What's the best way to do a BP on a snowsuited patient in extreme cold?

[mycrofft]

Yes, yes, I know, but besides taking him/her to the ski chalet first!

I used to rapidly snake the stethoscope head up the sleeve (or, if needed, tetrasnip my way to the antecubital fossa) then use a big cuff around the entire suit sleeve if it wasn't ridiculously puffy. PSI (or mmHg) are PSI (or mmHg), it took longer to inflate it but my readings in the situation seemed to be pretty close to what we would get once we could shuck the pt out of the suit.

(Actually, after my chem warfare training, I changed my attitude to first ascertaining if the pt could be/needed to be moved to a safe and warmer situation first; a hotile environment greatly limits what you can safely do while it still is impacting the pt. "Care on the spot" was then the second consideration, after what you could call "environmental scene safety" I guess).
Thoughts? Policies?

 

[mycrofft]

OOps I buried my own post!

Any comments?:blush:

 

[traumateam1]

I used to rapidly snake the stethoscope head up the sleeve (or, if needed, tetrasnip my way to the antecubital fossa) then use a big cuff around the entire suit sleeve if it wasn't ridiculously puffy. PSI (or mmHg) are PSI (or mmHg), it took longer to inflate it but my readings in the situation seemed to be pretty close to what we would get once we could shuck the pt out of the suit.

And this didn't work this time?

Can we get them OUT of the extreme cold, then take some layers off to do the BP?

 

[akflightmedic]

What is your transport time to definitive care or a warmer location?

Is a BP absolutely necessary prior to moving locations?

This kind of question all comes down to the actual details of the event.

Does the nature of their injury demand knowing a BP instantly? If not, transport to warmer location and then assess.

If they have a strong radial pulse, then you know their systolic is at least 80, odds are if its strong and its a minor injury it is even better...right? So what is the hurry to get a BP?

From someone who worked in the Arctic for several years, I think there are many times you can forgo a BP or an intervention until you arrive a warmer location or circumstances change.

 

[mycrofft]

Thanks! Have a good one!

mycrofft.....

 

[yowzer]

Take the BP around their neck.

Seriously... unless you can easily get them out of the bulky warm stuff and into something else that'll keep them warm and yet give access (Say a sleeping bag)... BP can be done via palpation (Which isn't going to be incredibly accurate, but is better than nothing and will give a rough idea of if they're high or low). Get what vitals you can, but not at the cost of increasing their chance of becoming hypothermic. If you need to remove clothing anyways, might as well get one, but I wouldn't do it just for the sake of am ausculated blood pressure.

 

[mycrofft]

The method I used worked OK, I was asking if there was a better one.

Of course, the answer is "Get them where it's warmer"! I was target-fixated upon better ways to do something the hard way. Triage is probably the only imperative dictating BP like that, and even then getting warm and accessible-er is needed quickly.

 

[BossyCow]

I've snaked a cuff around an arm inside a snowsuit/parka leaving the majority of the pt covered I would think that would be more accurate than the bigger cuff over the sleeve.

 

[Veneficus]

Why not just look for clinical signs of perfusion until you get somewhere warm?

If you get a BP of 280/160 what are you going to do out in the cold?
If you get a BP of 50/p what then?

(aside from maybe questioning that number if the person is talking coherently to you) But you get my point.

What good are these numbers without a proper physical exam anyway?

 

[BossyCow]

Why not just look for clinical signs of perfusion until you get somewhere warm?

It totally depends on the circumstances. How close to the rig is the pt? How long before they are able to transport. Is this a packout of an hour plus? What symptoms was the pt experiencing. Are they down from a possible cardiac event? Are they a trauma pt and bleeding out into their belly? A set of baseline vitals is important.. probably why they call them vital.

The OP was asking a question on technique, not on whether or not to do it.

 

[Veneficus]

It totally depends on the circumstances. How close to the rig is the pt? How long before they are able to transport. Is this a packout of an hour plus? What symptoms was the pt experiencing. Are they down from a possible cardiac event? Are they a trauma pt and bleeding out into their belly? A set of baseline vitals is important.. probably why they call them vital.

The OP was asking a question on technique, not on whether or not to do it.

I wasn't/still not trying to be accusatory, just putting out some food for thought.

What if the rig is far away? How much does it change?

Isn’t time of transport as soon as possible? 5 minutes, an hour, 10 hours, 72 hours, you will do what you can with what you have based on the patients clinical issues.

You will need more info than a BP to treat a cardiac event. Though I admit hypotension would be an indicator of right sided insult or infarction. A weak pulse, altered LOC, could probably give that away as well. But to treat it, you are going to have to ditch the snow suit anyway.

In a trauma patient with intraperitoneal bleeding, time to transport will be a much more critical factor than anything that can be done for him in the field, no matter what his pressure. You would probably have to take off the suit to assess that anyway. So if suit is off, why not take the BP then?

Please entertain my thoughts:
Patient A: BP: 120/70 pulse: 86 resps: 10
Patient B: BP: 90/70 pulse: 70 resps: 12
Patient C: BP:140/82 pulse: 110 resps 16
Who is sicker?

I was trying to illustrate a set of vital signs is not enough to make treatment decisions on. I realized he was asking the best way and I wanted to offer food for thought before he decided on technique, that it may alter the one he chooses.

 

[Jon]

Wow. Any ski patrollers out there? What do you do "on the mountain" for first aid?

My gut instinct would be that I'm doing nothing more than a "rapid assessment"... +radial pulses=moderately adequate perfusion, and leave it at that until I can get the patient out of the elements.

No sense killing him faster because he's hypothermic.

 

[BossyCow]

Wow. Any ski patrollers out there? What do you do "on the mountain" for first aid?

My gut instinct would be that I'm doing nothing more than a "rapid assessment"... +radial pulses=moderately adequate perfusion, and leave it at that until I can get the patient out of the elements.

No sense killing him faster because he's hypothermic.

Absolutely Jon.... when the temp is in the low teens, our treatment of the pt is going to be much different. The old strip and flip just isn't an option.

and as to:

In a trauma patient with intraperitoneal bleeding, time to transport will be a much more critical factor than anything that can be done for him in the field, no matter what his pressure. You would probably have to take off the suit to assess that anyway. So if suit is off, why not take the BP then?

If its possible to get a quick and nasty assessment of early BP to compare without exposing the pt to the extreme temps.. its a good thing. We don't necessarily have to take the suit completely off, instead we can do a piecemeal peek a boo of areas followed by quickly covering the pt back up.

It's important to know these types of things becaues a stable pt is more likely to get a safer, gentler transport while an unstable pt is going to be looking at an airlift or another less safe, faster extrication.

Since many of our pack outs can be several days, that's time for a slow spleen rupture to show up, or other slower developing issues. Having a nice set of baselines gives us a starting point. If its possible to get that baseline without exposing the pt to the elements.. don't you think it might be nice to do that?

 

[Veneficus]

Since many of our pack outs can be several days, that's time for a slow spleen rupture to show up, or other slower developing issues. Having a nice set of baselines gives us a starting point. If its possible to get that baseline without exposing the pt to the elements.. don't you think it might be nice to do that?

Without disrespect,
I am highly suspect of the effectiveness of “spot checking” for occult injuries such as liver or splenic lacs, especially in the early stages where clinical signs such as Cullen’s or Grey Turner’s may not have manifested yet. For me personally, if I suspect I cannot do a thorough assessment or that there may be a serious injury, we are getting out of the elements if it means a lean to, and then anything that interferes is coming off. My opinion on this matter like others is not gospel; it is what I would do based on my knowledge and ability. (If I ever become all knowing or all powerful I will start charging a lot more for my service)

I understand low grades can be managed without surgical intervention, but I wouldn’t want to try that out in the wilderness unless I had no other option, and only until help could come.

Since I know in trauma that SBP does not correlate to CVP and therefore end tissue perfusion, I find limited diagnostic use with it. Pulse pressure is much more useful. So the BPs would need to be accurate, a quick and dirty one would not due. I heard a quote that I think are words to live by.

“Critical care is a mindset, not a place.”

I have seen “stable patients” crash suddenly more times than I can even remember. Anyone can read vital signs, I prefer to focus on finding the injuries, especially the occult ones, and then preserving or resuscitating organism function. I would rather have an exam without a set of numbers than a set of numbers without a good exam, ideally it would be both. It’s just my way. Not the only way. But I am glad to be able to discuss all the different opinions.

 

[Luno]

Wow. Any ski patrollers out there? What do you do "on the mountain" for first aid?

My gut instinct would be that I'm doing nothing more than a "rapid assessment"... +radial pulses=moderately adequate perfusion, and leave it at that until I can get the patient out of the elements.

No sense killing him faster because he's hypothermic.

BP Cuff over the jacket, palpate, it's not important in most outdoor/extreme weather circumstances to be 100 percent accurate, but it's important to establish a baseline to watch for changes. If you're in a situation where it's critical to be 100 percent accurate, then you should PUHA.

 

[mycrofft]

In twenty-below Farenheit, quick and dirty had better do.

Happily, I'm away from those temps now but when I was in 'em, it was suburban and urban, mostly hips and showshovel MI's, no more than ten miles to nearest hospital...although sometimes that meant forty minutes due to ice and accidents blocking the way.

If you think snow suits in deep cold are tough, try "ground crew ensembles" (chem warfare defense suits) wearing M-17 masks in a chemical-laced environment?

 

[FF894]

About 8 years ago we were at a MVC-guy entrapped but not severly injured. Guys awake, talking, and complaining of pain - all good signs in my book. My junior partner procedes to whip out the shears and cut up the sleeve of his goose-feather down jacket while I was going around the other side. Next thing I know we are all in white-out conditions, and its not snow. I could have killed him. Weeks later I still had feathers on me and in our bags.

 

[medicdan]

Happily, I'm away from those temps now but when I was in 'em, it was suburban and urban, mostly hips and showshovel MI's, no more than ten miles to nearest hospital...although sometimes that meant forty minutes due to ice and accidents blocking the way.

If you think snow suits in deep cold are tough, try "ground crew ensembles" (chem warfare defense suits) wearing M-17 masks in a chemical-laced environment?

Can you feel a pulse to palp through those suits? Assuming you havent deconed, how do you get inside to feel the pulse?

 

[BossyCow]

If I find a pt lying in a snowbank or in below freezing temps.. I'm going to do an initial assessment based on the most information I can get in the fastest way possible without increasing the danger to the pt. Now, does this mean that I expose a pt to the elements in order to get a BP or does it mean that I don't bother with a BP at all.. because these are two of the suggestions made. My answer was neither.. I will attempt to get a BP as part of my initial rapid trauma assessment. If what I see there, or what is evident by the mechanism of injury shows a high likelihood of internal trauma, then I have a number of decisions to make. First.. how fast and by what method can I get this patient out of the wilderness and to a trauma center.. second.. what do I do in the meantime to improve the pts chances of survival?

Yes a lean to is an option.. but if making a lean to and starting a fire takes more time than tranporting the pt to an LZ for airlift, I'm opting for the transport. Wilderness EMS is about weighing options and picking the best one for that patient in that situation. For an initial assessment and taking an initialB/P I'm going with my original post. Care doesn't stop there and its not the complete description of total pt care.. but its where I'm going to start.

 

[frogtat2]

bp

I was fascinated as I read this thread. Its interesting how different people look at things in different ways.

I live in an area where we treat hypothermia year round. In listening to the comments and suggestions made previously, I can only speak to what I would do.

After assessing the mechanism of injury and noted the time frame to when you can get this person some place warm leaves you with a tough decision to make.

Rule number one we teach all our emt students is you NEVER cut a down coat in an enclosed enviornment. That being said, if it were me, I would go ahead and cut the sleeve to access the arm and obtain an accurate bp. Afterwards, I would then close the sleeve back up using duct tape. It would hold the sleeve together and keep the pts arm warm and dry, while giving us the ability to reassess the bp in the future.

We rednecks love duct tape!!!