Initial blood presure do's and dont's, and lead placement

[medic511]

From my perspective, we are really looking at a combination of ideal/textbook on the one hand and practical/in-the-field on the other hand. "Best" is meaningless until defined: most accurate under all conditions is one thing and which is in the patient's best interest in the existing circumstances may be quite different. So, you have to know, IMHO, if the call is a trauma with major MOI on the one hand or a probably minor medical with a not-likely-life-threatening NOI on the other.

I don't think that a properly taken BP over a loose (neither really tight nor really bulky) shirt or blouse will vary significantly from one taken at the same time, same situation but with the single layer of cloth removed. IF the clothing bunches up around the upper arm, you are much more likely to get a bigger variation than you would had you left the single layer of loose but not-bulky clothing in place.

I personally STRONGLY prefer a manual initial (or soon thereafter) BP but I really think that it's more because I get a better "feel" for the patient's overall condition. I have found that properly taken machine readings are actually more CONSISTENT in difficult conditions (usually noise related such as on-scene radio chatter or en route road and siren noise) as compared with readings taken by different personnel manually. ANY unexpectedly high or low machine readings should, IMHO, be immediately confirmed by manual readings and I like to use the other arm because its quicker and kind of has a built-in check for whether is this a unilateral rather systemic issue.

Regarding the ECG lead placements, my initial observation about varying with circumstances is still true but maybe less important. The clinically "best" locations in a still room, with a patient without muscle tremors, and in an environment without problematic radio or electromagnetic interference, is clearly the just proximal from ankles and inside of wrists. However, in a moving vehicle, in an electrically noisy room, or with a patient that has continuous tremors, these placements will frequently increase the artifact (that's the meaningless random noise), which makes manual interpretation harder and thus less accurate. Machine or computer interpretation can filter out much of the artifact and thus better placement MAY result in a more accurate interpretation even though it also brings increased artifiact.

Regardless of location chosen, you will improve results by (1) making sure that the locations are bilaterally symmetrical (that is not right clavicle and left wrist) and (2) making sure that the location chosen is backed by solid masses (like bone) rather than bouncing muscles that produce electrical impulses that are unhelpful (i.e., noise).

Just remember, time is blood and muscle and brain, so DON'T waste time when it's critical trying to get the "best" or most "accurate" pressure or waveform. Your patient may be "best" served by a quick and sufficiently accurate assessment to get enroute quickly to the most appropriate facility. A few or even several millimeters of mercury or a few degrees of axis deviation really don't matter in the pre-hospital setting. Especially with BP, the trend is FAR more significant than the actual numbers as long as you are in the right ballpark; thus, consistency is often more important than absolute accuracy.

[EMS49393]

I think you'll find that for every way you can do something, at least one paramedic wants it done that way. For instance, when I'm monitoring a patient, the leads can be closer to the chest, although I prefer upper arm and lower leg placement. In the hospital, the leads are generally places on the chest to decrease artifact. Most telemetry patients move around quite a bit, reaching for the call button, going to the bathroom, adjusting sheets, etc. In that instance, the purpose of the monitor is just that, to monitor. Diagnostic ECG's are performed when ordered by the physician.

As far as the blood pressure thing goes... I like to get the initial blood pressure manually, and I prefer to do it myself, at least the initial. It's not that I don't trust a basic, it's that I have a different partner every shift, and rather than wonder if they got me an accurate pressure, I just do it myself. Unfortunately, our little one month wonder academy has failed to teach them correct diagnostic ECG placement, so I'm often left doing my own 12-lead as well.

When you're with a new partner, just ask them how they like to do things. I make it a point to lay out how I function at the start of a shift, that way my partner knows what direction I'm coming from. It also saves the steps of me having to explain things in the heat of battle. I encourage questions, and I'll teach any basic or medic anything they want to know, they just have to ask me. Any good paramedic should be the same way, and if they are vile and mean to you for asking them how they like these simple tasks performed, they suck.

[medic_texas]

Anytime we get a trauma in the ER, we do a MANUAL BP first. This is a level 1 trauma center and that is the protocol, manual BP before NIBP. Working as a tech almost 10 years ago in that ER has stayed in my mind; need a manual BP before you utilize the NIBP. Do you really trust those stupid things? If time allows, I recheck my BP enroute. Ever have someone take your BP and you're like ok.. and going down the road you recheck and its WAY off? Yeah, that sucks.

Secondly, lead placement. Leads should be placed on "meatier' surfaces meaning do not place them over boney surfaces (clavicles, ankles, ribs, etc) if possible. I know some skinny patients its more difficult but you can use the deltoids and calves. If you go too far below the ribs you will get a lot of artifact from breathing. So, I mainly use the upper arms (deltoids) and the inside of the lower leg (lower calf muscle).

[letmesleep]

I HATE NIBP!!!!!!! sorry had to let that out. I still take the manual BP on all my Pts. we have this fancy gizmo attached to the monitor (LP12), but for me it stays in the side pouch. I'm won't judge any one who uses it for continued monitoring, but it's not for me. As far as bare arms, that is of course the optimal means of getting your BP, but the trick is being a "MASTER" of this skill. VS are far to important in Pt assessment to slack off on. I will back up for a second as far as not judging, any student that rides with me does not get to utilize the NIBP either, this gets back to mastering the skill.

Ekg lead placement is as follows for me: RA to the right forearm (the meat as posted above), LA repeat to the left forearm, RL to the right calve (again to the meat), and LL to the left calve. I was taught many years ago (hammered in to my head that is) that there is a reason they are called "limb leads", they go on the limbs. I will also agree (before any one comes after me) that there are exceptions and the "limbs" are not always available..........

[zippyRN]

<tinned meat product alert>

to the OP i presume you had permission to advertise?

[firedoc5]

Yes, for your initial/ base line BP do it manually. Don't rely on machines the best you can. NIBP is for monitoring at certain intervals. Even if you are using NIBP, occasionally take a manual BP. I worry less about human error than machine error. If you are wanting to compare bi-lateral BP's, don't do them at the same time, at least that's what I've always been told. Check with your Project Medical Director or Supervisor to find out what is preferred.

Same with lead placement. Check with someone who calls the shots for your program. I've found that if you are just wanting to do a three-lead ECG in the field to more or less monitor your patient, just place your leads on the chest where the electrodes instruct you to. Just don't place them directly onto a bone such as a clavicle. At first you might have to practice by trial and error to see where the lead placement gives you the best picture. After awhile it'll become second nature. And of course it depends on the patient. Their weight, body type, breast size, needs to be taken into consideration.

Just a side note. When defibrillating, watch your wires and electrodes. Don't defib on top of them. Move them if you have to.

[Arizonaffcep]

Manual BP is best over bare skin...etc etc etc, like everyone has said. The one thing that I find interesting is that most modern monitors have attenuated leads, meaning they are ment to go on the chest, not the arms/legs of old and will give the same reading, chest or arms/legs. This doesn't always hold true for a 12 lead, but for 3/4/5 leads, it is.

[medic511]

NIBP stands for Non-Invasive Blood Pressure. That is, as opposed to an intra-arterial transducer placed inside the artery by an MD such as used in the ICU, CCU, etc.

Manual BPs are also NIBPs.

So, ALL EMS BPs are NIBP but they can be machine or manual. (The button on the machine often says NIBP).

[mobey]

NIBP stands for Non-Invasive Blood Pressure. That is, as opposed to an intra-arterial transducer placed inside the artery by an MD such as used in the ICU, CCU, etc.

Manual BPs are also NIBPs.

So, ALL EMS BPs are NIBP but they can be machine or manual. (The button on the machine often says NIBP).

Good point my swift friend!

I guess it's like I always say "stick on the paddles". Of course I mean pads.... but the button says paddles!

Non- invasive means no stethoscope in my ears......... Ya, thats it

[Arizonaffcep]

NIBP stands for Non-Invasive Blood Pressure. That is, as opposed to an intra-arterial transducer placed inside the artery by an MD such as used in the ICU, CCU, etc.

Manual BPs are also NIBPs.

So, ALL EMS BPs are NIBP but they can be machine or manual. (The button on the machine often says NIBP).

Correct. All BP's are NIBP unless they have an ARTERIAL LINE, where they INVASIVELY measure the pressure. The discussion is auscultation vs. machine...as has been stated a lot previously in the thread, the machine NIBP, due to road noise and other things, isn't always a reliable tool, which would make auscultation more reliable. Of course, the trick is to know when EACH is being "questionable." I have found it's not necessarily always about the numbers per se, as opposed to the trends in the pressures taken.