100 point drop in systolic pressure?

[MarineMedic_834]

So, I'm new to this site and the reason for this scenario/post is because I am quite perplexed with a call that I went on today. First of all, this was a late call-20 minutes before shift change and our relief had yet to show up, and we had just ran a major trauma call a couple hours earlier. Dispatched to an assisted living center for a report of chest pain. On arrival, an elderly female patient was found sitting up in a chair, conscious, alert and oriented x 4, GCS 15. Chief complaint of sharp, intermittent chest pain to the left chest wall near the mid-axillary line. Patient denies SOB, nausea or vomiting or any cardiac history for that matter. Primary medical history of hypertension, cerebral palsy, hypothyroidism. Patient was moved to unit and vitals were obtained. I am absolutely sure that the pressure I got was 218/78-no question in my mind. Patient denying headache or spots in vision. Normal sinus on the monitor. This was my partners call, I established an IV and got us enroute to the hospital. 10 minute transport time, one SL nitro 0.4mg given enroute. On arrival, NIBP of 108/62. I obtained a manual pressure about 15 minutes after my first (218/78) and got 110/66. My partner seemed pissed and the nurses at the facility all looked at us with that "bull:censored::censored::censored::censored:" look. No one seemed to believe that this patient had a 100 point drop in systolic pressure over 15 minutes. However, I know what I heard. Now, I feel like my partner will second guess my vitals and I will be talked about as "one of those" medics. Has anyone had a similar experience?

 

[MrBrown]

SL GTN is prone to inducing very large falls in blood pressure.

A blood pressure THAT high with a pulse pressure THAT wide just aint right.

I am suspicious on this one, esp if it was a NIBP

 

[usafmedic45]

My guess is a false reading. It's going to be very unusual for someone with a 200+ mm Hg systolic reading to not have at least some neurologic symptoms. Also, as Brown said, that wide of a pulse pressure is not normal. Also normally you're going to see the diastolic drop dramatically when you give nitro and see a major drop in the systolic. Actually, at least in my experience, it's more common to see a bigger change in the diastolic than in the systolic post NTG.

 

[LondonMedic]

It's going to be very unusual for someone with a 200+ mm Hg systolic reading to not have at least some neurologic symptoms.

Are you sure about that? :unsure:

I see quite a lot of patients with BPs around 200, while they're often not well, only one has had specific neurological sx.

As far as the topic goes, I'd have that "bull:censored::censored::censored::censored:" look, almost certainly a false reading.

 

[MrBrown]

We had a guy one day with a BP of like 190/70 and he had no neurological symptoms eg headache, visual spots, wonky feeling

 

[usafmedic45]

I see quite a lot of patients with BPs around 200, while they're often not well, only one has had specific neurological sx.

I was talking about people who are not chronically hypertensive. I know a lot of people who walk around just fine in the 170s, 180s and a few with 190 systolic readings but the ones who seem to have symptoms are the ones who are normally 130 or 140 and abruptly spike their pressure for some reason. One of the hypotheses I kick around is that it's not the pressure itself but the gradient between the patient's normal that makes the most difference in whether the patient demonstrates the signs and symptoms classically associated with a hypertensive urgency or emergency. Never bothered to look into it any further (too busy with other stuff) but that's the half-assed explanation I theorize.

 

[LondonMedic]

I was talking about people who are not chronically hypertensive.

As was I. Given that all of my punters are lying in a hossie bed, maybe I just haven't seen any yet.

One of the hypotheses I kick around is that it's not the pressure itself but the gradient between the patient's normal that makes the most difference in whether the patient demonstrates the signs and symptoms classically associated with a hypertensive urgency or emergency. Never bothered to look into it any further (too busy with other stuff) but that's the half-assed explanation I theorize.

From what I understand of the physiology that's essentially true, but it's hard to put into a protocol which is why I end up running to see well patients with a BP of "80/40" who normally run with a systolic of 90 and miss sick people who drop from 150 or 160 to 100.

 

[MrBrown]

As was I. Given that all of my punters are lying in a hossie bed, maybe I just haven't seen any yet.

From what I understand of the physiology that's essentially true, but it's hard to put into a protocol which is why I end up running to see well patients with a BP of "80/40" who normally run with a systolic of 90 and miss sick people who drop from 150 or 160 to 100.

It's really a contextural matter; i.e. putting the blood pressure in context with all the other things going on and making an objective decision based on a total picture rather than one isolated sign or symptom.

I mean the judge told me because it was my first offense I wouldn't go to jail for rolling round in an orange jumpsuit with "DOCTOR" written on it, see, context

Seriously tho I have seen people up and talking perfectly perfused and haemodynamically stable with a BP of 70 something, last time I got a bit crook mine probably fell a couple mmHg and I felt like I was going to die.

 

[Sassafras]

I can attest that you can walk around that high and be perfectly normal. During my EMT class my partner normally had a systolic of around 142. Imagine my surprise when over half way through the class we were practicing vitals yet again and I get a systolic of 210. ...Wait, that can't be right. So I did it again. And it was the same. "Are you feeling o.k?" I asked and he said he was fine. I asked him again and he laughed and asked why? So I told him and that I didn't trust my result so I called another student over. Two students and an instructor later my partner was tanking over 200 systolic and I was trying to send him home LOL. I made him swear to go to the doctor and he didn't that week, but the next class was tanking over 200 again. Finally we went to the doc and was put on meds but at no point did he feel odd, headachish, nauseous or anything other than normal.

 

[MarineMedic_834]

The problem is; I obtained the first BP of 218/78 by auscultation. After a 10 minute transport the NIBP reading was 108/62 which caused me to obtain an auscultated pressure and I got the 110/66. I am quite familar with how to take a BP and I know what I heard. Problem is, I'm afraid that know all my vitals will be questioned by my partner.

 

[mycrofft]

Just press on and do as well as you can.

There are instances where the mechanical med tech will not catch outlandish vital signs (atrial fib being one, and that is the most common dysrythmia). The rate and quality (or lack thereof) of pulse measured on a machine will affect the BP program and give you an erroneous one.

That said, if you see a platypus, you take another look. Same for outlandish vitals. Check it again, including rate/ryhtmicity and quality of the pulses, then record and stand by your results, while listning to reason just the same.

 

[EMS123]

there are instances where the mechanical med tech will not catch outlandish vital signs (atrial fib being one, and that is the most common dysrythmia). The rate and quality (or lack thereof) of pulse measured on a machine will affect the bp program and give you an erroneous one.

That said, if you see a platypus, you take another look. Same for outlandish vitals. Check it again, including rate/ryhtmicity and quality of the pulses, then record and stand by your results, while listning to reason just the same.

like!!! Cya!

 

[EMTBell]

Equipment fail?

I've had BP cuffs (appropriately sized) give me readings around 250/65. With that kind of a pulse pressure I was wondering why the guy hadn't stroked out yet, so to confirm I used a different cuff and got a 130/75. Could just have been the equipment! Or you may have had some clothing caught under the cuff that kept pressure off the artery slightly, allowing blood to come through early.

 

[Medic535]

Check and see how old that cuff is, may be time for a new one. I've had a few over the years begin to give bad readings after heavy use.

 

[MRSA]

Have you tried checking your equipment? Some older equipment can give a mis reading. For example, I had a super old cuff where the reading disc would slip on it's own from time to time. Meaning if someones blood pressure was actually 110/70 I'd get either 90/50 or 130/90 (depending on if it slipped to the left or right)

I've had this moment before myself actually. I knew I heard a b/p of 132/60 and when I took my last set it was 90/50. Turned out they gave my patient morphine and even though I asked about medications I wasn't given that latest tidbit By the time we got her into her dialysis chair she was bradycardic. I found out later they overdosed her. The transport time was roughly 15 minutes and I took my set before taking off and after.

My partner absolutely questioned my skills, and yours very well might too. Just check your equipment and spend a little extra time on B/P's just to be safe. That's what I did and I came out fine.