HOW VITAL ARE VITAL SIGNS? What do they really tell us? As firefighter/EMTs and firefighter/paramedics, we are judged by peer chart review, quality improvement (QI), and sometimes a lawyer during a deposition. If we always know why we’re doing what we’re doing and can support our actions with clear-cut reasons, then our care is appropriate and will withstand peer scrutiny (and the scrutiny of a lawyer or jury).
Vital signs are an important component of patient care. They determine which treatment protocols to follow, provide critical information needed to make life-saving decisions, and confirm feedback on treatments performed. Accurate, documented vital signs are a very important part of EMS.
The four components of a set of vitals include blood pressure (BP), pulse, respiratory rate, and temperature. In the field, we may be very precise, such as a “heart rate of 136 beats per minute”; at other times, we might infer a blood pressure is greater than 60 mmHg because only a carotid pulse can be palpated.
We assess and retain the information needed to make treatment decisions. Other important initial assessment indicators include level of consciousness, skin condition, and presence or absence of pain.
We know from experience that one of our first tasks after arrival on-scene is to identify the problem. Often, the dispatch information does not match the problem. Acquiring patient information helps us narrow down the problem.
The first set of vitals in the field provides a baseline reference for the entire chain of health care. Accurately taking vital signs is just as important as the vital signs themselves. BP 120/80, P 80, and R 18 appear only in textbooks. We all know the patients never read the textbook!
Blood pressure is a measurement of the force exerted on the walls of the blood vessels associated with the contraction and relaxation phases of the heart. It is expressed in a ratio of millimeters of mercury during the contraction phase (systolic) over the resting phase (diastolic) of the heart. In firefighting terms, blood pressure could be translated to handline discharge pressure with respect to residual hydrant pressure.
Photos by author.
The instrument used to detect blood pressure is the sphygmomanometer. Remember, proper fit is necessary to ensure an accurate reading. Hearing then not hearing the thump-thump is the correct way to obtain a blood pressure. Seeing the needle bounce on the gauge only tells us we’re in the neighborhood.
A general rule of thumb to estimate normal blood pressure is 100 plus the patient’s age until age 50, depending on the reference cited. A 22-year-old male should have a BP of 122/P. Notice the “P” in the diastolic position reminds us this blood pressure was palpated (to touch). If the pressure was auscultated (heard), we would have seen the bottom (diastolic) number as well, such as 122/86 mmHg.
Hypertension (high blood pressure, abbreviated HTN) is often seen in the prehospital setting but is not normally acutely life threatening. HTN is ordinarily defined as a diastolic BP greater than 90. Systolic BP can be somewhat relative in the field. This is when knowing why we’re doing what we’re doing is important.
Remember the saying from school “pump, pipes, and fluid”? Let’s keep it simple. Blood pressure can be altered by any of the three. The heart (pump), arteries/veins (pipes), and blood (fluid) work interactively with one another. For instance, if the fluid level is low because of explosive diarrhea for two days, blood pressure may be low. In turn, the patient would be tachycardic (pulse of more than 100 beats per minute) to compensate for the low fluid level. An orthostatic blood pressure check is indicated for such a patient. BP normally does not drop more than 20 points, unless under duress. When the patient is lying down, take a BP. After the patient is standing for a minute or two, take another BP. A noticeable drop in the systolic BP would be one indication that this patient is dehydrated. Other indicators would include a high pulse rate; poor skin condition in the form of pale, cool, and possibly moist skin; lightheadedness; and, of course, a history of the illness. Horizontal positioning during transport and an IV would be good for this patient.
If the pipes have constricted from a prescribed medication and the pump and fluid levels remain constant, hypertension may occur. Remember, understanding the problem is the first step in deciding how to fix it.
For instance, the elderly male patient with a spontaneous nosebleed (not caused by trauma from a fall) may very likely exhibit a higher than normal systolic BP. Perhaps he recently had his blood pressure medication changed or dose adjusted by his health-care provider, which affected his pipes. Accompanying signs might include blurred vision, difficulty speaking, headache, or dizziness. Yet, these are also possible signs of a stroke (cerebral vascular attack, or CVA). In the field, our treatment may be the same: Attempt to control bleeding, continue to monitor BP, “get a strip” (EKG), and possibly start an IV. Transport is important for this potentially life-threatening or life-altering emergency.
Assessing and reassessing blood pressure are very important. Excellent times to take a blood pressure include the following:
- On initial patient contact.
- Before and after medication administration.
- After any type of intervention (such as a fluid bolus or intubation).
- Every 15 minutes.
Auscultated (heard) blood pressures are better than palpated (felt) blood pressures if circumstances permit. If you’re lucky enough to have an automated BP machine, use it frequently.
In firefighting terms, the heart is like a two-stage pump set in the pressure setting. Blood pressure is like the discharge gauge reading 140.
Remember, of all the vital signs, blood pressure is the last to change. As a stand-alone indicator of patient condition, it is late in the game. Although many protocols specify large-bore IVs and fluid boluses for a BP below 90, this must always be taken in context with other contributing factors. The patient with a BP below 90 and wet lungs makes it challenging to simply set the IV wide open for a bolus. Remember, we must always know why we’re doing what we’re doing. A logical, well-written patient care report will be a solid defense when our patient care is questioned by a grieving family or peer review. Also, justifiable patient care will keep you from hurting patients who don’t fit a cookbook approach to medicine.
The pulse is the number of times a heart beats in one minute. The normal adult pulse range is 60 to 100 beats per minute. It can be palpated most commonly at the wrist (radial) or auscultated on the chest by placing a stethoscope over the heart. When an EKG is in use, you can see or hear a rate on the monitor.
The pulse is one of the quickest vitals to change and one of the most important to obtain during initial patient assessment. The first pulse check is simply to determine whether the patient has a pulse. If a pulse is present, is it fast or slow, regular or irregular?
The pulse results from the pump. Effective perfusion of organs such as the brain, the heart, and the skin not only are important but can provide indicators of a patient’s current status.
Another aspect of the pulse is blood oxygen saturation. We all know hemoglobin is responsible for transporting oxygen. However, if the oxygen is present but not being circulated, what good is it? The pulse-ox is a noninvasive piece of medical monitoring equipment every EMS provider should have.
The pulse-ox measures the percentage of oxygen in the blood. Remember, this number can be misleading. If a person has only one red blood cell and it is 100 percent saturated with oxygen, the pulse-ox would read 100 percent, but the patient would not be perfusing effectively to maintain life. This is the reason we base our action/treatment on protocol and justifiable patient care. Stand-alone absolutes can lead you down the wrong path.
The pulse-ox also provides the pulse rate.
The respiratory rate is the number of times a patient breathes each minute. Normal adult respirations range from 16 to 20 breaths per minute. Respirations are arguably one of the most important, if not the most important, of all the vital signs. Without respirations, we can’t get past “B” of the “A-B-Cs” during our primary assessment. “B” must occur before other vital signs such as blood pressure can be addressed. Realistically, a quick pulse check is reasonable while counting respirations. It helps determine if CPR or simply rescue breathing is needed.
Whether you are listening with a stethoscope or feeling the patient’s chest rise and fall, respiratory rate can be very difficult to count. Distracting factors such as body fat, clothing (heavy garments or layering), or inaccessibility from an entrapment or a rescue situation can hinder a responder’s ability to assess respirations.
As with the pulse, we want to assess respirations by rate and quality: regular or irregular, slow or fast, labored or normal. Are they effective? Are they spontaneous? Are they artificial (such as by a bag valve mask)? Are they shallow or deep? Are they wet or dry?
Although not a vital sign, lung sounds go hand in hand with respiratory rate. Wet lungs could mean pneumonia in the elderly patient, congestive heart failure (CHF) in the cardiac patient, or “productive” in the snotty-nosed child.
If you are lucky enough to carry a thermometer on your unit, great! Use it! Most of us do not have that luxury. So, we basically narrow temperature down to generalized terms: hot, warm (normal), cool, or cold.
Take a temperature by touching the body core, if possible. Extremities can be deceiving.
Also, take into consideration during the assessment the ambient temperature in which the patient is found. For example, if an elderly woman dies in her sleep sometime around 2200 hours during the winter and she sleeps with an electric blanket, her body would still be warm despite the fact that she is dead.
Temperature is very important in heat and cold exposure-related emergencies. Summer heat with or without high humidity can be a firefighter’s downfall. For the pediatric patient, increased body temperature can lead to seizures.
TRICKS OF THE TRADE
A simple yet effective way to gather some relevant information very quickly is to assess visually, tactilely, and audibly while you question the patient.
When addressing an adult patient sitting in an easy chair in the living room, squat down and gently place one hand on the patient’s wrist to assess a pulse and the skin. Place the other hand on the patient’s shoulder/neck just under the clothing to attempt to feel a core temperature and respiratory rate. This establishes a rapport quickly with the patient as well as provides reassurance by means of a calming touch to the patient.
The information we can quickly obtain is as follows: BP is greater than 80-90 mmHg (depending on the reference cited) because of pulse present radially, pulse strong and regular (and if you’ve been doing this for awhile you may be able to get the rate as well), skin dry and warm, respiratory rate within normal limits, nonlabored, and no audible rales.
Furthermore, the patient is maintaining eye contact and answering questions appropriately, indicating a normal level of consciousness (alert and oriented x3), skin has good turgor and color (elasticity, which is indicative of adequate perfusion and hydration), and a quick look at the patient’s feet/ankles reveals no edema present. This all can be done in a matter of five to 10 seconds.
Here are two questions for you to consider while cooking for your company tonight:
1 Can a patient have a pulse and NOT be breathing? YES, but not for long! Immediately beginning rescue breathing with an airway adjunct will keep the heart beating. A sign of impending trouble would be slowing of the heart rate.
2 Can a patient be breathing and NOT have a pulse? YES. Respirations often continue for three to five minutes after the absence of heart function. Following cardiac arrest, breathing rapidly becomes agonal at four to five breaths per minute and will not support life. Laypersons often mistakenly think agonal breathing implies that a pulse is present when, in fact, CPR is urgently needed.
AARON DEAN has been a firefighter/paramedic for the Sacramento (CA) Fire Department since 2001 and began his career as a volunteer firefighter in 1990. He has a master of science degree in emergency services administration from CSU, Long Beach, and received his paramedic training from the Stanford Prehospital Care Program in 1994. He is the coordinator for the Every 15 Minutes program at Sacramento Fire, which teaches high school students the consequences of drinking and driving.