C – Circulation Assessment

A good circulation assessment should start from the patient’s hands and fingers, assessing
the peripheral perfusion, moving up to biceps and then the clavicle.
Are the hands/fingers pink?
If not, what do they look like? (mottled, blueish, cool/warm).
If they are mottled, it may be because of poor peripheral perfusion or sepsis; if they are
blueish it might be because of poor oxygenation. The colder the hands and fingers the
poorer the peripheral circulation is.
Capillary refill time (CRT) is a good way to assess the peripheral circulation and it is
performed by placing the hand at the level of the patient’s heart, gently squeezing the nail
bed for 5 seconds and then releasing. The nail bed should appear a whiter and, after
releasing, should refill and become pink again. The normal CRT is less than 2 seconds; any
prolongation of the CRT indicates poor perfusion.
Moving up the arm, the next thing to assess is the radial pulse: can we feel it? If not, it
indicates low blood pressure (lower than 70mm/Hg).
Pulses can be divided into peripheral and central pulses and can be felt in the femoral groin,
popliteal (back of the knee), posterior tibial (ankle), dorsalis pedis (foot) areas, radial (wrist),
brachial (forearm) and carotid (neck) areas.
While feeling the pulse is important to look at its quality as well: if it’s weak and thready, it
may indicate a poor cardiac output; if it’s bounding it may indicate sepsis. Is the pulse
regular or irregular?
Moving further up the arm, the IV access should be assessed and if there is any fluid
running. A fluid challenge should be considered if appropriate: 500ml warmed crystalloid
over 5 minutes, before reassessing the patient (250ml in case the patient has any known
cardiac failure).
NIBP (Remember high HR and low BP could be hypovolaemia)
ECG- 3 lead or 12 lead?
Has the patient got a catheter?
Normal urine output 0.5ml/kg/h (less than this can indicate dehydration or poor renal
perfusion).