Question about reading really low BP's

papawjohn · Sep 30, 2005

Hey Vampireslayer

Yeah, you understood the Dopler BP right. It gives no diastolic reading. Palp means 'palpation'--as in, you put a finger on the radial pulse, inflate the cuff until no pulse is palpable and then sloooowly deflate the cuff until the radial is again palpated. Of course this also gives no diastolic--you can think of it as 'tactile dopler'.

Unbelievable amount of Dopamine. In my humble opinion--useless to go that high. (I wasn't there at the time, you understand, so I'm not specifically calling anyone any dirty names....) But if that were given to you as a test, the right answer would have been to add different drugs to make a customized 'cocktail' of pressors. For example NeoSynephrine for vasoconstrition is frequently combined with Dopamine for cardiac stimulation. Epinephrine can be given as a gtt.

Sounds like a clear case of CTD

Papaw John

hrtprncss · Sep 30, 2005

HI...In my experience, when patients are severely vasoconstricted due to multiple gtt's that's been maxed like dopa/epi/neo...sometimes the extremities when u feel them they get kinda cold and sometimes it can be difficult to do manual bp on them, but not as bad as when you go and respond to the code on the floor and they're using the dinamap and you see the dopa w/o(which personally I cringe on that, let's fry the heart while we're at it...and i know know the patient is in cardiac arrest but believe me, post resuscitation when i take the patient to the ICU, so many other complications can arise that could have been avoided by not infusing the whole bag of dopamine). Anyways sometimes we just don't use dinamap anymore and just use your regular stethoscope and manual, but amidst all the chaos, it's quite hard to hear it also. That's when we use the doppler.

When it comes to ''palp'', it's just an emergent way they use when determining bp by palpation with a cuff. Though another method by palpation that you can use as a guideline is that if you can feel a carotid pulse, then sbp is at least 70, if you feel the femoral then sbp at least 80, and if you can feel the radial, then sbp is at least 90. it's the 70/80/90 rule, but like i said it's only a guideline.

hope this helps

IMHO

hrtprncss

EDIT...Just sayin hi to papaJ...

tridil2000, MSN, RN · Sep 30, 2005

I had a pt. the other day who'd coded, they'd gotten her back but she was unresponsive, very little brain activity (but some...). During the code they'd given dopamine wide open...then when I got there, she was on a dopamine drip @ 50mcg/kg/min (yes, 50). Still, her pressures were unreadable by our auto. BP monitors, and I couldn't hear anything when I tried to do manual pressures. The code was over, no one was in the room but me, it was quiet...is it common not to be able to hear it if the BP's really low? Or is it me?
So for her vitals, the only thing I could think of was to use the manual BP cuff & the doppler, find her pulse with the doppler, then inflate the cuff until I couldn't hear the pulse anymore, and slowly deflate it until I could hear it. I assume the point at which I could hear the pulse via the doppler would be considered her systolic BP, is that right? But then there's no diastolic since you continue to hear the pulse via the doppler as the cuff is uninflated....right? Could this method be skewed simply based on how firmly I was holding the doppler against her artery?
Also, I've just been watching the very first season of ER (never watched it before now, but since I've gotten this job in the ER, it's become fascinating to me!) and they're constantly calling out really low pressures like "60/40"...can you REALLY hear a pressure that low? Is that real? Why couldn't I hear it? I tried several times, couldn't hear a thing. & I tried both arms, many times, with the auto. BP monitor, it couldn't detect it.
Oh, one more question...what does "palp" mean, when they say "pressure's 50 palp"...
And finally, before anyone wonders why I was the only one there with her pressure that low...she was DNR. They didn't know that before the ran the code, of course...
Thanks!
VS

well, your last sentence says a lot!!

if she wasn't a dnr, yes, you can get a 'palp' pressure by just feeling for the pulse while deflating the cuff. this would be '40 palp'...and yes, you can feel that. if you can't, get the doppler out, just like you did... and try to 'listen' for it.

if you're using 50 mics per kilo of dopamine and you still have a pressure below 60, you should consult with the dr to try either levophed or neosynephrine.

when you're using that much dopamine (or any pressor really), you're going to notice blue extremities etc b/c of 'clamping down'. pt's can infarct their bowels and brain, and of course, lose all kidney function. additionally, sometimes the pressures can cause ectopy, so watch for that.

sounds like you're doing ok. did the pt make it???

vampireslayer · Sep 30, 2005

Thanks everyone.

Yes the patient made it, at least as long as it took for me to get her out of there & up to ICU. The ICU nurses said the exact same thing you all have said, that just adding more & more dopamine was senseless, and the docs should have added another drug.

Thanks!

VS

Aneroo, LPN · Sep 30, 2005

In EMS, we use palp BP's a lot- kinda hard to hear diastolic in the back on a truck. -Andrea

jbwozny · Sep 30, 2005

Granted I work in an ICU, not an ED, but does anyone else find it odd that a pt that had so little pressure that they neede to be left on 50 mcg/kg/min of Dopa (agree with the above posters about adding in other pressors instead of going that high on Dopamine) didn't get an a-line placed? Again, I know it is different paradigms in the the unit vs the ED, but one of the things that always happens whe we have some one code (or respond to one on the floors) is placement of a central line and an a-line. Likewise, any patient that gets placed on pressors gets both as well.

Vampireslayer, this is not an attack on you. Just want to raise the point and see what folks from an ED environment think.

oh yeah, good thinking on using the doppler with the manual cuff....strong work.

UM Review RN, ASN, RN · Sep 30, 2005

We use the doppler to get an idea of the SBP for crashing patients quite often.

I prefer it to the palpation method because I do palpation BPs so seldom I don't trust my readings.

shadowflightnurse · Oct 12, 2005

I agree with the others in that the patient probably should have been put on something else. Since she was a DNR, I would guess (and it is only a guess) that the ED doc probably wanted to let the attending deal with her. Kind og like, hey I got her pulse back, but now why bother with anything else since she's a DNR. That is probably why you were left alone with someone with such bad VS.

I had an experience with a little lady that coded, we got her back and the family decided to make her a DNR. The ED doc would not treat her at all after this. He wrote "basic" ICU admission orders, but nothing else. Her pressure was in the crapper and he wouldn't order anything. The admitting doc wouldn't give any phone orders (since he hadn't seen her). So here's this little lady with a horrible pressure, intubated and with who knows what (if anything) going throught her head. And what do we do for her...NS and ventilation. Some people don't seem to understand that DNR doesn't mean "do no treat."

Sorry for the rant on your post, but it brought back memories.

teeituptom, BSN, RN · Oct 13, 2005

well if the BP is that low, so low that you have to worry about whether to use doppler or palpation then insert an art line, in the meantime consider

put her on another pressor

give her fluids

or call a priest

austin heart, BSN, RN · Oct 14, 2005

Ditto on the art line. My question is if the person needed that much Dopa why did they not think of calling the code?????? To heck with adding other pressors.

teeituptom, BSN, RN · Oct 14, 2005

Welcome to the wonderfull world of ER Nursing