Vital Signs: Non Limmer Flashcards
Resp: Birth
40-60
Pulse: Birth
140-160
BP: Birth
70 Systolic
Resp: Neonate
30-40
Pulse: Neonate
100-160
BP: Neonate
70-90
Resp: At 1 yr
20-30
Pulse: At 1 yr
100-120
BP: At 1 yr
90 systolic
Resp: Toddler
20-30
Pulse: Toddler
80-130
BP: Toddler
70-100
Resp: Preschooler
20-30
Pulse: Preschooler
80-120
BP: Preschooler
80-110
Resp: School Age
20-30
Pulse: School Age
70-110
BP: School Age
80-120
Resp: Adolescent
12-20
Pulse: Adolescent
55-105
BP: Adolescent
100-120
Resp: Early Adulthood
16-20
Pulse: Early Adulthood
70
BP: Early Adulthood
120/80
Resp: Middle Adulthood
16-20 Late depends on pt health
Resp: Middle Adulthood
70 Late depends on pt health
BP: Middle Adulthood
120/80 Late depends on pt health
Ventilation Rate with a Pulse: Adult
10 - 12 or 1 every 5-6 seconds
Ventilation Rate with a Pulse: 1 mo to Adult
12-20 or 1 every 3-5 seconds
Ventilation Rate with a Pulse: Newborn
40-60 or one every 1 to 1.5 seconds
One Person Ventilation without a Pulse: 1 mo to Adult
1 rescuer
30 compressions to 2 ventilation
One Person Ventilation without a Pulse: Newborn
1 rescuer and 2 rescuer
3 compressions to 1 ventilation
Two Person Ventilation without a Pulse: Adult
2 rescuer
30 compressions to 2 ventilation
Two Person Ventilation without a Pulse: 1 mo to Adolescent
2 rescuer
15: 2
Ventilation Rate without Pulse: Advanced Airway
1 mo to Adult
8-10 per minute or one every 6-8 seconds
100 compressions with no pause for ventilation
Ventilation Rate without Pulse: Advanced Airway
Neonate to 30 days
30 per minute or one ventilation after every 3 compressions
Normal BP Formula: Adult Male
100 + age to 40: Diastolic 60-85
Normal BP Formula: Adult Female
90 + age to 40: Diastolic 60-85
Normal BP Formula: Adolescent
90mm lower limit normal: 2/3 of systolic
Normal BP Formula: 1-10years
Upper Limit: 90 + 2x Age
Middle Range: 80 + 2x Age
Lower Limit: 70 + 2x Age
Normal BP Formula: Infant
70 mm lower limit of normal: 2/3 of systolic
When do you do chest compressions for a neonate
HR 60 bpm → Chest compressions can be
stopped
want to see improvement within 30 seconds
baby placed in sniffing position
Chest Compressions: Indications
Heart rate remains less than 60 beats per minute
(bpm) despite 30 seconds of effective positive pressure
ventilation
Chest Compressions: Coordination With Ventilation
• One cycle of 3 compressions and 1 breath takes 2 seconds
• The breathing rate is 30 breaths per minute and the compression rate is 90 compressions per minute. This equals 120 “events” per minute
When do you ventilate a baby
Resp 100 bpm and breathing → Positivepressure
ventilation can be stopped
want to see improvement within 30 seconds
baby placed in sniffing position
Sympathetic Response
Pupils Dilate Saliva Decreases Bronchioles Dilate Blood Vessels Constrict Epinephrine Secreted Sweat Increases Gastric Juices Decrease Heart Rate Increases
Parasympathetic Response
Pupils constrict
Saliva decreases
Bronchioles Constrict
Blood Vessels Dilate
Gastric Juices increase
Heart Rate decreases
Alpha 1 effects
vessels constrict - skin significantly affected (pale & cool)
sweat glands release sweat - skin clammy
Alpha 2….
regulates the release of Alpha 1
Beta 1 effects
Related to the heart
HR increase
Force of Contraction increase
Electrical Impulses speed up
One heart and two lungs
Beta 2 effect
Dilate smooth muscle - especially bronchioles and some vessels
One heart and two lungs
Epinephrine
Has Alpha 1, 2, Beta 1, 2
The bronchodialation from Epi-Pen is a B2 effect
Adverse reactions to adrenaline include palpitations, tachycardia, arrhythmia, anxiety, panic attack, headache, tremor, hypertension, and acute pulmonary edema.[49]
Use is contraindicated in people on nonselective β-blockers, because severe hypertension and even cerebral hemorrhage may result. Although commonly believed that administration of adrenaline may cause heart failure by constricting coronary arteries, this is not the case. Coronary arteries have only β2 receptors, which cause vasodilation in the presence of adrenaline. Even so, administering high-dose adrenaline has not been definitively proven to improve survival or neurologic outcomes in adult victims of cardiac arrest.[52]
Narrow Pulse Pressure
Difference between the Systolic and Diastolic is less the 25% of Systolic
Narrow (low) pulse pressure: shock, cardiac tamponade (blood filling the pericardial sac, compressing the heart), tension pneumothorax (injury to one lung, causing pressure on the heart and the other lung).
⬇️ in cardiac output, ⬆️ SVR, ⬇️Systolic, ⬆️ Diastolic
Orthostatic Vital Signs Test (Tilt Test)
Measures heart rate and blood pressure for a patient while supine and while standing up. A positive result occurs when the heart rate increases 10-20 bpm and the blood pressure decreases 10-20 mmHg up standing up. This indicates significant blood loss.
it can mean that the patient is dehydrated, is experiencing hypovolemic shock, has some type of cardiac compromise or an arrythmia, is anemic, has a problem regulating their blood pressure, has an electrolyte imbalance, and a few other conditions. It can also be caused by medications such as Beta Blockers or even Viagra. Orthostatic Hypotension is also a common cause of Syncope, or fainting
Critical (Severe) Burns
Any burn injury complicated by respiratory tract injuries or other accompanying major traumatic injury
Full or partial thickness burns involving the face, eyes, ears, hands, feet, genitalia, respiratory tract, or major joints
Full or partial thickness burn injury covering 10% or more BSA
An partial thickness burn injury covering 25% or more BSA in adults 50yr
Burn injuries complicated by a suspected fracture to an extremity
Any burn that encircles a body part (e.g. arm, leg, chest)
Any burn classified as moderate in an adult younger than 55 is considered critical in adult older than 55
Children under age 5:
full or partial > 20 % BSA
Any burn involving the face, eyes, ears, hands, feet, genitalia, respiratory tract, or major joints
Any burn classified as moderate for an adult
Moderate Burns
Full thickness burns with 2-10% BSA excluding the face, eyes, ears, hands, feet, genitalia, respiratory tract, or major joints
Partial thickness burns with 15-25% BSA involvement
Partial thickness burns of 20% or more in adults younger than 50 years or 10% or more in adults older than 50
Children under age 5:
Any partial thickness burn of 10-20% BSA
Minor Burns
full thickness burns involving less than 2% BSA
partial thickness burns less than 15% BSA
superficial burns less than 50% BSA
children less than 5
any partial thickness burn less than 10% BSA
Wide Pulse Pressure found in
⬆️ Inter-cranial Pressure
cardiac tamponade
tension pneumotharax
Difference in BP of greater than 20 could indicate:
It has been shown that there may be a normal 10 to 20mmHg difference in blood pressure between the arms in a small minority of patients. Therefore it is important to take blood pressure readings from both arms when diagnosing hypertension. It is also useful to note when there is a difference in readings above 20mmHg from one arm to another. This can be a sign of Increased intra-thoracic pressure, a Thoracic Aneurism, or something called “Subclavian Steal Syndrome”.
In a thoracic aneurism, a condition with a mortality rate reaching up to 80%, the aortic arch in the chest is compromised. This results in severe pain (usually described as “ripping” or “tearing”), hypotension, and usually death if it ruptures. As the aneurism tears, it compromises the entrance to the right subclavian artery before the left, causing the blood pressure in the right arm to drop. This is an important diagnostic tool to use in diagnosing chest pain and should be documented.
Pulsus Paradoxus
is a condition where the heart’s pumping capacity is compromised by the thoracic pressure and the blood pressure rises and falls with inspiration and exhalation. The blood pressure drops (and sometimes even the radial pulse disappears) with inspiration and rises again with exhalation based upon the volume/pressure of air in the chest. The “paradox” results from the fact that you can hear cardiac beats on auscultation of (listening to) the chest, but cannot detect them with the blood pressure and/or pulse.
What does this mean?
Lots of conditions can cause Pulsus Paradoxus and roughly they can be broken down into three groups: Cardiac causes, Pulmonary Causes, and Other causes.
First, let’s give a nod to the other causes, the non-cardiac and non-pulmonary causes, which are Anaphylaptic Shock and an obstruction of the superior vena cava.
The cardiac causes can be: (and THANK YOU Wikipedia for being smarter than me and very accessible)
cardiac tamponade – A “bruise” of the heart resulting in the pericardial sac filling with blood that cannot escape and compromises cardiac function. (Treated with a pericardiocentesis, which some EMS providers can do in the field. I can).
constrictive pericarditis – Inflammation or purulent (puss-filled) infection of the heart which compromises pumping ability.
pericardial effusion – Fluid around the heart
pulmonary embolism – A blockage in the pulmonary artery or vein
cardiogenic shock – Impaired pumping ability of the heart due to cardiac damage or other compromise. Commonly seen in severe myocardial infarctions. (Heart attacks)
It can also be caused by pulmonary (lung) conditions, such as a tension pnuemothorax, COPD, and sometimes in severe and acute asthma, where the patient traps so much inhaled air in the lungs that they cannot exhale the excess pressure due to the inflammation of the air passages.
When you see these signs, make sure to take multiple blood pressure measurements to trend the patient’s progression. Calculate their Pulse Pressures, as cardiac tamponade, tension pneumothorax, and other conditions are characterized by narrowing of pulse pressure and compromised cardiac output also resulting in hypotension.
Cushings Triad
Cushing’s reflex, is a group of symptoms that has been shown to reveal increased intracranial pressure (ICP), the pressure within the cranial vault around the brain. This reflex shows three distinct signs which are predictive of Stroke (both ischemic and hemorrhagic), intracranial bleeding, head trauma, and some other conditions that raise ICP. These signs are:
Slowed pulse rate
Markedly increased systolic pressure (high BP) with widened pulse pressure, as the diastolic pressure usually stays normal, and:
Irregular breathing (Cheyne-Stokes pattern respirations)
Any time you suspect an injury or condition that may raise ICP, check the blood pressure and look for Cushing’s Reflex. It can help you zero in on the patient’s condition.
Pulmonary Ventilation
breathing - mechanical process of moving air in and out of the lungs
External respiration
gas exchange btwn the alveoli & surrounding pulmonary capillaries
Internal Respiration
cell/capillary gas exchange
Cellular respiration
aerobic metabolism - use of glucose and O2 to produce ATP releasing CO2 as a by-product
Signs of Severe Hypoxia
Tachypnea
Dyspnea
Cyanosis
Tachycardia may lead to dysrhythmias and eventually bradycardia
Severe Confusion Loss of Coordination Sleepy Appearance Head Bobbing Slow Reaction Time Altered Mental Status Seizure
Signs of Mild to Moderate Hypoxia
Tachypnea Dyspnea Pale, cool, clammy skin (early) Tacycardia ⬆️BP Restlessness and agitation Disorientation & confusion Headache
In a newborn bradycardia may be
a early sign of hypoxia
ie a HR of 80 in a weak old infant may be an indication of hypoxia as you would expect a HR of 120-150
For a patient to have adequate breathing…
both rate and tidal volume must be ok
✅Normal respiratory rate
✅clear and equal breath sounds
✅adequate air movement heard and felt from nose and mouth
good chest rise and fall
what is the rate, rhythm and quality
is breathing full and deep
shallow and fast…
alveolar ventialtion
the amount of air that reaches the alveoli
dead volume ~150ml in an adult
Respiratory Distress
patient is working harder to breath
rate and volume are still adequate
needs supplemental O2
D cylinder
350L
E cylinder
625L
M cylinder
3000L
G cylinder
5300L
H cylinder
6900L
Pressure Regulator reduces the pressure in an O2 tank to
30-70 psi
tank full at 2000 PSI
controls flow from 1-15
Indications for Oxygen use:
•
Any patient in cardiac arrest or respiratory arrest (100
percent oxygen, or as close to 100 percent as possible, attached to a ventilation device)
•
Any patient who is being ventilated via positive pressure ventilation
•
Any signs of hypoxia in a patient with an adequate respiratory rate and an adequate tidal volume (amount
of air breathed in and out)
•
Any patient with an SpO2
reading less than 94%, depending on the condition
•
Medical conditions that may cause hypoxia to cells or
organs, such as stroke, heart attack, drug overdose,
toxic inhalation, suffocation, foreign body airway obstruction, drowning, asthma attack, allergic reaction, seizures, poisoning, and environmental emergencies
where the patient is exhibiting signs and symptoms
of hypoxia, shock, or heart failure, or complains of dyspnea.
•
Any patient with an altered mental status or who is
unresponsive
• Injuries to any body cavity or central nervous system component, including head, spine, chest, abdomen, and pelvis
•
Multiple fractures and multiple soft tissue injuries
•
Severe bleeding that is either external or internal
•
Any evidence of hypoperfusion (shock)
•
Exposure to toxins (e.g., carbon monoxide, cyanide)
There are conditions such as ischemic stroke, acute coronary syndrome, and post-resuscitation from cardiac arrest in which making too much oxygen available in the arterial blood may increase the damage to the tissue once reperfusion of the ischemic area is achieved.
Based on the current research, found in the American
Heart Association guidelines of 2010, patients with acute
coronary syndrome who are exhibiting evidence of hypoxia or hypoxemia, have a complaint of dyspnea, have signs of heart failure, and have an SpO2
of 94% should receive supplemental oxygen. In these cases, a nasal cannula, not a nonrebreather mask, will be applied, starting with a liter flow of 2 lpm and titrated upward
based on the patient’s response to the oxygen therapy.
the AHA 2010 guidelines, a
patient suspected of having an acute ischemic stroke should receive oxygen only if evidence of hypoxemia is present, such as an SpO2 reading of <94%, a nasal cannula is applied and 2 to 4lpm of oxygen is administered. It is no longer deemed appropriate to provide oxygen by a nonrebreather mask at 15 lpm in an attempt to maximize the oxygen concentration in the arterial blood.
when to deliver oxygen
If either the respiratory
rate or the tidal volume is inadequate, immediately begin positive pressure ventilation with oxygen flowing at 15lpm to the ventilation device.
A patient who exhibits any evidence of hypoxia, hypoxemia, or poor perfusion should receive supplemental oxygen. Supplemental oxygen should also be administered if any of the following are present:
•
The patient has an SpO2
reading of <94% or the oxygen saturation level is unknown
•
The patient complains of dyspnea or exhibits signs of respiratory distress
•
Signs of poor perfusion are present (pale, cool, and clammy skin; delayed capillary refill; hypotension; decreased mental status)
•
Obvious signs of heart failure
•
Suspected shock
•
Any situation or condition in which hypoxia or hypoxemia is suspected
Signs of Inadequate Breathing
Signs of Inadequate Breathing and need PPV Abnormal work of breathing • retractions • nasal flaring • abdominal breathing • diaphoresis • Abnormal breath sounds • stridor • wheezing • crackles • silent chest (no breath sounds heard) • unequal breath sounds (trauma, infection,pneumothorax) • Reduced minute ventilation • decreased tidal volume • inadequate respiratory rate • Inadequate chest wall movement or chest wall injury • paradoxical chest wall movement • splinting of the chest wall • asymmetrical chest wall movement • Irregular respiratory pattern (head injury, stroke, metabolic derangement, toxic inhalation) • Rapid respiratory rate without clinical improvement in the patient’s condition
common causes of dypsnea in the geriatric pt
Congestive Heart failure Chronic Bronchitis Pulmonary Embolism Pneumonia Pulmonary Edema Heart Attach Asthma Emphysema
common causes of AMS in the geriatric pt
Head Injury Cardiac dysrhythmias and acure coronary syndromes Delirium, dementia and Alzheimer disease Seizure Infection Medication or drug toxicity Shock or sever dehydration Hypoxia or hyperthermia Stroke and TIA Blood glucose abnormality
Vital Signs in the geriatric pt
the resting RR is normally higher
the resting HR in normally higher
The skin is normally dry & less elastic
Fever is less common, even with infection
systolic BP will increase, making systolic hypertension more common..the hypertension may give a false reading with blood loss or dehydration & will fall rapidly in decompensation
The pupils are more sluggish to respond to light
TRACEM
Thermal Radiological Asphyxiation Chemical Etiological Mechanical
Blue Diamond Placard
Health Hazard
Higher the #, higher the hazard
Red Diamond Placard
Fire
Yellow Diamond Placard
Reactivity
White Diamond Placard
Symbols like radioactivity, oxidation, PPE
RAIN
Recognize
Avoid
Isolate
Notify
Triage reports to and does..
Incident Command
Operations Section Chief
EMS Branch Director
Triage Unit Leader
Triage Personnel
Primary and Secondary Triage
Treatment reports to and does..
Incident Command
Operations Section Chief
EMS Branch Director
Tx Unit Leader
Immediate Tx
Delayed Tx
Minor Tx
Transport reports to and does..
Incident Command
Operations Section Chief
EMS Branch Director
Transport Unit Leader
Ground Ambulance
Air Ambulance
Medical Command
Staging reports to and does..
Incident Command
Operations Section Chief
EMS Branch Director
Staging Unit Leader
Ground Ambulance
Air Ambulance
Medical Equipment Unit Leader
Morgue Unit reports to
Incident Command
Operations Section Chief
EMS Branch Director
Morgue Unit Leader
START Triage
Simple Triage and Rapid Transport
Used older than 8 and greater than 100 ponds
Uses RPM
Walking Wounded - Green
No Open airway/respiration-Black
Red
RPM
Respiration
Perfusion
Mental Status
Start Triage: Who is red tagged
Resp >30
Cap refill >2 sec
Altered Mental Status - Doesn’t Obey Commands
Pediatric Breathing after opening airway & 5 rescue breaths Resp Rate >15 and <45 No palpable pulse Inappropriate posturing or unresponsive
Secondary Triage: Airway and breathing difficulties Uncontrolled of severe bleeding Decreased Mental Status Severe Medical Problems: poisoning, diabetic and cardiac emergencies Severe burns shock (hypoperfusion)
Start Triage: Who is Yellow tagged
Unable to walk
Resp rate 15 and <45
Palpable Pulse
Alert or responds to verbal or painful stimuli
Secondary Triage
Burns without airway problems
Major or Multiple bone or joint injuries
back injuries with or without spinal cord damage
