a BP while we're moving.

If you're running without lights/siren, get one at a stoplight.

If you're running with lights/siren, you're not going to hear it. Palpate.


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## InsidiousStealth (Mar 16, 2012)

At least you have an encouraging partner...I lost a job recently because of my skills not growing to mastery within a month pretty much....dumb partner.

Anyways here's what to do. practice locating your own brachial pulse in your arm then you'll know exactly where to put the stethescope.

then what you also do is you put the stethescope UNDERNEATH the blood pressure cuff while it inflates...making it quieter and easier to hear.

Also keep your feet off the floor when you do it because the sound moving up through your legs creates extra noise.

I've acquired a few BP's on the road thanks to these measures. Sometimes its just a hard to hear though if its a hard to hear pulse area.


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## Kale (Mar 16, 2012)

Just some tips:

From the bench seat, put your feet on the bottom of the gurney, place the pt's arm on your knee, if you can try to hear a pulse prior to inflating the cuff, while you're deflating the cuff prevent the various tubes from banging together and if at any point you're unsure of whether you hear the pulse or just the ambo bouning around, just close the valve and reinflate a little bit.

And if you sincerely can't get it, palp. It's better than nothing.


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## ATrain (Mar 17, 2012)

Best is to try to isolate the extremity from the cot.  Prop their arm up on your knee, and try to get your foot as high off the floor of the truck as you can.  I go up on tiptoe on the leg that their arm is resting on.  Just keeps all the road noise from coming up through your leg and jacking with your reading.  

Also, if it's a continuing problem, maybe check out buying your own BP cuff that is just one tube with the gauge fixed on the bulb, and keep that with you whenever you're working.  I know sometimes the tubes bouncing around and rubbing against each other chand the head of the stethoscope could be a problem.

I've used ones like this before.  They're pretty nice.


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## the_negro_puppy (Mar 17, 2012)

NiBP

More accurate than auscultating in a moving vehicle.


popcorn.gif


in b4 10 pages


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## ATrain (Mar 17, 2012)

the_negro_puppy said:


> NiBP
> 
> More accurate than auscultating in a moving vehicle.
> 
> ...


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## Christopher (Mar 18, 2012)

The simple approach is to go 20mmHg higher than your initial BP from in the house (or before wheels were rolling) and listen from there down.

If that fails, go to a palp pressure and then go 20-30mmHg above that, and listen from there down.

If that fails, you at least have a by-palp pressure.

If that fails, go to pulse quality. While a positive radial pulse likely means a BP >80mmHg, it doesn't necessarily mean that; I've had septic shock patients with radials and BP's <80mmHg.

Correlate their palpable pulses with their mental status: answering questions appropriately and without hesitation? Joking with you? Those are higher level mental functions which require adequate perfusion. Their cerebral perfusion pressure is most likely greater than 70mmHg!

If their CPP is >70mmHg, this means their mean arterial pressure (MAP) is greater than 60mmHg!

If you don't have a systolic and diastolic pressure to use, think of MAP as: (CO x SVR) + CVP

CO = Cardiac Output
SVR = Systemic vascular resistance
CVP = Central venous pressure

So with radial pulses and good mentation we know that the patient is maintaining the appropriate level of Cardiac Output, Vessel Tone (SVR), and Blood return (CVP) in order to perfuse their brain!

Not being able to auscultate a blood pressure is going to happen on occasion, so give yourself credit for the appropriate level of examination. Document the secondary findings of an adequate blood pressure and you'll be fine.


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## SoCal911 (Mar 18, 2012)

I bring it up to 220ish *higher is Hx of htn or got a high reading inside* and watch the needle as you drop it down listen for the sound as the needle moves, it helps you discern from the rest of the bumps/sirens/noises. If you're desperate, you can use the bell of the scope - but the bp sounds more like a whoosh than a thump. Best advice I can give is to go buy a decent littman scope and  practice - keep the arm fully exstended and palp if you can, if you can't use your best guess - the littman scopes do a great job of picking it up even if your not right on the artery.


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## SoCal911 (Mar 18, 2012)

also, on fleshy patients you can place the cuff on the forearm and listen at the radius.


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## KyleG (Mar 18, 2012)

Couple tricks I use is one use stop lights and stop times to find a pulse and get your bearings. For the BP press hard on your scope to  clear out a lot of sounds.


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## tnoye1337 (Mar 18, 2012)

Thanks for all the tips guys and gals. I'll try them out on my next call if I ever get one -_-


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## SoCal911 (Mar 19, 2012)

Clinicals?


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## Akulahawk (Mar 19, 2012)

First off, don't stress. Getting stressed out about not hearing/feeling the appropriate stuff in the back of the ambulance won't help you. It also stresses your patient out. You look stressed, then they're going to wonder what's wrong and they'll start on ya...

The biggest thing to do is to try to isolate the patient's arm from all background noise/sources of noise. That means you pick the arm up and "float" it off the gurney. For the radial pulse, support the weight of the wrist with your thumb and 4th and 5th fingers. Your index and middle finger pads are then free to place as much or as little pressure as needed to feel even a weak/thready pulse. If I remember, I'll take a picture of me doing this with a classmate in a couple days. Sometimes it just takes a picture...

For BP, cradle their arm in yours or put your toes on gurney and get those heels off the floor. Lay the arm across your knee and palpate for the brachial pulse. Once it's located, inflate the cuff as you palpate the pulse. Once it goes away, inflate a bit more and put your steth head on that spot. Then deflate the cuff slowly while you LISTEN to the road noise. You'll start hearing the Korotkoff sounds come up out of the background noise and there's your SBP... It's all the same, just with more background noise than you're used to. 

There have been very few times that I've been unable to get a manual BP in the back of the ambulance, even when running Code 3 using the above technique.  I've had more trouble getting an autocuff to take a BP accurately than me hearing one in less time... 

This is a skill and once learned, it's a little like riding a bike - you don't forget but you can get rusty at it. I've probably done between 20k and 30k BP measurements to date...in the back of moving ambulances. After you've done a couple hundred, it's not so difficult to do. It just takes practice. You'll improve with time and practice and soon you'll wonder why that new guy is having such a hard time with getting vitals in the back of your ambulance. Really.


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## tnoye1337 (Mar 19, 2012)

SoCal911 said:


> Clinicals?



My problem isn't getting a blood pressure on solid ground. It's the fact that all of the background noise is making it very hard to hear the sounds. I wouldn't have passed my EMT skills test if I didn't know how to take a BP


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## docmoods (Mar 21, 2012)

Quickly obtain a baseline BP prior to loading your pt. then if you cant hear a manual BP while enroute try obtaining a palpated BP this also takes practice but it will give you a ball-park estimate of where the pressure is. (Palpated BP refers to feeling for a radial pulse and follow the radial pulse while utilizing your cuff, when you feel a pulse after deflating the cuff there's your systolic BP, you can not get a diastolic pressure accurately this way however).

-Moods


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## tnoye1337 (Mar 21, 2012)

docmoods said:


> Quickly obtain a baseline BP prior to loading your pt. then if you cant hear a manual BP while enroute try obtaining a palpated BP this also takes practice but it will give you a ball-park estimate of where the pressure is. (Palpated BP refers to feeling for a radial pulse and follow the radial pulse while utilizing your cuff, when you feel a pulse after deflating the cuff there's your systolic BP, you can not get a diastolic pressure accurately this way however).
> 
> -Moods



Yeah I know how to do BP by palp. They taught it to us briefly in my EMT class, but I won't be able to do that, until I can feel a damn radial pulse in the rig. Sooooo bumpyyyyy


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## Brandon O (Mar 21, 2012)

Akulahawk said:


> That means you pick the arm up and "float" it off the gurney. For the radial pulse, support the weight of the wrist with your thumb and 4th and 5th fingers. Your index and middle finger pads are then free to place as much or as little pressure as needed to feel even a weak/thready pulse. If I remember, I'll take a picture of me doing this with a classmate in a couple days. Sometimes it just takes a picture...


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## Tigger (Mar 21, 2012)

tnoye1337 said:


> Yeah I know how to do BP by palp. They taught it to us briefly in my EMT class, but I won't be able to do that, until I can feel a damn radial pulse in the rig. Sooooo bumpyyyyy



If you keep saying you're not going to find it, you're not going to. Don't make excuses, go practice. There is rarely an excuse for not being able to obtain a pulse in the truck, it is not a difficult skill if you practice.


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## ExpatMedic0 (Mar 21, 2012)

in the rig sometimes you have to get a b/p by palpation. Keep practicing feeling for radial pulses in your spare time. You might find your own little nack/ sweet spot. Its a lot easier to acquire one by palp than auscultation in a moving ambulance. Do not make a lazy habit out of doing B/P's by palp on every occasion. Sometimes palp the way to go, especially in the rig or when its very difficult to auscultate.  Also remember to get proper baseline vitals before transport.

PS: as the other guy said, make sure you buy yourself a nice stethoscope. Your own personal one, like a littmann or something.


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## Tigger (Mar 21, 2012)

I'm not trying to sound all high and mighty, but I think I've taken maybe 5 BPs by palp ever, and those were special situations like bariatrics or not being able to remove clothing during a dialysis trip. If you never have to "resort" to palp, you're ears will have a lot easier time learning to hear the right noises.


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## Akulahawk (Mar 21, 2012)

There have been times that I've had to "resort" to taking a palpated BP. Although I'm good at it, I never preferred it. Those times have always been when I can not hear the sounds because it's too loud, bumpy, or the patient's too large and a lot of sub-q fat just buries the artery. I've probably had to do it maybe on 50 patients out of probably 4-5 thousand...


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