Vitals and what they mean.

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Information about Vitals and what they mean.
Health & Medicine

Published on November 18, 2013

Author: nickmchargue



My conceptualization of how vitals work in diagnostics. Incomplete in places and really just my notes from p-school and emcrit.

Toolbox We have these tools

Vitals! • Vitals indicate that the organism is alive • There are only 4 true vitals: heart rate, respiratory rate, temperature, and blood pressure • Some include pain • The rest are bonus metrics • BGL, SpO2, CO2, EKG, GCS

Heart Rate! • Kind of a misnomer. • This value should read ‘pulse.’ • Because associated with it are rate (obviously), strength, regularity, symmetry, and presence. • Always palpate a pulse. Bilateral palpation is even better. • I sometimes do this on the dorsalis pedis pulse of supine patients.

Respiratory Rate! • Also a misnomer • Should read ‘ventilation’ • Associated with it are all the mechanical aspects of breathing, including rate, depth, pattern, work of breathing, and symmetry

Temperature! • It’s either relevant, or it’s not • Irrelevant more often than not • Increased heart rate and mouth breathing are associated with highly variable oral temps • The only true temps are esophageal, rectal, urinary (from a Foley cath), you know, core temps. • Axillary temps? Please.

Blood pressure! • High is associated with many exciting and excruciating ways to die early! • Really high is probably a kidney problem! • Low means you’re probably in shock. • Systolic perfuses the brain (minus ICP) • Diastolic perfuses the heart • Low pulse pressure means tamponade • High pulse pressure means increased ICP

Pain! • • • • • • Scale of 1-10 People are hilarious. They’re all like, “11!” But if 10 is the worst pain they can imagine They all have pretty shitty imaginations Mostly used as a trending tool And to titrate pain medication

Glascow Coma Scale • • • • • Seems like bullshit to me Values have little interoperator reliability Does not accurately stratify severity But does indicate a trend in “oh shit” factor In the same way an almost arbitrary scale of 315 would

Hemipelegic Migraines • People who are faking them will often not know that the tongue, when stuck out, points ipsilateral to the lesion. • So they point their fake droopy tongue towards their fake droopy arm. • Like a faker.

Speaking of hemipelegia • We all know the Cincinnati stroke scale • Make ‘em do the thriller thing, smile, and tell you they’re having a nice day (they think you’re an asshole) • You should also probably check bilateral radial pulses • Just in case they have a dissecting thoracic aneurism and the tunica intima is obstructing the lumen of the vessels leaving the thoracic aorta.

Unknown Unconscious? • • • • • Pinpoint pupils? Probably an opiate. Narcan! Low BGL? Probably hypoglycemia. D-50! High BGL? HHNK or DKA! Normal saline! No pulse? Push on their chest! Not breathing? Squeeze a bag at their face!

Electrolytes wonky? • Reflexes • EKG • They may need hypertonic saline, but we don’t have that, so sodium bicarb

Reflexes • They test an arc from the limb to the spine • It seems like hypo- or hyperreflexia would have to be determined by establishing a healthy baseline. • So I don’t really know their use • Not really done in the field • Except perhaps the Babinski reflex • Also, highly operator dependant.

Speaking of Operator Dependant … • Fundoscopy is tough • You have to get really close to a lot of people before you get good at it • Most people don’t get good at it • Except ophthalmologists • Cause they have to • From it you can determine diabetes and increased ICP

Percussion! • Another thing people don’t do anymore! • Requires a keen ear and a large sample of normal resonance to be sensitive • And even when you’re sensitive, it’s not particularly specific • But neither is auscultation

Hyponatremia • Can be caused by diuretics or endurance athletics.

Hypocalcemia • Negative inotropic effect

Hyperkalemia • • • • • Oh shit! This can cause every dysrhythmia. Fatal within seconds Wide QRS Serum levels are cause the dysrhythmia. If you can cause cellular uptake, you fixed the problem • Albuterol- rapid fix • Insulin + glucose = the cellular symporter uses K.

Want to know proteinurea? • Shake their pee! • High protein = super foamy

Adenosine • Because you can’t figure out how to double the paper speed. • Stops the heart for 5-10 seconds • Restarts slowly • And will probably return to its normal pace • Unless it’s a WPW • In which case you’ve killed them

Wanna see how their heart’s electricity is doing? • EKG! There’s a thing for that! • Long intervals all around? Consider metabolic phenomena. • Low amplitude all around? Probably tamponade.

EKG • Possible use for determining neuromuscular weakness?

Calcium channel blocker • Dihydropyridine (amlodipine, nifedipine, Celvidipine!) • Phenylalkylamine (verapamil) • Benzothiazepine (diltiazem) • Overdose? Hit em with calcium gluconate/calcium chloride per SOP, pressors to temporize, then 1 unit/kg insulin.

Beta Blockers • • • • Nonselective (propanolol, alprenolol) B1 selective (esmolol, metoprolol) B2 selective (butaxamine, useless) B3 selective (SR 59230A, useless)

Potassium Channel Blockers • Amiodarone • Sotalol

Sodium Channel Blockers • • • • Class 1a (quinide, procainamide) Class 1b (lidocaine, phenytoin) Class 1c (encainide, propafenone) TCAs!

ACE Inhibitors • • • • Sulfhydryl- Captopril Dicarboxylate- Lisinopril, Benazipril Phosphonate- Fosinopril They can cause fibrosis of the lung parenchyma, and a chronic dry cough

Diuretics • HCTZ- One of the few things that can still cause hyponatremia, besides ultramarathoning.

Gradients! • High O2, low CO2, glucose, insulin. • The rest of the body is meant to keep the few grams at the front of your brain alive. • Hydrostatic pressure gradient between left ventricle and brain. • Cerebral perfusion pressure is mean arterial pressure minus the ICP.

pH • Dem free H+ ions are a bitch. • You can get them from lactic acid • And the strong ion gap (difference between Na+ and Cl-) • And, surprisingly, Albumin. That shit’s got a net negative charge

Albumin • The chief protein in your plasma • Primarily used as a “big thing” to facilitate oncotic pressure. • Too big to cross the endothelium of the capillaries • So fluids rush out of the interstitial space to dilute it • Assists in “Starling’s forces”

Immunoglobulins • They’re the other proteins in your plasma • And tears • I’d imagine they contribute to oncotic pressure • But they have more specialized purposes • Mostly immune function • You get your starter dose of them from breast milk • Not now, hopefully, but during infancy

Sodium Bicarb! • You can breath out that CO2 • And keep all that sodium • Which is good for things like TCA overdose, which block sodium channels • Never push

CSF • Brain buoyancy!

Labs! • They seem like they’d be useful • But there are a lot of normal ranges to remember • A good one to know is lactate • 2 mmol/dL (often just said 2)= sepsis • 4 mmol/dL = oh shit value

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