SECTION 1: Vital Signs and Patient Monitoring Techniques 1
CHAPTER 1: which time it begins to rise to
Vital Signs Measurement
INTRODUCTION
Recommended in every ED:
- Temperature
- Pulse
- RR
- Blood pressure
- Pulse oximetry
o Vital signs may indicate the severity of illness and also
dictate the urgency of intervention.
o Emergency medical service (EMS) personnel begin
assessment of the patient’s status and vital signs in the
prehospital setting.
- Surges of epinephrine and norepinephrine commonly
occur during transport by the EMS, and these
catecholamines are known to alter vital signs and lead
to increases greater than 10% in the heart rate.
o Blood pressure and pulse are frequently evaluated
together as a measure of blood volume.
o Capillary refill is discussed as an assessment of overall
perfusion, circulatory volume, and blood pressure.
o Body temperature is usually the last vital sign measured
during resuscitation, it has special importance for patients
suffering from thermal regulatory failure.
NORMAL VALUES
- Normotensive or normal systolic blood pressure
▪ 90 to 140mmHg
- Normotensive or normal diastolic blood pressure
▪ 60 to 90 mmHg
- Heart rate
▪ 60 to 100 bpm
- Respiratory rate
▪ 12 to 24 breaths/min
▪ 8 to 24 breaths/min
o Pregnancy results in alterations in the normal adult values
of pulse and blood pressure.
- Pregnancy is characterized by significant increases in
minute ventilation and is thought to be due to the
combined facilitatory effects of progesterone and
estrogen on central and peripheral chemoreflex
drives to breathe.
- Resting pulse rate increases throughout pregnancy
from 10% to 15% over baseline values.
- Norms for systolic and diastolic blood pressure are
dependent on patient positioning.
▪ sitting or standing, systolic pressure is
essentially unchanged.
▪ Diastolic pressure declines until
approximately 28 weeks’ gestation, at
Chapter 1: Vital Signs and Measurement
nonpregnant levels.
▪ lateral decubitus position, both systolic
and diastolic pressure decline until the
28th week and then begin to rise to
nonpregnant levels.
RESPIRATION
Breathing is initiated and primarily controlled in the medullary
respiratory center of the brainstem.
The respiratory center is modulated by the pneumotaxic
center, which limits the length of the inspiratory signal and
greatly influences the RR and apneustic center in the pons.
Increased RRs may be seen in patients with a variety of
pulmonary or cardiac diseases, and acidosis, anemia,
temperature, stress, and drugs (such as stimulants and
salicylates) can significantly alter the RR in the absence of
cardiopulmonary dysfunction.
INDICATIONS AND CONTRAINDICATIONS
The only contraindications to careful measurement of RR are
the scenarios of respiratory distress, apnea, and upper airway
obstruction.
o A prehospital RR of less than 10 breaths/min or greater
than 29 breaths/min is associated with major injury in 73%
of children.
o Using tachypnea alone as a predictor of pulmonary
pathology, infants with an RR higher than 60 breaths/min
are found to be hypoxic 80% of the time.
o An RR higher than 25 breaths/min in prehospital trauma
patients was associated with increased mortality.
PROCEDURE
o Count the respirations when the patient is unaware that
his or her breathing is being observed.
o Count for a full minute.
o Frequency of breathing is less regular than the pulse.
o An infant’s RR can easily be determined by observing or
palpating the excursion of the chest or the abdominal wall.
o Infants should be observed for grunting respirations, which
are produced by expiration against a partly closed glottis
(an attempt to maintain positive airway pressure).
 SECTION 1: Vital Signs and Patient Monitoring Techniques 2
INTERPRETATION
Respiratory Rate
o Reproducibility of RR measurements may be limited by
significant interobserver variability:
- Interobserver variability may account for a difference
of up to 6 breaths/min.
- Variability in the same observer may account for up to
5 breaths/min.
o RR is an independent risk marker for in-hospital mortality
in community-acquired pneumonia.
o The RR will generally increase in the presence of fever.
Respiratory Pattern and Amplitude
Abnormal Respiratory Patterns.
o Decreased RR is commonly seen with opiate toxicity.
o Hyperpnea, or a normal RR but clinically significant
hyperventilation secondary to increased tidal volume, may
be seen with salicylate poisoning.
o In infants, it is essential to distinguish normal periodic
breathing from apnea.
- Periodic breathing consists of three or more
respiratory pauses longer than 3 seconds in duration
with less than 20 seconds between pauses.
▪ There is no associated bradycardia or
cyanosis.
▪ Particular problem in preterm infants.
Chapter 1: Vital Signs and Measurement
▪ Periodic breathing is considered a
benign disorder.
- Apnea is defined as a respiratory pause longer than
20 seconds.
▪ It may be associated with bradycardia
and hypoxia.
▪ Infants with symptomatic apneic
episodes that result in apparent life-
threatening events are thought to be at
increased risk for sudden infant death
syndrome.
PULSE
Examine the pulse to establish the cardiac rate and regularity
of the rhythm.
Doppler ultrasound has utility in locating a pulse, assessing
fetal heart tones beyond the first trimester of pregnancy,
evaluating peripheral lower extremity vascular insufficiency
with an ankle-brachial index, and assessing blood pressure in
infants or in patients with low-flow states.
o Blood flowing into the aorta with each cardiac cycle
initiates a pressure wave.
o Blood flows through the vasculature at approximately 0.5
m/sec, but pressure waves in the aorta move at 3 to 5
m/sec.
o Therefore palpated peripheral pulses represent pressure
waves, not blood flow.
INDICATIONS AND CONTRAINDICATIONS
No contraindications exist to assessment of the pulse rate.
Assessment of blood flow by palpation of the pulse can be used
to gauge the presence of cardiac contractility and not just the
electrical rhythm.
o Continuous monitoring is not routine but may be helpful
when the clinical situation predicts significant variability in
heart rate, as in the setting of sepsis.
o Absence of a radial pulse or absence of both radial and
femoral pulses and hypotension has been demonstrated in
hypovolemic trauma patients.
o Avoid concurrent bilateral carotid artery palpation because
this maneuver could theoretically endanger cerebral blood
flow.
o Massage of the carotid sinus, found at the bifurcation of
the external and internal carotid arteries at the level of the
mandibular angle, may result in reflex slowing of the heart
rate.
- To avoid inadvertent carotid sinus massage, palpate
the carotid pulse at or below the level of the thyroid
cartilage.
o In adults with atherosclerotic disease, there is a rare risk of
precipitating a cerebrovascular event by vigorous palpation
of the carotid artery.
 SECTION 1: Vital Signs and Patient Monitoring Techniques 3
- Minimize this risk by prior auscultation of the carotid
artery.
- If a bruit is present, gently palpate the carotid pulse
while avoiding vigorous palpation, or use a Doppler
ultrasound probe to assess carotid flow instead.
PROCEDURE
o For convenience the radial pulse at the wrist is routinely
used.
o Use the tips of the first and second fingers to palpate the
pulse. Two advantages of this technique:
- (1) the fingertips are quite sensitive, thereby enabling
the pulse to be located easily and counted, and;
- (2) the examiner’s own pulse may be erroneously
counted if the thumb is used.
o Pulses are easily palpated at the carotid, brachial, femoral,
posterior tibial, and dorsalis pedis arteries.
o Palpate the pulse at the brachial artery to appreciate its
contour and amplitude.
- Locate the pulse at the medial aspect of the elbow
and note that it is more easily palpated when the
elbow is held slightly flexed.
- Determine the pulse rate by counting for 1 minute,
particularly if any abnormality is present.
o Common convention in the acute care setting is to count a
regular pulse for 15 seconds and multiply the resulting
number by 4 to determine the beats per minute.
o In neonates, use direct heart auscultation and umbilical
palpation as the methods of choice to determine the heart
rate.
o In unstable children, palpate the central arteries,
particularly the femoral and brachial pulses, instead of the
more peripheral arteries.
INTERPRETATION
Pulse Rate
o In infants and children, interpret the pulse rate with
reference to age.
Chapter 1: Vital Signs and Measurement
o Pulse varies with respiration: it increases with inspiration
and slows with expiration. This is known as sinus
dysrhythmia and is physiologic.
o Bradycardia is most commonly defined as a heart rate
lower than 60 beats/min in adults.
o Consider whether a patient’s abnormal pulse rate is a
primary or secondary condition. Examine the entire set of
vital signs when attempting to discern the cause of the
abnormal rate.
o Consider the medications that the patient may be taking or
the presence of a mechanical pacemaker.
- Digitalis compounds, β-blockers, and
antidysrhythmics may alter the normal heart rate and
the ability of this vital sign to respond to a new
physiologic stress.
- Sympathomimetic drugs such as cocaine and
methamphetamine increase heart rate, as do
anticholinergic drugs.
Heart Rhythm
Obtain information about the regularity of the pulse by
palpation.
o An irregular pulse suggests atrial fibrillation or flutter with
variable block, and accurate assessment should be carried
out by auscultation of the apical cardiac sounds.
- The apical pulse is frequently greater than the
peripheral pulse because of inadequate filling time
and stroke volume, with resultant non-transmitted
beats.
Pulse Amplitude and Contour
o Superimposition of one pathophysiologic state on another
may modify the pulse.
- For example, sepsis may result in variable pulse
amplitudes, depending on the stage in the
development of the disease.
 SECTION 1: Vital Signs and Patient Monitoring Techniques 4
- Early in sepsis, cardiac output increases and vascular
resistance decreases, causing bounding pulses.
- In advanced sepsis or septic shock, falling cardiac
output and increased vascular resistance are seen,
and pulses are diminished.
o Age-related changes in pulse amplitude and contour.
- Such changes are due to an increase in arterial
stiffness, resulting in increased pulse wave velocity
and progressively earlier wave reflection.
▪ Pulse wave analysis may be useful in
determining arterial stiffness and the
likelihood of atherosclerotic disease in
a vascular laboratory setting.
o Weak pulses can be a significant finding in hypotensive
patients, or an indication of limb ischemia if isolated to one
extremity.
o Bounding pulses can be seen with a widened pulse
pressure.
o Routine measurement of pulse amplitude requires
instrumentation.
Pulses During Cardiopulmonary Resuscitation
A carotid pulse is preferred when assessing the adequacy of
chest compressions during cardiopulmonary resuscitation.
ARTERIAL BLOOD PRESSURE
An abrupt reduction in a patient’s arterial blood pressure
usually indicates the need for immediate intervention or
reconsideration of therapy.
o Arterial blood pressure indicates the overall state of
hemodynamic interaction between cardiac output and
peripheral vascular resistance.
o Arterial blood pressure is the lateral pressure or force
exerted by blood on the vessel wall. It indirectly measures
perfusion, and blood flow equals the change in pressure
divided by resistance.
o Mean Arterial Pressure:
INDICATIONS AND CONTRAINDICATIONS
o Patients with minor ambulatory complaints unrelated to
the cardiovascular system may not necessarily need their
blood pressure measured in the ED, and those with
hemodynamic instability need frequent monitoring of
blood pressure.
o In general, the younger the patient, the less likely blood
pressure will be measured.
o In newborns, infants, and even toddlers, capillary refill is
sometimes substituted for standard blood pressure
measurement.
o In low-flow states, Doppler measurement of blood
pressure may be obtained rapidly.
Chapter 1: Vital Signs and Measurement
- Repeated measurements will provide an evaluation of
the adequacy of resuscitation in patients whose blood
pressure cannot be auscultated by standard
techniques and in those in whom intraarterial blood
pressure measurements are either contraindicated or
technically unobtainable.
o Placing a catheter for direct intraarterial measurement of
blood pressure may be performed safely in the ED, but is
not standard of care and has a higher risk for complications.
- In particular, direct measurement of arterial pressure
during pulseless electrical rhythms may help
discriminate between a severe shock state and
otherwise non-resuscitatable status.
o Alternative noninvasive devices for continuous blood
pressure measurement (CBPM) have been introduced
clinically:
- One common method of CBPM uses finger cuffs
equipped with infrared (IR) photoplethysmography
and sophisticated technology for quantification of
finger blood pressure levels.
o Relative contraindications to specific extremity blood
pressure measurement include an arteriovenous fistula,
ipsilateral mastectomy, axillary lymphadenopathy,
lymphedema, and circumferential burns over the intended
site of cuff application.
EQUIPMENT
Two types of blood pressure monitoring equipment are
currently available and used in EDs: cuff type and noninvasive
waveform analysis.
Cuff Type
Equipment required for indirect blood pressure
measurement includes:
- Sphygmomanometer (cuff with an inflatable bladder,
inflating bulb, controlled exhaust for deflation, and
manometer)
- Stethoscope
- Doppler device (for auscultation), or oscillometric
device
American Heart Association Guidelines:
- The width of the bladder should be at least 40% of
the distance of the limb’s midpoint (i.e., from the
acromion process to the lateral epicondyle).
- The length of the bladder should be 80% of the
midarm circumference or twice the recommended
width.
The manometers in common use are either aneroid, digital,
or mercury gravity column, though the mercury type is much
less common in modern use.
PROCEDURE
o Obtain indirect blood pressure measurements at the
patient’s bedside by palpation, auscultation, Doppler, or
oscillometric methods.
 SECTION 1: Vital Signs and Patient Monitoring Techniques 5
o The patient may be lying or sitting, as long as the site of
measurement is at the level of the right atrium and the arm
is supported.
o Unless the arm is kept perpendicular to the body with the
elbow resting on a desk, measurements will be 9 to 14
mmHg higher, regardless of body position.
o Allowing the arm to be parallel to the body when supine
and supporting the arm perpendicular to the body when
measuring blood pressure may create a pseudo-drop in
blood pressure.
o To palpate arterial blood pressure, inflate the cuff to 30
mmHg above the level at which the palpable pulse
disappears.
o Palpate directly over the artery and deflate the cuff at a
rate of 2 to 3 mmHg/sec.
o Report the initial appearance of arterial pulsations as the
palpable blood pressure. This practice, known as the Riva-
Rocci palpatory technique.
o The Doppler method is preferred when determining blood
pressure in infants.
o When auscultating blood pressure at the brachial artery,
apply the blood pressure cuff approximately 2.5 cm above
the antecubital fossa with the center of the bladder over
the artery.
Chapter 1: Vital Signs and Measurement
o Apply the bell of the stethoscope directly over the brachial
artery with as little pressure as possible.
- Systolic blood pressure is defined as the first
appearance of faint, clear, tapping sounds that
gradually increase in intensity (Korotkoff phase I).
- Diastolic blood pressure is defined as the point at
which the sounds disappear (Korotkoff phase V).
- In children, phase IV defines diastolic blood pressure.
- Phase IV is marked by a distinct, abrupt muffling of
sound when a soft, blowing quality is heard.
o Alternative sites include the radial, popliteal, posterior
tibial, or dorsalis pedis arteries, although any fully
compressible extremity artery may be used.
o Novel noninvasive continuous finger cuff technology
offers the benefit of uninterrupted monitoring and has the
advantage over invasive techniques of being safer and
immediately available.
o Wrist blood pressure has been shown to have good
average accuracy in the surgical environment when
compared with oscillometric devices.
o Inadvertent prolonged application of an inflated blood
pressure cuff may result in falsely elevated diastolic
pressure and ischemia distal to the site of application.
INTERPRETATION
o Blood pressure tends to increase with age and is generally
higher in males.
o Individual factors that influence blood pressure include
body posture, emotional or painful stimuli,
environmental influences, vasoactive foods or
medications, and the state of muscular and cerebral
activity.
- Exercise and sustained isometric muscular
contraction increase blood pressure in proportion to
the strength of the contraction.
- Normal diurnal pattern of blood pressure consists of
an increase throughout the day with a significant,
rapid decline during early, deep sleep.
o Systolic blood pressure in infants and children:
- Normal lower limits of systolic blood pressure in
infants and children can be estimated by adding 2
times the age (in years) to 70 mmHg.
- The 50th percentile for a child’s systolic arterial blood
pressure from 1 to 10 years of age can be estimated
by adding 2 times the age (in years) to 90 mmHg.
- Children older than 2 years are considered
hypotensive when systolic blood pressure is less than
80 mmHg.
 SECTION 1: Vital Signs and Patient Monitoring Techniques 6
o Most adults are considered hypotensive if systolic blood
pressure is lower than 90 mm H g, but some individuals
normally exhibit a systolic pressure in that range.
o In the elderly, the presence of normotension within
defined or published limits may not be reassuring. WHY?
o When considering systolic blood pressure cutoffs for
trauma patients:
- 85 mm H g for patients aged 18 to 35 years
- 96 mm H g for patients aged 36 to 64 years
- 117 mm H g for those older than 65 years
o In patients with shock, blood flow cannot be reliably
inferred from heart rate and blood pressure values.
Hypertension
Adults are hypertensive if either systolic or diastolic pressure
consistently exceeds 140 or 90 mm H g, respectively.
o A metaanalysis showed strong correlation of blood
pressure to vascular (and overall) mortality down to at least
115/75 mmHg.
o Patients with hypertension require repeated
measurements to assess whether therapy is required in the
ED.
o White coat hypertension (WCH) is defined as a persistent
elevation in blood pressure in the clinical setting only.
Measurement Errors
o Falsely low blood pressure may be caused by using an
overly wide cuff, by placing excessive pressure on the head
of the stethoscope, or by rapid cuff deflation.
o Falsely high blood pressure may be caused by the use of
an overly narrow cuff, anxiety, pain, tobacco use, exertion,
an unsupported arm, or slow inflation of the cuff.
o There appears to be a statistically significant difference in
the error rate associated with patients weighing more than
95 kg.
o The use of small cuffs was associated with a mean error of
8.5 and 4.6 mmHg in systolic and diastolic pressure.
o Hypotensive patients have unreliable Korotkoff sounds,
but Doppler measurements are well correlated with direct
arterial systolic pressure measurements in these patients.
o An auscultatory gap can be appreciated in hypertensive
patients.
- It is heard during the latter part of phase I and should
not be confused with diastolic readings.
o Measurement of diastolic blood pressure should occur at
Korotkoff phase IV:
- In patients with aortic insufficiency
- Hyperthyroidism
Chapter 1: Vital Signs and Measurement
- In those who have just finished exercising
- In children younger than 5 years
o Irregular heart rates may also interfere with accurate
determination of blood pressure.
- Take a second or third reading, with 2 minutes of
deflation between recordings, and obtain an average
when premature contractions or atrial fibrillation are
present.
o Hemiplegic patients may exhibit different blood pressures
in the affected and unaffected arms.
- A flaccid extremity tends to yield lower systolic and
diastolic pressure.
- A spastic extremity tends to yield higher values than
the extremity with normal motor tone.
- It is preferable to monitor blood pressure in the
unaffected limb.
o There is an increasing number of patients with heart failure
treated with left ventricular assist devices (LVADs). 2 types
of VADs:
- Pulsatile
Pulse and blood pressure reading in patients with
pulsatile VADs are comparable to the general non-
VAD population.
- Nonpulsatile
Nonpulsatile VADs function by either centrifugal or
axial blood flow, and this has a significant impact on
the ability to detect pulses.
Pulse Pressure
o The difference between systolic and diastolic pressure.
o Increased pulse pressure (i.e., ≥60 mm H g) is commonly
observed with:
- Anemia
- Exercise
- Hyperthyroidism
- Arteriovenous fistula
- Aortic regurgitation
- Increased intracranial pressure
- Patent ductus arteriosus
o Narrowed pulse pressure (≤20 mm Hg) may be a
manifestation of:
- Hypovolemia
- Increased peripheral vascular resistance (as seen in
early septic shock)
- Decreased stroke volume
- A narrowed pulse pressure is classically noted in
aortic stenosis and pericardial tamponade.
o There is evidence that an early indicator of reduced central
blood volume in the presence of stable vital signs is the
reduction in pulse pressure.
 SECTION 1: Vital Signs and Patient Monitoring Techniques 7

Differential Brachial Artery Pressure - Initially, the arterial pulse will be heard only during
o The presence of a systolic blood pressure difference of 10 expiration and will disappear during inspiration.
to 20 mmHg between the arms suggests a normal Deflate the cuff further until arterial sounds are heard
condition. throughout the respiratory cycle.
- If greater, it may indicate advanced focal - Palpation at the radial or femoral arteries may yield
atherosclerosis, coarctation of the aorta proximal to complete disappearance during inspiration. When
the left subclavian artery, type A aortic dissection, present, this technique is a quick bedside
aortic arch syndromes, or other vascular processes confirmation of the possibility of severe tamponade.
preferentially affecting one extremity.
Pulse-Pressure Variation
o Fluid resuscitation is an integral piece of the management
of patients with circulatory failure.
o Fluid responsiveness: ability of the left ventricle to increase
stroke volume in response to fluid administration.
- This concept is based on the Frank-Starling curve and
the knowledge that pulse pressure (systolic pressure
minus diastolic pressure) is directly proportional to
stroke volume.
o The variation in pulse pressure seen with the respiratory
cycle, or pulse-pressure variation, reflects the magnitude of
respiratory change on stroke volume.
- This is best demonstrated by the influence of
mechanical ventilation on right ventricular preload.
- Pulse-pressure variation of greater than 13% is highly
predictive of fluid responsiveness in mechanically
ventilated patients.
o Standard method to assess fluid responsiveness is done
with passive leg raising (PLG).
- This “self-volume challenge” increases preload
through translocation of venous blood from the lower
extremities to the thorax.
- Patient who exhibits a rise of more than 10% in their o An alternative method for determination of pulsus
aortic blood flow (measured with esophageal paradoxus is by visually observing the loss of the pulse
Doppler) or cardiac index (measured with oximetry waveform and then its reappearance.
thermodilution) is considered a “fluid responder,” o If the difference between inspiratory and expiratory
which is indicative of the need for further fluid pressure is greater than 12 mm H g, the paradoxical pulse
administration. is abnormally wide.
Pulsus Paradoxus - Most patients with proven tamponade have a
o Normal respiration briefly decreases systolic blood difference of 20 to 30 mm H g or greater during the
pressure by approximately 10 mm H g during inspiration. respiratory cycle.
o Pulsus paradoxus occurs when there is a greater than 12- - This may not be true of patients with very narrow
mmHg decrease in systolic blood pressure during pulse pressures (typical of advanced tamponade),
inspiration. who have a “deceptively small” paradoxical pulse of
o Occur in patients with chronic obstructive pulmonary 5 to 15 mmHg.
disease, pneumothorax, severe asthma, or pericardial o Pulsus paradoxus has been correlated with the level of
tamponade. impairment of cardiac output by tamponade.
- To measure a paradoxical pulse, have the patient lie - In an uninjured patient with pericardial effusion, a
comfortably in the supine position at a 30- to 45- pulsus paradoxus greater than 25 mmHg (in the
degree angle and breathe normally in an unlabored absence of relative hypotension) is both sensitive and
fashion. specific for moderate or severe versus mild
- Inflate the blood pressure cuff well above systolic tamponade.
pressure and slowly deflate it until the systolic sounds
that are synchronous with expiration are first heard.

Chapter 1: Vital Signs and Measurement

 SECTION 1: Vital Signs and Patient Monitoring Techniques 8

o The absence of a paradoxical pulse does not rule out - One crystal transmits the signal and the other
tamponade. receives it.
o In the pediatric population, pulsus paradoxus has been o Probes with a frequency of 2 to 5 MHz are best for
studied to determine the severity of obstructive and detecting fetal heart sounds.
restrictive pulmonary disease, most commonly asthma. o Frequencies of 5 to 10 MHz are appropriate for limb
- A value of 15 mmHg or greater correlates well with arteries and veins.
the clinical score, peak expiratory value, flow rate, PROCEDURE
oxygen saturation, and subsequent need for o Place the Doppler probe against the skin with an acoustic
admission. gel used as an interface. The gel ensures optimal
Shock Index transmission and reception of the ultrasound signal and
o The ratio of pulse rate to systolic blood pressure has been protects the crystals.
suggested as a measure of clinical shock. - In an emergency, water-soluble lubricant (e.g.,
o The shock index (SI) has a normal range of 0.5 to 0.7. Surgilube or K-Y Jelly) may be substituted for
- An SI above 0.85 to 0.90 suggests acute illness in commercial acoustic gel.
medical patients and a marked increase in the o Angle the probe at 45 degrees along the length of the
potential for gross hemodynamic instability in trauma vessel to optimize frequency shifts and signal amplitude.
patients. o To evaluate peripheral perfusion:
o Although the SI appears to correlate with the left - Place a sphygmomanometer cuff proximal to where
ventricular stroke work index, it has little correlation with the arterial pulse is being evaluated and inflate it.
systemic oxygen transport in patients with hemorrhagic - Place the probe over the arterial pulse and slowly
and septic shock. deflate the cuff.
DOPPLER ULTRASOUND FOR EVALUATION OF PULSE - The pressure at which flow is first heard is the systolic
AND BLOOD PRESSURE pressure under the cuff, and not the pressure at the
PRINCIPLES OF DOPPLER ULTRASOUND level of the Doppler probe.
o In the evaluation of peripheral vascular disease, one may
o The frequency of sound waves varies depending on the
determine the ankle-brachial index.
speed of the sound transmitter in relation to the sound
- Examine both brachial arteries at the medial aspect of
receiver.
the antecubital fossa.
o Doppler devices transmit a sound wave that is reflected by
- Angle the probe until the most satisfactory signal is
flowing erythrocytes, and the shift in frequency is detected.
obtained.
o Frequency shift can be detected only for blood flow
- Inflate the cuff and slowly deflate it until the systolic
greater than 6 cm/sec.
pulse is heard.
- Repeat the procedure for the posterior tibial and
dorsalis pedis arteries of both lower extremities.
INDICATIONS AND CONTRAINDICATIONS
Doppler ultrasound is commonly used in the ED for the
measurement:
- blood pressure in low-flow states
- evaluation of lower extremity peripheral perfusion
- assessment of fetal heart sounds after the first
trimester of pregnancy
o Doppler’s sensitivity allows detection of systolic blood
pressure down to 30 mm H g in the evaluation of a patient
in shock.
o In a patient with peripheral vascular disease in whom there
is concern about the adequacy of peripheral perfusion, the
ankle-brachial index provides a rapid, reproducible, and
standardized assessment.
o The use of Doppler ultrasound for the evaluation of deep
venous thrombosis is a valuable tool.
EQUIPMENT
o A nondirectional Doppler device has a probe that houses
two piezoelectric crystals:

Chapter 1: Vital Signs and Measurement

 SECTION 1: Vital Signs and Patient Monitoring Techniques 9

o In evaluating fetal heart tones, an examination of several

locations and angles over the uterus must be performed in
search for the optimal signal due to the variable positioning
of the fetus.
- It is best to begin in the mid-suprapubic area and then TYPICAL PRESSURES IN NORMAL INDIVIDUAL:
explore the uterus via angulation of the probe.
- Once tones are located, move the probe along the
abdomen to reach a position closer to the origin of
the sound.
- Distinguish fetal heart tones from placental flow by
differentiating the quality of the fetal heart tones,
which will not match the maternal pulse. The
placental flow and maternal pulse should be identical.
INTERPRETATION
o In low-flow states Doppler ultrasound can detect blood
pressure as low as 30 mmHg.
o Calculate the ankle-brachial index of each limb by dividing
the higher systolic pressure of the posterior tibial or the
dorsalis pedis artery of the limb by the higher of the systolic
pressures in the brachial arteries.
- In normal individuals, the index should be greater
than 1.0.
- Patients with mild to moderate claudication have
values between 0.4 and 0.9. Normal findings:
- Values lower than 0.4 indicate severe impairment 1. ankle-to-brachial pressure index of 1.0 or higher
and are consistent with critical limb ischemia 2. segmental pressure gradients lower than 30 mm H g
o Segmental lower extremity pressure measurements may 3. upper thigh pressure at least 40 mm H g above
help identify the level of the obstruction. brachial pressure

Chapter 1: Vital Signs and Measurement

 SECTION 1: Vital Signs and Patient Monitoring Techniques 10
TYPICAL PRESSURES IN A PATIENT WITH OBSTRUCTION
OF THE RIGHT POPLITEAL OR TIBIAL ARTERIES
Significant findings:
1. ankle-to-brachial pressure index less than 0.9 in the
right leg
2. abnormally high gradient from the ankle to below the
knee and again from below to above the knee in the
right leg
3. upper thigh pressure 50 mm H g higher than brachial
pressure, consistent with normal flow at the aorta-
iliac level
*Findings are suggestive of right popliteal occlusion or right
anterior and posterior tibial occlusion, or both
o When the lower extremity has been amputated or injured,
brachial-brachial indices can be used (i.e., comparison of
systolic blood pressure in the injured or diseased upper
extremity with the other extremity).
o Patients with ankle-brachial index values of 0.9 or lower
have increased cardiovascular morbidity and mortality.
o Obese patients, diabetic patients, or those with calcified
vessels that are not compressible may have abnormally
high systolic pressure (e.g., 250 to 300 mm H g) and indices
that do not accurately reflect flow.
VITAL SIGN DETEMRINATION OF VOLUME STATUS
- evaluation of skin color
- skin turgor
- skin temperature
- supine, serial, and orthostatic vital signs
▪ Serial vital sign measurements have been
used for assessing blood loss, but they do
not reliably detect small degrees of blood
loss.
- neck vein status
- transcutaneous oximetry
Chapter 1: Vital Signs and Measurement
- hemodynamic monitoring (e.g., monitoring of central
venous pressure)
o The ideal test for determining volume status would rapidly
and accurately detect 5% or greater depletion of volume
with a noninvasive technique. At present, no such test
exists.
ORTHOSTATIC VITAL SIGNS MEASUREMENT
o Orthostatic vital signs have historically been used to
evaluate patients with fluid loss, hemorrhage, syncope, or
autonomic dysfunction.
o Although orthostatic testing is commonly cited as a method
to detect hypovolemia, it is frequently misleading and has
less clinical value.
o In patients with an acute loss of less than 20% of total blood
volume, orthostatic vital signs have been shown to lack
both sensitivity and specificity.
PHYSIOLOGIC RESPONSE TO HYPOVOLEMIA
o Acute blood loss or severe hypovolemia related to
dehydration decreases venous return.
- This can be seen with acute blood loss (usually greater
than 20% of blood volume), severe burns or
prolonged vomiting or diarrhea that depletes body
fluids.
- As a result, cardiac output falls and clinical
manifestations of shock ensue.
o Several compensatory mechanisms are initiated by acute
hypovolemia:
- The dominant compensatory mechanism in shock is a
reduction in carotid sinus baroreceptor inhibition of
sympathetic outflow to the cardiovascular system.
This increased sympathetic outflow results in several
effects:
1. arteriolar vasoconstriction, which greatly
increases peripheral vascular resistance
2. constriction of venous capacitance vessels, which
increases venous return to the heart
 SECTION 1: Vital Signs and Patient Monitoring Techniques 11
3. an increase in the heart rate and force of
contraction, helping maintain cardiac output
despite significant loss of volume.
o 30% to 40% of blood volume can be lost before death
occurs.
- When sympathetic reflexes are absent, a loss of only
15% to 20% of blood volume may cause death.
o Increased sympathetic nerve activity results in the
commonly recognized physical signs of shock, including
pallor, cool clammy skin, rapid heart rate, muscle
weakness, and venous constriction.
o An inadequate immediate compensatory response will
result in dizziness, altered mental status, or loss of
consciousness.
o The central nervous system response to ischemia further
stimulates the sympathetic nervous system after arterial
pressure falls below 50 mmHg.
o Subsequent compensatory mechanisms that work to
restore blood volume to a normal level include the release
of angiotensin and antidiuretic hormone (vasopressin).
- This causes arteriolar vasoconstriction, conservation
of salt and water by the kidneys, and a shift in fluid
from the interstitium to the intravascular space.
PHYSIOLOGIC RESPONSE TO CHANGES IN POSTURE
When an individual assumes the upright posture, complex
homeostatic mechanisms compensate for the effects of gravity
on the circulation to maintain cerebral perfusion with minimal
change in vital signs. These responses include:
1. Baroreceptor-mediated arteriolar vasoconstriction
2. venous constriction and increased muscle tone in the
legs and the abdomen to augment venous return
3. sympathetic-mediated inotropic and chronotropic
effects on the heart
4. activation of the renin-angiotensin-aldosterone
system
o When a normal individual stands, the pulse increases by an
average of 13 beats/min, systolic blood pressure falls
slightly or does not change, and diastolic pressure rises
slightly or does not change.
o In patients with vasodepressor syncope, the normal
compensatory reflexes that preserve cerebral perfusion
with changes in posture are altered.
- The normally increased sympathetic tone on standing
is paradoxically inhibited, and an exaggerated
enhancement of parasympathetic activity
(bradycardia) occurs and can lead to syncope.
VARIABLES AFFECTING ORTHOSTATIC VITAL SIGNS
Most of the conditions that affect postural blood pressure
regulation involve a pathologic condition that affects the
sympathetic nervous system or the use of medications that
alter normal cardiovascular compensatory functions.
Chapter 1: Vital Signs and Measurement
- Orthostatic hypotension caused by autonomic insufficiency
is not usually accompanied by tachycardia, and the
orthostatic hypotension produced by acute volume
depletion is commonly accompanied by a pronounced
reflex tachycardia.
- Even in normal individuals, passive tilting generates a high
incidence of orthostatic syncope.
- Because of decreased vasomotor tone, limited
chronotropic response, and other factors, the elderly have
a higher incidence of orthostatic hypotension leading to
syncope and fall-related injuries.
- Patients with hypertension may also have abnormal
vasomotor responses to tilt testing and demonstrate more
instability.
- Chronic anemia patients, who exhibit compensated blood
volume, seem to have the same postural response as
normal individuals.
- Ethanol ingestion exaggerates postural pulse changes and
mimics the hemodynamic changes seen with acute blood
loss.
- Another complicating factor in interpreting orthostatic vital
signs is the development of paradoxical bradycardia in the
presence of blood loss.
- This paradoxical bradycardia may be more frequently
associated with rapid and massive bleeding.
- Patients with more gradual blood loss tend to have a
more typical tachycardic response.
INDICATIONS AND CONTRAINDICATIONS
Many factors influence orthostatic blood pressure, including
age, preexisting medical conditions, medications, and
autonomic dysfunction.
o Contraindications to orthostatic measures:
- supine hypotension
- the clinical syndrome of shock
- severely altered mental status
- the setting of possible spinal injuries
- lower extremity or pelvic fractures
- use of medications that block the normal vasomotor
and chronotropic response to orthostatic tests is also
a contraindication to using this test for the
assessment of volume status
o Orthostatic vital signs are often used to assess a patient’s
response to therapy. In patients receiving intravenous
rehydration therapy, serial orthostatic vital signs are widely
used to judge the end point of therapy before release.
TECHNIQUE
 SECTION 1: Vital Signs and Patient Monitoring Techniques 12
o To obtain orthostatic vital signs, record the blood pressure
and pulse after the patient has been in the supine position
for 2 to 3 minutes.
o Next, ask the patient to stand and be prepared to assist if
severe symptoms or syncope develop.
- A supine-to-standing test is more accurate than a
supine-to-sitting one. If severe symptoms develop on
standing, defined as syncope or extreme dizziness
requiring the patient to lie down, the test is
considered positive and should be terminated.
- If not symptomatic, allow the patient to stand for 1
minute and then record the blood pressure and pulse.
INTERPRETATION
The most sensitive criteria for orthostasis are tachycardia or
symptoms of cerebral hypoperfusion (e.g., near-syncope).
- BLOOD PRESSURE is too variable to be an indicator of
loss of blood volume
o In the setting of suspected blood loss, if the patient has a
rise in pulse of 30 beats/min or manifests severe symptoms
and if other complicating factors have been excluded,
blood loss is highly likely (2% false-positive rate).
o Orthostatic changes in the SI were no more sensitive than
established tilt test criteria in discriminating normal
individuals from those with moderate acute blood loss (450
mL).
o Criteria for significant orthostatic changes in blood
pressure cannot be definitively set for the following
reasons:
1. Large variability in postural blood pressure has been
found in the adult ED population
2. the results of studies using passive tilt tables cannot be
extrapolated to the bedside use of orthostatic vital
signs
3. studies using healthy patients with acute blood loss
may not reflect the orthostatic changes seen in the
elderly, those with chronic bleeding, dehydration,
other medical problems, or in association with certain
medications
4. many studies of orthostatic changes did not use a
criterion standard in their determinations
Chapter 1: Vital Signs and Measurement
CAPILLARY REFILL
The capillary refill test is a measurement of the interval of time
from the release of pressure on the nail bed or soft tissue
sufficient to blanch the nail bed or superficial soft tissue, until
the return to normal coloration.
o Delayed capillary refill is an indication of reduced skin
turgor, often as a result of volume depletion or limited
perfusion.
o Skin elasticity is the characteristic that allows skin to spring
back to its original shape after it has been deformed, and
the speed of refilling the capillary bed after compression is
responsible for the return of color to the skin.
INDICATIONS AND CONTRAINDICATIONS
o CRT should not be determined from a dependent
extremity, from a recently burned or injured extremity, or
at the site of an infection or acute injury.
o Useful bedside assessment of perfusion and dehydration
when used in conjunction with other objective signs of the
adequacy of perfusion.
o It should not be considered accurate as a stand-alone tool.
PROCEDURE
o The preferred sites for determining CRT are the nail bed,
the thenar surface of the palm, and the heel.
o Regardless of the site chosen, position the extremity at
approximately the level of the right atrium.
o The minimum pressure necessary to produce blanching
yields the most reproducible values. Release the nail bed
and begin timing with a stopwatch or simply by counting
out “one-thousand-one, one-thousand-two” for an
approximation of the interval.
o Stop the clock when the nail bed becomes pink again.
INTERPRETATION
o The normal CRT increases with age and is slightly longer in
female patients.
o It is further increased by degrees of dehydration or
hypoperfusion.
o INCREASE CRT:
- Hypothermia
- Hyponatremia
- Congestive heart failure
- Malnutrition
- edema
o Environmental conditions such as ambient air temperature
can falsely alter capillary refill.
o Fever alone did not appear to prolong or shorten CRT in
children, and a study of healthy adults found a 5% decrease
in CRT for each degree Celsius rise in patient temperature.
o Measurements obtained from the nail bed were more
reproducible than those from the heel.
o The presence of a 2-second or longer delay in CRT when
combined with any two or more of the findings of absent
 SECTION 1: Vital Signs and Patient Monitoring Techniques 13
tears, dry mucous membranes, or ill general appearance
predicted clinical dehydration (>5% deficit in body weight)
in children (1 month to 5 years of age) with 87% sensitivity
and 82% specificity.
o Frequent monitoring of capillary refill may be useful in
assessing responses to rapid fluid resuscitation in children.
- A normal CRT of 2 seconds or less has been shown to
correlate with superior vena cava oxygen saturation
of 70% or higher in critically ill children
o When an abnormal CRT was defined as greater than 4.5
seconds, coupled with extremity coolness, these
parameters identified patients who had been
hemodynamically stabilized and continued to have more
severe organ dysfunction and higher lactate levels.
o In adults, CRT was found to be less sensitive and less
specific than orthostatic vital signs in detecting 450-mL
blood loss during blood donation.
TEMPERATURE
An inability to maintain normal body temperature is indicative
of a vast number of potentially serious disorders, including
infections, neoplasms, shock, toxic reactions, and
environmental exposures.
o Under normal conditions, the temperature of deep
central body tissues (i.e., core temperature) remains at
37°C ± 0.6°C (98.6°F ± 1.08°F).
o Environmental temperature varies from as much as 13°C to
60°C (55°F to 140°F).
o Mean oral temperature is 36.8°C ± 0.4°C (98.2°F ± 0.7°F).
o Maintenance of normal body temperature requires a
balance of heat production and heat loss.
- Heat loss occurs by radiation, conduction, and
evaporation by approximately 60%, 18%, and 22%,
respectively.
- Heat loss is increased by wind, water, and lack of
insulation (e.g., clothing).
- Sweating, vasodilation, and decreased heat
production serve to decrease temperature.
- Piloerection, vasoconstriction, and increased heat
production serve to increase body temperature.
- Heat production is increased by shivering, fat
catabolism, and increased thyroid hormone
production.
o Temperature is controlled by feedback mechanisms
operating through the hypothalamus.
- Heat-sensitive neurons in this area increase their rate
of firing during experimental heating.
- Receptors in the skin, spinal cord, abdominal viscera,
and central veins primarily detect cold and provide
feedback to the hypothalamus that signals an
increase in heat production.
INDICATIONS AND CONTRAINDICATIONS
Chapter 1: Vital Signs and Measurement
o Measurement of actual core body temperature requires
the placement of invasive monitors, such as an esophageal
or pulmonary artery (PA) probe.
o Ingestion of hot or cold beverages has shown they can alter
oral temperature readings for 5 to 30 minutes, and can
falsely elevate a normal temperature or mask a fever.
MEASUREMENT SITES
Core Body Temperature
The following sites accurately reflect core body temperature
and changes in it:
- the distal third of the esophagus
- the tympanic membrane (TM) (with a direct
thermistor in contact with the anterior inferior
quadrant of the TM)
- the PA (pulmonary artery)
Other sites may represent core body temperature under
certain conditions; for example:
- the rectum when the temperature is obtained at least
8 cm from the anus with an indwelling thermistor and
the body temperature is relatively constant.
- the bladder when measured with an indwelling
thermistor.
o Rectal temperature is often considered the criterion
standard for body temperature in ambulatory patients and
it is often used routinely in children younger than 3 years
- Disadvantages include longer intervals for
measurement, safety concerns, and inconvenience.
o Neutropenia and recent rectal surgery represent relative
contraindications to measurement of rectal temperature.
o Thermistor probes are available for measurement of
esophageal, bladder, and rectal temperature.
Peripheral Body Sites Approximating Core Temperature
o A body temperature measurement by IR radiation can be
detected from the ear, including the auditory canal and
TM; it is easy to use, hygienic, convenient, and quick.
- It is possible that alterations of regional blood flow
accompanying critical illness (TMs may behave as an
extension of the skin or the mucous membrane in the
critically ill) and the peripheral vasoconstriction that
occurs with inotropes and some forms of shock may
occur in the TM, making such measurements less
accurate in this population.
- A theoretical disadvantage of TM temperatures
might be a falsely elevated estimate of the core
temperature in the presence of otitis media.
o Rectal temperature measurement as the “gold standard”
for detecting fever in the pediatric population.
o Prehospital providers who might wish to measure IR TM
temperature at low ambient temperatures should be
aware that below 24.6°C, the TM readings will greatly
underestimate core temperatures.
 SECTION 1: Vital Signs and Patient Monitoring Techniques 14
PROCEDURE
o Begin the temperature measurement by selecting the body
site.
o Insert the temperature probe and allow the probe to
equilibrate with the temperature of the local body tissues.
- Obtain sublingual oral temperatures in either the
right or the left posterior sublingual pocket with the
mouth closed.
- Obtain a rectal temperature with the patient in the
left or right lateral decubitus position and advance
the probe gently to a depth of 3 to 5 cm to ensure
accurate, atraumatic results.
o Complications associated with rectal temperature
measurements are extremely rare and include rectal
perforation, pneumoperitoneum, bacteremia,
dysrhythmias, and syncope.
- Falsely low supranormal rectal temperature
measurements may be seen during shock.
- Rectal temperature may also lag behind changes in
core temperature.
o Digital electronic probes are commonly used for the
measurement of oral temperature in ambulatory patients.
o Disposable single-use oral thermometers are now
available and are as reliable as mercury or TM
thermometers.
o The average time needed to record a reading with a
pacifier thermometer is 3 minutes and 23 seconds, thus
making its application in emergency medicine limited.
o TM perforation and pain have been reported as
complications of placement of the thermistor probe in the
auditory canal.
INTERPRETATION
Normal values for body temperature are affected by the
following variables:
1. site and methods used for measurement
2. perfusion
3. environmental exposure
4. pregnancy
5. activity level
6. time of day
Although core body temperature remains nearly constant
(37.0°C ± 0.6°C or 98.6°F ± 0.18°F), surface temperature rises
and falls with changes in ambient temperature, exercise, and
time of day.
o The definition of fever varies by the site of measurement
and is defined by a temperature greater than 2 standard
deviations above the mean.
- Fever has been defined as an oral temperature of
37.8°C or higher (100.0°F)
- rectal temperature of 38.0°C or higher (100.4°F)
- An IR ear temperature of 37.6°C or higher (99.6°F)
Chapter 1: Vital Signs and Measurement
o Based on measurement of temperatures in normal, healthy
infants, it is recommended that fever be defined as a rectal
temperature of:
- 38°C or higher in infants younger than 30 days,
- 38.1°C or higher in infants 30 to 60 days (1 to 2
months)
- 38.2°C or higher in infants 60 to 90 days old (2 to 3
months)
o Hypothermia has been defined as a core body temperature
lower than 35°C (<95°F) with accompanying symptoms and
signs.
o Hyperthermia has been defined as a core body
temperature higher than 41°C (>105.8°F) with
accompanying symptoms and signs.
o Interpretation of temperature measurements during
clinical assessment must consider the use of antipyretics,
level of activity, pregnancy, environmental exposure, and
patient age.
o Body temperature is increased during sustained exercise,
pregnancy, and the luteal phase of the menstrual cycle.
o Temperature also increases in the late afternoon because
of diurnal variation.
o Body temperature is generally reduced with advanced age,
and age may have an impact on the magnitude of fever.
o Axillary temperatures have a low sensitivity but a high
specificity for fever. Axillary temperatures should not be
used to screen for fever.
o Oral temperature measurements are affected by the
ingestion of hot or cold liquids,227 tachypnea,257 and cold
ambient air.
o When an elevated temperature is suspected or crucial in
decision making and not evident with an oral thermocouple
probe or IR TM thermometer, measurement with a
mercury in- glass thermometer is indicated.
 SECTION 1: Vital Signs and Patient Monitoring Techniques 15

o When rapid changes in body temperature occur, oral and

TM temperature measurements appear to be more reliable
than rectal temperature.
o Infrequently, ED patients require constant monitoring of
temperature (e.g., in cases of profound hypothermia or
hyperthermia). This can usually be performed by using a
bladder or esophageal probe attached to a potentiometer.
o Interpretation of ear IR temperatures requires knowledge
of the mode of thermometer operation and ambient
temperature.
- Occlusion of the ear canal by cerumen may produce a
falsely low reading.
PAIN AS A VITAL SIGN
o Pain is viewed as a mechanism to provide a mechanical
warning of actual or potential damage to cells and tissues
in a specific area.
o Pain can cause sympathetically mediated changes in vital
signs, but standard vital signs (pulse, respiration, blood
pressure) do not meaningfully correlate with the level of
perceived pain.
o Reliably quantifying pain should be the goal of ED clinicians
and is an appropriate step in the triage process.
PROCEDURE/INTERPRETATION
A patient’s self-report of the pain is considered the gold
standard for the initial assessment of pain and tracking of a
response to interventions, although such reporting does not
mandate specific interventions.
o Common instruments include the verbal rating scale,
numerical rating scale, visual analog scale (VAS), and
graphic rating scales.
o The most used pain scale in the ED is the 1 to 10 VAS.
- The VAS uses a 10-cm line bounded on each end by
perpendicular stops and descriptors.
- Zero equates to no pain, and 10 equates to the worst
pain ever experienced.
o There is wide variability in this technique, and at least a 13-
mm to 30-mm (1.3-cm to 3-cm) change on the scale is
required to validate clinically relevant worsening or relief.
o Graphic rating scales are useful for patients with limited
cognitive and expressive ability, especially children.
OVERALL GOAL OF PAIN RELIEF
The goal of pain management in the ED is to adequately relieve
or control pain without compromising diagnosis, treatment
plans, or the safety of the patient and population.
o Theoretically ideal objective is to totally relieve pain, this
goal is difficult to consistently achieve in the complex ED
milieu, and should not be the standard of care.

Chapter 1: Vital Signs and Measurement