Blood Pressure Location
Domiano KL, Hinck SM, Savinske DL, et al: "Comparison of upper arm and forearm blood pressure."Clinical Nursing Research. 17(4):241Ï250, 2008.
If a patient has an upper arm wound, is hooked up to an IV or is too large for the blood pressure (BP) cuff, it_s often difficult to measure their BP. In these instances, you can use the lower part of the arm, between the elbow and wrist. But do these two locations provide the same measurement? These authors compared the mean upper- and lower-arm BPs in 106 adults of various age groups, health conditions and body types.
For the majority of the population, the traditional upper-arm BP is lower than it is when measured on the forearm. The authors found the most significant difference between upper- and lower-arm BPs in men, adults 51Ï65 years of age, and individuals with a body mass index greater than 29. Smokers demonstrated a larger difference in diastolic blood pressure than non-smokers.
These authors suggest that if you take the blood pressure at an alternative site, you should note this location to help the receiving staff account for the difference.
Direct Transport of STEMI Patients
Wong HE, Marroquin OC, Smith KJ: "Direct paramedic transport of acute myocardial infarction patients to percutaneous coronary intervention centers: A decision analysis."Annals of Emergency Medicine. 53(2):233Ï240, 2009.
One of the biggest questions facing many EMS systems is whether transporting directly to a chest pain center improves patient outcomes. Because this isn_t a randomized study that would realistically be approved, these authors developed a mathematical model, using real data, to evaluate the effect of redirecting chest pain patients away from the local community hospital where the treatment would include fibrinolytic therapy.
The outcome measure was 30-day survival. Interestingly, the authors found that redirecting chest pain patients provided only a small improvement in the rate of survival. The biggest concern was the lengthier transport time, which increases the potential risk for adverse events.
Hospitals and EMS agencies need to carefully evaluate the cardiac care in their community, comparing and contrasting options that might improve the outcome for STEMI patients. Because it was mathematical and not randomized, this was not the most scientific study. Certainly, more research is needed in this area.
Backboard Pressure Areas
Kosashvili Y, Backstein D, Ziv YB, et al: "A biomechanical comparison between the thoracolumbosacral surface contact area (SCA) of a standard backboard with other rigid immobilization surfaces."Journal of Trauma. 66(1):191Ï194, 2009.
Backboards have long been the standard of care for spinal immobilization. However, remaining on a backboard longer than 30 minutes has been associated with sacral pressure ulcers, primarily because of the way the body fits on the board. These authors placed sensors on the backs of 12 volunteers and recorded pressure maps when they lay on various items: a stretcher, a stretcher with a blanket under their thighs and thoracolumbar area, an aluminum backboard, an aluminum backboard padded with 3 cm and 5 cm of padding, and a medical grade mattress.
The findings aren_t surprisingƒunpadded aluminum boards concentrate pressure on the scapula and sacrum. Adding just 5 cm of padding almost completely redistributed the pressure over the entire posterior of the body.
This study supports the need to continue evaluating alternative spinal immobilization devices and padding. It might also spur more interest in developing spinal clearance protocols for prehospital use.
IO location & Flow rate
Ong ME, Chan YH, Oh JJ, et al: "An observational, prospective study comparing tibial and humeral intraosseous access using the EZ-IO."American Journal of Emergency Medicine. 27(1):8Ï15, 2009.
Intraosseous (IO) access has become a standard of care for children and is now being used routinely in adults. Some of the first adult IO devices used the sternum, which may interfere with ongoing resuscitation. Newer adult IO equipment uses a drill to allow insertion into the large bones of the tibia and humerus. But do these locations provide an adequate flow rate? Are the insertion points easy to locate and central enough for fluids and medications?
These authors evaluated the Vidacare EZ-IO device, looking at flow rates, complications and ease of use. They found no difference in the flow rate between the tibia and humerus locations. The flow rate was significantly increased with the use of a pressure bag. In the 35 insertions studied, the drill was found to be easy to use and there were no complications with IO insertion.
This is the first evaluation of the flow rate of the adult IO device. The important question that must be answered is can it, or should it, replace the more dangerous external jugular or subclavian line insertions?JEMS
Elizabeth Criss, NP, MEd, MS, CEN, CCRN, is a nurse practitioner in the emergency department at Tucson Medical Center. She was a founding member of the Board of Advisors of the Prehospital Care Research Forum. Criss has been involved in emergency care and disaster management since 1982. Contact her firstname.lastname@example.org.