Orthostatic Vital Signs

[EMSrush]

I would like to find out what everyone's opinion is on the usefulness/sensitivity/specificity of obtaining orthostatic vital signs in the field. If you do use orthos, which conditions do you use them for and how do they affect your treatment plan?

 

[usafmedic45]

everyone's opinion is on the usefulness/sensitivity/specificity of obtaining orthostatic vital signs in the field

Rather than relying on people's "opinions", why not actually look it up on PubMed and see what the actual specificity and sensitivity is?

 

[KellyBracket]

If you want to start looking at the Pubmed stuff, a good place to start would be the meta-analysis that was published in JAMA a few years ago. It was titled Is This Patient Hypovolemic?

One pearl I appreciated from this review - researchers do not use the seated position for BP and HR assessment. It's just supine and standing!

 

[EMSrush]

Rather than relying on people's "opinions", why not actually look it up on PubMed and see what the actual specificity and sensitivity is?

Specificity and sensitivity will vary, depending on the types of patients that the test is used on, and the many "variations" in testing technique. I was curious to know who uses orthostats in the field and how they are used by individual EMS providers; I am familiar with their use in the hospital. I came to a forum for opinions because I wanted just that.

Directing me to PubMed wasn't quite what I was looking for, but thanks for the resource.

 

[usafmedic45]

Sorry....it's just one of those sorts of questions we get on here that is often asked because someone doesn't know exactly how to word what they are looking for. I only used it rarely in the field, usually when I suspected someone might be a little volume depleted/dehydrated but wasn't frankly hypotensive. I also would use it if the patient was reporting symptoms similar to what one might expect to be orthostatic in nature.

 

[mycrofft]

Orthostatics: yield versus time and risk.

Risk of falling or initiating syncope or arrhythmia.
TIME: how long to equilibrate? How many iterations? How long to try to puzzle out the results and record them?
YIELD: what difference will it make to your initial treatment?

I liked monitoring the pulse for rhythm and consistency of strength, not just rate, while in the act of tilting/sitting up or down for the orthostatic in the exam room. Now, what are we looking at when the pt sits up rapidly or squats to stand, and the rate becomes faster, irregularly irregular and with irregularly palpable strength? (Syncope follows). One of our MD's had this, kept trying to get back up and passing out.

 

[Brandon O]

I shared some thoughts on it here: http://emsbasics.com/2011/05/08/get-up-stand-up-orthostatics/

Like many advanced exam techniques, I find it mainly useful when things look pretty normal and you're trying to dig deeper to "rule in" some badness -- perhaps because you've got a long transport and you're bored, but in particular, when the patient wants to sign a refusal.

But they need to be pretty orthostatic to show clear changes between supine and high Fowler's. So the practicalities can be a challenge.

 

[mycrofft]

HAHA love the AMA thing

They refuse sitting down, make 'em stand up fast, pass out, implied consent...just kidding as usual.

 

[Brandon O]

They refuse sitting down, make 'em stand up fast, pass out, implied consent...just kidding as usual.

Yeh, but whatcha gonna do, transport 'em standing?

 

[mycrofft]

Trendelenburg STAT

Ride 'em feet first and jam on the brakes when they start to wake up?

 

[Brandon O]

The Human Centrifuge, eh? I can dig it.

 

[bstone]

Orthostatic hypotension can be a mystery for it's underlying pathology and the patient likes it even less.

 

[mycrofft]

Oh, answer to the question I posed above:

He sucked a heart valve. I recount more of his tale under the prehospital ECMO thread.

 

[Thriceknight]

I shared some thoughts on it here: http://emsbasics.com/2011/05/08/get-up-stand-up-orthostatics/

Like many advanced exam techniques, I find it mainly useful when things look pretty normal and you're trying to dig deeper to "rule in" some badness -- perhaps because you've got a long transport and you're bored, but in particular, when the patient wants to sign a refusal.

But they need to be pretty orthostatic to show clear changes between supine and high Fowler's. So the practicalities can be a challenge.

This was a great article!! Definitely should take a look at it.. h34r:

 

[Tigger]

My ATC is of the school of thought that they can help confirm that someone is dehydrated and is in need of some fluid replenishment...I take them when he asks but I can't say that obtaining them is some sort of be all-end all assessment technique...

 

[mycrofft]

Pinch test for hypohydration (skinn tenting).

Also obvious xerostomia, c/o thirst, sunken eyes, oliguria. For conversation's sake orthostatic could reveal dehydration, but many other signs are faster and more sure.
Like starting an IV and sand comes out.

 

[Brandon O]

In my personal experience, obvious clinical signs are often absent in younger/healthier dehydration patients.

 

[mycrofft]

...who are better able to resist it's influences.

HOw about thirst (not a good indicator in itself) and viscosity of oral secretions?

Actually, thirst isn't a bad one if you are not going to be making demands that can rapidly increase the dehydration. IOW, if I get thirsty doing EMTLIFE, I could need a drink now or later; if I get thirsty running a race, I need more than a sip or two and right now, because my water loss curve is too steep.

I know, thirst can be allayed by rinsing out the mouth....

 

[Too Old To Work]

Useless in EMS for the most part. Especially since very few people at the BLS or ALS level are taught what they mean or how to interpret them.

I've seen many cases where people who should know better will sit or stand up a patient who is already hypotensive to see if they are "postural". They find out that they are when the patient loses consciousness.

If the patient is hypotensive lying down, they are going to be hypotensive sitting or standing.

If the patient is normotensive lying down, and has a pulse rate in the normal range, you aren't going to learn much by checking postural vital signs.

Just more long taught and essentially useless EMS knowledge along with looking for battle sign, Raccoon eyes, and of course blown pupils. All of which are late signs and the absence of minutes or hours after an injury tell you nothing about the patient's condition.

 

[Brandon O]

I've seen many cases where people who should know better will sit or stand up a patient who is already hypotensive to see if they are "postural". They find out that they are when the patient loses consciousness.

If the patient is hypotensive lying down, they are going to be hypotensive sitting or standing.

Patient: [hypotensive, lying lateral in a pool of blood from his butt]
Us: [help him sit up to move him to a stairchair]
Patient: [immediately seizes]
Us: Hmm... whoops.