Recently I have been taking 90% of my blood pressures with an automated cuff off of a LifePak 12. Cool, right ? Not really. You see up until now, all my blood pressures have been done manually with a cuff and stethoscope. Now some would argue that the “convenience” and “accuracy” of this technology is an asset to modern Pre-Hospital care. And that I should get with the times. (I’m young and only 4 1/2 years in… I’m with the times)
To be honest, I don’t like it. And I don’t like what its training our Paramedics and EMT’s to do. And that is to play the monitor like a penny slot in Reno. Before I get into that, I’ll highlight the pros of an auto BP cuff, to which there are some.
First: Yes, it is convenient. And who could argue with data storage, and the ability to transmit that data to the ER or an e-PCR… That’s about it. What I see are providers doing their assessments, and when the auto PB pops up its reading, their is a moment of contemplation. The questions is do i like this Blood Pressure? Or, Do these numbers make sense? sometimes there is even an exchange among care givers that goes something like: “you ok with that?… sure” or “you like that one?… nah, try it again”.
So what happens if you don’t like the first BP? take it again. How about the second? No? well we’ll try it one more time. So now after 3-5 minutes, you have 3 different BPs and what?
There are many factors that can interfere with an Auto Cuffs reading. Things like: A moving ambulance. A moving patient. An incorrectly sized cuff. A patient that is especially Hypo or Hypertensive, and so on. Yes, movement of the patient and the ambulance can disturb the process of taking a manual BP, but by holding the patients arm, it allows you to support and stabilize the arm, while also discouraging the patient from moving it.
The deal is, when I take a manual BP, and its 230/110, I know it is because I heard the pulse at 230, saw the needle bounce at 230, and followed it down to 110. Same goes for 88/60. I saw it, heard it, felt it. I find another advantage to manual BPs, is that you can assess skin signs, respiratory effort, and you can hear and feel the strength and rhythm of the pulse. If you allow it, a manual BP can tell you a lot about the cardiovascular status of your patient.
Now I’m not calming that my ears, or anyone else are the best in the world. And of course there are times when you just cant hear anything, and a few other situations when an Auto BP cuff can help, but generally, I prefer a manual. In the end it all comes down to a good assessment , and an accurate Blood Pressure is a major piece of that assessment.
Do good, and treat well.
I’m the same way, I’ve seen the auto BP cuffs be WAY off, so I like to auscultate a BP, then use the auto cuff, if the readings are close, then I will use the auto cuff and trust it, if not, I’ll use the manual cuff. Of course, I haven’t tried to auscultate in the back of the moving rig yet, I’ve only done it in a clinical setting….
~Brad
@EMTGoose
Great feedback, Guys. You all bring up a lot of good points. I can see the differences in our systems at work here. I agree with the aspect of freeing up hands, but in my system there was a Medic and EMT in the back during ALS transports, not to mention four or so other people on scene. So free hand were not much of in issue And yes, stable Pt’s, not much to worry about with them. And the use of good judgment. If the PT is awake and alert, with normal skin and pulse, but the BP is 88/50, the monitor is most likely wrong.
for me i prefer to take the first BP manualy or systol over P to at least have a compar then i will go with the zoll PNI C serie and also some time for long run i will programe the 5 minutes delay
I mostly agree with you on that, although the automated BP machines in the prehospital arena are quite accurate when you are not moving and the cuff is appropriately sized, etc. (there are studies on this).
Ultimately it comes down to good clinical judgment when using the machine. If your first BP was taken manually or at standstill and you get a drastic change take a manual one. Look at your patien. If you’re in the back of the ambulance and you go over a patch of bad road and the monitor looks like VF you don’t clear and shock, you look at your patient and confirm they’re still alive. It’s a similar situation here.
Unfortunately this can sometimes be difficult especially if you are short on personnel. For instance if you have an critical patient and one medic in the back of the bus then you need to make the risk/benefit whether it’s worth it to take your time and get a manual BP or do other interventions/assessments, etc.
– @medicjosh
I’m with you on this one. I’ve read the studies and such on the accuracy and think that’s great, but even if it is accurate, I’ve never minded having to do my own BP and personally prefer it. Since we usually have a third person on our crews anyways, it’s never been a problem.
I partially agree with you on this topic. I have had EMT-Bs take a pressure and tell me that it was 74/42 (while the patient is sitting up talking to me with no abnormal signs). The EMT didn’t take the time to listen; The patient had A-fib and was bradycardic with a rate in the 50s. The EMT-B thought the first sound he heard was at 74 (I used this as a teaching point that you can’t just rapidly deflate the cuff, it has to be slow and controlled). The PTs pressure was actually around 122/64. We are humans and therefore can make mistakes. I have heard (and it sounds reasonable) that BPs taken with a machine are easier to use in legal cases. Of course you can place the cuff on wrong.
I try to use both approaches. I take a manual BP first to get a baseline, then let the machine verify and monitor the BP for the PT. I am in the back by myself with the patient and it is nice to have a machine to check the BP every 5 minutes (or 15 minutes) for me while I perform other interventions.
I’m with the Monkey on this one… They’re good for continued transport, but not initial pressures. I worked the back of the bus as a medic a long time ago, before auto-cuffs were popular or accurate for pre-hospital use. Today, my department has multi-function monitors in use on the ambulances and rescue truck. They are great for those days when I want to see “just how hypertensive I am today”.
For patients that are clearly stable, complaining of a twisted ankle playing b-ball at the gym, I don’t mind using it at all… it’s not that important in the big picture. Anyone else, however, fugheddaboutit, I’m taking a manual pressure for the initial. Why? Because I don’t trust the machine. It’s got to be calibrated regularly, the slightest interference throws it off, it takes too long to read a high – or low – pressure accurately, and it goes too many days without being used. Simply put, I’m skeptical that the machine is going to accurately tell me something I can bet the patient’s life on the first time, every time.
fm, I tend to do it the other way. When I need hands free, I use the automatic cuff because a lot of the time we won’t have extra help, or even really need it (I don’t like a bunch of people in the back of my ambulance, some things are better done by me and me alone) and I can do multiple procedures quickly while the cuff is doing it’s thing. I use the manual cuff in transit for patients where I do very little or have reached the end of what is appropriate. Good topic Jeramedic.
NIBP uses arterial pulses, so irregularities such as atrial fibrillation result in inaccurate and irratic readings. Unfortunately, AFib is quite common.
i really liked what you have said
here with the pro on manual b/p.
i have been taking manual b/p in
the back of a moving ambulance for
24 years now (still counting). i too
have witnessed just yesterday the
problems of a manual vs machine!
i took a pressure on a trauma pt.
then we took the auto prssure it was higher then mine. we recycled it and it came back with the same b/p as mine. pt was moving due to the pain and the pressure was off. we too have bought through the years some sort of auto cuffs but time and again we end up taking a manual pressure. now for the people out there that just are not that good at pressures it might work in that sense..my husband and i were partners for years he just could not hear b/ps that good esp if we were in a veh with a lot od noise or the back of a moving rig. so i always took the b/p. i have come to trust my b/ps. now thats not over confident or anything else other then years of experience. great article.
taking an auscultated bp is a good way to have some “alone time” on a call…
I agree and disagree. I really enjoy the auto blood pressure cuffs on my monitor. For the most part, it’s accurate and it frees up my hands to do other things while transporting. The monitor wont forget to take a second BP because it “ran out of time” or “got too busy”. It works well in loud environments when hearing a manual BP can be difficult.
On the flip side, when it’s off….IT’S OFF. They can be very picky of the environment that they work in. Moving patients, vibration, etc can alter it’s reading. If I get an off-the-wall reading, I usually just listen with my own ears to confirm.
I think it’s a great tool, but not a necessity. Nothing can ever truly replace the traditional method for taking vital signs.
Good post Jer.