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

[Veneficus]

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!!!

I think we all agree that how far off your transport is makes the decision what to do. If you are out in the wild, you might have to do more before you can move or make decisions than if you can pull your truck up curbside and toss the snow shoveler (is that even a word/) in the back. But the scenario keeps morphing, so of course the decisions and priorities do as well.

 

[FF894]

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.

When my boy cut a down sleeve with sheers, it exploded in a flood of feathers. There is no holding those suckers back once seal has been ruptured.

 

[marineman]

We don't do SAR and I've never been on a call that we couldn't get the ambulance within 100 yards of the patient but we have a company policy that anything outdoors when the temp is below 40* is an emergency response regardless of dispatch code and all patients require urgent moves to a climate controlled environment. Therefore we wouldn't take a BP in the field for this type of emergency, it's a snatch and run.

My thought for anyone that would have to do this would be rather than cutting all the way up the sleeve why not start at the elbow and go up a few inches and just cut yourself a window big enough to get the BP cuff in on the arm, then you can either palp the pressure or send the steth just below your "window" to auscultate it.

 

[Lin57EMT]

BPs

After reading all the posts, I think there may be two scenarios that are the crux of the differing answers.

In prehospital ambulance situations, assessing ABCs (where a pulse is only palpated, not counted) is enough to get you to the next step, which is your transport decision. Stay and play, or load and go? After that we can fiddle all we like with actual vitals. We don't have to expose a patient to extreme weather to get the BP, unless you're administering nitro or something similar.

In the wilderness situation, there is no real "load and go", because getting a patient to definitive care can take hours, even days. In that situation a responder MUST have vitals to formulate a treatment plan.

Nobody wants to trade hypothermia for a systolic and diastolic IF THEY DON'T HAVE TO. But in the wilderness situation, where time moves ten times slower than our usual prehospital setting, obtaining and monitoring vitals is an essential part of the treatment plan and must be addressed.

I, too, live in hypothermia land. Truthfully, there are very few scenarios where exposing an arm or leg for the short length of time it takes to obtain a BP will put the patient in any real jeopardy, but still we would hesitate to do it. Take a quick feel at the pulse, do a good "look test", use other methods to check perfusion, and get your patient into a forgiving environment.

Wilderness people, as always it's a judgement call and each injury and each patient will require that you evaluate on an individual basis.

No pat answers for this one, I think.

 

[rjz]

My 10 years of ski patroling says to take a radial pulse and get them to "base". If they don't have a radial pulse get them to base faster and call a helicopter. Nothing I can do on the hill but transport, and nothing I can do ALS in "base" as I am only a BLS ski patroller. So a good dose of ski wax is the best thing I would say.

 

[EMT-P633]

Open parka, move 1 arm out of the sleeve, apply cuff. close parka. (assuming your cuff has the trigger mech. with the gauge on the trigger) route trigger/guage through either the neck or wrist opening. and use XXX/P. toss a couple hot packs in the arm pits for good measure on rewarming after exposing....

 

[LucidResq]

My 10 years of ski patroling says to take a radial pulse and get them to "base". If they don't have a radial pulse get them to base faster and call a helicopter. Nothing I can do on the hill but transport, and nothing I can do ALS in "base" as I am only a BLS ski patroller. So a good dose of ski wax is the best thing I would say.

Hallelujah.

If you suspect shock, get them the hell out of there and focus on monitoring other indicators like their mental status and HR. BP is obviously an important assessment. However, patient care is more important than having that number to write down. Sure, most of the time they're not going to die of hypothermia or suffer frostbite because you exposed their arm, but they're going to be uncomfortable. I can think of few situations where getting a BP is so urgently important that I would want to make my patient uncomfortable.

They say in SAR that 98% of our patients will be stable. Meaning, they will either be dead by the time we get there or they are not going to die anytime in the near future. So yes, in an extended carry-out situation, I'd probably feel alright with exposing a bit to take a BP unless they're so critical I am entirely focused on getting that person to definitive care and little else. We're not going to be rewarming them actively at all anyways.

It's killing me because I don't remember the name of it - but another local SAR team has a big snowsuit for patients they rescue in winter operations that provides easy access to important sites like the AC but is easily closed back up to minimize heat loss. If I remember it I'll repost.

 

[crotchitymedic1986]

Any condition that is serious enough to mandate an immediate B/P in the outdoor setting, will also require the removal of the coat. If you are just doing it for your report because you are not transporting, a B/P can be taken at the wrist, by sliding the jacket up a few inches.

 

[BossyCow]

Any condition that is serious enough to mandate an immediate B/P in the outdoor setting, will also require the removal of the coat. If you are just doing it for your report because you are not transporting, a B/P can be taken at the wrist, by sliding the jacket up a few inches.

No it doesn't

 

[crotchitymedic1986]

Sure it does, if you can not wait to get them to a warmer setting, then they must have an emergent condition. Any emergent condition, will require access to the patients arms and torso (whether medical or trauma). If it is not emergent enough that you feel the need to undress them in the bitter cold, then they can wait until you get to a warmer area.

But please give me an example.

 

[BossyCow]

Sure it does, if you can not wait to get them to a warmer setting, then they must have an emergent condition. Any emergent condition, will require access to the patients arms and torso (whether medical or trauma). If it is not emergent enough that you feel the need to undress them in the bitter cold, then they can wait until you get to a warmer area.

But please give me an example.

Taking a BP is part of a set of baseline vitals. There are issues that can show up in a wilderness situation that would not be obvious on initial assessment, even if we did open them up and expose them to the elements. For example, a ruptured spleen, sepsis, if its possible.. and it is, to get the BP without exposing uneccessary parts to the cold.. seems to me it makes sense to do it that way. Why compound the initial issue with hypothermia if its not necessary?

 

[rjz]

I agree that a BP is part of a baseline set of vitals (here it goes) BUT....in my experence the majority of things that I see on a ski run a BP is not needed. If I do need to know about their circulation status I can check a radial pulse, check their LOC, look in their eyes, and look at their skin and get a good feel for what their blood is doing. This is just like being able to look at a pt. from across the room and decide if they are sick or not. If they are sick you know they are sick, please don't waste scene time trying to remove clothing to get a BP that won't change your treatment. If they do have splene injury, closed head, etc. that BP's would be nice for; you will catch it w/o having to worry about a BP. ( with proper assessment techniques.) Yesterday I took care of a busted sternum and a dislocated shoulder neither of which needed a BP. A simple pulse check surficed until I got into base. The sternum had every botton, velco strap, metal clip in use to close himself up against the elements that trying to get it all off was a NIGHTMARE. however a simple move of the glove cuff and I was able to assess his ciculation, the wrist is usually well protected from the elements and so skin signs can also be checked there.

So my two cents...BP are not needed on a ski hill they can wait.

 

[BossyCow]

I agree that a BP is part of a baseline set of vitals (here it goes) BUT....in my experence the majority of things that I see on a ski run a BP is not needed. If I do need to know about their circulation status I can check a radial pulse, check their LOC, look in their eyes, and look at their skin and get a good feel for what their blood is doing. This is just like being able to look at a pt. from across the room and decide if they are sick or not. If they are sick you know they are sick, please don't waste scene time trying to remove clothing to get a BP that won't change your treatment. If they do have splene injury, closed head, etc. that BP's would be nice for; you will catch it w/o having to worry about a BP. ( with proper assessment techniques.) Yesterday I took care of a busted sternum and a dislocated shoulder neither of which needed a BP. A simple pulse check surficed until I got into base. The sternum had every botton, velco strap, metal clip in use to close himself up against the elements that trying to get it all off was a NIGHTMARE. however a simple move of the glove cuff and I was able to assess his ciculation, the wrist is usually well protected from the elements and so skin signs can also be checked there.

So my two cents...BP are not needed on a ski hill they can wait.

Not on a ski hill maybe, but in the backcountry yes. Totally depends on your packout time.

 

[Summit]

Since the question is what is the BEST way... not should you...

Four ways:
1. Do they have big pit zips? They do? Life is so easy!
2. Unzip coat front, stuff BP cuff down coat arm (works sometimes).
3. Remove one arm from coat, put on cuff, replace sleeve with pump/guage coming out at the neck.
4. Radial pulse means systolic is prolly above 80... unless they are hypothermic... or my fingers are numb...

 

[rjz]

BHey Summit,

I like it I had never thought of using the pit zips before. Thanks!!B)