Asymptomatic hypotension?

Mitchellmvhs

Mitchellmvhs

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Just started my ALS training with my new AMR ops, I’m a basic and with a medic and emt fto, I just ran this call and could use some input. One of the most intense calls I’ve run.

70 yo F who’s friend called 911 for falling out of her walker. Pretty extensive hx, chf, copd, db. We’re code 3 to call and get on scene before fire. Initially she said she felt fine and just needed help up to her walker. Lady was 280LBS, we help her sit on her walker. Fire medic and my medic convince her to let us check her out. I put her on the monitor and mind you our Large Adult BP cuff had a hard time fitting her. It didn’t get a BP, so we run it again and It’s coming back 60/20ish. We run it again and its continually not wanting to get a BP. We’re a little concerned now, so we load her up into ambulance, medic goes for IV and I try to get a manual, same issue, cuff doesn’t fit that great I can’t hear a BP, my EMT fto can’t hear it accurately. I was going to try for a Palp as wel, but I couldn’t get a radial or brachial. We decided to transport at this point Code 3. We get fluids going and medic gives epi. I try again for another manual and I still can’t hear **** (then again we were going c-3 as I try to take it) but i see the needle jumping around 100. We get the auto monitor cuff back on her and once we get to hospital it comes back around 110 systolic. We get to ER transfer care etc.

The biggest thing that confused me was SHES A/Ox4 SEEMS TOTALLY FINE but a little weak, but she’s got an extensive hx and pretty normally this way. Was her BP that low? can you really hear a manual BP that low? I’m questioning myself if I’m still **** at manual BPS. I even bought a Littman classic III to help awhile back, but still couldn’t hear ****. But at the same time our largest cuff didn’t fit that well.
 
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EKG? Putting the cuff on the forearm and putting the index arrow thingy along the radial artery is a legit way to get a NIBP on a fat arm. Generally speaking, volume before pressor/inotrope in the setting of isolated, suspected hypotension.

SBP 110 after epi? Guess that's one way to do it....
 
I'm with E tank on this. Put the cuff on the forearm and let it run. Doing manual BPs that way can be a bit difficult but it's not impossible. Asymptomatic hypotension is certainly possible but not typically when you legitimately have an SBP of 60. If you stood the patient up and she became dizzy, that would make me worry... but otherwise, there are people that normally "live" at 90/60-ish, though none of the people I know that do are 200+ pounds...
 
My money is on the BP not being accurate. Like others have said, I would try the forearm. I've seen an NIBP get a SBP in the 40s on a bedrail, so sometimes you have to evaluate the accuracy of them.

It's important to clinically correlate vitals and clinical presentation, and it doesn't really seem like that was done here. I would go with a small fluid bolus (maybe) if I was getting consistently low BPs, and I probably wouldn't go straight to epi. If I did have to start a pressor on this patient for some really weird reason, I'd probably use levophed, not epi.

It seems like they were just treating a number in this case. I'm not a fan of the whole "treat the patient, not the monitor" mantra because both the patient and the monitor will tell you important information, but I feel that this is one of those situations where the monitor was displaying false information.

I'm assuming "code 3" means L&S? Curious why they did L&S on this one, any idea?
 
Accurate BPs are difficult to obtain in the obese patient. I had an obese septic,.intubated patient once, BP cuff could not get a pressure and was very labile 60s to 140s,.wtf. How can I titrate pressors and sedation with an inaccurate pressure!? Pain in the ***. I told MD to put in an A-line and CVC and we were solid. Love me my A-lines.
 
Mitchellmvhs said:
Just started my ALS training with my new AMR ops, I’m a basic and with a medic and emt fto, I just ran this call and could use some input. One of the most intense calls I’ve run.

70 yo F who’s friend called 911 for falling out of her walker. Pretty extensive hx, chf, copd, db. We’re code 3 to call and get on scene before fire. Initially she said she felt fine and just needed help up to her walker. Lady was 280LBS, we help her sit on her walker. Fire medic and my medic convince her to let us check her out. I put her on the monitor and mind you our Large Adult BP cuff had a hard time fitting her. It didn’t get a BP, so we run it again and It’s coming back 60/20ish. We run it again and its continually not wanting to get a BP. We’re a little concerned now, so we load her up into ambulance, medic goes for IV and I try to get a manual, same issue, cuff doesn’t fit that great I can’t hear a BP, my EMT fto can’t hear it accurately. I was going to try for a Palp as wel, but I couldn’t get a radial or brachial. We decided to transport at this point Code 3. We get fluids going and medic gives epi. I try again for another manual and I still can’t hear **** (then again we were going c-3 as I try to take it) but i see the needle jumping around 100. We get the auto monitor cuff back on her and once we get to hospital it comes back around 110 systolic. We get to ER transfer care etc.

The biggest thing that confused me was SHES A/Ox4 SEEMS TOTALLY FINE but a little weak, but she’s got an extensive hx and pretty normally this way. Was her BP that low? can you really hear a manual BP that low? I’m questioning myself if I’m still **** at manual BPS. I even bought a Littman classic III to help awhile back, but still couldn’t hear ****. But at the same time our largest cuff didn’t fit that well.
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Remember, treat the pt, not the numbers or machine. She was A/O X 4, and I assume she had good color, no diaphoresis? Did you try a leg BP? She didn't need fluids or epi. What was her HR by the way?
 
Just adding to what others have said with a reason why:

Some people with class II (BMI >35) and more so class III (BMI >40) have arms that are conically shaped and as a result have inaccuracies using a standard shaped rectangular BP cuff.
 
silver said:
Just adding to what others have said with a reason why:

Some people with class II (BMI >35) and more so class III (BMI >40) have arms that are conically shaped and as a result have inaccuracies using a standard shaped rectangular BP cuff.
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"cone arm the Barbarian" we sometimes un-charitably refer to them as ..and, being rectangular, the thigh cuff (only ever have seen them used on these obese patients, never once on an actual thigh) don't help at all either. I think probably the only way you'd get a reliable upper arm blood pressure on this kind of patient is with an antique sphygmomanometer with the 3 feet of velcro-less cloth you'd wrap around the arm a hundred times to get a snug fit.

Lest anyone crack wise...those were long gone by the time I started....
 
medichopeful said:
My money is on the BP not being accurate. Like others have said, I would try the forearm. I've seen an NIBP get a SBP in the 40s on a bedrail, so sometimes you have to evaluate the accuracy of them.

It's important to clinically correlate vitals and clinical presentation, and it doesn't really seem like that was done here. I would go with a small fluid bolus (maybe) if I was getting consistently low BPs, and I probably wouldn't go straight to epi. If I did have to start a pressor on this patient for some really weird reason, I'd probably use levophed, not epi.

It seems like they were just treating a number in this case. I'm not a fan of the whole "treat the patient, not the monitor" mantra because both the patient and the monitor will tell you important information, but I feel that this is one of those situations where the monitor was displaying false information.

I'm assuming "code 3" means L&S? Curious why they did L&S on this one, any idea?
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I’ll answer your last question for you, the OP has a picture of Doctors ambulance for his profile picture. Doctors = Orange County in California. Orange County = Fire is in control of all aspects paramedic in the county, aside from one city. Orange County Fire is not known for being stellar in regards to medicine nor does the county as a whole.
 
DesertMedic66 said:
I’ll answer your last question for you, the OP has a picture of Doctors ambulance for his profile picture. Doctors = Orange County in California. Orange County = Fire is in control of all aspects paramedic in the county, aside from one city. Orange County Fire is not known for being stellar in regards to medicine nor does the county as a whole.
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Curious as to what your comment means vis-a-vis the scenario?
 
MackTheKnife said:
Curious as to what your comment means vis-a-vis the scenario?
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The last question in the comment that I quoted is where my information is relevant. Pretty much anything and everything in LA/OC gets a code 3 transport.
 
E tank said:
"cone arm the Barbarian" we sometimes un-charitably refer to them as ..and, being rectangular, the thigh cuff (only ever have seen them used on these obese patients, never once on an actual thigh) don't help at all either. I think probably the only way you'd get a reliable upper arm blood pressure on this kind of patient is with an antique sphygmomanometer with the 3 feet of velcro-less cloth you'd wrap around the arm a hundred times to get a snug fit.

Lest anyone crack wise...those were long gone by the time I started....
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R I g h t......;)
 
DesertMedic66 said:
I’ll answer your last question for you, the OP has a picture of Doctors ambulance for his profile picture. Doctors = Orange County in California. Orange County = Fire is in control of all aspects paramedic in the county, aside from one city. Orange County Fire is not known for being stellar in regards to medicine nor does the county as a whole.
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Ahh. So the less time they have to spend with the patient, the happier they are.
 
medichopeful said:
Ahh. So the less time they have to spend with the patient, the happier they are.
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Pretty much yeah. I’ve been on bed delay at hospitals out there multiple times and will hear a unit come in code 3, lights/sirens, to the hospital. I’ve asked the EMTs and their response is “anytime the fire medic rides in, they make us go code 3”.
 
DesertMedic66 said:
I’ll answer your last question for you, the OP has a picture of Doctors ambulance for his profile picture. Doctors = Orange County in California. Orange County = Fire is in control of all aspects paramedic in the county, aside from one city. Orange County Fire is not known for being stellar in regards to medicine nor does the county as a whole.
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This was actually with AMR riverside. I just transfered out here from Doctors and going through my fto time. We Initially were code 2 to RCH but my medic wanted to upgrade. I probably didn’t grasp the whole situation entirely since it’s one of the first times I’ve been apart of such a stressful call, but it was definitely interesting and a good learning experience. The medic has also only been a medic for a little under 2 years I believe. IMO he’s a really solid medic, and pretty by the book with the calls I’ve run with him. He definitely is not lazy. I’d also like to add as a basic I’m only now starting to pick up on some of the ALS stuff since I’ve gotten to actually work a little more 1 on 1 with a medic, so my understanding of their protocols is not that great
 
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E tank said:
EKG? Putting the cuff on the forearm and putting the index arrow thingy along the radial artery is a legit way to get a NIBP on a fat arm. Generally speaking, volume before pressor/inotrope in the setting of isolated, suspected hypotension.

SBP 110 after epi? Guess that's one way to do it....
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12 lead was done nothing significant from my understanding, then again I’m a basic so I didn’t really look at the ekg I just put the leads on lol. We actually did try the Large cuff on her forearm, but it was the same thing, it was not giving us a BP
 
MackTheKnife said:
Remember, treat the pt, not the numbers or machine. She was A/O X 4, and I assume she had good color, no diaphoresis? Did you try a leg BP? She didn't need fluids or epi. What was her HR by the way?
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I don’t remember the HR tbh but I don’t think it was anything super significant, maybe a little tachy. It was definitely a strange call for me, but this is my first time doing a lot more 911 lol I’ve learned more in 2 days I feel like than I ever did in my 10 months in Orange county
 
Mitchellmvhs said:
12 lead was done nothing significant from my understanding, then again I’m a basic so I didn’t really look at the ekg I just put the leads on lol. We actually did try the Large cuff on her forearm, but it was the same thing, it was not giving us a BP. I also tried palping a BP with the manual. I was not able to feel any peripheral pulses. Idk if that’s bc I’m super incompetent at my job or if there really wasn’t any.
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