Had to BP femoral artery

[ryujinn]

Hey all,

I wanted to post about this situation I had the other day when I was with a patient on a ER con run. The patient was about 60 years old, and was fairly obese (not incredibly large), and her chief complaint from charge nurse was fever onset 3 hours prior (about 101 degrees), and congestion.

When I came into her room, she was very rigid and tense. I could NOT move her arm at all without incredible force (I was surprised at such rigidity for a old lady, but the human body is quite the wonder when it is defensive against something). She was conscious and alert with spontaneous eye movement, but I could not communicate with her although I'm sure she could hear the sound of my voice.

Her arms were in almost like a rabbit-like position if you can imagine it. Because her arm was bent, I could not put the steth or even wrap my cuff around her arm due to the lack of straightening for the antecubital region.

So I went for the femoral artery. This was my 1st time ever doing BP by femoral artery. It was mentioned during my course, but I never actually tried it. So I put the cuff proximal above the femoral artery around the thigh, and palpated to find the femoral artery itself. Now it was very difficult for me to find it because I've never really needed to palpate for that artery before. It took me a couple of tries but I found it underneath all the mass. I proceeded to take the BP normally and was surprised that the value was about 204/104 mmHg. Patient also was tachycardic. This was quite the concern for me as I prepared for the worse; it was also difficult for me not being able to communicate with her as she was unable to speak so I could ask any SAMPLE or OPQRST questions especially if she had chest pain. However, the nurse did not report this so I did not want to jump to any conclusions.

I took the BP a second time and I got about around the same values, 200/100ish. At this time my partner comes in and I'm like, "Man, I'm really iffy about this BP." So he told me to take it by palpation via radial on the brach. I was able to somehow shimmy the cuff into adequate positioning and I proceeded to take the BP twice. And I got about 130/90 both times. At this time the nurse also checked and said she got that as well. We transported her to ER and hooked her up to the monitor and her BP was about 130-140 as I palpated.

So after this call I was really kind of bugged about it. Why when I auscultated by femoral artery was the BP so high? I did it twice and I got the same results and I am PRETTY confident with my auscultating BP skills. But, as this was my first femoral artery - I was a bit insecure thereafter. I'm glad I know how to do it now - but I am just concerned with the accuracy of it. I'm glad that my palpated radial worked out to be the correct. If any other situation and I had power to make a choice when it came to 130 vs. 200 BP, things could have been mad. I want to ask you all for your opinion about taking the femoral artery for BP. Is it accurate? Did I just do it wrong? is the femoral artery the only other "reasonable" way to take BP if you can't take it by brachial? And how can you easily find the femoral artery generally? (for brachial you can hear at the antecubital region, to palpate it under the bicep generally works). With general alternatives to BP by brachial, if we can't do it by arm at all - is femoral the logical choice (say if condition is good to take BP)? And if that doesn't work -> can you do palpation by pedal pulse with cuff? (just thinking outside the box since the order is usually BP by femoral -> BP by palpation radial -> or BP by femoral -> and also palpate by pedal BP?)

With regard,

Michael

 

[exodus]

Did you happen to use the right BP Cuff size?

 

[Melclin]

Her arms were in almost like a rabbit-like position if you can imagine it.

Sounds like decorticate posturing.... but I'm hoping you/the nurse know what that is and were confident it wasn't that.

Did you ever find out what was wrong with her?

 

[trevor1189]

I have never done femoral BP. I usually go normal method (cuff over humerus/Auscultate over brachial fossa)> Radial Palp.

If neither works, I have placed the cuff over the proximal radius/ulna distal to the brachial fossa and done palp over the radial pulse (mainly large pts. when I'm on scene and don't want to run out to the truck for a large cuff.)

Helpful points:
Also, be careful listening to nurses about pt.'s condition other than normal LOC, medications and PMH. We have some really bad nurses around here that seem to not know what they are doing. A good example is one that I have heard from someone who got back from a call. Nurse placed a SOB on 6 L/min NC. She said that wasn't helping so she turned the O2 down???

 

[Aidey]

You can take a BP on the forearm the same as you would do on the upper arm. Wrap the cuff around the forearm and then auscultate or palpate at the wrist.

I'm actually kind of confused about what you did. The femoral artery is usually palpated in the groin. When taking a BP you want a pulse point distal to the BP cuff. I can't see how you could do the BP on the thigh using the femoral artery, unless you are talking about assessing it in a different location.

 

[rescue99]

Sounds like decorticate posturing.... but I'm hoping you/the nurse know what that is and were confident it wasn't that.

Did you ever find out what was wrong with her?

Contractures. Common with neuro damage and long term immobile patients.

 

[ryujinn]

I have never done femoral BP. I usually go normal method (cuff over humerus/Auscultate over brachial fossa)> Radial Palp.

If neither works, I have placed the cuff over the proximal radius/ulna distal to the brachial fossa and done palp over the radial pulse (mainly large pts. when I'm on scene and don't want to run out to the truck for a large cuff.)

Helpful points:
Also, be careful listening to nurses about pt.'s condition other than normal LOC, medications and PMH. We have some really bad nurses around here that seem to not know what they are doing. A good example is one that I have heard from someone who got back from a call. Nurse placed a SOB on 6 L/min NC. She said that wasn't helping so she turned the O2 down???

Thanks for the tips trevor. I realized I recorded down some mistakes. The nurses at the con homes are really shady and try to not make it a ALS call. Dispatch told me that nurse reported "low fever" but it was approaching 102.

For Aidey,

I realized that it was not the femoral artery that I auscultated, you're right that's near the groin. But it was a artery behind the kneecap. Definitely felt a pulse, but I may have been completely wrong. And you're right, cuff maybe was not large enough - as this could have contributed to the high BP.

My partner was getting the report so I did not have a chance to talk to her - though he debriefed me in the rig but nothing really stood out. She had Hx of anemia, dysphasia, ALOC - as Rescue999 pointed out, history of neurological damage perhaps.

I also had no idea you could auscultate at radial via cuff on forearm. Thanks for that tidbit!

So when are the situations you need to cuff the legs? And where is the correct place to take BP on the leg? (I wrapped cuff above knee near thigh, and auscultated below). And was it inaccurate because I should have used a larger cuff? (It did go all the way, but I admit was not a clean wrap that overlaps perfectly, about 2-3 inches on the velcro as opposed to a good wrap).

I just want to learn from my mistakes and new information - thank you for all the great feedback.

 

[usafmedic45]

But it was a artery behind the kneecap

You mean the popliteal artery? Which is on the back of the leg in the appropriately named "popliteal fossa", aka the "back of the knee" or the "knee pit" as my daughter called it once. It's not really "behind the kneecap" (patella) as there are no (significant) vascular structures between the patella and the anterior surfaces of the femur and tibia. Sorry for being an anatomy Nazi, but my old medical director would have had a field day with you if you described it that way in his presence.

 

[ryujinn]

Popliteal sounds right! And yes, I was just generalizing area. Apologies for the bad description. I was never taught that in detail when it came to the arteries, especially the ones on the leg or even how to cuff on the leg. But I'm glad I am learning a lot from the emtlife community, thank you.

 

[VentMedic]

Placing a BP cuff on the femur of a child is possible. However, for leg blood pressure measurements, the cuff must be at least 25% wider than the average leg diameter and long enough to encircle the limb with ease. If this person was obese, there is probably room for doubt that the BP you took was totally accurate.

This thread shows what I meant by by post on this thread.
"What every EMT should be required to experience before they graduate".
http://www.emtlife.com/showthread.php?t=15533&page=3

Not many EMTs are going to be doing lead even when providing first aid to patients. But unfortunately for the patients, they are put alone in the back of a truck with those that need a medical assessment rather than first aid. Since EMTs do primarily IFT runs on medical patients where vital signs are important, the EMT should shadow CNAs and do no less than 100 sets of vitals on a variety of different patients. The EMTs should be trained by the CNAs to move the elderly, frail and patients with lots of attached accessories without causing pain and injury. They could also take a lesson on how to maneuver obese patients safely. EMTs are not adequately trained to be providing even "BLS" care to medical IFT patients such as those requiring dialysis.

Thanks for the tips trevor. I realized I recorded down some mistakes. The nurses at the con homes are really shady and try to not make it a ALS call. Dispatch told me that nurse reported "low fever" but it was approaching 102.

Unfortunately it is not the nurses that often make the judgment whether it is ALS or BLS. Some county EMS systems put serious mandates and restrictions on when, how and why the 911 system is activated and will seriously penalize the LTC facilities. The RN can then be severely scrutinized about calling 911 even if it is a cardiac arrest. The other issue is Medicare and insurance reimbursement. Each call must be justified to the fullest.

I am not trying to be harsh. I a glad that you recognize the limitations of your EMT training and that you are asking questions. It is good that you now realize a few things about BPs and I would still recommend that you get additional training if possible on a med-surg floor of a hospital doing no less than 100 sets of vitals. It would be good to see a wide variety of patients with different body shapes, contractures, amputees, venous access ports, male and female mastectomies, lymphadema and dialysis shunts. As well, you should recognize if the patient is having a focal or some other type of seizure. If there is a decent full service VA hospital that has dialysis, rehab and SNF units attached, that would be a great place to see if you could shadow someone.

Keep on learning. You are demonstrating your ability to think things through which means you are destined for higher education.

 

[EMTim]

The two factors that seem to come into play here are cuff size and contractures.
Obviously the wrong cuff size will give false readings. Also, the brachial and/or radial BP will probably not be accurate on a patient with severe contractures. In those scenarios, popliteal is definitely the best route, just make sure you get the thigh cuff (unless they are very thin/frail).

 

[ryujinn]

These are all great pieces of insight. I feel very satisfied with knowing what I did wrong and should have done differently/recognized. Thank you all!

 

[Brandon O]

I've done the forearm bit a few times, only had especially good results approximately once. Doublecheck your anatomy if necessary to remember just WHERE that artery runs... and then you can scratch your chin and wonder how it's going to be possible to trap it against a bone... but never mind. IMO it takes some balls to do it by auscultation; as usual palp becomes the scaredy-cat road ^_^

One thing I've thought about but never had to actually pull was cuffing the calf and palpating at the ankle. I can never find the posterior tibial pulse anyway so that would probably be an exercise in futility.

 

[redcrossemt]

I was able to somehow shimmy the cuff into adequate positioning and I proceeded to take the BP twice. And I got about 130/90 both times. At this time the nurse also checked and said she got that as well. We transported her to ER and hooked her up to the monitor and her BP was about 130-140 as I palpated.

How did you palpate the 90?

 

[ryujinn]

Butter fingers!

Sorry redcross I meant 130/p .