VITAL SIGNS: VITAL SIGNS WHY THEY ARE VITAL Objectives: Objectives Identify national standards for obtaining vital signs during the initial assessment and reassessment of Trauma patients >> List normal parameters for adult vital signs to include respiratory and heart rates, as well as systolic and diastolic blood pressures. >> Describe normal and abnormal vital sign physiology and pathophysiology to include: cardiac output, stroke volume and vascular resistance. >> List conditions that increase and decrease blood pressure, heart rate and respiratory rate. >> Explain the terms trending and linked reassessment as they relate to vital signs and patient assessment. Buzz Words : Buzz Words Trending vital signs: The use of more than one set of vital signs to detect changes or "trends" in patient conditions. Linked reassessment: Reassessment of the patient based on vital sign changes, or reassessment of vital signs because of changes or new complaints from the patient. Peripheral vascular resistance (PVR): The resistance that occurs in blood vessel walls as blood moves through them. Muscles lining blood vessels allow them to dilate (lowering resistance and blood pressure) and constrict (increasing resistance and blood pressure) to maintain perfusion and balance. Vital signs are the fundamental objective data collected on all patients by medical personnel. At a glance, review of the initial heart rate, blood pressure and respiratory rate gives you an immediate sense of whether your patient is "sick" or "stable." Patients with marked abnormalities in their vital signs, such as rapid heart rate or very low blood pressure, provide obvious, immediate patient information. However, the practice of taking several sets of vital signs and looking for trends within them is often overlooked by EMS providers. The subtle changes in vital signs that can be observed over time are a critical part of the ongoing assessment Physiology: Physiology What constitutes "normal" adult vital signs is a matter of some debate and must always be viewed in the context of each patient. A systolic blood pressure of 92 mmHg in a 100-pound female athlete may be a normal value for her, whereas the same blood pressure in a 300-pound male with a history of hypertension would clearly be an abnormal value. PowerPoint Presentation: Normal Respiratory Rate 12 to 20 breaths/minute Normal Heart Rate 60 to 100 beats/minute Normal Systolic Blood Pressure 90 to 150 mmHg Normal Diastolic Blood Pressure 60 to 90 mmHg Cardiac Stuff: Cardiac Output= Heart Rate X Stroke Volume (the amount of blood the heart pumps out with each beat) Blood Pressure= Cardiac Output X Vascular Resistance of the body's blood vessels : Cardiac Stuff: Cardiac Output = Heart Rate X Stroke Volume (the amount of blood the heart pumps out with each beat) Blood Pressure = Cardiac Output X Vascular Resistance of the body's blood vessels In both these equations, the body strives to maintain a constant cardiac output and a constant blood pressure. If the stroke volume falls in such situations as blood loss from TRAUMA, the body will mobilize the endocrine and sympathetic nervous systems to elevate the heart rate and maintain cardiac output. Ultimately, the body can only raise the heart rate so far to compensate (to perhaps 140 or 150 bpm in the adult), and cardiac output will begin to fall as blood loss continues. As cardiac output falls, the body will strive to maintain blood pressure by increasing the peripheral vascular resistance (PVR). PVR is also increased by stimulation of the endocrine and sympathetic nervous systems and the release of vasoactive chemicals, such as epinephrine and norepinephrine . PVR…huh?: PVR…huh? Increased PVR manifests in several ways: Because the diastolic blood pressure is dependent on PVR, an initial elevation in the diastolic blood pressure may be seen. However, as hypoperfusion (shock) progresses, the increased PVR results in such classic shock findings as decreased blood flow to skin, which results in pale, cool and clammy skin seen on examination. Ultimately, as all these compensations fail in the face of continued blood loss (i.e. TRAUMA), the blood pressure will eventually fall. Why we do what we do:: Why we do what we do: trending of vital signs allows you to see if the patient changes (or doesn't change) over time. The second critical concept is to always link a change in vital signs or patient complaint to a physical reassessment of the patient. For example, a standard 15-minute reassessment of vital signs reveals an abnormally slow heart rate that wasn't present in the baseline vitals. This prompts you to re-examine the patient, and she reports a new complaint of lightheadedness. Conversely, during transport, a patient tells you she's suddenly feeling lightheaded. This prompts you to obtain a new full set of vital signs, and you discover her heart rate has dropped from 55 to 45. Vignette: Vignette 53-year-old male presents to ED (Board and Ccollar on) s/p MVC, man vs. telephone polewho has driven his car into a telephone pole. The patient is visibly intoxicated with slurred speech. Initial vital signs are BP 120/64, pulse 100, respirations 18 and ambient SpO 99%. The physical exam reveals no obvious external signs of trauma, his lung sounds are clear, and there's no evidence of abdominal tenderness or distension. The patient repeatedly states, "I'm fine," and denies any specific pain. His neurological exam is normal, and he has a Glasgow Coma Scale (GCS) score of 15. About 15 minutes, the patient reports increasing abdominal pain. His repeat vital signs are: BP 110/84, pulse 130, respirations 26, SpO 99%. Secondary Assessment: abdomen: diffuse tenderness and mild rigidity. increased heartbeat. 7 minutes later…: 7 minutes later… As you complete your third set of vitals. His heart rate continues to elevate—now at 144. His blood pressure is now 82/palpation, his respirations are 30, and his skin has become cold and moist to the touch. He's now difficult to communicate with and losing consciousness. Trauma Activation is in place: General surgeon has already responded to the emergency department (ED), and an operating room has been placed on standby. Within 12 minutes of arrival, the patient is taken to the operating room, where he's found to have more than two liters of blood in his abdominal cavity. His shattered spleen is surgically removed, and then he survives. The Honest Truth: The Honest Truth TDHS standards require providers to obtain a baseline set of vital signs as part of the initial assessment, and subsequent sets of vital signs as part of patient reassessment—every 1 hour in stable patients and every 5 minutes in unstable patients. In addition, repeat vital signs after each drug administration. Because most of our patients’ initial (aka, "baseline") vital signs are within normal limits, we tend to become complacent about obtaining and trending vital signs. Sometimes providers even fabricate vital signs (especially respiratory rates) rather than actually taking the time to properly obtain additional sets of accurate vital signs. References:: References: National Highway Traffic Safety Administration. EMT-Basic: National Standard Curriculum. 1994. Bledsoe BE, Porter RS, Cherry RA. Essentials of Paramedic Care. Brady, Pearson-Prentice Hall: Upper Saddle River, N.J., 2003. Goyal M, Hollander JE, Gaieski DF. Images in emergency medicine. Synypnea . Ann Emerg Med. 2005;46:469. O'Keefe MF, Limmer D, Dickinson ET ( Eds ): Emergency Care, 11 ed. Brady, Pearson-Prentice Hall: Upper Saddle River, N.J., 2009.