# Blood Pressure on the Road



## bnn987 (May 25, 2012)

Attempting to get an accurate blood pressure reading in the back of a moving ambulance isn't the easiest task. Do you guys have any tips for getting use to hearing a pressure while moving?

Normally I'll feel for the strongest point on the brachial pulse prior to pumping the cuff. I'll begin to pump the cuff while holding the radial pulse. After losing the radial pulse I'll pump it up 30 mg higher. I'll then slowly lower the pressure until I get the best reading.

Any other field tips?


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## Achilles (May 25, 2012)

bnn987 said:


> Attempting to get an accurate blood pressure reading in the back of a moving ambulance isn't the easiest task. Do you guys have any tips for getting use to hearing a pressure while moving?
> 
> Normally I'll feel for the strongest point on the brachial pulse prior to pumping the cuff. I'll begin to pump the cuff while holding the radial pulse. After losing the radial pulse I'll pump it up 30 mg higher. I'll then slowly lower the pressure until I get the best reading.
> 
> Any other field tips?


 If you have a monitor on your truck, you could use that. I'll may get crap for saying this but watch the needle bumps.


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## adamjh3 (May 25, 2012)

One tip I got off of here (mycrofft I think gave it to me): try to "isolate" yourself from the ambulance. Feet off the floor, patient's arm off the gurney, and so on


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## bnn987 (May 25, 2012)

Sorry for being redundant. I found a similar forum in March of this year. Sorry!


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## medichopeful (May 25, 2012)

Achilles said:


> If you have a monitor on your truck, you could use that. I'll may get crap for saying this but watch the needle bumps.



DON'T find a BP by this manner.  It will help give you a ballpark of around when the Phase I Korotkoff will start, but is by no means a correct way to take a BP.


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## CBentz12 (May 25, 2012)

The bouncing needle could be from muscle spasms so I wouldn't use that but I usually find my spot pump it up between 100-140 and listen for it. Then if I find a good pulse I continue on but if not I find another spot until I can find a good enough one. This has worked for me very well even on the PT who has a very faint pulse.


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## marcus2011 (May 25, 2012)

put your foot in the bottom of the stretcher and the patients arm on your leg then take the bp. If nothing take a palpation


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## TB 3541 (May 25, 2012)

adamjh3 said:


> One tip I got off of here (mycrofft I think gave it to me): try to "isolate" yourself from the ambulance. Feet off the floor, patient's arm off the gurney, and so on



This is my method of choice as well.


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## EMT John (May 25, 2012)

Lots and lots of practice. It took my a while when I first started. Now it's no problem getting a b/p rolling code 3. You'll get it eventually.


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## dawgsfan11 (May 25, 2012)

Practice, Practice, Practice


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## Tigger (May 25, 2012)

dawgsfan11 said:


> Practice, Practice, Practice



Practice does not make perfect. Only perfect practice makes perfect. 
~Vince Lombardi

Make you sure you're setting yourself up properly every time. Isolate yourself and the patient as much as you can. If the patient or someone is talking, see if you can make them shush. Personally I pump it up to 200 since many of my patients have less than well controlled hypertension. Let the air out slowly. It's better to get it on the first time and go slow than have to try multiple times. 

Eventually you'll have your ears trained to hear the sounds, and you can isolate them no matter what the environment.


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## kindofafireguy (May 25, 2012)

Invest in a good stethoscope, such as a Littman, etc. While not necessary, they are definitely much better at picking up sounds, and the earbuds do an excellent job of cancelling noise, much better than the stock ones on the truck (if your service is anything like ours).

Again, you don't have to, but I'm a fan of anything that works well and still makes my life easier.

Plus you know where the earbuds have been.


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## Ewok Jerky (May 26, 2012)

Good scope and good ears, know what you are listening to and be able to hear it.

Feet off the floor.

When all else fails palpation is perfectly acceptable. Do not use needle bounce (in a moving ambulance are you kidding me?)


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## hyperlyeman1 (May 27, 2012)

Get a good stethoscope, that will help isolate the noise, and amplify sounds to make everything louder.from the bell. It makes a huge difference.


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## Chris07 (May 28, 2012)

hyperlyeman1 said:


> Get a good stethoscope, that will help isolate the noise, and amplify sounds to make everything louder.from the bell. It makes a huge difference.


+1
The $10 cheap-o scopes that are provided by my service are horrible. They work when I forget to bring my personal scope, but my Littmann makes it waaaayy easier to hear the korotkoff sounds. $70 scope vs a $10 scope is night and day in my opinion. I'd mostly attribute it to both increased sensitivity and the excellent noise canceling ability.


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## joegrizzly (Jun 3, 2012)

Alot of great tips to go around, so I guess I'll add my two cent also. Before I even begin usually with a bloody or (insert body substance here) person I keep a disposable pillow case behind me and fold it over my knee like a napkin. Have the pt relax their arm with their elbow resiting on your knee. I then put my ears around my neck and then put the BP cuff on high over the antecubital space. Every time I palp the brach artery to find where my steth is going. (You can either just palp it and go straight into your bp or get your pulses first and then go into your BP, for me it is easier to remember the numbers that way, your preference) Get your BP and your good. If you are having a gnarly trauma or pt with low bp, I personally will attempt once or twice, then fully deflate the cuff, wait a few seconds, re inflate and close my eyes to zone out any noise I can and hopefully hear it then open to see where the number was. If all goes out the window, go for a palp.

Since we are discussing a few tips here I recently got an amazing tip from a fire Captain for getting an accurate heart rate count on a ped. Put your steth on the center of their chest. Close your eyes, zone out, and start tapping the beat of their heart with your other hand on your knee. Once you have the rhythm down, open your eyes while still tapping your knee and count your taps with the seconds on your watch, works every time. Congrats, you got a pediatric heart rate.


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## shannonlovesth (Jun 3, 2012)

Oh great thread. Righting some of these tips down to try. Thank You guys!


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## jjesusfreak01 (Jun 3, 2012)

Isolate the patient's arm from the truck by resting it on your leg, and your feet on the stretcher. Expose the patient's arm as much as possible. Palpate the patients arms for a good brachial pulse. Put the stethoscope directly over that spot. If you can, lift the arm above your leg with the same hand holding the stethoscope head and take the BP.


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## daughteroftheking (Jun 25, 2012)

I'd have to say practice...I used to have a lot of trouble taking it in the back of the truck, but it has gotten easier. A good stethoscope does wonders also  And don't be afraid to admit you can't hear it...there is no point in giving the hospital an incorrect reading...


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## xrsm002 (Jun 25, 2012)

Using the needle bounce on a Bp cuff is extremely inaccurate. I put my feet on the bottom off the stretcher, patients arms in my lap and feel for the brachial pulse, so I know where to place my stethoscope. Also if it's not a critical patient, you can wait till you are stopped at a signal light then take one. I have even been known to take a bp in the patients house.


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## Melclin (Jun 26, 2012)

xrsm002 said:


> I have even been known to take a bp in the patients house.



..you er...don't normally do this?

@OP: If you can't get a BP on the move, just have your driver pull over so you can get a proper accurate pressure.


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## xrsm002 (Jul 15, 2012)

Ok am I correct to say two different people taking a blood pressure on the same patient will get different readings? I have one preceptor my head one and his partner. The head one trust my blood pressure. His partner however takes a blood pressure 30 seconds to a minute after I take mine and gets a lower reading. That being said I had the save thing happen with another preceptor but when we got to the ER their NIBP had gotten the reading close to mine just about every time


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## xrsm002 (Jul 15, 2012)

Who would you trust. I've been an EMT for 6 years and am finishing up my medic ride outs


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## med51fl (Jul 16, 2012)

I always do one on scene (initial pt contact), one before starting transport, and one upon pulling up at the ED.  This will usually suffice for most of the "vanilla" patients I run on.  When there is a need for repeat pressures during transport, my Littman works well (as well as years of practice).  If all else fails, palp the blood pressure.


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## NYMedic828 (Jul 16, 2012)

I use the monitor onscene, enroute.

I rarely take a manual BP.

Honestly I trust the monitor over just about anyone. Just make sure conditions are right for an accurate reading. It is far more capable and sensitive than a human ear.


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## Tigger (Jul 16, 2012)

xrsm002 said:


> Using the needle bounce on a Bp cuff is extremely inaccurate. I put my feet on the bottom off the stretcher, patients arms in my lap and feel for the brachial pulse, so I know where to place my stethoscope. Also if it's not a critical patient, you can wait till you are stopped at a signal light then take one. I have even been known to take a bp in the patients house.



I should hope vitals are taken in the house. We had such an issue with crews not starting in the house/bedside that the state issued a series of directives mandating that care begin there. I have no problem with this, I was doing it already and it just makes sense given the fact that the majority of our calls are neither time sensitive nor are we working at an "unsafe scene." I'd rather figure out what's going on with my patient immediately instead of making them feel like they are being herded to the truck.


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## med51fl (Jul 16, 2012)

A BP monitor must be nice.  Only the boys on the chopper get those here.  Those of us on the streets do it manual.


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## NYMedic828 (Jul 16, 2012)

med51fl said:


> A BP monitor must be nice.  Only the boys on the chopper get those here.  Those of us on the streets do it manual.



Dont have a lifepak or equivalent device as a medic?


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## med51fl (Jul 16, 2012)

We do have LP-15, but the auto BP is optional (not standard).  We also do not use the built in SAO2 on the LP-15.  We do manual BPs, use a handheld SAO2, and use the EKG for EKGs.  I know it sounds pretty silly, but the intent is two-fold.

First, the more gadgets on a machine, the higher the chances it breaks.  The built in BP, SAO2 are nice features, but it is still fluff.

Second, by making crews take BPs it encourages more "hands on" the patients.  So many crews today put on the probes, electrodes, and monitors and don't actually put hands on the patients.


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## xrsm002 (Jul 16, 2012)

When I graduate and I work on a truck, I plan on getting a manual on scene in a quiet environment, then hook them up to the monitor so I can work on getting IV and other things (drawing up meds etc) going. Where I'm at it's pick patient up do a manual in back of truck while idling at the scene, get IV then go. I think it takes more time and it doesn't look like the crews are being very caring of their patients. At least in my eyes. I've had calls where the first or second thing out of the crews mouths is what hospital do you wanna to to.


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## WestMetroMedic (Jul 16, 2012)

med51fl said:


> We do have LP-15, but the auto BP is optional (not standard).  We also do not use the built in SAO2 on the LP-15.  We do manual BPs, use a handheld SAO2, and use the EKG for EKGs.  I know it sounds pretty silly, but the intent is two-fold.
> 
> First, the more gadgets on a machine, the higher the chances it breaks.  The built in BP, SAO2 are nice features, but it is still fluff.
> 
> Second, by making crews take BPs it encourages more "hands on" the patients.  So many crews today put on the probes, electrodes, and monitors and don't actually put hands on the patients.



The biggest problem with the handheld devices is that they don't generally give you the ability to see a waveform (pleth).  Much like capnography, the number is completely useless unless you have a good, consistent waveform.

My service also choose not to get non invasive blood pressure on our Zoll E series, and i prefer that way.  We only deal with 5 to 25 minute transport times and NIBP is really nice for IFT but in the emergent seeing, i prefer the easy way.  You also don't get in the habit of dragging in a monitor everywhere and straining your back.


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## emtva724 (Jul 16, 2012)

LOL i wouldnt trush the needle bumps man... everyone else if giving u good advice... take you feet off the floor, put the patient arm on ur leg, and concentrate on one thing... dont worry about the road, how far u gotta go until u reach the hospital, just watch that dial the needle bumps will still happen even after you stop hearing the BP...


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## Bullets (Jul 17, 2012)

Also, do not put the bell of the stethoscope under the edge of the cuff, which i see everyone do, but it is wrong and can cause bad readings


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## xrsm002 (Aug 7, 2012)

What do you all think of using electronic stethoscopes on the road.


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## Medic Tim (Aug 7, 2012)

xrsm002 said:


> What do you all think of using electronic stethoscopes on the road.



Why waste the money. With time and experience bps, lung and heart Sounds will become easier to do/ distinguish......even with a run of the mill scope.


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## JPINFV (Aug 7, 2012)

xrsm002 said:


> What do you all think of using electronic stethoscopes on the road.



I don't have a problem as long as the person using them knows how to take a manual AND can trouble shoot a bad reading. There's nothing worse than having a hypotensive patient and have everyone fixated on the automatic cuff that's just coming up as an error message.


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## xrsm002 (Aug 7, 2012)

In talking electronic stethoscopes not NIBPs. The ones that amplify the sounds


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## JPINFV (Aug 7, 2012)

xrsm002 said:


> In talking electronic stethoscopes not NIBPs. The ones that amplify the sounds





Oh, wait I see that now... hehe... opps.


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## MedicalSlick (Aug 21, 2012)

*Head for the Forearm*

Many of times I couldn't obtain a BP in a moving ambulance. There are a few techniques that I have picked up over the years that might help. 

First one, head for the forearm. By placing your BP cuff between the pt's radial pulse and elbow hinge you can obtain a very dominant palpation BP. Obviously you won't catch a diastolic reading but it's something.

Another method, if the pt can have them make a fist about 2 or 3 times. It can increase blood flow and make it easier to auscultate. Hope this helps!!

-Slick


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## msaver (Aug 21, 2012)

I realize it is very tempting to just use the monitor on your truck. However, if you do not know how the monitor takes a blood pressure I'll explain it like a paramedic explained to me the other day. The cuff inflates like any blood pressure cuff but instead of listening for sounds the cuff will detect the pulse through the brachial. The only problem with this is the fact that you are driving down a road and the cord is bouncing around so it's not accurately feeling the brachial pulse.

The reason I had asked him about this was because the pt's blood pressure was normal then 5 minutes later the diastolic had dropped by about 60 and this made me worried, but he assured me it was fine that it was just a bogus reading and that's why we always use a manual blood pressure.


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## bahnrokt (Aug 21, 2012)

xrsm002 said:


> What do you all think of using electronic stethoscopes on the road.



I tried one of the electronic stethoscopes and hated it.  It was fantastic in a house but on a moving rig it amplified background noise as much as it did the sounds you wanted to hear.  Personally I found my $90 littman to work much better for ems use.  An ER doc made a comment when I had it that they are only going to benefit cardiologists and any extra clarity is wasted in emergency medicine. 

While you can't trust the needle bumps for a bp, they give you a ball park to pay attention to.  If on your first try to heard nothing but saw bumps at about 140, then listen really close to 130-150. But as long as you are getting good on scene vitals your shouldn't need this.  

My BLS squad does not carry monitors but we have a rig mounted auto BP / spo2.  I hate it.


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