"Let’s get a set of vitals” is a phrase that rolls off the tongue with ease. As well it should, since it’s said thousands and thousands of times a day out in EMS land. In theory, every single patient seen by EMS, irrespective of whether they are en route to a hospital emergency department or being taken home from an extended care facility, will have at least one set of vitals taken during the routine course of events. Sicker patients may get five or six sets, but everybody gets a least one. This month in BTB, I’m offering up a collection of tips, tidbits, suggestions and pearls I’ve accumulated over the years, all focused on gathering and interpretation of vital signs.
Arguably, vital signs represent some of the most objective and helpful patient care information you gather on anyone. At worst, the vital signs are just a set of numbers, providing little to no valuable information or insights. Problems multiply if the vitals are inaccurate or simply made up. By comparison, accurately assessing all of the parameters of the vitals and then integrating and comparing them, i.e., the patient with a pulse of 38 and decreased mentation, frequently leads to identifying the “why” a problem is occurring, thereby increasing the likelihood you can correct or stabilize it.
Find a pulse and immediately assess rate. Note if it seems unusually slow or fast. Is it weak or strong? Assess regularity. A particularly irregular pulse is more often than not a rhythm disturbance called atrial fibrillation. Why is that important? Because the moment your patient goes into a-fib their cardiac output drops by approximately 25%. Practically speaking, that can take 122/74 and turn it into 98/68, or even worse if it’s a particularly slow a-fib.
Remember the two big rules of pulses:
1. Slow pulses will always drop blood pressure and decrease mentation. The slower the rate, the worse the problem.
2. Fast pulses point to a heart that is working excessively, which in turn increases cardiac oxygen demand. If that oxygen demand cannot be met, the heart muscle gets increasingly irritable and unstable and at some point finally fibrillates, putting your patient into cardiac arrest.
With adult trauma patients, start to worry if the pulse heads into the 130s. These are really sick patients. Worry more if the pulse moves into the 140s. If the pulse rate continues to rise above that, a catastrophe (cardiovascular collapse) is usually not far away. Hopefully, the trauma center is closer than the time of the patient’s collapse.
When it comes to adult medical patients, pay attention to any pulse over 150. If the pulse continues to rise, there is less time for the heart to fill. As a result, it squeezes with the ventricles only partly full (inadequate preload), resulting in reduced blood pressure and poor perfusion. With rates >180, inadequate preload will precipitate cardiovascular collapse.
At some point, check both radial pulses and compare equality side to side. Do the same with the pedal pulses. Significant differences from side to side point to vascular compromise, possibly from swelling, a displaced fractured bone or a leak above the level of where you are checking the pulse.
Assessment of rate only tells you if your patient is breathing within normal limits, which in and of itself is not that crucial. Far more important is determining adequacy and work of breathing. Any patient who is working hard at breathing is in trouble, possibly serious trouble. Excessive work of breathing for pediatric patients is much more dangerous and needs to be addressed immediately.
At a minimum, assess four anterior lung fields on every patient. Ideally, check six posterior lung fields. Keep in mind that for a sitting or semi-sitting patient, fluid in the lungs will be pulled to the bases by gravity.
Any patient who is awakened because he can’t breathe should be categorized as serious to critical.
Be attentive to various breath sounds and what needs to be done to correct them: snoring/sonorous—reposition the airway; for wheezing, think breathing treatment for bronchodilation; gurgling, think suction; for rales/wet lungs, sit the patient up and think diuresis. For pockets or various areas with diminished/absent breath sounds, think pneuomothorax. If the patient has a fever, think pneumonia.
Obtaining a blood pressure needs to focus on accuracy. Wrapping an adult cuff around a child’s arm will not provide accurate data, nor will a peds cuff with one-half inch of Velcro touching work on an adult. Along with having the right size cuff, position it properly over the artery or you will get an errant blood pressure.
Always obtain your first B/P manually before switching to taking it automatically and periodically by machine. When in doubt, take it again manually.
Unless you know a patient intimately, a single blood pressure means little, but it at least provides a baseline. A second blood pressure provides comparative data, helping to assess patient status and stability. A third or fourth pressure allows you to map trends, i.e., is your treatment plan working? Are things getting better? Staying the same? Getting worse?
Often called the fourth vital sign, checking a temperature is not required or indicated on every patient. If the patient feels warm, check his temp. The patient who is prone to infections, such as paraplegics/quadraplegics or other bedridden patients who are moving into sepsis, may be unable to create a fever. That is an ominous sign. Viruses usually create a spike in fever; bacterial infections often produce low-grade fevers.
Here’s hoping this collection of information is helpful in improving your patient assessment and patient care. Vital signs are as valuable as you choose to make them, so make sure they’re valuable!
Until next month…
Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of the EMS World editorial advisory board.