chapter 13 vital signs and monitoring devices the best way we can tell what's wrong with a patient is assess their vital signs and take a picture of the inside of what's going on in their body and that's why we come with the vital signs and monitoring devices so our first step is gathering the vital signs are one of the key components to assessing what is wrong with our patients they give us a look at how the body's functioning and give us a way to compare how they're they're doing as we provide treatment through trending of vital signs so we look at this as a way to gauge our effectiveness of our treatments during the secondary assessment we take vital signs during the primary assessment we are doing looking for life threatening problems the vital signs we're looking for were pulse respiration the skin condition the color the temperature uh cap refill if it's for a child or infant pupils pupils are a good uh look into how the brain is functioning and then the last thing is the blood pressure how well is the heart pushing the blood through the body sometimes we include o2 saturation we're looking at how much oxygen is actually attached to the red blood cells but as we're going to point out in a little bit where there are some potential uh drawbacks to monitoring o2 saturation some complications that can cause false readings and give us a false sense of security there final signs we we take our initial set it's called the baseline vitals these are the first ones to start a process and every few minutes up to every 15 minutes we take another set as we gather three or more we can establish a trend we're looking at how whether they're going up or down or staying the same or whether they're erratic so the the these all give us some clues on what might be going on within our patient the pulse we've talked about that a little bit it's where the blood uh where the heart squeezes and pushes the blood through the arteries you can feel a pulse anywhere you've got a artery running close to the surface that you can have that you have a bone behind so you can press the artery between the bone and your fingertips can feel that pulse going through the artery every time the heart beats things we're looking at in the pulse with a rate how fast is it is it going that's so many beats per minute and then we're also looking at the quality is it strong is it weak is it thready uh is it regular is it irregular and if it's irregular is it a regular irregularity pattern or is it very chaotic and totally irregular what we call irregularly irregular taking a pulse grab the wrist that's our most common place for a conscious patient check the pulse for 30 seconds multiply by two you notice the emt is using a watch that is the key tool that we're going to need to have when we're doing pulses don't use your phones don't use a clock on the wall don't ask the patient if you can use their watch use your own watch you're counting the number of beats per minute a normal heart rate is 60 to 100. so we're in that range tachycardia remember our medical terminology tachy means fast so tachycardia is a heart rate that's too fast it's over 100 beats per minute bradycardi is below 60 beats per minute the question sometimes comes up is tachycardia bad it could be if i just ran a mile and my heart rate is 120 i am tachycardic do i need to go to the hospital probably not it should come back down on its own there are plenty of people in our city that uh are uh olympic athletes that their heart rates typically are below 60 if they're even exercising so those are the people we need to be aware of ask the question is this a normal rate for you use some judgment so don't just assume because it's below 60 or above 100 the patient is bad but we need to ask the questions and use some assessment skills anything above 150 or per minute or above 120 or below one or below 50 we need to start thinking there might be a problem but again you're trying to assess your patient just think if i have to if you have to call 9-1-1 because of an emergency are you going to have an adrenaline rush in your body that's going to bring your pulse rate up you're just in a car crash and your pulse is 130 that's accepted but you also have to look at the other symptoms is that 130 combined with other changes in the vitals other issues with the mechanism of injury or the nature of their illness do they do the all the pieces come together to say this pulse is bad compel in relation to everything else the quality we're looking at the regularity is it skipping between beats can you set her pattern to it is it three beats and then a skip beat three beats in the skip beat think uh kind of gauge what's going on that's why we want to take a pulse at least 30 seconds that gives us a good representation of the rhythm so that we can compare it some people i've seen take pulses for six seconds and multiply by ten that's not really enough to get you a good pattern established so we're looking at thirty seconds just like in the force is a really strong or is it weak weak says they're they're having troubles with their heart strong pulse maybe they're excited or they've got a good healthy heartbeat so look at your patient as a whole and use the vital sign that you're getting as a reference point to judge what and verify everything else you're seeing most common location radial for one years and up the reason we don't do the radio on the child is because it's kind of hard to get they don't their their pulses aren't too strong at the wrist so those are going to be at the brachial up underneath the bicep on top of the humerus looking at three fingers on the thumb side of the wrist do not use your thumb because you will have your own pulse at your thumb that's fairly strong and you may feel that possibility that you might have a little elevated heart rate yourself when you're taking care of patients so we want to make sure you use the best options there and use three fingers on the thumb side brachial is the kid's upper arm underneath the bicep here's an example of that one pushing up on the upper arm of the kid carotid pulse this is typically the the core pulse that we're checking on patients that are unresponsive alternate mental status altered levels of consciousness uh just seeing if we've got the very basic pulse going through the heart because it's only a few inches away from the heart so you should feel a strong pulse there do not check both sides of the deck at the same time that would be a bad thing if you cut off flow to the brain so we just check one side at a time when checking the pulse you count for 30 seconds multiply by two if you've got a hypothermic patient that has a really weak slow pulse or the patient's pulse is very irregular take the time and take a full 30 or full 60 seconds and see if you can get a good accurate reading respirations remember it's the movement of air in and out of the lungs we're measuring how fast and how well they are breathing so we're going to look for rate and quality thing about counting breathing if i tell the patient just breathe normal they will not breathe normal so i want to kind of fake them out a little bit and check the pulse and then after 30 seconds keep watching their chest but keep your finger on their pulse so they think you're still taking the pulse and they should breathe normal for you because i guarantee you if any of you my simulation patients you tell tell them you are going to check their respirations they will quit breathing for you just so you don't get any reading at all but count for 30 seconds multiply by two so 30 seconds pulse 30 seconds breathing and you're you're on your way rate looking at number of breaths per minute normal rapid or slow normal for adults is 12 to 20. so less than 12 could be a bad thing could be they're just really healthy greater than 20 could be their little short of breath look at your patient as a whole consider their age their gender the size physical condition emotional state all kinds of factors change your breathing rate so we have to assess the patient as a whole and try to figure out if they're breathing normally or not 12 to 20 is our normal range if it's less than 8 or more than 24 then we start getting nervous for them but we want to talk to them and see if there's a reason they're breathing outside of the normal range we've got normal on the on the quality we've got normal shallow labored noisy ever walked into a room and you could hear the person breathing because they've got so much congestion in their lungs uh chronic smokers with emphysema and copd you can hear them around the corner those are the people we're talking about there's junk in their lungs and you just you can hear them breathing or they're really labored you look at them and they're working to breathe shallow breathing that you can hardly see any movement look for irregularities in breeding sometimes we have people that have some neuro neurological disorders that will cause their breathing rhythm to change it'll be really fast and then apnic or no breathing and then go back to really fast and then go haptic again so be aware of what's going on with your patient if you have to take a full 60 seconds otherwise take 30 and multiply by two skin you're looking for color temperature and condition know what normal is look at people all around you everybody's got a different color skin so you look in this you can tell on pretty much every skin pigment what pale looks like you can feel the temperature take the pull the glove back on your hand put the back of your hand against their forehead against their belly try to feel the temperature and you're looking for condition is it wet is it dry is it hot to touch is it cold to touch these are all good information about how the circulation is going with your patient again putting all the pieces together and trying to form a conclusion based on multiple points of data checking the nail beds you're looking for it should be a nice pink color inside the cheek inside the lower eyelids you just pull the eyelids down you can tell the color of the skin is kind of pink that's normal in infants we're looking at the palms of hands and soles of feet dark skin patients lips and nail beds practice looking at people's skin this is not something you want to go up to in the mall and say hey can i check your eyelids but look around get to know your friends get to know new friends but always ask permission first before you check them abnormal colors we're looking for pale they are not having good perfusion at this surface level you have cyanotic or kind of blue gray look that means they don't have good perfusion and the body's not getting enough oxygen to the surface so that's called cyanosis flush or red skin you've seen people when they get embarrassed or they get fever their skin's kind of flushed that's telling us there's something wrong there's more perfusion to the skin than normal jaundiced or yellow that is mainly associated with liver dysfunction it can tell us there's problems with the liver or chronic condition that we maybe need to be aware of as we treat our patients skin temperature is either hot cold cool warm normal most ambulances now carry thermometers thanks to coven so you can get a good core temperature your patient but it's it's a quick assessment you can get just put your hand on the back of the forehead and feel as their hot cold and just kind of get you an idea of what's going on with your patient there's an example of what you do just pull your glove back i would check your patient makes if they don't have make sure they don't have any blood or anything else on their forehead before you do this but you can't feel through the gloves you need to pull the glove back a little bit and you can use your forearm where you don't have any dry skin or anything like that so that you don't have to worry about any transmission of diseases kids under six we're going to look for cap refill take your fingers squeeze the nail bed wait for the color to change it'll go white and then it'll start going pink again if it had if it goes within two seconds they're normal if it's greater than two seconds or note how long it took a friend of mine uh she's a firefighter for uh colorado springs fire she got uh some hypothermia or nose uh frostbite damage to her feet during some uh cold water rescue training several years ago and her cap refill still is around the seven or eight second mark on her feet so you push her feet they go white and it takes seven or eight seconds to actually get blood flow back to the skin so that that's a good example of what it looks like but if you have that ask the patient if it's normal for them if you did a quick assessment on her you did a cap refill on her feet you think she was having circulatory problems that were acute but there's a chronic condition so you can ask and you can find out pupils they should get smaller when you get light and they get bigger or dilate when they get dark if your patient's eyes don't change with the light ask them if they've got a glass eye that's a a good option to consider there and rule that out as a possible cause but it could be a head injury could be a drug or some type of drug poisoning overdose so we're going to look at them we're looking at the size what are they what size are they in normal lighting most of our pin lights have a little gauge on the side that gives us some little dots with the millimeters that correspond to the dots great tool for sitting up next to the eye and saying okay the eyes are three millimeters and reactive so they should change when the light changes with them you can shine the light into them you can cover their eyes let the bright lights come in lots of options there they should be the same size on both sides and they should react the same on both sides if you have an abnormal reaction not make a note of it people on the left does not dilate when exposed or does not constrict when exposed to light document what you find and those pieces all go together to find our conclusion about what's wrong with our patients note the baseline size cover one eye shine the light in the other repeat they should change if they're working normal you see on the light they've got the little dots there those are what i was talking about with the uh comparing the sizes here's kind of an example what constricted looks like on the top dilated on the bottom and then unequal there is a certain percentage of our population that has unequal pupils in general if they're unequal ask the patient is this normal if they can't answer you assume it's something that's causing them to not answer you and then just go with that here's the unequal pupil that is probably uh yeah this one says is a topical a drug they put some drugs to dilate one side of the eye so you can see in there and see the back of the pupil or back of the orbit that's a common thing they do for diabetics when you go in for your eye exams or it could be a head injury or eye injury if a patient is altered mental status and they have changes in their pupils that is typical or one excuse me if they have unequal pupils that is typically the mechanical problem with their head versus a psychological problem so it's a great tool for using to try to decide if the patient's got head injury or psychological dysfunction in the head blood pressure it's the amount of force as the ventricles squeeze pushing the blood through the vessels that's the systolic diastolic is the resting pressure between contractions so our normal pressure 120 over 80 or less anything above that we start asking questions is that a normal for them do they take blood pressure medicines and then some good follow-up and put the pieces together we measure it with a sphygmomanometer or spelled bp cuff much easier and your stethoscope so the cuff needs to be the right size they have lines on them that if you get the right size the lines will match up if you've got a patience whose arms too small or too big they won't fit correctly then you need to adjust to a bigger cuff or a smaller cuff depends on the size of your patient so it goes just above the elbow on the upper part of the arm there's a little label on the cuff that tells us where to put the the uh align the cuff based on where the arteries are in the elbow so that's something we need to practice when we start doing these in class there's you can see the arrow pointing down where you line it up you want to put it on the body so that you can see the gauge and there's a lot of uh discussion you'll hear complaints on both sides between the manual blood pressure cuff and the automated cuffs that attach to our cardiac monitors some people will say i need a real blood pressure take it with a cuff first and then we can use a machine some people just use the machine it all depends on your personal preference i can tell you having managed all the cardiac monitors at the fire department that we calibrated our blood pressure cuffs on a regular basis i think it was every six months we had a tech come in and calibrated all the machines so we knew they were accurate at that time i have yet to find a way to calibrate an emt to make sure they're accurate in hearing the blood pressure when they do it manually so there's some pros and cons there i pretty confident that i can do a good manual blood pressure but if i put it on the machine i can set it to do it every three minutes every five minutes and then just let it run for me you still need to monitor your patient but there's some pros and cons there wrap the cuff around the upper arm put it about an inch above the crease the elbow puts a bladder center of the bladder over the brachial artery so that's that line pointing down to the where you feel the pulse in the uh brachial artery right at the ac junction where the elbow is tell the patient what you're going to do they you're going to feel a little squeezing on your arm while we take a blood pressure put your stethoscope where the artery is pump the cuff up if you can't feel it or you can't hear it you can always do palpation that's what this this uh picture showing is you feel the artery you pump it up and when you can't feel it that's your systolic pressure you go a little bit higher than let it out slowly and where you start feeling it again you've confirmed that's what the pressure is inflate the cuff some some professions teach you to inflate the cuff to 200 some to 180. what we do in ems is we want to go 30 millimeters higher than where the pulse disappears so you keep your fingers on that uh pulse or you keep it on the radial and you pump up until it disappears and go a little bit higher the thing is if you go too high and it sets there the heart is going to push a little bit harder to try to get a pressure high enough to go past what is obstructing it so you're going to create a little bit higher blood pressure by putting by going up to the higher numbers and you give you a little false reading there it's not a mu not a lot but it's not necessary because you don't need to keep going higher if you know it's only going to be 120 you can go up to 150 and come back down and find it so you go up to 150s 160s slowly release it and when you hear the lub you start hearing boop boop boop in your stethoscope that's on the artery that's your systolic when it disappears that's your diastolic so you've got your upper and lower record the dot measurements it's always even numbers so that's all we our gauges are unevens you might if you do a uh automated cuff it might give you odds but that's fine document what you did but on manual blood pressures it's always going to be even if at all possible do not document 120 over 80 if if it comes out 120 over 80 that's fine but don't just write down or make up a blood pressure just so you have a number actually take the blood pressure and get document what you hear we don't expect you to be able to do this the first try second try third or fourth try you may be getting better on pediatrics it's kind of hard to get a blood pressure on the really little kiddos we do have cuffs but most of time we just go with pulse respirations and skin temperature if you can get a blood pressure great it helps you out but if you can't that's okay too use the blood pressure monitor put it on most of these have disposable cuffs so you can put their single use so your patient gets a fresh cuff every time so document it temperature if you have a thermometer on your ambulance you can use it document the temperature most of these are tympanic or i don't see very many oral thermometers or axillary thermometers most of where they had scanners at one time we were doing some therapeutic hypothermia treatment at springs fire and we used core temperatures so we had a temperature probe on our cardiac monitors that would go into the core of the body either through the esophagus or through the rectum so they were monitoring right in the center of the body but to those that's not your typical way you monitor uh with covid we've got plenty of tympanic thermometers out there so we just scan them and get the good temperature on the patient document the all the variables that might affect your temperature time of day activity age of the patient where you took it especially if you're using a thermometer that can major different body parts whether it's a axillary you put it under the armpit whether it's a oral thermometer whether it's a tympanic nerve the one that goes in the ear or just one that scans the forehead document where you measured it that helps is adjust for the differences in the different locations in the temperatures here's the oral thermometer i doubt we have any of those left with coven i would bet everything switched over to these scanning thermometers probably don't want to have a glass thermometer in the ambulance and definitely you do not want to have a red glass thermometer that's a bad thing that's a paramount skill don't touch it all right other monitoring devices we want to measure how much oxygen is in the red blood cells floating through the blood this is called the o2 saturation or spo2 it's how many it measures how many red blood cells are in the sampling set and how many of those have oxygen attached to them so this tool is a pulse oximeter or pulse ox it's the little clippy thing that you put on your finger and it tells you a percentage here's what it looks like you take it put it on the finger it's even got the picture of the finger so you know how to put it on there the heart rate on there is for confirmation purposes only that is not how you check a pulse on your patient actually feel for a pulse don't get lazy and use this and then the spo2 is your percentage of red blood cells that are saturated with oxygen when you use a pulse ox we use them on pretty much every patient now put it on you get a pulse ox you just have to be aware that there's some limitations and some things that can fool the machine and hopefully you're smart enough that you're not fooled so hypothermia you're going to draw the blood to the core you're not going to have any red blood circulating through the the fingertips you're also going to worry about fingernails or fake fingernails or fingernail polish they're going to disrupt the signal going through so we got to be aware of the complications there normal range is 96 over 100 mild hypothermia or hypo hypoxia is 91 to 95 at our elevation anything over 90 is good as long as the patient looks good if the patient looks like they're struggling to breathe and they've got a 92 treat them like they need a little oxygen if they're breathing normal talking normal and it's 92 then you probably don't need to anything below 90 we're starting to get a little concerned now that's not normal at our altitude we need to get them some oxygen and we're going to look at several factors before we determine how much but if it's below 90 that's a trigger that says i gotta look there might be a problem so we're using the pieces to put create a picture here and it's not a final final decision so people that are in shock or hypothermia may not have good perfusion to the fingertips so remember i i said it measures the percentage of the red blood cells that are saturated with oxygen if i have a hundred red blood cells and 99 of them are saturated with oxygen i've got a 99 o2 sat if i have four red blood cells and all four of them have oxygen i've got a hundred percent but i've only got four red blood cells saturated versus 99 which would be a lower number so think about that as a possible cause the patient looks bad sick but they have a good number that could be the problem the other thing that messes with us is carbon monoxide it latches on to the red blood cells it's it's kinda like that friend that never leaves your apartment they just keep sleeping on the couch and you can't get rid of them so you've got these red blood cells with the carbon monoxide floating around and it won't drop off when it goes through the lungs so you've got saturated red blood cells it looks like it's carrying oxygen because it's got one oxygen on there so you get a high number but the patient's not doing well if the patient's moving around in the in the probe is not getting a good connection problem uh nail polish anemia anemia is lack of red blood cells and hypovolemia they don't have any volume in the bloodstream if you don't have any red blood cells they can't be saturated so think about this if you get a good reading or a bad reading are there any contributing factors that are giving me a false reading help us out here blood glucose meters as emts you can do a glucose test on a patient really simple process most of your diabetics already do this multiple times a day and so if you're not sure they can help you but it's it's a simple little uh tool we carry them in the ambulance we've got those in our trauma bags here so we're going to practice with them but it's the kit's pretty simple it comes with a box or a a container full of the test strips you've got the alcohol swipe swap here to clean off the fingertips we've got lancets these you just twist off that little blue tab there and you push the button it shoots a needle into the skin just maybe a millimeter in so it's not a big deal and then you've got your glucometer glucometer you've got this place here to put the strip in once you put the strip in it comes up that it's ready you drop a drop of blood on it and it gives you a number you can use the patience or you can use you one in the ambulance just kind of depends on what you get if the number comes up really high or really low and the patient looks normal maybe test with a different machine see if it is really true sometimes uh the machines the the glucose strips go out of date the machine battery may be low so question the numbers i i got one i was testing that um oh i forgave oh i even forgot the name of them they were the ones that you put on in continuous monitor glucose and it told me i had a glucose reading of 20 and i felt fine tested on a regular glucometer and it got 96. so check your monitor before you freak out use your protocols we have protocols that authorize emts to use these check your local system and what they allow and use it only if you're authorized they have to be calibrated most of the newer ones to calibrate when you put the stick in so you don't have to worry about anything on that get the device set up get the test strip put in get the lancet out clean the finger make sure we're getting the good clean surface to do the finger prick stick the finger tell them what you're doing before you stick it some systems recommend you take a gauze pad and wipe off the first drop of blood and then get a second drop of blood out and test that one some you test the first though so know your local protocols my preference is just test the first drop that comes out and then once you get the reading dispose of the lancet and the test strip in your bio hazards and document your reading normal levels are 70 to 100 ask if they've eaten ask when the last time they ate what they ate that may have some changes on it or ask them what their normal is if their normal is 160 and you get a hundred that's not good that means they are low compared to what they normally function at so that might be causing your problems even though they're in the normal range for us so that's why we got to go back and ask them what their normal range is another tool we use for measuring our effectiveness of metabolism in the body is carbon dioxide monitoring or call it in tidal co2 or capnography when you have good metabolism in the body your body produces carbon dioxide yes we produce the greenhouse gases so every time you exhale as long as you've got good metabolism you're exhaling between 35 and 45 millimeters of mercury of carbon dioxide out in the air we have a little device that looks like a nasal cannula actually it's a nasal cannula with an extra attachment on it that hooks into our cardiac monitor and we'll measure our co2 exhalations we use that on patients are having difficulty breathing patients that are in shock patients having cardiac issues it gives us a lot of information to work with it's not going to change our treatment as emts but it's going to tell us a lot of things that can help us give a big picture to the doctor at the hospital on what's going on with our patients so they can they can get prepared correctly for when we bring our patient in if the patient's breathing normally you put this looks like a little nasal cannula over the the fa their into their nose gives them the oxygen then it has a little cup that goes down into the right over the mouth area that picks up the co2 as it comes out if they are not breathing on your their own and you're breathing for them we have a little adapter that goes on top of their your mask or on top of the airway that they're using to breathe so we've got two systems there so we've got lots of different tools that we're going to use to take vitals we're looking for pulse respirations looking for blood pressure capnography spo2 skin temperature condition temperature in general pupils so we've got lots of information we're gathering and these are all pieces to the puzzle one thing doesn't tell us the pig picture it may get as nervous but just one issue i think i guess take that back if we check a pulse and it's zero that's enough to get me nervous but if i need to put all the other pieces together and see how they work so like always if you have questions write them down and bring them to class and let's have some fun talking about them so thanks guys