Vital Signs Assessment In Emergency Department Z.Vaseie MD Emergency Medicine Resident

General Vital signs

Vital sign For all ED patients: 1. Respiratory Rate 2. Pulse Rate 3. Blood Pressure 4. Tempreture 5. Pulse Oximetry 6. Pain Assessment (some patient) (some patient)

Vital sign Vital Signs :  Severity of illness  Urgency of intervention  V/S should measured at intervals:  Clinical judgement  Patients clinical state  After significant change in these parameters

Vital sign Normal vital signs change with gender, race, pregnancy, residence in an industrialized nation.

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

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

Respiratory rate Vital signs

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

Respiratory Rate Patient should be unaware about checking of his RR RR

Respiratory Rate Increased RR: Pulmonary or cardiac diseases AcidosisAnemiaFeverStress Drugs(stimulants & salicylates)

Respiratory Rate Contraindications to careful measurement of RR: Respiratory distress Apnea Upper airway obstruction Immediate Immediate Intervention Intervention

Respiratory Rate Count for a full minute (most accurately)

Respiratory Rate Cheyne – Stokes Respiration Cheyne – Stokes Respiration

Respiratory Rate Biots (Cluster) Respiration Biots (Cluster) Respiration

Respiratory Rate Kussmaul Respiratory Hyperpnea

Respiratory Rate Apneustic Respiration

Respiratory Rate Ataxic Respiration

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

Pulse Vital signs

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

Pulse rate Don’t use of PULSE as an absolute gauge of BP Avoid bilateral carotid artery palpation Palpate the carotid pulse at or below the level of the thyroid cartilage

Pulse rate Avoid carotid sinus massage Adult + Atherosclerotic disease: prior auscultation of prior auscultation of carotid artery. If a bruit is present, gently palpate the carotid pulse. carotid artery. If a bruit is present, gently palpate the carotid pulse.

Pulse radial pulse radial pulse is routinely used is routinely used Use the tips of the first and second Use the tips of the first and second fingers to palpate the pulse. fingers to palpate the pulse.

The two advantages of this technique: (1) the fingertips are quite sensitive (1) the fingertips are quite sensitive (2) the examiner’s own pulse may be counted if the thumb is used instead of the first and second fingers. (2) the examiner’s own pulse may be counted if the thumb is used instead of the first and second fingers. Pulse

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

Pulse: Quantity If the rate is particularly slow or fast, it is probably best to measure for a full 60 seconds in order to minimize the error.

Pulse: Regularity Is the time between beats constant? Irregular rhythms are quite common. are quite common. (atrial fibrillation or flutter)

Pulse: Volume Does the pulse volume feel normal? This reflects changes in stroke volume. In hypovolemia, the pulse volume is relatively low

Pulse Pressure P systolic - P diastolic Increased pulse pressure (≥60 mm Hg) : Anemia Anemia Exercise ExerciseHyperthyroidism Arteriovenous fistula Arteriovenous fistula Aortic regurgitation Aortic regurgitation Increased ICP Patent ductus arteriosus Patent ductus arteriosus

Pulse Pressure P systolic - P diastolic Narrowed pulse pressure (≤20 mm Hg) : Narrowed pulse pressure (≤20 mm Hg) : Hypovolemia Hypovolemia Increased peripheral vascular resistance Increased peripheral vascular resistance Early septic shock Early septic shock Decreased stroke volume Decreased stroke volume

Pulsus Paradoxus Normal respiration decreases SBP by approximately 10 mm Hg during inspiration. Pulsus paradoxus >12–mm Hg decrease in SBP during inspiration. in SBP during inspiration.COPD Pneumothorax Pneumothorax Severe asthma Pericardial tamponade

Blood pressure Vital signs

Preparation for measurement

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

Preparation for measurement Painful procedures and exercise should not have occurred within one hour. Painful procedures and exercise should not have occurred within one hour. Patient should have been sitting quietly for about 5 minutes.

Relative contraindications Arteriovenous fistula Ipsilateral mastectomy Axillary lymphadenopathy Lymphedema Circumferential burns over the limb Circumferential burns over the limb

Position of the Patient

The patient may be lying or sitting, as long as the site of measurement is at the level of the right atrium and the arm is supported. The patient may be lying or sitting, as long as the site of measurement is at the level of the right atrium and the arm is supported.

Equipment

In order to measure the Blood Pressure (equipment) Adult Cuff size –Cuff Width: 40% of limb's circumference –Cuff Length: Bladder at 80% of limb's circumference

In order to measure the Blood Pressure (equipment) Pediatric Cuff size –Minimum Cuff Width: 2/3 length of upper arm –Minimum Cuff length: Bladder nearly encircles arm

Blood Pressure If it is too small, the readings will be artificially elevated. The opposite occurs if the cuff is too large.

Cuff Position

In order to measure the Blood Pressure (Cuff Position) Patient's arm slightly flexed at elbow Push the sleeve up, wrap the cuff around the bare arm

In order to measure the Blood Pressure (Cuff Position) Cuff applied directly over skin (Clothes artificially raises blood pressure ) Position lower cuff border 2.5 cm above antecubital Center inflatable bladder over brachial artery

Measurement of the BP The manometer scale should be at eye level, and the column vertical. The patient should not be able to see the column of the manometer

Technique of BP measurement

In order to measure the BP Feel for a pulse from the artery through the inside of the elbow (antecubital fossa).

In order to measure the BP With your left hand place the bell of the stethoscope directly over the brachial artery with as little pressure as possible. artery with as little pressure as possible.

Technique of BP measurement Use your right hand to pump the squeeze bulb several times and inflate the cuff to 30 mm Hg above the level at which the palpable pulse disappears. 30 mm Hg above the level at which the palpable pulse disappears.

Technique of BP measurement Deflate cuff slowly at a rate of 2-3 mmHg per second until you can again detect a radial pulse

In order to measure the BP Avoid moving your hands or the head of the stethescope while you are taking readings as this may produce noise that can obscure the Sounds of Koratkoff.

In order to measure the BP The two arm readings should be within mm Hg. Differences greater then 20 imply differential blood flow.

Blood pressure may be affected by many different conditions Various medications "White coat hypertension" may occur if the medical visit itself produces extreme anxiety

Blood pressure may be affected by many different conditions Falsely low BP: wide cuff wide cuff excessive pressure on the head of the stethoscope excessive pressure on the head of the stethoscope rapid cuff deflation rapid cuff deflation Falsely high BP: narrow cuff narrow cuff Anxiety Anxiety pain pain tobacco use tobacco use Exertion Exertion unsupported arm unsupported arm slow inflation of the cuff slow inflation of the cuff

Orthostatic Hypotention

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

Orthostatic Tilt Test 1. Blood pressure and pulse are recorded after the patient has been supine for 2 to 3 minutes. 2. Blood pressure, pulse, and symptoms are recorded after the patient has been standing for 1 minute; the patient should be permitted to resume a supine position immediately if syncope or near-syncope develop.

Orthostatic Tilt Test POSITIVE TEST POSITIVE TEST 1. Increase in pulse of 30 beats/min or more in adults or 2. Presence of symptoms of cerebral hypoperfusion (e.g., dizziness,syncope)

Temperature Vital signs

Temperature Core Body Temperature: the distal third of the esophagus the tympanic membrane (TM) pulmonary artery the rectum when the temperature is obtained at least 8 cm from the anus the bladder

Temperature Acceptable times Acceptable times in oral 7 min rectal 3 min rectal 3 min axillary 10 min axillary 10 min

Temperature

Oxygen Saturation Vital signs

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

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

Oxygen Saturation For those suffering from either acute or chronic cardio- pulmonary disorders, Oxygen Saturation can help quantify the degree of impairment.

PAIN Vital signs

Pain As a Vital Sign