[DVarmit]

Just curious for your thoughts on this.....

I'm working in a VERY small ER (after doing level I trauma a few years back) and I've encountered a doc that just makes me crazy!

He and I have clashed on a number of issues.....it's pretty unanimous across all the staff that he's not the best physician we have

Anyway - he was admitting a patient with test results that showed a pericardial effusion and the woman was stable and not having pain at that point. He starts running around the bed wanting us to manually check the B/P on inspiration and expiration for the pulsus paradoxus. This is AFTER he went to the desk and looked up "pericardial effusion" in a text book.

One of my coworkers with gads of experience told me about just checking the pulse for a change in strength with breathing..........but has anyone really, really done a slow B/p check to try to measure this manually? I really thought it was just something one might monitor through a line readings?

(This is from a doc who ordered a CTabd on a patient - then gave her lasagna to eat from the staff fridge himself.) I am really trying to appreciate all the lessons I can learn from being in a smaller environment, but I think this one makes me nervous!
Dawn

[EricEnfermero]

The procedure for that seems pretty confusing to me, especially in a patient without an art line. This link describes one method:

http://www.emedicine.com/med/TOPIC283.HTM

I've seen electrical alternans (big QRS, little QRS alternating) in a late pericardial effusion patient and I thought that was pretty diagnostic, but according to the above article, it's not entirely specific to tamponade.

[Cathlabnurse46]

I was going to suggest the pulsus alternans also. After years of being away... I walked into our CVICU and looked over at the monitor to see the taller and shorter QRS complex. I immedatley said "hey... how long has that patient had pulsus alternans".? The staff said "what". None of them knew what or why this was happening. So I just had to ask "Is the patient here for a tamponade or effusion"? They said "how did you know"?

LOL.... sometimes with all the modern tech stuff people forget basics. You don't always need a stat echo to confim it. Yes pulseus paradoxus and pulsus alternans are old ways to DX tamponade and effussions as is just a plain old 12 lead. Also listen for the rub.

[Cathlabnurse46]

I believe that the pulsus paradoxus occurs because the filling of the LV is compromised as the RV ejects. there is a slight delay between the two normally. As the LV is squeezed by exudate or blood in the pericardium the shift causes the the difference in pulse pressure (measured in systolic height). This alternates back and forth. the second issue become the shift in the electrical conduction in the ventricles in the QRS complex. That's why they often go together. Palpating the pulse is subjective whereas printing out a graphic of an arterial tracing is not. Often we can feel PVC's that do not perfuse as well like pulsus paradoxus so it is helpful to see a monitor.

I hadn't had to do it in YEARS. But sometime it's scary what you remember when you see something and other "newer nurses" have never seen. It's a real teaching opprotunity.

[Cathlabnurse46]

From the link above

Pulsus paradoxus or paradoxical pulse: <LI class=plain>

• This is an exaggeration (>12 mm Hg or 9%) of the normal inspiratory decrease in systemic blood pressure.
• To measure the pulsus paradoxus, patients are often placed in a semirecumbent position; respirations should be normal. The blood pressure cuff is inflated to at least 20 mm Hg above the systolic pressure and slowly deflated until the first Korotkoff sounds are heard only during expiration. At this pressure reading, if the cuff is not further deflated and a pulsus paradoxus is present, the first Korotkoff sound is not audible during inspiration. As the cuff is further deflated, the point at which the first Korotkoff sound is audible during both inspiration and expiration is recorded. If the difference between the first and second measurement is greater than 12 mm Hg, an abnormal pulsus paradoxus is present.
• The paradox is that while listening to the heart sounds during inspiration, the pulse weakens or may not be palpated with certain heartbeats, while S1 is heard with all heartbeats.
• A pulsus paradoxus can be observed in patients with other conditions, such as constrictive pericarditis, severe obstructive pulmonary disease, restrictive cardiomyopathy, pulmonary embolism, rapid and labored breathing, and right ventricular infarction with shock.
• A pulsus paradoxus may be absent in patients with markedly elevated LV diastolic pressures, atrial septal defect, pulmonary hypertension, and aortic regurgitation.

If I remember right, there are 5 K sounds. So you would be listening for the first 2 sounds and recording those to get the dfferance. Again I haven't had this type of dicussing in 20 years! I better brush up.

[mpccrn]

cardiology has us doing this all the time when they suspect an effusion or beginning tamponade....and yes, we do it manually.

[robinbird]

Pulsus Paradoxus or (pulse parodox) is an art. The person who taught me how to do it said if you want to get really good at pulse paradox, do it as part of your assessment on every patient. I've done in many times and always with a manual cuff. It's not always easy, depending on the patient's condition, size, cooperation. Follow the directions in the link above but here are some tips that I have learned to make in easier:

• Position yourself so your head is at the patient's chest level (I squat down)and you can see the sphygmomanometer on the wall.
• Take a manual blood pressure first, the way you normally would.
• Explain to the patient that you are going to take another blood pressure but this time it will take a while.
• Inflate the cuff above what the systolic pressure was in the first BP and let it deflate by itself. Don't turn the little screw on the cuff.
• Watch the patient's breathing. You will hear the first heart sound which should be during expiration (when the chest falls). Glance up at the sphygmo. This is your first number.
• Keep watching and listening. When you hear a beat during inspiration (when the chest rises) this is the second number.
• I usually do this a couple of times, especially if the parodox is abnormal.
• If the second number is within 10 mmHg (at our facility) of the first number this is generally normal. Greater than 10 is abnormal.
• I record it as: "Pulse parodox of 14 mmHg".

Robin