Wednesday, September 12, 2007

Endangered Species

A Regular Sphygmomanometer (Blood Pressure Cuff)
Have you notice how manual blood pressure cuffs are becoming extinct on hospital wards? I'm adding them to my "endangered species" list. It seems fewer and fewer people use these on the inpatient wards anymore. Instead, hospitals seem to be gravitating toward wall-mounted or cart-mounted electronic versions that can take your temperature and pulse oximetry, too, like the one to the right.
These electronic versions do not require the use of - dare I say it - a stethoscope and ears. (I've already commented on the quality of stethoscopes has suffered with the advent of the little plastic stethoscopes, so with these new-fangled gizmos, we don't even need those!).

One reason hospital administrators have migrated away from these manual BP cuffs is because they have lots of complicated detachable parts - the rubber bulb cracks and loses air, the tubing similarly fractures, and the calibration of the BP meter itself was difficult to maintain from the heavy use these devices see. But the new devices have even more issues, it's just that now we have to call a specialist to fix them. But, hey, at least they look cool.

The mobility of these old-fashioned, untethered devices had several advantages over their technogeek counterparts: (1) they permitted measurement of blood pressures in different patient positions - supine, sitting, and standing (recall that we call these orthostatic blood pressures) - since they are less resistant to motion artifact and (2) the manual version can recognize a drop in blood pressure faster than you can say "Holy Sh**!" Many a poor patient has hit the deck while the techoversion keeps inflating the cuff higher and higher in its attempts to find a hypotensive patient's blood pressure.

Recently, I have been struck by the number of patients I have seen with loss of consciousness (syncope). Most are men over 70, and most of them on a ton of medications - and all episodes of syncope seem to generate a consultation for the cardiac electrophysiologist (my kids appreciate this - really they do).

But one of the more common drugs I see elderly men on are medications for prostatic hypertrophy - in particular, terazosin hydrochloride (Hytrin®) or tamsulosin hydrochloride (Flomax®). These medications are prescribed for benign prostatic hypertrophy (BPH) to improve urine flow, especially at night.

But they also can drop blood pressure.

And nothing will make you hit the deck faster that a full bladder, warm body (after being in bed), rapidly standing, and being on too much Hytrin - blammo - down like a ton of bricks. Quick, call the electrophysiologist for a pacemaker!

For some reason (and I suspect its the abandonment of the manual BP cuff), few people check orthostatic blood pressures anymore, and so a simple diagnosis (and treatment) is missed.

But then again, I guess I shouldn't complain.



Wanderer said...

Not even threatened on the cards floor where I work. We just bought several new manual cuffs. I trend to use the manual cuffs more than the automatics these days, especially when the automated one gives "off" or way out of whack readings. Out docs will ask when called for hypotension if it was done manually or not. You learn real quick after getting your rear chewed by an angry cardiologist at 3am to double-check yourself manually before calling.
And for orthostatics? As much as some nurses complain, we'll do 'em, especially for those syncopal patients.
All hope is not lost yet...

DrWes said...


Glad to hear others are still using the old fashioned cuffs and that cardiologists are riding the staff to double-check questionable readings manually!

But there might be one advantage to the newer BP systems: they prevent the potential for most of the prior evening's blood presures to be exactly 120/80. (I can recall after a busy evening before, that many of the patients charts had remarkably similar blood pressures) ;)

Doctor on a bike said...

BP readings with automated cuffs are NEVER correct in Atrial fib patients. It's hard to get it right even with manual cuffs, but MANY "hypertensive" crisis visits I see are the result of this issue.
Oh, and just how can you check for Osler's Sign ('s_sign)
with an automatic cuff? Again, many elderly hypertensives have this phenomenon, but you can't even begin to guess it's the situation without a manual cuff.

Anonymous said...

Just want you to know there is a nursing instructor out there who HATES the electronic cuffs and explains why to students.