Question: On a recent ischemic chest pain call with an approximately 60 year old female patient, conscious and alert, 2 nitro sprays prior to arrival. The 12 lead was normal and I gave ASA, but decided to withhold nitro as I had difficulty obtaining a BP on scene. The patient had no palpable radial or brachial pulses bilaterally. My partner and I made 4 NiBP attempts on scene with no reading on either arm and manual BP attempts bilat with no sound on auscultation or deflection of the needle. I was unable to also confirm the HR that showed on the monitor as she was uncooperative while attempting a carotid (although present). After extricating the patient on a stair chair, I decided to continue my care with an IV TKVO in the truck. I did not want to delay scene time any further. While in the truck I continued to attempt NiBPs which was now displaying a reading of hypertension, yet no pulses other than carotid were palpable. Although the monitor was always showing vitals within my parameters to administer nitro, I withheld it, as I was treating the findings with the patient, not the monitor. She had stated her pulses were usually weak. She remained conscious and alert with no signs of hypotension other than weak/absent pulses. My question is€¦ was I ever justified to administer a bolus to this patient?

 Interesting question! The essence of this scenario is determining which vital signs you feel are most accurate. If a patient initially has no measurable blood pressure on multiple NIBP attempts, remains with poor pulses during your entire patient contact, and only later during transport you acquire NIBP measurements which are hypertensive, one has to wonder if these latter values (the hypertensive ones) are artifactual/unreliable.

To answer your question, this boils down to a judgment call.

We support your withholding of NTG if there is any concern about a NIBP that is un-measurable on repeated attempts.

As for a fluid bolus, given the discordant and confusing (and hopefully rare) clinical picture, we believe it could be appropriate to withhold or administer the fluid bolus and initiate rapid transport based on your clinical judgment.

As an example, a reliable BP measurement may be hard to assess in a strong combative patient, but their level of consciousness could be good evidence for decent blood pressure. In the case you provided, based upon the initial presentation, we would also support a decision to administer a fluid bolus based on the inability to obtain a BP, weak/absent distal pulses and patient presentation indicative of hypotension.

Cardiac Ischemia,Cardiac/Circulation,Intravenous and Fluid Therapy

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