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Blood pressure in peds patients

Emergency   (807 Views | 1 Replies)

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Background- My experience until recently has been 3 years in an adult only ER. I now have a second per diem job in a a busier emergency department that sees a ton of kids, not a population I am familiar or very comfortable with yet. Last night I was in triage, and felt a little overwhelmed by how many kids came through and I realized I'm needing to review somethings and work on new skills! Its fun.

Here's my question to the community of experienced ER nurses!- At what age is it necessary and valuable to check a blood pressure on kids? Is this something you routinely do, or skip in kids with certain high ESI scores under a certain age?

This question occurred to me last night when I was going through my triage process like I would with a large person, and I was so exasperated to realize that IT IS NOT EASY to get a BP on crying squirming babies and toddlers, and furthermore, are the values even reliable when they are not calm? I wonder how useful a blood pressure is under a certain age when, as I know from PALS, children compensate their pressures and sick kids will have other poor perfusion signs first.

I bring this question here because when I asked some nurses I worked with last night, I got inconsistent ideas about practice. One nurse told me she measures BP on all patients, and another said that they don't measure on kids under 3 years.

When I look online for best practice, I found this interesting study ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3385663/ ) which in summary, discusses that for kids with an ESI of 3 or 4, blood pressure may not be valuable in kids <5 years old.

I would like to hear what your practice is when triaging and caring for kids in the ED, or maybe be pointed in the direction of pediatric emergency standards of practice. Having a hard time finding definitive info from my Google searches.


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I can only tell you what I've heard:

- Some places have policies for their own reasons that demand blood pressures on all patients, including all peds.

- Because of ^ this, some nurses put blood pressure cuffs on every peds patient, whether squirming, clenching, flailing or screaming bloody murder, and will enter the resulting value into the chart.

- Some nurses assess patients by other means, including those you have mentioned, and make an attempt at blood pressure; if it is clear that an accurate value cannot be obtained in a low-acuity patient at that time, the attempt is abandoned.

There's no arguing that in general children should be screened and monitored for hypertension. I haven't yet read any widespread standards about how a blood pressure on a frightened, crying/screaming, active or resistant patient has anything to do with appropriate screening.

The referenced article was interesting, but due to innumerable observations, I don't think that their definition of calm is sufficient and I also doubt the accuracy of the determination that a child was calm.


Calming techniques included distraction and parental soothing as deemed appropriate for age, acuity, and behavioral state. Patients were determined to be “calm” if they were cooperative, still, and accepting of BP procedure. Patients were considered to be “not calm” if they were crying, fighting, or moving during the measurement.

My experience is that it's fairly rare for a generally healthy infant/young child at a lower-acuity ED visit to tolerate a blood pressure without the fine movements they usually do in response to it: the fine clenching, twisting and intermittent muscle movements--even when they otherwise could generally be said to be calm (even cooperative).

There are other factors (anecdotally) that would also suggest that a triage b/p is particularly worthless even if a b/p was absolutely mandatory sometime during the visit. They come into the triage area and, whether in pain or particularly fearful or not, they are encountering stranger, they're very curious about their surroundings, they are uncertain about what's going to happen to them or if it's going to be painful or scary.

I would make the argument that in the absence of conditions (whether congenital, chronic/acute, etc) that place them at high risk, this is a very low-value activity in the ED.

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