traumatic aortic aneurysm care

[spenac]

ok, on further investigation the article referenced was the Brady book and not the Bledsoe book. My bad. But I emailed Dr. Bledsoe and he did not concur with this article's premise on the left arm blood pressure.

I'll try to find contact information with the brady people.

But Bledsoes book is the Brady book. They publish his book. Or was it in a different Brady textbook?

[Just Plain Ruff]

they used these two references

References

Sanders M: Mosby’s Paramedic Textbook, Revised Second Edition, 2001 Mosby Lifeline, Baltimore, 686-708

Brady Emergency Care 9th Edition, 2001 Limmer, O'keefe, et. al, 509-513

Does anyone have these books that can look up this info? I for one do not have these books.

[AnthonyM83]

You know, it would kinda make sense. When you take a BP, your overall blood pressure gets increased to a degree, right? Regardless of what side. Out of left or right, obviously left side because the aorta more directly goes to the left arm.

But I imagine you'd never know exactly what the breaking point is going to be that causes the full rupture and a case where the breaking point is that low, one would imagine they weren't going to make it anyway.

If no one can find a study on it, then my guess is the author created that piece of advice...it's not that it doesn't make sense, just that it's usually negligible pressure, except for 1 out of whatever hundred cases?

[firedoc5]

After thinking about it for awhile, I was just wondering if taking a BP would create enough pressure to effect the aorta. If it does I would think it would be very slight.

Besides, to check for a suspected aortic anurysm you have to do bilateral BP's anyway. If it is a concern I'd say get the one bilateral BP as a base line. But after that don't use the left arm, especially an automatic BP monitor.

[JPINFV]

Thanks Doczilla! Now I went and hit my patho book this afternoon, but I can't figure out what about the aneurysm causes the difference in BP's. Any direction or where I might want to look to figure this out? A starting point concept to consider?

Follow the path of the arteries to the left arm and right arm while paying attention to where they branch off of the aortic arch,

[WolfmanHarris]

Thanks JPINFV, appreciate the direction. I'm not sure if I have a total handle on it yet and have a couple questions.

If the aneurysm was right in the aortic arch would we still see the difference in BP as the location is right at the brachiocephalic trunk? What about if it's in the ascending aorta, before the brachiocephalic trunk?

[swn919]

Ok did some digging and I found this stuff:

Aortic Aneurysm- Many cases of aortic aneurysm have a normal arterial pressure According to Williamson4 blood pressure tends to be higher in cases of simple aortic dilatation than in cases in which a distinct aneurysm is present A pressure difference 5 to 20 mm in the two arms is very commonly found and occurs in about the same proportion of cases whether the innominate artery is actually involved or not. Differences amounting to 30 mm or more occur in about one third of the cases and indicate aneurysm rather than simple dilatation or mediastiual tumor which latter causes inequality of tension somewhat less frequently than does aneurysm Small inequalities of pressure are of little practical diagnostic value Unilateral differences of 10 mm in the two arms without any constancy as to the side occurred in 20 per cent of 36 cases studied by Phipps1. The administration of potassium iodide or the injection of sterilized gelatin which often relieves pain has no effect on arterial tension2. Unilateral pressure differences may also be encountered in arteriosclerosis in hemiplegia and in cases of cervical rib In the last named condition lowering of the arm sometimes produces a demonstrable decrease in the pulse-pressure.

4 Lancet, November 30, 1907

1 Boston Med and Surg., Jour 1915 cIxxiii 476

2 Mackinuon M,: Arterial Pressure in Thoracic Aneurysms, British Med. Jour., October 4, 1913.

Sorry for the poor grammer only way I could get it to copy over. If you want to read it for your self go here:

Blood Pressure-By George William Norris on page 245-246

The Peripheral Arteries.—The pulse in the vessels beyond the aneurysm b delayed. Hence the two radial pulses may exhibit differences in time. The volume of the pulse beyond the aneurysm is lessened, and in aneurysm of the abdominal aorta or the femorals it may be obliterated. Such differences as these will not only point to the existence of thoracic aneurysm, but also its seat. Thus, if there be dilatation of the transverse arch with no implication of the innominate, the pulse at the right wrist is strong and almost simultaneous with the cardiac impulse, while that on the left side is small, weak, and delayed. If the reverse be true with respect to the pulse, then the aneurysm may be near or involve the innominate. O. K. Williamson has found a marked difference in the blood-pressure of the two arms in cases of thoracic aneurysm, a variation of more than 20 mm. Hg. being in favor of aneurysm.

A Text-book of the practice of medicine By James Meschter Anderson Pg. 704

Take these for what they are worth they do of course come from books published in the 1920s. I did find newer books that spoke on this but they are copyrighted and I could not access them.

[Camulos]

Never heard anything about not taking a BP in the left arm due to the possibility of making the situation worse. As far as anatomy goes I suppose that theoretically the left arm BP could cause more “back pressure” on the aortic arch than a BP on the right side as the left subclavian artery has more of a direct communication with the aortic arch than the right subclavian which additionally branches with the right common carotid before entering the arch. Just a VERY wild guess though.

My personal feeling is that a simple BP, left or right arm, would not cause this problem and we routinely do bilateral BP’s in pts suspected of traumatic aortic injuries. Would be great to have some actual research on this though.

Stay safe,

Curse :evil:

[Just Plain Ruff]

Ok, I got information on this from the publisher. He states that it indeed said this in the book but he is unable to verify it anywhere else so they are removing that part from the article. they are also going to be retiring this particular CEU article.

[DwayneEMTP]

Never heard anything about not taking a BP in the left arm due to the possibility of making the situation worse. As far as anatomy goes I suppose that theoretically the left arm BP could cause more “back pressure” on the aortic arch than a BP on the right side as the left subclavian artery has more of a direct communication with the aortic arch than the right subclavian which additionally branches with the right common carotid before entering the arch. Just a VERY wild guess though.

Awesome post, and great thought. I actually thought the same thing, though didn't have the balls to post it. It makes sense to me if you assume that there is an issue, know what I mean?

If you KNOW that there is such a negative physiological result, then this logic lines up well for me. If you assume that there is not any such issue, then it does seem to me that the body is going to compensate almost immediatley, if not sooner, for any change in pressure that a temporary brachial occlusion would be able to provide.

Thanks for you thoughts man, and welcome to the City!

Dwayne