Anesthesiologist quick physical exam findings?

[RxBoy]

Advertisement - Members don't see this ad

So I thought it would be nice to compile responses of useful physical exam findings during an anesthetized patient. We have an arsenal of monitors for anesthesia but anyone know any good physical exam finding techniques and there clinical correlation.

Example, a patient with a blood pressure cuff that displays a very hypotensive patient, first thing I do is check for a pulse before I reposition or recycle the cuff. Anyone know what the minimum blood pressure required to have a palpable temporal pulse? Or how about capillary refill clinical correlation? ect.

I also know cyanosis is a late physical exam finding (I think <75% sat with a normal hemoglobin) any earlier physical signs of hypoxia?

Or any other useful physical exam findings?

 

[Idiopathic]

ive become friends with the carotid pulse

physical findings of hypoxemia are fairly worthless because if you see them then you are bad off, IMHO.

 

[rsgillmd]

So I thought it would be nice to compile responses of useful physical exam findings during an anesthetized patient. We have an arsenal of monitors for anesthesia but anyone know any good physical exam finding techniques and there clinical correlation.

Example, a patient with a blood pressure cuff that displays a very hypotensive patient, first thing I do is check for a pulse before I reposition or recycle the cuff. Anyone know what the minimum blood pressure required to have a palpable temporal pulse? Or how about capillary refill clinical correlation? ect.

I also know cyanosis is a late physical exam finding (I think <75% sat with a normal hemoglobin) any earlier physical signs of hypoxia?

Or any other useful physical exam findings?

Don't know about temporal pulse, but when I worked EMS I was taught a good general rule of thumb:

Carotid: minimum systolic = 60 mmHg
Femoral: minimum systolic = 70 mmHg
Radial: minimum systolic = 80 mmHg
Dorsalis Pedis: minimum systolic = 90 mmHg

It's not 100% accurate. I have seen patients with a radial pulse who have a systolic of less than 80 mmHg (certainly not below mid-70s). However, as I said it is a rule of thumb.

Don't forget to take into account the quality of the pulse -- how easily is it felt, weak or strong? That can supplement the above rule of thumb to make it a little more accurate.

 

[rsgillmd]

I've also noticed in patients who have been given a non-depolarizing muscle relaxant, their heart rate will usually increase a small (maybe by up 10 beats/minute) but noticeable amount from baseline a couple of minutes (usually 1-3) prior to evidence of return of spontaneous breathing.

If there is nothing in the surgical field to attribute the increase in heart rate to, check their twitches again. They'll usually be 4/4.

 

[pgg]

I also know cyanosis is a late physical exam finding (I think <75% sat with a normal hemoglobin)

As I recall cyanosis is supposed to become noticable when the amount of deoxyhemoglobin exceeds 5 g/dL, which could be present with varying degrees of saturation and hemoglobin levels. The lower the Hb, the more desaturation it takes to cause cyanosis.

ive become friends with the carotid pulse

A couple weeks ago I had a healthy young female patient in for a diagnostic laparoscopy go asystolic for about 15 seconds while the circ nurse was prepping her belly. ECG alarm went off, I looked up from the chart and saw the flat line, figured the nurse knocked off a lead. Even said to her "hey, don't knock my leads off" ... Then I heard/saw the pulse ox had gone squiggly, and as I was looking to see if I'd put the pulse ox on the same arm as the BP cuff I started feeling for a carotid, not really believing that this 25 year old person in for elective surgery was in asystole 5 minutes after intubation but before the case even started. Last BP was normal, 130/something. Told the nurse to stop prepping.

I can't feel a pulse, still don't really believe she's in asystole, now the ETCO2 is 20 (wasn't it 40 a few moments ago?) and I believe it. I told the nurse "I need you to start co-" when she had a QRS ... and another, HR of about 20, by the time I got the atropine in line she was up to 30. Pulse ox is back again, BP normal. First time I've seen someone get that vagal during skin prep ... damn episode harshed my mellow for the morning.

Felt kind of stupid for being in denial for ~10 seconds, but then how many times have I felt a neck while starting an IJ line and had trouble finding a carotid in a person who's awake and talking?

Anyway, the point of this story is that I've started feeling the carotid at the beginning of every case just so later on I'll be more confident in going from a not-feeling-it to believe-it-start-CPR. I'm trying to cultivate a closer friendship with everyone's carotid now.

 

[Idiopathic]

Anyway, the point of this story is that I've started feeling the carotid at the beginning of every case just so later on I'll be more confident in going from a not-feeling-it to believe-it-start-CPR. I'm trying to cultivate a closer friendship with everyone's carotid now.

you articulated it better but thats my point. i feel a carotid and radial pulse on everyone in preop holding.

 

[fakin' the funk]

Any tips on auscultating? The ridiculous gymnastics I have to do to bag-ventilate with one hand while reaching 3 feet under the drapes, Bair Hugger, etc, to reach the axillae are getting old.

 

[rsgillmd]

Any tips on auscultating? The ridiculous gymnastics I have to do to bag-ventilate with one hand while reaching 3 feet under the drapes, Bair Hugger, etc, to reach the axillae are getting old.

I suppose you could place two separate precordial stethoscopes (one on each side), but I usually just do the gymnastics as you call them. It's a little easier as an attending if you are supervising someone so no gymnastics is required.

If you just want to listen for wheezing in general, like in an asthmatic, I suppose an esophageal stethoscope (the combo stethoscope/temp probe things) would suffice.

 

[Intensivist]

Don't know about temporal pulse, but when I worked EMS I was taught a good general rule of thumb:

Carotid: minimum systolic = 60 mmHg
Femoral: minimum systolic = 70 mmHg
Radial: minimum systolic = 80 mmHg
Dorsalis Pedis: minimum systolic = 90 mmHg

It's not 100% accurate. I have seen patients with a radial pulse who have a systolic of less than 80 mmHg (certainly not below mid-70s). However, as I said it is a rule of thumb.

Don't forget to take into account the quality of the pulse -- how easily is it felt, weak or strong? That can supplement the above rule of thumb to make it a little more accurate.

Had a patient in pericode state due to hyerkalaemia with only palpable pulse at dorasal perdis, quite strong l might add with BP reading below 60 systolic and few people tried to feel radial or carotid, no one could. How can someone who is extremely hypotensive have a strong dorasal pedis pulse? 😕

 

[sevoflurane]

That is odd. But:

What happens to measured systolic blood pressure as you go from the proximal aorta to the periphery?

 

[RxBoy]

That is odd. But:

What happens to measured systolic blood pressure as you go from the proximal aorta to the periphery?

I think resistence increases the more distal you from the aorta causing a higher systolic blood pressure so radial bp would be higher then aorta unless there was systemic vasodilation. Clinically context putting a bp cuff over the wrist would give a blood pressure that would give a higher than expected blood pressure reading then a bp cuff over the arm.

 

[sevoflurane]

I think resistence increases the more distal you from the aorta causing a higher systolic blood pressure so radial bp would be higher then aorta unless there was systemic vasodilation. Clinically context putting a bp cuff over the wrist would give a blood pressure that would give a higher than expected blood pressure reading then a bp cuff over the arm.

That is pretty good RxBoy.

On an arterial pressure waveform, the measured systolic b.p. in the periphery will have more reflected waves (which are additive) vs. those near the aorta thereby giving you a larger systolic b.p.

What about MAP? periphery vs. near aorta? which one is higher?

 

[SitraAchra]

*breaks out morgan mikhail*