Trouble with BP enroute

thowle

thowle

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Situation:
~75 y/o female, c/c CVA/TIA. Initial BP taken by medic on scene, was something like 225/180 maybe(ish); gave labaterol IV, and then I went to re-acquire BP.. after 5 tries of not being able to hear anything, I try to palp... and can't feel anything either...

Medic decides to give it a whirl, and he tries a few times and can't get a BP either.

Of course, it's an older lady, plus we're moving down the road (bumpy) code 3. But, none the less I felt like an idiot because I couldn't accomplish an easy, and important (in this situation) acquisition of blood pressure. I felt better once the medic wasn't able to either after a few tries; but none the less....

Does anyone else out there have trouble getting BP in the back of the rig? Any advice?
 
they might move this to a different forum but to answer...

one thing that can help it is obtaining the BP w/ a monitor. which im suprised you didnt have seeing you were on an ALS rig.
 
Pretty sure we don't have a monitor that will get BP -- may be wrong though.
 
Some people you just can't get a BP on. Some bigger patients, it's nearly impossible to feel or hear anything through all the fat. Maybe her BP was tanked. Or maybe it's because you were in the back of an ambulance going Code 3. Going down a bumpy road or in some older trucks, the korotkoff sounds can sound suspiciously like a diesel engine or a few thousand pounds of ambulance bouncing around. Don't beat yourself up over it. Just keep practicing and you'll get the hang of it. I don't know how long you've been an EMT, but I know, speaking as somebody who was once a sparky and chipper brand-spankin' new EMT, getting BPs while moving can be tough. Just keep at it.

And I second the surprise at you not having an automated cuff on an ALS unit.
 
We have old Lifepak 12's... don't think they have the NIBP system... but then again, I've been wrong before.
 
Not all trucks have monitors.

Not all companies allow basics to work monitors.


You can't trust a monitor without doing your own auscultated one first, and even then I prefer auscultation over NIBP ANY day.
 
Linuss said:
Not all trucks have monitors.

Not all companies allow basics to work monitors.


You can't trust a monitor without doing your own auscultated one first, and even then I prefer auscultation over NIBP ANY day.
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Lift one shoe toe or foot off the floor to reduce road noise while you listen for a BP. Just prop it on the bottom rail. Usually helps quite a bit.
 
thowle said:
Situation:
~75 y/o female, c/c CVA/TIA. Initial BP taken by medic on scene, was something like 225/180 maybe(ish); gave labaterol IV, and then I went to re-acquire BP.. after 5 tries of not being able to hear anything, I try to palp... and can't feel anything either...

Medic decides to give it a whirl, and he tries a few times and can't get a BP either.

Of course, it's an older lady, plus we're moving down the road (bumpy) code 3. But, none the less I felt like an idiot because I couldn't accomplish an easy, and important (in this situation) acquisition of blood pressure. I felt better once the medic wasn't able to either after a few tries; but none the less....

Does anyone else out there have trouble getting BP in the back of the rig? Any advice?
Click to expand...

Yes. Pull over.
 
We had a medic at NSLIJ that would intentionally hide the LP BP cuffs, he felt that strongly against field BP's off of the monitor. Always auscultate first, and base the monitor BP's off of theat for the duration if you like.

If you absolutely can't get a BP no matter what, you can always do a palp BP for a systolic. It's better than nothing. If you can't get a radial, you can always auscultate the apical pulse while checking the pt for other signs of perfusion. If the pt is maintaining their mental status, skin CTC, has good cap refill (if delayed, not reliable unless it's a ped), it's likely that their BP hasn't tanked. If you're doing long distance and have a foley, is the pt producing urine?

Remember that if they're a heavy hitter you can always get a BP off of the wrist via the radial artery.

Remember also that a pt may have an elevated BP initially along with cool, clammy skin. Watch them for possible decompensation later.

Compare the rate, rhythm and quality of their initial pulse check to later reassessments. Is it weaker, bounding, absent? In the absence of a BP this can tell you something, as long as you're looking at the big picture.
 
i occasionally work in an off-highway-vehicle park with sand dunes that people love to get hurt on... its next to impossible to hear anything when you're trying to get a bp with dirt bikes and atv's BRAAAAPPPing next to you
 
Make sure the tubing on both the BP cuff and the stethoscope isn't touching anything else, specially the railing on the gurney. The vibrations travel and can make it much harder to hear.

If worst comes to worst, flip on all the lights and pull over.
 
If you have a stethoscope with dual tubes, make sure they aren't rubbing against each other. It also helps me to closely watch the needle on the gauge; sometimes you can see it jumping, and that helps me tell a pulse apart from random road noises.
 
I've had this happen plenty of times to me. Sometimes the blood pressure is too faint to hear it over the noise.

After two attempts,, I go for a palpated to acertain it is obtainable. Then, ill palpate a brachial to confirm proper diaphragm placement. Also, I found that out-stretching the arm laterally will help expose the arm better for auscultation. Lastly, there's the pausing while pumping technique. This enable you to hear the pulse as you pump upwards, letting you know it's ball park while deflating the cuff.
 
Apparently I'm the only one thinks pulling over and even shutting the unit off if needed in order to get a BP on a difficult auscultation might be an idea.
 
MSDeltaFlt said:
Apparently I'm the only one thinks pulling over and even shutting the unit off if needed in order to get a BP on a difficult auscultation might be an idea.
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Not an unreasonable thing to do at all. Pulling over to gain control is always an option.
 
rescue99 said:
Not an unreasonable thing to do at all. Pulling over to gain control is always an option.
Click to expand...

To senior medics. How does an exact pressure differ from a palpated pressure according to your treatment?
 
try putting both feet on the rungs of the gurney so they are off the floor. this helps eliminate road noise so that you can hear the bp better.
 
cm4short said:
To senior medics. How does an exact pressure differ from a palpated pressure according to your treatment?
Click to expand...

A palpated pressure of course only gives a part of the picture but, having a palpated systolic gives me a direction to head. I want a manual pressure asap and certainly prefer it to just a systolic.
 
MSDeltaFlt said:
Apparently I'm the only one thinks pulling over and even shutting the unit off if needed in order to get a BP on a difficult auscultation might be an idea.
Click to expand...

No, you're not. I hadn't had time to reply. You're talking about pushing drugs designed to lower the blood pressure, now you can't obtain a blood pressure, and no one thinks they should pull over and shut it down? What if this medication rendered your patient nearly pressure-less? If you're treating hypertension and you can't reassess your treatments, that is a VERY major problem. PULL IT OVER AND TURN IT OFF!

It took me years to be able to hear a blood pressure well in adverse conditions. After years of practice, and practicing with my good stethoscope for all of those years, there are few situations where I can't hear a blood pressure. I don't do "palp" pressures because I can't trend the MAP. I don't like the cuffs on the monitors because I can't physically hear the blood pressure and therefore I don't trust it.

Seriously, they call it a vital sign for a reason.
 
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