How often should you take vitals on a critical patient?

Veneficus

Forum Chief
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The textbook and national registry claim every 5 minutes.

I have worked at hospitals where the NIBP was set to every 3 minutes by default in the code bays.

Now while this study was done in surgery, on patients recieving spinal anesthesia, should we start looking at re-examining how often EMS should be taking vitals in unstable patients?

What are the chances that the mechanism inducing hypotension changes the ability to detect it?


Detection of Hypotension During Caesarean Section With Continuous Non-invasive Arterial Pressure Device or Intermittent Oscillometric Arterial Pressure Measurement

C. Ilies; H. Kiskalt; D. Siedenhans; P. Meybohm; M. Steinfath; B. Bein; R. Hanss

Authors and Disclosures

Posted: 09/10/2012; Br J Anaesth. 2012;109(3):413-419. © 2012 Oxford University Press


"Results When averaged over all cycles, the lowest systolic AP identified by CNAP in each cycle [105 mm Hg, (24.4)] was significantly lower (P<0.001) than the average of the individual corresponding single NIAP measurements [126 mm Hg (22.1)] and highest CNAP average [126 mm Hg (24.5)]. Hypotension (systolic AP <100 mm Hg) was detected in 39% of all cycles with CNAP and in 9% with NIAP. Hypotension was detected in 91% of the patients based on CNAP and in 55% based on NIAP. Fetal acidosis defined by an umbilical vein pH under 7.25 did not occur when the lowest systolic AP measured by CNAP was above 100 mm Hg.
Conclusions The CNAP device detected more hypotensive episodes after SPA and significantly lower AP compared with NIAP. AP monitoring based on CNAP may improve haemodynamic management in this patient population with potential benefit for the fetus."
 

JPINFV

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The bigger issue for EMS is that often taking a blood pressure takes 100% of the crew attending to the patient. As such, the better question is when should a new set of vitals take precedence over providing interventions (assuming the vitals are based on a schedule and not looking for change due to intervention)?
 
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Veneficus

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The bigger issue for EMS is that often taking a blood pressure takes 100% of the crew attending to the patient. As such, the better question is when should a new set of vitals take precedence over providing interventions (assuming the vitals are based on a schedule and not looking for change due to intervention)?

there are services outside of IFT that are still using manual BP?

I advocate the balance between skill and technology, but really, no automated BP in 2012?

Do they push the ambulance with their feet like Fred Flintstone?
 

NYMedic828

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Just set my monitor to Q5 :). Takes no member of the Crew.
 

DesertMedic66

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there are services outside of IFT that are still using manual BP?

I advocate the balance between skill and technology, but really, no automated BP in 2012?

Do they push the ambulance with their feet like Fred Flintstone?

The only ambulance we have that is equipped with automated BP is our CCT. BLS and ALS (911) still have manual.

Only one of our fire departments has automated BPs with all the other departments still using manual.
 

bigbaldguy

Former medic seven years 911 service in houston
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The bigger issue for EMS is that often taking a blood pressure takes 100% of the crew attending to the patient. As such, the better question is when should a new set of vitals take precedence over providing interventions (assuming the vitals are based on a schedule and not looking for change due to intervention)?

Excellent point. Taking vitals every 3 minutes is great if you have the resources to do so without compromising patient care. On the other hand if you're taking vitals every 3 minutes but don't have time to even look at the results because you're too busy plugging holes then what's the point. It looks nice on the report I guess.
 

Aidey

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It was just this year we got NIBP on all of our trucks. The shortest interval we can set the NIBP to is 5 minutes.
 
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Veneficus

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I think that some perspective in this technique needs to be added.

Taking continuous BP is not instantaneous. It takes several seconds per cycle.

In EMS, it is customary to record every set of vitals. For this technique to be valuable, I do not believe recording every number is time well spent.

I also would like to point out that the purpose of this is to detect hypovolemia and of course trending if treatment is working.

Most automated cuffs I am familiar with also calculate map. But if it doesn't a quick and dirty method I have found useful is pulse pressure. Surely it is easy to find a trend of "narrowing/widening/same?

That would put this suggest in the populations where shock is suspected but not yet clinically apparent and of course as a guage of intervention.

I would suggest if you are doing this on every patient, it is not really time well spent.

As for inhibiting intervention, what interventions does EMS have that take so much time and concentration to not press a cycle bp button every few minutes to treat shock?
 

NYMedic828

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Most automated cuffs I am familiar with also calculate map. But if it doesn't a quick and dirty method I have found useful is pulse pressure. Surely it is easy to find a trend of "narrowing/widening/same?

Granted my monitor does show MAP, I just do diastolic+diastolic+systolic divided by 3


Not too hard to divide 300-400 by 3 in ur head. But it does take time away from things I suppose.
 

EMSrush

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I usually go every 5, and I'm always happy to hit the NIBP at anytime in between as needed.
 

MSDeltaFlt

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Q5 here as well for critical pts. But question is more liquid than some might want to admit. One's definition of critical might vary from medic to medic according to clinical presentation.
 

Brandon O

Puzzled by facies
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there are services outside of IFT that are still using manual BP?

I advocate the balance between skill and technology, but really, no automated BP in 2012?

Do they push the ambulance with their feet like Fred Flintstone?

I have yet to see automated NIBP in a BLS ambulance. It's generally built into the cardiac monitor which we usually don't carry.
 

Eli

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I'm required to get VS Q5 on critical patients. I get dinged a lot in QA when I don't get a BP every 5 minutes. Yes, I am constantly evaluating these patient's enough that I can chart my findings. But during the initial phases of a call I am too busy with other aspects of care to take a BP every 5 minutes. "Use the monitor BP" I'm told. I still hear this despite showing that the NIBP is more than statistically unreliable when it comes to pressures that are unusually high or low.

So my answer is 5 minutes and if you want to know what the BP is clinically speaking, take it manually. If you just want something to write down to keep out of trouble, then just use the automated BP cuffs.
 

VFlutter

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During RRTs (Rapid response team) we do Q3 NIBP unless they get an Art line. Most of these patients will be getting pressors, nitro, or Cardizem.
 

fast65

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there are services outside of IFT that are still using manual BP?

I advocate the balance between skill and technology, but really, no automated BP in 2012?

Do they push the ambulance with their feet like Fred Flintstone?

I'm sad to say that my service is one of those you speak of. It seems to be a combo of our MD not wanting automated BP's and our company not wanting to shell out extra cash for them. It's definitely not right considering how many IFT's we do.
 

mycrofft

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My cardiologist won't let his techs use automated equipment for VS besides pulse-ox, and the pulse is taken manually as well.

Automatic equipment does not differentiate between irregular and regular pulses, types of irregularities (such as pulses of unequal strengths, or the irregularly-irregular versus regularly-irregular).
Automated equip is easily fooled by road noise, pt movement, and worn-out probes/transducers.
 

Jambi

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Automatic equipment does not differentiate between irregular and regular pulses, types of irregularities (such as pulses of unequal strengths, or the irregularly-irregular versus regularly-irregular).
Automated equip is easily fooled by road noise, pt movement, and worn-out probes/transducers.

I don't care for auto BPs personally. I don't trust them. I use it after I have a good manual BP, then it's for trending.

As an aside. Anyone take BP's on both arms? I found using the NIBP suppressing my use of Bi-Lat BPs.
 
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