vital signs assessment in emergency department z.vaseie md emergency medicine resident

Vital SignsVital Signs Assessment In Assessment InEmergency DepartmentEmergency Department

Z.Vaseie MD Emergency Medicine

Resident

GeneralGeneral

Vital signsVital signs

Vital signVital sign

For all ED patients:For all ED patients:1.1. Respiratory RateRespiratory Rate

2.2. Pulse RatePulse Rate

3.3. Blood PressureBlood Pressure

4.4. TempretureTempreture

5.5. Pulse OximetryPulse Oximetry

6.6. Pain AssessmentPain Assessment

(some patient)(some patient)

Vital signVital signVital Signs :Vital Signs : SeveritySeverity of illness of illness UrgencyUrgency of intervention of intervention

V/SV/S should should measuredmeasured at at intervalsintervals::

Clinical judgementClinical judgement Patients clinical statePatients clinical state After significant change in After significant change in

these parametersthese parameters


NormalNormal vital signs vital signs change with change with gender, gender, race, pregnancy, race, pregnancy, residence in an residence in an industrialized nation.industrialized nation.


All measurements All measurements are made while the are made while the patient is patient is seated.seated.


Prior Prior to measuring to measuring vital signs, the patient vital signs, the patient should have had the should have had the opportunity to opportunity to sit for sit for approximately fiveapproximately five minutes.minutes.

Respiratory rateRespiratory rate


What is the respiration rate?What is the respiration rate?

The respiration rate is The respiration rate is the the number of breathsnumber of breaths a person takes per a person takes per minute. minute.

Respiratory RateRespiratory Rate

Patient should be Patient should be unawareunaware about about checking of his checking of his

RRRR


Increased RR:Increased RR:Pulmonary or cardiac Pulmonary or cardiac diseasesdiseases

AcidosisAcidosis

Anemia Anemia

FeverFever

StressStress

Drugs(stimulants & Drugs(stimulants & salicylates)salicylates)


ContraindicationsContraindications to to careful measurement careful measurement of of RRRR::

Respiratory distressRespiratory distress

ApneaApnea

Upper airway Upper airway obstructionobstruction

ImmediateImmediate

InterventionIntervention


Count for a full Count for a full minute minute

(most accurately)(most accurately)


Cheyne – Stokes RespirationCheyne – Stokes Respiration


Biots (Cluster) RespirationBiots (Cluster) Respiration


Kussmaul Respiratory HyperpneaKussmaul Respiratory Hyperpnea


Apneustic RespirationApneustic Respiration


Ataxic RespirationAtaxic Respiration

Abnormal Respiratory RateAbnormal Respiratory Rate

Respiration rates Respiration rates over 24over 24 or under or under 16 breaths16 breaths per per minute (when at minute (when at rest) may be rest) may be considered considered abnormal in EDabnormal in ED

under 16 breathsunder 16 breaths

over 24 breathsover 24 breaths

PulsePulseVital signsVital signs

Pulse ratePulse rate

The normal The normal pulse for healthy pulse for healthy adults ranges adults ranges from from 45 to 9545 to 95 beats per minute beats per minute in ED. in ED.


Don’t use of PULSE Don’t use of PULSE as an absolute gauge as an absolute gauge of BPof BP

Avoid bilateral carotid Avoid bilateral carotid artery palpationartery palpation

Palpate the carotid Palpate the carotid pulse at or below the pulse at or below the level of the thyroid level of the thyroid cartilage cartilage


Avoid carotid sinus Avoid carotid sinus massagemassage

Adult + Adult + Atherosclerotic Atherosclerotic disease: disease:

prior prior auscultationauscultation of of

carotid artery. If acarotid artery. If a bruit bruit is present, is present, gently gently palpate palpate the carotid the carotid pulse.pulse.

PulsePulse

radial pulseradial pulse

is routinely usedis routinely used

Use the tips of the Use the tips of the first and secondfirst and second

fingers to palpate the fingers to palpate the pulse. pulse.

The two advantages of this The two advantages of this technique:technique:

(1) the fingertips are (1) the fingertips are quite sensitivequite sensitive

(2) the examiner’s own (2) the examiner’s own pulse may be counted if pulse may be counted if the thumb is used instead the thumb is used instead of the first and second of the first and second fingers.fingers.

PulsePulse

PulsePulse: Quantity: Quantity

Measure the rate of Measure the rate of the pulse (recorded in the pulse (recorded in beats per minute). beats per minute). Count for Count for 30 seconds30 seconds and multiply by 2 (or and multiply by 2 (or 15 seconds x 415 seconds x 4). ).

PulsePulse: Quantity: Quantity

If the rate is If the rate is particularly particularly slow or slow or fastfast, it is probably , it is probably best to measure for best to measure for a a full 60 secondsfull 60 seconds in in order to minimize order to minimize the error. the error.

PulsePulse: Regularity: Regularity

Is the time between Is the time between beats beats constantconstant??

Irregular rhythmsIrregular rhythms

are quite are quite commoncommon..

(atrial fibrillation or (atrial fibrillation or flutter) flutter)

PulsePulse: Volume: Volume

Does the pulse Does the pulse volumevolume feel normal? feel normal?

This reflects changes This reflects changes in in stroke volumestroke volume. In . In hypovolemiahypovolemia, the pulse , the pulse volume is relatively lowvolume is relatively low

Pulse PressurePulse Pressure

PPsystolic - systolic - PPdiastolicdiastolic

Increased pulse pressure Increased pulse pressure (≥60 mm Hg) :(≥60 mm Hg) :

AnemiaAnemia

ExerciseExercise

HyperthyroidismHyperthyroidism

Arteriovenous fistulaArteriovenous fistula

Aortic regurgitationAortic regurgitation

Increased ICPIncreased ICP

Patent ductus arteriosusPatent ductus arteriosus

Pulse PressurePulse Pressure

PPsystolic - systolic - PPdiastolicdiastolic

Narrowed pulse pressure Narrowed pulse pressure (≤20 mm Hg) :(≤20 mm Hg) :

HypovolemiaHypovolemia

Increased peripheral Increased peripheral vascular resistancevascular resistance

Early septic shockEarly septic shock

Decreased stroke Decreased stroke volumevolume

Pulsus ParadoxusPulsus Paradoxus

NormalNormal respiration respiration decreases SBP decreases SBP by approximately by approximately 10 mm Hg 10 mm Hg during during inspirationinspiration. .

Pulsus paradoxus Pulsus paradoxus >12–mm Hg>12–mm Hg decrease decrease

in SBP during inspiration.in SBP during inspiration.

COPDCOPD

PneumothoraxPneumothorax

Severe asthmaSevere asthma

Pericardial tamponadePericardial tamponade

Blood pressureBlood pressure


Preparation for Preparation for measurementmeasurement

Preparation for measurementPreparation for measurement

Patient should Patient should abstain from eating, abstain from eating, drinking, smoking and drinking, smoking and taking drugs that taking drugs that affect the blood affect the blood pressure one hour pressure one hour before measurement. before measurement.

Preparation for measurementPreparation for measurement

Painful proceduresPainful procedures and exercise should and exercise should not have occurred not have occurred within one hour. within one hour.

Patient should have Patient should have been sitting quietly for been sitting quietly for about 5 minutes. about 5 minutes.

Relative contraindicationsRelative contraindications

Arteriovenous fistulaArteriovenous fistula

Ipsilateral mastectomyIpsilateral mastectomy

Axillary lymphadenopathyAxillary lymphadenopathy

LymphedemaLymphedema

Circumferential burns over the limbCircumferential burns over the limb

Position of the PatientPosition of the Patient

Position of the PatientPosition of the Patient

The patient may The patient may bebe lying lying or or sittingsitting, , as long as the site as long as the site of measurement is of measurement is at the at the level of the level of the right atriumright atrium and the and the armarm is is supportedsupported..

EquipmentEquipment

In order to measure the Blood In order to measure the Blood Pressure (equipment)Pressure (equipment)

Adult Cuff size Adult Cuff size – Cuff Cuff WidthWidth: : 40% of 40% of

limb'slimb's circumference circumference

– Cuff Cuff LengthLength: : Bladder at Bladder at 80% of 80% of limb's limb's circumference circumference

In order to measure the Blood In order to measure the Blood Pressure (equipment)Pressure (equipment)

Pediatric Cuff size Pediatric Cuff size – Minimum Cuff Minimum Cuff

Width: Width: 2/3 length of 2/3 length of upper armupper arm

– Minimum Cuff Minimum Cuff length: length: Bladder Bladder nearly encircles nearly encircles armarm

Blood Pressure Blood Pressure

If it is tooIf it is too small small, the , the readings will be readings will be artificially artificially elevatedelevated. . The opposite occurs if The opposite occurs if the cuff is toothe cuff is too large large. .

Cuff PositionCuff Position

In order to measure the Blood In order to measure the Blood Pressure (Cuff Position)Pressure (Cuff Position)

Patient's arm Patient's arm slightly slightly flexed at flexed at elbow elbow

Push the Push the sleeve upsleeve up, , wrap the cuff wrap the cuff around the bare armaround the bare arm

In order to measure the Blood In order to measure the Blood Pressure (Cuff Position)Pressure (Cuff Position)

Cuff applied directly Cuff applied directly over skinover skin (Clothes (Clothes artificially raises artificially raises blood pressure )blood pressure )Position lower cuff Position lower cuff border border 2.5 cm 2.5 cm above antecubitalabove antecubitalCenter inflatable Center inflatable bladder over bladder over brachial artery brachial artery

Measurement of the BPMeasurement of the BP

The The manometer scale manometer scale should be at eye should be at eye levellevel, and the column , and the column vertical. vertical. The patient The patient should not be able to should not be able to see the columnsee the column of the of the manometer manometer

Technique of BP Technique of BP measurementmeasurement

In order to measure the BPIn order to measure the BP

Feel for a pulse Feel for a pulse from the artery from the artery through the through the inside of the inside of the elbowelbow (antecubital (antecubital fossa). fossa).


With your left hand With your left hand place the place the bellbell of the of the stethoscopestethoscope directly directly over the brachialover the brachial

artery with as little artery with as little pressure as possible.pressure as possible.

Technique of BP measurementTechnique of BP measurement

Use your right hand to Use your right hand to pump the squeeze pump the squeeze bulbbulb several times several times and inflate the cuff toand inflate the cuff to

30 mm Hg30 mm Hg above the above the level at which the level at which the palpable pulse palpable pulse disappears.disappears.

Technique of BP measurementTechnique of BP measurement

Deflate cuff slowlyDeflate cuff slowly at at a rate of a rate of 2-3 mmHg 2-3 mmHg per secondper second until you until you can again detect a can again detect a radial pulseradial pulse


Avoid moving Avoid moving your your handshands or the or the head of head of the stethescopethe stethescope while while you are taking you are taking readings as this may readings as this may produce noise that produce noise that can obscure the can obscure the Sounds of Koratkoff. Sounds of Koratkoff.


The two arm readings The two arm readings should be within should be within 10-10-20 mm Hg.20 mm Hg. Differences greater Differences greater then then 2020 imply imply differential blood flow.differential blood flow.

Blood pressure may be affected by Blood pressure may be affected by many different conditionsmany different conditions

Various Various medications medications ""White coat hypertensionWhite coat hypertension" may occur if the " may occur if the medical visit itself produces extreme anxietymedical visit itself produces extreme anxiety

Blood pressure may be affected Blood pressure may be affected by many different conditionsby many different conditions

Falsely low BP:Falsely low BP:

wide cuffwide cuff excessive pressure excessive pressure

on the head of the on the head of the stethoscopestethoscope

rapid cuff deflationrapid cuff deflation

Falsely high BP:Falsely high BP:

narrow cuffnarrow cuff AnxietyAnxiety painpain tobacco usetobacco use ExertionExertion unsupported armunsupported arm slow inflation of the cuffslow inflation of the cuff

Orthostatic HypotentionOrthostatic Hypotention

Orthostatic HypotentionOrthostatic Hypotention

Orthostatic (postural) Orthostatic (postural) measurements of measurements of pulse and blood pulse and blood pressure are part of pressure are part of the assessment for the assessment for hypovolemia. hypovolemia.

Orthostatic Tilt TestOrthostatic Tilt Test

1. 1. Blood pressure Blood pressure and and pulsepulse are recorded are recorded after the patient has been after the patient has been supinesupine for for 22 to to 3 minutes3 minutes..

2. Blood pressure, pulse, and symptoms 2. Blood pressure, pulse, and symptoms are recorded are recorded afterafter the patient has been the patient has been standing for 1 minutestanding for 1 minute; the patient should ; the patient should be permitted to resume a supine position be permitted to resume a supine position immediately if syncope or near-syncope immediately if syncope or near-syncope develop.develop.

Orthostatic Tilt TestOrthostatic Tilt Test

POSITIVE TESTPOSITIVE TEST

1. 1. IncreaseIncrease in pulse of in pulse of 30 beats/min 30 beats/min or or more in adults more in adults oror

2. Presence of symptoms of cerebral 2. Presence of symptoms of cerebral hypoperfusion (e.g., dizziness,syncope)hypoperfusion (e.g., dizziness,syncope)

TemperatureTemperature



Core Body Temperature:Core Body Temperature:

the distal third of the esophagusthe distal third of the esophagus

the tympanic membrane (TM) the tympanic membrane (TM)

pulmonary arterypulmonary artery

the rectum when the temperature is obtained the rectum when the temperature is obtained at least 8 cm from the anusat least 8 cm from the anus

the bladderthe bladder


Acceptable times Acceptable times

in oral 7 minin oral 7 min

rectal 3 minrectal 3 min

axillary 10 minaxillary 10 min

Oxygen SaturationOxygen Saturation



Over the past decade, Over the past decade, Oxygen SaturationOxygen Saturation measurement of gas measurement of gas exchange and red exchange and red blood cell oxygen blood cell oxygen carrying capacity has carrying capacity has become available in become available in all hospitals and all hospitals and many clinicsmany clinics. .


Oxygen SaturationOxygen Saturation provide important provide important information about information about cardio-pulmonary cardio-pulmonary dysfunctiondysfunction and is and is considered by many considered by many to be a to be a fifth vital signfifth vital sign. .


For those suffering For those suffering from either from either acuteacute or or chronic cardio-chronic cardio-pulmonary disorderspulmonary disorders, , Oxygen SaturationOxygen Saturation can help can help quantifyquantify the the degree of impairment.degree of impairment.

PAIN PAIN


Pain As a Vital SignPain As a Vital Sign

vital signs assessment in emergency department z.vaseie md emergency medicine resident

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