• Rapid Reviews: Vital signs in CVAs – which arm?

    by Alan Batt. Last modified: 07/02/14

    bp

    This question often arises – in patients with a CVA, which arm should be used for blood pressure and vital sign measurement? Only just today we were asked this very same question again. Below are some readings on this topic, but the issue is lacking in recent robust research and evidence-based recommendations. Our conclusion from reading the literature is to go with the recommendation of using the non-affected arm for measurement of BP and pulse oximetry; we also recommend future robust research be carried out in this area to guide practice.

    1. The effect of hemiplegia on blood pressure measurement in the elderly.

     
    Dewar R, Sykes D, Mulkerrin E, Nicklason F, Thomas D, Seymour R. The effect of hemiplegia on blood pressure measurement in the elderly. Postgrad Med J. 1992 Nov;68(805):888-91. PMID: 1494509.
    The blood pressure in both arms of 103 unselected hemiplegic patients was measured using a random-zero sphygmomanometer. Although for the whole sample the mean blood pressure in the paretic and unaffected arm was similar, a significant difference was found when the patients were subdivided according to the tone of the arm. The blood pressure was higher in paretic arms of patients with a spastic stroke and lower in the affected arm if the tone was flaccid. No other characteristics were associated with significant blood pressure differences, so that the findings appear to be directly related to changes in muscle tone. After a stroke the blood pressure should always be measured in the unaffected arm because changes in tone make measurements unreliable.

    Fulltext (free):

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2399466/ & http://pmj.bmj.com/content/68/805/888.full.pdf

    2. Blood pressure monitoring in hemiplegic patients.

     
    Moorthy SS, Davis L, Reddy RV, Dierdorf SF. Blood pressure monitoring in hemiplegic patients. Anesth Analg. 1996 Feb;82(2):437. PMID: 8561373.

    Letter to the Editor Fulltext (free): http://journals.lww.com/anesthesia-analgesia/Fulltext/1996/02000/Blood_Pressure_Monitoring_in_Hemiplegic_Patients.66.aspx

     3. Blood Pressure Measurement in Hemiparetic Patients: Which Arm?

     
    Uijen AA, Hassink-Franke LJ. Blood pressure measurement in hemiparetic patients: which arm? Fam Med. 2008 Sep;40(8):540. PMID: 18988037.

    Fulltext (free): http://www.stfm.org/fmhub/fm2008/September/Annemarie540.pdf

    4. Effect of Hemiparetic Stroke on Pulse Oximetry Readings on the Affected Side

     
    Roffe C, Sills S, Wilde K, Crome P. Effect of hemiparetic stroke on pulse oximetry readings on the affected side. Stroke. 2001 Aug;32(8):1808-10. PMID: 11486109.

    BACKGROUND AND PURPOSE: Hypoxia is common after stroke, and monitoring by pulse oximetry is suggested in the acute phase. Physical changes on the affected side or intravenous infusions may affect oximeter readings. This study was designed to test whether pulse oximetry recordings are the same on the affected and nonaffected sides in stroke patients.

    METHODS: Oxygen saturation (SpO(2)) and heart rate (HR) were assessed simultaneously in the left and right hands in patients with hemiparetic stroke over a 3-hour period with 2 Minolta Pulsox-3i oximeters attached to the index fingers.

    RESULTS: Fifteen patients (53% men; 67% left hemiparesis; mean age, 73 years [SD, 7.5 years]) were recruited. HR and SpO(2) (12 measurements per minute) were monitored. The maximum difference between simultaneous left and right arm readings was 2% SpO(2). HR fluctuated more, but no affected/nonaffected side pattern was seen. Means for each patient of HR and SpO(2) for the affected and nonaffected sides were compared by t tests. Mean SpO(2) was 96% (SD, 1%) on both  sides. Mean HR was 81 bpm (SD, 11 bpm) on the affected side and 80 bpm (SD, 10 bpm) on the nonaffected side. There was no significant difference between the 2 sides for either parameter (n=15; P=0.86 for SpO(2) and P=0.91 for HR).

    CONCLUSIONS: Oximeters can be attached to either the affected or nonaffected side in hemiparetic stroke. Full text (free): http://stroke.ahajournals.org/content/32/8/1808.long

    5. Stroke emergency: evidence favours laying the patient on the paretic side.

     
    Brainin M, Funk G, Dachenhausen A, Huber G, Matz K, Eckhardt R. Stroke emergency: evidence favours laying the patient on the paretic side. Wien Med Wochenschr. 2004 Dec;154(23-24):568-70. PMID: 15675430.

    OBJECTIVE:
    In the preclinical phase of stroke care there are still many uncertainties. One of them includes the decision on which side to lie an acute stroke victim until professional help arrives and the patient is transported to hospital.

    METHODS AND RESULTS:
    This controlled study aimed at finding possible advantages of laying the patient on the paretic versus the non-paretic side in the acute phase. In 10 consecutive patients (five right-sided and five left-sided paresis) no differences were noted when comparing vital parameters including peripheral oxygen saturation, mean arterial blood pressure, breathing pattern, or ECG changes.

    CONCLUSION:
    Patients should preferably be positioned on the paretic side to prevent aspiration, to have the unaffected arm free for movement and to avoid additional hemianopia or visual hemineglect to the paretic side possibly disrupting communication with the helpers.

    6. Interarm blood pressure difference in acute hemiplegia.

     
    Panayiotou BN, Harper GD, Fotherby MD, Potter JF, Castleden CM. Interarm blood pressure difference in acute hemiplegia. J Am Geriatr Soc. 1993 Apr;41(4):422-3. PMID: 8463530.

    Blood pressure was measured in 15 patients with acute hemiparesis and flaccidity and found the systolic and diastolic blood pressures to be higher in the paretic arm in 8 of 15 patients and lower in 7 of the 15 patients.

    7. Measuring Blood Pressure: Which Arm?

    Barnabas N. Panayiotou, MRCP JAMA. 1995;274(17):1343

    Letter to the Editor Fulltext (free): http://jama.jamanetwork.com/article.aspx?articleid=389907

    What are your thoughts? Any additional evidence for or against the recommendation of using the non-affected arm?

    References

     
    1.

    Dewar R, Sykes D, Mulkerrin E, Nicklason F, Thomas D, Seymour R. The effect of hemiplegia on blood pressure measurement in the elderly. Postgrad Med J. 1992 Nov;68(805):888-91. PMID: 1494509.

     
    2.

    Moorthy SS, Davis L, Reddy RV, Dierdorf SF. Blood pressure monitoring in hemiplegic patients. Anesth Analg. 1996 Feb;82(2):437. PMID: 8561373.

     
    3.

    Uijen AA, Hassink-Franke LJ. Blood pressure measurement in hemiparetic patients: which arm? Fam Med. 2008 Sep;40(8):540. PMID: 18988037.

     
    4.

    Roffe C, Sills S, Wilde K, Crome P. Effect of hemiparetic stroke on pulse oximetry readings on the affected side. Stroke. 2001 Aug;32(8):1808-10. PMID: 11486109.

     
    5.

    Brainin M, Funk G, Dachenhausen A, Huber G, Matz K, Eckhardt R. Stroke emergency: evidence favours laying the patient on the paretic side. Wien Med Wochenschr. 2004 Dec;154(23-24):568-70. PMID: 15675430.

     
    6.

    Panayiotou BN, Harper GD, Fotherby MD, Potter JF, Castleden CM. Interarm blood pressure difference in acute hemiplegia. J Am Geriatr Soc. 1993 Apr;41(4):422-3. PMID: 8463530.

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    Alan Batt

    Alan Batt

    Paramedic, educator, researcher
    Alan is a critical care paramedic, paramedic educator and prehospital researcher, currently working around the world as an educator and researcher. He has previously worked and studied across Europe, North America and the Middle East. He holds a Graduate Certificate in Intensive Care Paramedic Studies, and an MSc in Critical Care. His main interests are in care of the elderly, end-of-life care, patient safety, professionalism (including role and identity), and paramedic education.

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