# amputee bp?



## KyleG (Feb 26, 2012)

If someone has no arms were do you get a BP? Ive heard leg but what part and I also heard side makes a difference.


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## Aprz (Feb 26, 2012)

Have you tried the carotid?

Jokes aside, you could do it at the leg by placing the appropriate size blood pressure cuff (usually thigh size) an inch or two above the popliteal fossa, and place the bell of the stethoscope where you palpate the popliteal pulse. I imagine you could also put the appropriate size blood pressure cuff on their ankle, and place the bell of the stethoscope where you palpate the dorsalis pedis (pedal) pulse or posterior tibial pulse; it's what they do when they find the Ankle Brachial Pressure Index (video) except with a doppler instead of a stethoscope or by palpation.


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## Anonymous (Feb 26, 2012)

Aprz said:


> Have you tried the carotid?
> 
> Jokes aside, you could do it at the leg by placing the appropriate size blood pressure cuff (usually thigh size) an inch or two above the popliteal fossa, and place the bell of the stethoscope where you palpate the popliteal pulse. I imagine you could also put the appropriate size blood pressure cuff on their ankle, and place the bell of the stethoscope where you palpate the dorsalis pedis (pedal) pulse or posterior tibial pulse; it's what they do when they find the Ankle Brachial Pressure Index (video) except with a doppler instead of a stethoscope or by palpation.



agreed, would you adjust the reading obtained on the thigh?


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## Epi-do (Feb 26, 2012)

It could be worse.  I once transported a guy that had no long bones in his arms.  Basically, his hands were attached directly to his shoulders.  The long bones in his legs were severely deformed, causing his legs to be shortened, twisted, contracted, and pretty much useless as an option for obtaining a BP.  I just ended up documenting that I was unable to obtain a BP, due to his physical condition.

Of course, that gave me even less to do on the trip from Indy to Hammond.  And he wasn't even a pleasant guy on top of it.  Yes, life dealt you a crappy hand, but I am not responsible for that.  Don't take it out on me!


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## Aprz (Feb 26, 2012)

Anonymous said:


> agreed, would you adjust the reading obtained on the thigh?


Nope. Just make sure it's the right size (use the white index and range lines marked on the sphygmomanometer) and the artery line is over the popliteal artery.


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## Oculuck (Feb 26, 2012)

Epi-do said:


> It could be worse.  I once transported a guy that had no long bones in his arms.  Basically, his hands were attached directly to his shoulders.  The long bones in his legs were severely deformed, causing his legs to be shortened, twisted, contracted, and pretty much useless as an option for obtaining a BP.  I just ended up documenting that I was unable to obtain a BP, due to his physical condition.
> 
> Of course, that gave me even less to do on the trip from Indy to Hammond.  And he wasn't even a pleasant guy on top of it.  Yes, life dealt you a crappy hand, but I am not responsible for that.  Don't take it out on me!



Life delt him two crappy hands, and two crappy feet!! Bahaha!!


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## mycrofft (Feb 26, 2012)

*Lep BP's*

http://www.medscape.com/viewarticle/471829


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## Brandon O (Feb 27, 2012)

Aprz said:


> I imagine you could also put the appropriate size blood pressure cuff on their ankle, and place the bell of the stethoscope where you palpate the dorsalis pedis (pedal) pulse or posterior tibial pulse; it's what they do when they find the Ankle Brachial Pressure Index (video) except with a doppler instead of a stethoscope or by palpation.



Goofy spots like this usually mean you're going to be palpating the result. Tough to place a scope somewhere like the medial malleolus. IIRC I've auscultated one of these maybe once, and palped a handful. Similar deal using the forearm and radial.

Automated NIBPs work better on these weird locations.

I have tried to "palpate" a pressure using the waveform of a distal pulse ox, but not with any particular success. One day.


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## johnrsemt (Feb 28, 2012)

Thanks Epi;  I had managed to block that patient out of my mind.   I was never so glad to be driving.   You were ready to shoot someone after that patient:  him, me  anyone


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## MedicBrew (Feb 28, 2012)

During my burn center rotation I saw a penile b/p cuff. I swear the nurses where lying to me but I looked it up, their real!! You need a doppler to use them, but DANG!!!


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## Tigger (Feb 28, 2012)

Brandon Oto said:


> Goofy spots like this usually mean you're going to be palpating the result. Tough to place a scope somewhere like the medial malleolus. IIRC I've auscultated one of these maybe once, and palped a handful. Similar deal using the forearm and radial.
> 
> Automated NIBPs work better on these weird locations.
> 
> I have tried to "palpate" a pressure using the waveform of a distal pulse ox, but not with any particular success. One day.



If the limb in question is the correct size for the cuff, will the result be accurate? Lately I've had issues where the large cuff is not large enough and have been using the standard size on the patient's forearm and auscultating a radial pulse...am I getting a meaningful reading with this technique?

I've used an auto NIBP cuff in an attempt to confirm, but I don't have a whole lot of faith in that particular cuff either.


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## Brandon O (Feb 28, 2012)

Should be, at least to the extent that palpated BPs are (5-20 points low usually). But I'd give it some wriggle room for sure, since other than general weirdness you'll probably have some trouble feeling/hearing those pulses. Definitely a ballpark thing unless you practice a ton.


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## Sasha (Feb 28, 2012)

Epi-do said:


> It could be worse.  I once transported a guy that had no long bones in his arms.  Basically, his hands were attached directly to his shoulders.  The long bones in his legs were severely deformed, causing his legs to be shortened, twisted, contracted, and pretty much useless as an option for obtaining a BP.  I just ended up documenting that I was unable to obtain a BP, due to his physical condition.
> 
> Of course, that gave me even less to do on the trip from Indy to Hammond.  And he wasn't even a pleasant guy on top of it.  Yes, life dealt you a crappy hand, but I am not responsible for that.  Don't take it out on me!



Life dealt him shoulder hands. 

Those patients are the ones (if its long distance) I monitor from the airway chair while reading or something.


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## Tigger (Feb 28, 2012)

Brandon Oto said:


> Should be, at least to the extent that palpated BPs are (5-20 points low usually). But I'd give it some wriggle room for sure, since other than general weirdness you'll probably have some trouble feeling/hearing those pulses. Definitely a ballpark thing unless you practice a ton.



I was actually surprised at how easy it was to hear the radial so long as the truck is not bouncing terribly. I was just hoping that this was a semi legit technique so my partners stop laughing. I'll use a child cuff on the forearm if it means not having to take the dialysis patients 9 separate layers off.


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## Brandon O (Feb 28, 2012)

Tigger said:


> I was actually surprised at how easy it was to hear the radial so long as the truck is not bouncing terribly. I was just hoping that this was a semi legit technique so my partners stop laughing. I'll use a child cuff on the forearm if it means not having to take the dialysis patients 9 separate layers off.



When I get home I'll look for some literature on different NIBP sites. Interesting question.

Just be aware that for the dialysis patients, vasculature distal to a fistula may also be affected; best to just leave that arm alone.

Also remember that auscultating the Korotkoff will only work fairly close to the cuff, where flow is turbulent; if you go too far downstream, all you can do is palpate. (Just make sure you're on the same artery!)


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## Veneficus (Feb 29, 2012)

*I was just wondering...*



Epi-do said:


> It could be worse.  I once transported a guy that had no long bones in his arms.  Basically, his hands were attached directly to his shoulders.  The long bones in his legs were severely deformed, causing his legs to be shortened, twisted, contracted, and pretty much useless as an option for obtaining a BP.  I just ended up documenting that I was unable to obtain a BP, due to his physical condition.
> 
> Of course, that gave me even less to do on the trip from Indy to Hammond.  And he wasn't even a pleasant guy on top of it.  Yes, life dealt you a crappy hand, but I am not responsible for that.  Don't take it out on me!



Sounds like a thalidomide baby.

But back to the BP question...

Rather than the technique, has anyone considered why they are taking a BP?

It seems like it would be a quantitative assessment of perfusion status?

In the absence of quantitative assessment of perfusion, perhaps documenting qualitative (physical findings) of perfusion would be appropriate?

Afterall, if the actual measurement were required for the patient condition, wouldn't there be an invasive BP device?

Solve for Y.


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## Anonymous (Feb 29, 2012)

Veneficus said:


> Sounds like a thalidomide baby.
> 
> But back to the BP question...
> 
> ...



I always understood the importance of vitals for trending purposes should they be needed at a later time, also very few present with physical signs of hypertension even at dangerous levels...


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## Veneficus (Feb 29, 2012)

Anonymous said:


> I always understood the importance of vitals for trending purposes should they be needed at a later time, also very few present with physical signs of hypertension even at dangerous levels...



Very true, but they also have limitations. (I would say "useful" rather than important though)

How often do you take a BP on 2 or more extremities?


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## Anonymous (Feb 29, 2012)

touche

useful would be a better word choice


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## beefaroni (Feb 29, 2012)

Cuff on calf/ pedal pulse.. Same as with a double mastectomy.


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## Epi-do (Feb 29, 2012)

Veneficus said:


> Sounds like a thalidomide baby.
> 
> But back to the BP question...
> 
> ...



It's really just one more piece of the puzzle that helps you form a better picture of what is going on with your patient.  Skin condition, LOC, and cap refill can also help in assessing perfusion.  I am sure there are others as well, but that is what comes to mind immediately.  I use a BP, combined with other parts of my assessment, to assist me in determining if my patient is sick, and if so, just how sick.  A single BP by itself doesn't tell me much.  If it's literally the only thing I have, it's just random numbers.

In the instance of the patient I mentioned, he was returning to a private residence after an extended hospital stay.  We were nothing more than a taxi ride.  Quite honestly, he didn't need me to do anything for him and were I not required to do an assessment by my employer, in that particular instance, I would have just kicked back and done nothing.


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## Sasha (Feb 29, 2012)

Veneficus said:


> Sounds like a thalidomide baby.
> 
> But back to the BP question...
> 
> ...



Because the billers tell me they need two sets of vitals or they can't bill.


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## adamjh3 (Feb 29, 2012)

Sasha said:


> Because the billers tell me they need two sets of vitals or they can't bill.



Glad I'm not the only one. Back when we had call bonuses, our paperwork needed - among other things - three sets of V/S, regardless of patient condition or transport time. 

The patient is going across the street to work out the rest of their psych hold? Three sets.

I can count on one hand the number of times I've assessed a BP during the six months I've had at my stand by job


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## Sasha (Feb 29, 2012)

adamjh3 said:


> Glad I'm not the only one. Back when we had call bonuses, our paperwork needed - among other things - three sets of V/S, regardless of patient condition or transport time.
> 
> The patient is going across the street to work out the rest of their psych hold? Three sets.
> 
> I can count on one hand the number of times I've assessed a BP during the six months I've had at my stand by job



Two PTAs and a fresh set


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## Steveb (Mar 11, 2012)

KyleG said:


> If someone has no arms were do you get a BP? Ive heard leg but what part and I also heard side makes a difference.


How would they call 911?


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## Sasha (Mar 11, 2012)

Steveb said:


> How would they call 911?



Voice activated phones, with their feet or asking "hey can you call the ambulance for me?"


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## Steveb (Mar 11, 2012)

Sasha said:


> Voice activated phones, with their feet or asking "hey can you call the ambulance for me?"


:rofl: Good Point


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