Beyond the Basics: Putting the VITAL Back in Vital Signs
Vital signs are important and obtained on every call, yet a sense of routine permeates their gathering.
CEU Review Form Beyond the Basics: Beyond the Basics: Putting the Back in VITAL SIGNS (PDF) Valid until November 7, 2008
Vital signs are important and obtained on every call, yet a sense of routine permeates their gathering. This month's article will help firm up basic skills, identify the role of vital signs in the thinking and decision-making process and cover some additional diagnostic procedures that can be performed.
CASE PRESENTATION
Your ambulance is called to a syncopal episode at a local community hall. Your patient is an 82-year-old male who responders say acted a bit "spacy" for about a minute and then passed out. A friend who assisted him to the floor described him as being "dead weight." He came to quickly after being placed in a recumbent position.
You arrive at the patient's side and find the man responsive, breathing adequately and a bit pale with some sweat visible around his face. Family members tell you the patient has had some sort of dementia and is a poor historian of medical complaints and conditions. You are unable to determine if he experienced any signs or symptoms before collapsing. The family wants to know if the patient really needs to go to the hospital because he seems alright now.
Completing your initial assessment while your partner administers oxygen by nasal cannula, you detect a strong, regular radial pulse at about 88/minute. You note that it is warm in the room.
His BG is 127; BP 110/72; respirations 20; pulse 88, strong and regular; skin a bit warmer and slightly moist. An EKG shows a normal sinus rhythm without ectopy at 88/minute.
You decide to sit the patient up and attempt orthostatic vital signs. He denies dizziness when changing position. Blood pressure changes to 98/68; pulse is 92/minute and weak; respirations are 22/minute; and he becomes a bit more diaphoretic.
This case highlights the most important part of vital signs: correct interpretation. While the change in systolic pressure is a borderline significant reading, many would look at the relatively stable pulse and respirations combined with the lack of lightheadedness and consider this a negative test.
Experienced clinicians recognize that not every set of vital signs will exactly match the clinical picture of orthostasis, much like patients rarely exhibit all of the signs and symptoms of a disease or condition. In this case, the EMTs on scene recognized the patient's inability to accurately present signs and symptoms. A patient of this age may be on medications like beta blockers, which could depress the sympathetic nervous system's ability to respond during the tilt test.
Looking at vital signs in combination with the overall patient presentation allowed the EMTs to strongly recommend transport to a patient who had considered refusal. Subsequent emergency department evaluation revealed dehydration secondary to poor feeding caused by dementia. The patient was found to be on atenolol, which explained the lackluster orthostatic changes in the tilt test.
RESPIRATIONS
While pulse and respirations may seem like "grounders" to the experienced provider, it is valuable to review even the most basic skills and look into problem areas.
Of all the vital signs, respirations may seem the most awkward to obtain because the patient shouldn't be speaking or aware his respirations are being counted. Increased respirations are part of the initial response to compensation for shock and therefore diagnostically significant.
A persistent problem for advanced and basic providers alike, both in the field and as identified by the National Registry of EMTs as an issue in exams, is identification and appropriate treatment of inadequate breathing.
