T he measurement of blood pressure is one of the most common examinations undertaken in family practice and has important health and management consequences for the patient. Accurate assessment of blood pressure, therefore, is very important. Current guidelines outline standards for obtaining accurate and reproducible blood pressure measurements.1 These standards include guidelines for the sizes of blood pressure cuffs and the position of the patient's arm, as well as a recommendation that the patient be seated for 5 minutes before his or her blood pressure is taken. In addition, it has been recommended that blood pressure be measured over the patient's bare arm.1 However, the current recommended method to determine blood pressure 2 has several limitations (e.g., high variability of blood pressure at different times of day or if measured only once, loss of proper technique post-training).Three previous studies have assessed whether blood pressure varies significantly when taken over a sleeved arm compared with a bare arm. Details of the literature review are described in Appendix 1, available online at www.cmaj .ca/cgi/content/full/178/5/585/DC2. In one study, involving 36 patients, Holleman et al 3 found no significant differences in systolic or diastolic blood pressure readings taken over the sleeved or bare arm of each patient. However, this study was limited because of its small sample and because blood pressure measurements were taken on both arms simultaneously. A study by Kahan et al, 4 involving 201 patients, compared blood pressure measurements taken over a sleeved arm, a bare arm and below a rolled-up sleeve. They found that the degree of clothing under the sphygmomanometer cuff did not have a clinically important effect on the reading. Although they found no significant difference in the effect of clothing on blood pressure readings, the study was limited by their design of measuring blood pressure below a rolled-up sleeve. The third study, conducted by Liebl et al, 5 was published while our study was in progress. Their study, which involved 201 patients, compared blood pressure measurements taken over a sleeved arm and a bare arm with both sphygmomanometric and oscillometric devices. They concluded no significant difference in readings between the sleeved and bare-arm groups. In contrast to previous studies, we sought to determine
In the setting of cardiac arrest, emergency physicians (EPs) are faced with the difficult task of diagnosing arrhythmias within seconds, a challenge that is critical for optimal patient outcome. Below, I present the case of an 83-year-old man in cardiac arrest whose initial arrhythmia fooled 3 EP attendings and, most probably, a semiautomatic external defibrillator. The patient's rhythm was misdiagnosed as pulseless electrical activity (PEA; formerly termed electrical mechanical dissociation), but in fact the patient wai .in fine ventricular fibrillation (VF) with background pacemaker spikes, and hence a shockable rhythm was missed. Arrhythmia interpretation must consider the possibility of background (non-capturing) pacing, and EPs should not be biased by a prior automated defibrillator (computer) analysis.
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