Live from Prospect St: Dizzy at Hillcrest (part 3)

Continued from Part 2

My apologies for the delay on this update: there have been major computer troubles here at EMSB HQ. We’re back in action now with the final piece of our scenario.

Ultimately, this patient was rapidly packaged and transported emergently to the nearer facility for immediate imaging to rule out intracranial hemorrhage. Her final diagnosis and disposition are not known.

This case demonstrates the ambiguity we’re often faced with in the field, where we may encounter findings in our assessment that are suggestive of Badness, but not definitively so. Particularly when faced with a patient whose complaints are minor or who generally presents well, it can be difficult to make the call to upgrade these patients to a higher level of care. Nobody wants to be the Boy Who Cried Wolf. However, our job is to get people to the most appropriate care, and although we should try to minimize overtriage, within reason, safe is better than sorry. The situation can be particularly difficult when we are dispatched as a low priority to an unremarkable complaint; changing gears from a low- to a high-severity mode takes more balls than merely continuing what’s already been set in motion.

Assessment: The Pink Flags

The suggestive if not outright alarming findings (I like to call them “pink flags” — not quite red, but close) with Ms. Smith were the following:

A recent fall, reportedly with a blow to the head and loss of consciousness.
A subsequent (apparently new) complaint of dysnomia (the inability to express oneself in words, a form of aphasia), which suggests some sort of neurological or metabolic insult.
A subsequent and sudden onset of vomiting with no other apparent explanation. This could be a sign of hemorrhagic stroke, although more minor head injuries can also induce vomiting.
A history of Coumadin (warfarin) use — a “blood thinner” or anticoagulant — which is a risk factor for intracranial bleeding.
A complaint of “head pressure,” which remotely suggests headache, typical in head bleeds.
A reported positive finding on a neurological test (failed finger-to-nose), which potentially supports a neurological event.
A complaint of dizziness, which is suggestive of either a balance-type (inner ear) pathology or a neurological one.
A finding of hypertension, which may or may not be elevated above the patient’s baseline.

On the other hand, the following findings point generally away from the likelihood of a stroke or intracranial bleed:

An alert and oriented patient mentating at her cognitive baseline.
A normal Cincinatti Stroke Scale, which assesses for arm drift, facial droop, and speech slurring.
A lack of other “focal” neurological deficits (an abnormality that is localized to a single sensory or motor region, such as a droop in one half of the face, or loss of sensation in the left arm but not the right). She has equal peripheral CSM, no complaints of partial vision loss, and so forth.
A lack of any significant headache. Although there is a vague complaint of pressure, which could be explained by the actual trauma to the head, headache associated with intracranial hemorrhage is typically severe and sudden.
Equal and non-dilated pupils. (Although they do present as small, this is an unremarkable finding in the elderly, as is poor reactivity — constricted pupils can’t constrict much more.) Furthermore, the eyes track well towards all sectors; gaze paralysis is suggestive of brain damage. None of this is highly predictive, however.
A lack of rigidity of the neck, which would support a hemorrhage.

Taken together, this cloud of positive and negative findings produces our clinical picture. We are not so fortunate that any one finding is diagnostic, or highly suggestive to either rule in or rule out Badness. Rather, we have a constellation of weak findings.

Differential: Strokes and Bleeds

It can be important to make a distinction between intracranial hemorrhage and stroke. Intracranial hemorrhage (we’ll call it ICH, not to be confused with “intracerebral hemorrhage,” discussed below — both abbreviations are seen in the literature) describes bleeding anywhere inside the dome of the skull, typically from a ruptured vein or artery. Sometimes, this occurs inside the skull but outside the brain, between the various membranes that lay between brain and skull: epidural (outside the dura), subdural (inside the dura), and subarachnoid (inside the arachnoid) are the main types and locations.

Bleeding deep within the tissue of the brain itself is also possible, and is a subcategory of ICH called intracerebral hemorrhage.

A stroke is a localized injury to brain tissue resulting in permanent neurological deficits. By far, the most common cause is known confusingly as ischemic stroke, and describes an event where a clot or other obstruction blocks an artery that feeds a portion of the brain. (This is the same mechanism that damages the heart in a myocardial infarction.) The other main cause of stroke is hemorrhagic, when an artery bleeds openly into the brain, causing damage both from the loss of perfusion to downstream tissue, as well as from the pressure caused by the growing pocket of blood. This is where stroke and head bleeds intersect: when either an intracerebral or subarachnoid hemorrhage is sufficient to cause local neurological damage and permanent loss of functional brain tissue, a stroke results. Epidural and subdural bleeds do not cause stroke per se, although they can still result in acute neurological symptoms due to the increase in intracranial pressure.

Although the effects of stroke are similar with either ischemic or hemorrhagic etiologies, hemorrhagic strokes may additionally produce the telltale signs of rising intracranial pressure, such as headache, vomiting, general (non-focal) neurological deficits, and in the late stages, Cushing’s triad (bradycardia, irregular respirations, and hypertension).

Applying the Differential

Ms. Smith’s history is certainly suggestive for a bleed. Head trauma is the most common cause of ICH, and with her Coumadin use, she should probably be worked up regardless of her minimal complaints. Her additional neurological complaints make this a potential “uh oh,” advising transport to a facility that can provide immediate care. However, there are some notable negatives that tamper this enthusiasm.

For one thing, it would be unusual for a bleed of this type to present so inconspicuously. If severe, we would expect to see a profoundly altered mental status, up to and including outright coma, and probably a significant headache. If there is also the localized infarct of a stroke, we would expect focal neurological complaints — local damage should cause focal deficits. The reason that the Cincinatti Stroke Scale uses facial droop and arm drift to screen for stroke is because the majority of strokes will be revealed by unilateral deficits. Ms. Smith has none of this.

If there is indeed a stroke, the type most consistent with her presentation is probably a cerebellar stroke affecting the vestibular (balance) system. This region is responsible for coordinating motor and sensory signals, allowing synchronized behavior, such as the finger-to-nose test she failed. It’s also responsible for proprioception and balance; hence, damage could produce her complaint of dizziness. It is always important to distinguish “dizziness” (a sensation of spinning, consistent with either vestibular stroke or BPPV) with “lightheadedness” (a dimming of the vision, as seen in orthostatic hypotension). This is a notable possibility mainly because cerebellar injuries often do not produce the focal deficits characteristic of other strokes.

If you are very enterprising, Dr. Scott Weingart describes a three-test screen (introduced by Dr. David Newman-Toker and Dr. Jorge Kattah here) which can help catch vestibular stroke in borderline cases such as these. It uses two simple and easy tests, plus a third — involving a head twist — which is more difficult to assess and vaguely terrifying to perform. If you plan to use any of them, it’s the sort of thing you should be practicing beforehand. (I personally find the head twist finicky and liability-prone in most circumstances.) Like all such tests, their role in the field should only be to help determine transport destination and priority, and give you additional information on how hard to push a reluctant patient towards transport. It is not appropriate for enterprising Dr. Medics to use as ammunition to say, “oh, it’s negative, you’re clearly fine.” The weight of a thousand lawyers will descend upon you, and rightly so, the day you decide that you have the power to rule out major sickness from your ambulance.

If an extra-cerebral hemorrhage proved to be the culprit, a subdural bleed is probably the most plausible, due to the relatively slow and insidious development of the symptoms.

Additional tests that were not performed, but might have been useful, include a visual field test (testing at minimum eyesight in both visual hemispheres), a “stick out your tongue” test (looking for deviation to either side), and a more complete test of reasoning and recall (portions of the Folstein Mini-Mental, for instance).

Many of the major components of the peripheral neurological exam we performed are taken from this excellent lecture by Dr. Gene Hern of AMR Contra Costa County (see 37:20 through 40:50), and is my favorite expansion on the typical “squeeze my hands.” Sharp sensation can be tested with the tip of a pen — or you can use Dr. Hern’s pinching method.

Two other tips: when performing the facial droop test, “show me your teeth” produces better results than “smile” — patients tend to give a larger, more symmetrical smile using more muscles. And when testing for arm drift, remember that the patient’s eyes should be shut, and the hands should be facing upward (supinated); this is a more difficult test and therefore more sensitive.

Treatment and Transport

The key points on our differential therefore come down to two: intracranial hemorrhage vs. anything else. “Anything else” could be any number of things that produce diffuse and global symptoms, including metabolic problems or even a brain tumor. Diabetic etiologies are always be a possibility, although glucometry was fortunately available to rule that out. In general, the old standby AEIOUTIPS is the sort of thing we’re looking at here. And remember, multiple concomitant pathologies are just as likely as one all-encompassing Badness, if not more so. As a starting point, we should bear in mind that around two-thirds of falls with loss of consciousness in the elderly will end in death. The risk is high.

As always, the differential only matters to the extent that it will affect our decisions. What will our field treatment be?

Certainly oxygen. Although hypoxia is unlikely to be significantly contributing to Ms. Smith’s complaints, it could be playing a role. Depending on local protocol, low-flow through a nasal cannula may be plenty.

In the case of stroke, there is some evidence that hyperoxygenation with high-flow O2 can contribute to worse outcomes. The 2010 Emergency Cardiovascular Care guidelines from the American Heart Association recommends titrating oxygen therapy to maintain an oxygen saturation of at least 94%, but not necessarily slapping on a non-rebreather at 15LPM. Depending on whether oximetry is available to you, and depending on your local policies and attitudes, this may or may not fly; it’s something to ask your boss and medical director.

What about C-spine immobilization? As always, this will be a matter of opinion and protocol. In some areas, any fall from standing height, with a blow to the head — especially for an elderly patient — must always be immobilized. However, clinically I would not consider it indicated here. Whatever criteria or standards you adhere to for selective immobilization, Ms. Smith likely meets them: she has had no peripheral neurological deficits (weakness, tingling, numbness, pain), no neck or back pain or tenderness, no factors that would impair her reporting of the above (such as distracting injuries or altered mental status), turns her head freely, and although not ambulatory on our arrival was obviously ambulatory for several hours prior. Remember that the only reason for the immobilization of blunt head trauma patients is the suspicion that any injury substantial enough to cause ICH may also be substantial enough to cause a cervical spine fracture — and while a valid reason for suspicion, this is just one factor to consider. (Conversely, if we had found focal neurological deficits, we would have likely been unable to determine whether it was secondary to the suspected ICH, or secondary to a spinal injury — immobilization would have been unavoidable.)

Close monitoring will be warranted, especially if we do suspect a bleed. Although Ms. Smith appears currently stable, there is a real possibility of her mental status deteriorating; epidural bleeds in particular are famous for a “lucid interval” following the initial trauma, after which the patient suddenly and catastrophically decompensates. Control of the airway and ventilatory support should be provided as necessary. If there are signs of herniation syndrome — an acute rise in intracranial pressure, resulting in “coning,” or the brain being forced through the openings in the skull — it may be reasonable to hyperventilate the patient slightly, at a rate of 1 breath every 3 seconds. Although the drop in systemic CO2 caused by a higher ventilatory rate results in a systemic respiratory alkalosis (high PH), which tends to reduce inflammation and hence lower intracranial pressure, it also reduces cerebral perfusion; it is therefore no longer recommended as a routine practice. Intracranial pressure is a challenging problem that produces a physiological tightrope that we need to delicately walk; hyperventilation is a last-ditch flailing that’s only advisable when things can’t get much worse.

Is an ALS intercept appropriate? Again, this may depend on your protocols. As Ms. Smith currently presents, there is no benefit to ALS care; whether or not she’s hemorrhaging, that’s a matter for the hospital, not the field. However, if should deteriorate, then ALS could prove very valuable in the management of her airway, seizures, cardiac arrhythmias, and other complications. With Ms. Smith’s currently excellent clinical picture, and the short transport to definitive care, I would not attempt to meet the paramedics unless I tripped over them in the driveway. However, the opposing argument can easily be made, and I wouldn’t call it wrong.

The most appropriate destination for this patient will likely be the nearest primary stroke center. A “primary” stroke center is required to have various resources available 24/7, the most important in our case being a CT scanner. The definitive determination of the presence or absence of our possible bleed will be via some form of CT, or possibly by MRI (if available).

Treatment may or may not involve surgical intervention, depending on location and severity. Many of these cases are managed conservatively, both because the benefits of surgery are often small and the harm (especially in deep brain bleeds) often large. As a result, my personal inclination is to steer towards the nearest facility that can provide immediate imaging; if surgical intervention beyond their capabilities is found to be indicated, transfer can be arranged. I would not advise transporting to the more distant requested facility; the only notable benefit other than the patient’s convenience and comfort (which we won’t diminish) is that her medical records and following physicians may be available there, and her history doesn’t seem complex enough for this to matter significantly.

In some areas, a few hospitals are designated as “comprehensive” stroke centers, a step above primary. These facilities are specialty centers with the most advanced stroke management capabilities, which may include diagnostic and interventional methods that would be appropriate to us. The system of comprehensive centers is still inchoate and only available in some states; check if yours is one of them.

Your local hospitals may follow a prehospital protocol that allows for a “stroke activation,” similar in principle to trauma or cath lab activations, where appropriate resources are mobilized by request of EMS and waiting upon your arrival. Depending on the local indications (for instance, your hospitals may demand a positive Cincinatti Stroke Scale), Ms. Smith might qualify.

Conclusion

In the end, I was unable to obtain patient follow-up on Ms. Smith. She received low-flow O2, was not C-spine immobilized, and was diverted to the nearer stroke center with an emergent transport and no ALS. An entry notification was made with an advisory of her status, although no formal stroke alert was given. She was stable throughout.

It’s important to note that our assessment of Ms. Smith, our analysis of her differential, and our resulting treatment and transport decisions, are not actually dependent on her eventual diagnosis. It doesn’t matter whether we ended up being “right” — hence, it doesn’t matter that we never found out the “answer,” even though I do love a good puzzle and I admit that I wanted to know. As long as we made an appropriate interpretation of our assessment findings, and made appropriate decisions based on them, then we got it right. Perhaps her complaints turned out to result from an alien egg incubating in her chest; that wouldn’t make us wrong, it would only mean that she was an aberration. Our business in the field is to play the odds in a responsible way, weighing risk-vs-benefit to provide our patient with the best chance of a good outcome.

That’s all. And that’s plenty.

Live from Prospect St: Dizzy at Hillcrest (part 2)

Continued from Part 1

While you chat, your partner helpfully places Ms. Smith on a nasal cannula running oxygen at 4 LPM.

You ask whether she lost consciousness when she fell, and she agrees that she may have briefly. When you ask why she fell, she states she simply tripped on the fringe of the rug. The fall was 3 hours ago, and she first vomited immediately afterwards. Until this morning, she was feeling normal, with nothing bothering her over the previous days. Her chief complaint seems to be her persistent inability to “find words,” although staff state that they called EMS mainly due to her dizziness.

When you pursue the “pressure” behind her eyes, she admits that it’s a pain of sorts, but it is obviously not too severe, and she refuses to quantify it with a number. She clarifies her dizziness by stating that although it may be worse when she stands or walks, it is continuous; she is experiencing it even as you speak.

Her pupils are equal, somewhat small, and react slightly to light. Her eyes track in all directions, with no appreciable nystagmus. When you ask her to show her teeth, she does so with no facial droop. When you ask her to hold her arms straight in front of her, palms up, with her eyes closed, she does so with no unilateral drift. She demonstrates good, equal grips, equal bilateral strength in finger-abduction and wrist flexion/extension, and equal bilateral strength in ankle dorsiflexion/plantarflexion. Her radial pulses are equal, as are her dorsalis pedis pulses, and she notes normal bilateral sensation when you pinch her hands and feet.

Throughout your conversation, she has demonstrated no slurring of speech, normal recall, and excellent orientation.

Consulting with the staff, you learn that her medications include Metoprolol, Simvastatin, Metformin, Lisinopril, Colace, Aspirin, and Coumadin for a recent hip surgery. She is allergic to Penicillin. They are unsure about her baseline BP, but Ms. Smith believes it is normally “in the 140s.” Staff believe her temperature has been recently normal, although they aren’t certain.

Your partner obtains her blood glucose at 149.

The nearest ALS is 15 minutes away.

At this point, what are the leading possibilities in your differential?

With that in mind, what is this patient’s priority?

What is your transport destination?

Is any treatment needed at this time?

Should you make any calls to mobilize further resources?

Live from Prospect St: Dizzy at Hillcrest (part 1)

Many moons ago, there was an enlightened discussion list run by Jeff Brosius and Valerie DeFrance called Live from Peachtree St. The format was this: Jeff would periodically present scenarios based on real-life calls, putting them out for debate on diagnosis and treatment; later he’d provide the outcomes, with a discussion of the relevant clinical issues. It was a great educational model, and I’ve always thought that scenario-based instruction was a fantastic way to learn to parse the details of a call, determine what matters, come up with a working diagnosis, and make your decisions. You can’t learn hands-on skills from scenarios, but you can exercise your noodle, and more noodle-exercise is what this business needs.

Sadly, Live from Peachtree St. closed its doors years ago, although its archives are available online and still a great read. In the same spirit, however, and with permission from the authors, I’d like to revive the tradition. With that in mind, and harkening from my own neck of the woods, I give you: Live from Prospect St!

To juggle the format a little, I’d like to break these cases up. Remember “Choose your Own Adventure” books? In a similar fashion, I’ll give you the first chunk of the call, let you analyze the facts and make some decisions, then go forward with another round of details, and finally present the outcome. Cases are either true to life (obviously edited for HIPAA) or closely based on reality with editorializing for educational purposes. Feel free to send in any cases of your own! We’re not only interested in intriguing or unusual calls, but also more run-of-the-mill cases that illustrate important fundamentals of assessment and care.

All levels are invited to play, but in keeping with our mission, we will assume a BLS scope of practice. Onward!

Dizzy at Hillcrest

You are the technician on A-8, a dual-EMT, transporting BLS ambulance. You are equipped with BLS epinephrine, aspirin, glucose, nebulized albuterol, pulse oximetry, and finger-stick glucometry. Intercepting ALS is available upon request. It is noon and the weather is fair.

The radio crackles: “Ambulance 8, respond cold to Hillcrest Manor, in the lobby, for the patient with dizziness.”

Driving non-emergently, you arrive several minutes later at an assisted living facility. In the lobby, you are met by staff, who direct you toward an elderly woman in a chair. A nurse informs you she has been feeling somewhat unwell all day, and 30 minutes ago began complaining of dizziness. She also states that she failed a finger-to-nose neurological test. They request that you transport her to Mount Doom Hospital, a high-quality community hospital several towns away (20 minute transport routinely; 13 with lights and sirens); it is a cath lab and stroke center, although not the nearest facility for either, and is not a trauma center. The nearest facility is a community hospital of similar size and capabilities (10 minutes routinely; 5 with lights and sirens).

You kneel in front of the patient, noting that she is alert and appears generally well, in no obvious distress. She introduces herself as Ms. Smith, is 68 years old and fully oriented, and tells this story:

“This morning when I was getting out of bed, I fell and bumped my head. After I got back up, I was trying to do my writing assignment for our group, but I kept finding that I just couldn’t seem to think of the words — I’d stare at a sentence for ten minutes without knowing how to finish it. I’ve been feeling a little dizzy most of the day, and a little sick — I vomited a few times. And I feel like there’s a pressure behind my eyes.”

While you talk, your partner obtains these vitals:

Skin: dry; unremarkable at the core; cool and slightly pale in the extremities
Pulse: 90 [at the radial, strong and regular]
Respirations: 14 [regular, normal depth and unlabored]
Blood pressure: 164/98
Oxygen saturation: 96%

When asked, staff report that Ms. Smith’s medical history includes coronary artery disease, diabetes, mild dementia, and hypertension.

What is your current impression of the patient’s priority?

What are the leading possibilities in your differential?

What further assessments or information would you like to better inform your decisions?

What actions or interventions, if any, would you like to take at this time?

Post responses to the comments.

Get Up, Stand Up: Orthostatics

Orthostatic vital signs. Nurses think they’re a pain in the neck. Some doctors think they’re of marginal usefulness. Many providers simply think they’re a dying breed.

Like many old-school physical exam techniques, though, they’re dying only because high-tech imaging and laboratory techniques have largely replaced their role. And I don’t know about you, but my ambulance doesn’t come equipped for an ultrasound or serum electrolytes. Diagnostically, EMS lives in the Olden Days — the days of the hands-on physical, the stethoscope, the palpation and percussion, the careful and detailed history. For us, orthostatics have been and still are a valuable tool in patient assessment.

How are they performed? Orthostatic vital signs are essentially multiple sets of vitals taken from the patient in different positions. (They’re also sometimes known as the tilt test or tilt table, which is indeed another way to perform them — if you have a big, pivoting table available. Postural vitals is yet another name.) They usually include blood pressure and pulse, and are taken in two to three positions — supine (flat on the back) and standing are the most common, but a sitting position is sometimes also included, or used instead of standing. This is useful when a patient is unable to safely stand, although it’s not quite as diagnostically sensitive.

Why would we do such a dance? The main badness that orthostatics reveal is hypovolemia. With a full tank of blood, what ordinarily happens when I stand up? Gravity draws some of my blood into the lower portion of my body (mostly these big ol’ legs). This reduces perfusion to the important organs upstairs, especially my brain, so my body instantly compensates by increasing my heartrate a bit and tightening up my vasculature. No problem. However, what if my circulating volume is low — whether due to bleeding, dehydration, or even a “relative” hypovolemia (in distributive shocks such as sepsis or anaphylaxis)? In that case, when my smaller volume of blood is pulled away by gravity, my body will have a harder time compensating. If it’s not fully able to, then my blood pressure will drop systemically.

“But,” you cry, “surely this is all just extra steps. Can’t I recognize hypovolemia from basic vital signs — no matter what position you’re in?”

Well, yes and no. If it’s severe enough, then it will be readily apparent even if I’m standing on my head. But we routinely take baseline vitals on patients who are at least somewhat horizontal, and this is the ideal position to allow the body to compensate for low volume. By “challenging” the system with the use of gravity, we reveal the compensated hypovolemias… rather than only seeing the severely decompensated shock patients, who we can easily diagnose from thirty paces anyway. Like a cardiac stress test, we see more by pushing the body until it starts to fail; that’s how you discover the cracks beneath the surface.

Do we run on patients with hypovolemia? Oh, yes. External bleeding is a gimme, but how about GI bleeds? Decreased oral fluid intake? Increased urination due to diuretics? How about the day after a frat party kegger? Any of this sound familiar? It would be foolish to take the time to do this when it won’t affect patient care — such as in the obviously shocked patient — but there are times when what it reveals can be important, such as in patients who initially appear well and are considering refusing transport.

Here’s the process I’d recommend for taking orthostatics:

Start with your initial, baseline set of vitals. Whatever position your patient is found in, that’s fine. Deal with your initial assessment in the usual fashion.
Once you’re starting to go down a diagnostic pathway that prominently includes hypovolemic conditions in the differential, start thinking about orthostatics. If your initial vitals were taken while seated, try lying the patient flat and taking another pulse and BP. If possible, wait a minute or so between posture change and obtaining vitals; this will allow their system to “settle out” and avoid capturing aberrant numbers while they reestablish equilibrium.
Ask yourself: can the patient safely stand? Even in altered or poorly-ambulatory individuals, the answer might be “yes” with your assistance, up to and including a burly firefighter supporting them from behind with a bearhug. (Caution here is advised even in basically well patients, because significant orthostatic hypotension may result in a sudden loss of consciousness upon standing. You don’t want your “positive” finding to come from a downed patient with a fresh hip fracture.) If safe to do so, stand the patient and take another pulse and BP. Again, waiting at least a minute is ideal, but if that’s not possible, don’t fret too much.
For totally non-ambulatory patients, substitute sitting upright for standing. Ideally, this should be in a chair (or off the side of the stretcher) where their legs can hang, rather than a Fowler’s position with legs straight ahead.
For utterly immobile patients who can’t even sit upright, or if attempting orthostatics in the truck while already transporting, you’ll need to do your best to position them with the stretcher back itself. Fully supine will be your low position, full upright Fowler’s will be your high position, and a semi-Fowler’s middle ground can be included if desired.

On interpretation: healthy, euvolemic patients can exhibit small orthostatic changes, so hypovolemia is only appreciable from a significant drop in BP or increase in heart rate. From supine to standing, a drop in the systolic blood pressure of over 20 is usually considered abnormal, as is an increase in pulse of over 30. (Changes from supine to sitting, or sitting to standing, will obviously be smaller, and therefore harder to distinguish from ordinary physiological fluctuations.) A drop in diastolic pressure of over 10 is also considered aberrant. You can remember this as the “10–20–30” rule.

Try to remember what’s going on here. As the patient shifts upright, their available volume is decreasing, for which their body attempts to compensate — in part by increasing their heart rate. It’s a truism that younger, healthier, less medicated patients are more able to compensate than older and less well individuals. So for the same volume status, you would be more likely to see an increase in pulse from the younger patient, perhaps with no change in pressure; whereas the older patient might have less pulse differential but a greater drop in pressure. (On the whole, the pulse change tends to be a more sensitive indicator than pressure, since almost everyone is able to compensate somewhat for orthostatic effects. As always, if you look for the compensation rather than the decompensation — the patch, rather than the hole it’s covering — you’ll see more red flags and find them sooner.)

Are substantial orthostatic changes definitive proof of hypovolemia? No, nothing’s certain in this world. Another possible cause is autonomic dysregulation, which essentially means that the normal compensating mechanisms (namely baroreceptors that detect the drop in pressure and stimulate vasoconstriction, chronotropy, and inotropy) fail to function properly. You do have enough juice, but your body isn’t doing its job of keeping it evenly circulating. Vasovagal syncope is one common example of this; I’ve got it myself, in fact, and hence have a habit of passing out while squatting. This sort of thing is not related to volume status, although if you combine the two the effect can be synergistic. A good history can help distinguish them: ask the patient if they have a prior history of dizziness upon standing.

Finally, pulse and pressure are not the only changes you can assess. One of the best indicators of orthostatic hypotension is simply a subjective feeling of light-headedness reported by the patient. Although sudden light-headedness upon standing can have other causes (the other big possibility is benign paroxysmal positional vertigo — although strictly speaking, BPPV tends to cause “dizziness,” which is not the same as “lightheadedness”), hypovolemia is certainly one of the most likely. So stand ’em up when it’s safe and reasonable, ask how they feel, grab the vitals if you can, and maybe even take the opportunity to see how well they walk (a nice, broad neurological test — the total inability to ambulate in a normally ambulatory patient is a very ominous sign).

Orthostatics are usually recorded on documentation by drawing little stick figures of the appropriate postures. For those who find this goofy, or are documenting on computers without “stick figure” keys, a full written description will do.

The Rhythm Method

One two three — five six seven

What’s the missing number?

If you said four, congratulations. You have a basic human ability to recognize patterns — one of the best tools we have to separate us from the monkeys and sea-slugs.

One of the simplest types of pattern is a rhythm, and the simplest rhythm is a steady cadence. Ba-dump, ba-dump, ba-dump. Imagine a metronome or a drummer tapping out a fixed, continuous pace at an unchanging rhythm.

This is also one of the most basic and useful tricks you’ll ever use when taking vitals!

See, measuring vitals involves feeling, hearing, or observing a series of fairly subtle blips over a period of time. Unfortunately, interference is common in the field, and it’s a rare day when bumps in the road and bangs in the cabin don’t eat up at least one of those blips.

When taking a radial pulse, if over 15 seconds you count 18 beats, you have a pulse of 72; but if just a couple of those beats are lost due to your movement or the patient’s, suddenly it becomes 64, which is a substantial difference. This is no good; we want better reliability than that.

Rhythm is the answer. A pulse is typically a regular rhythm. So are respirations. So are the Korotkoff sounds of a blood pressure. In order to establish this rhythm, you only need to hear two consecutive beats, and appreciate exactly how far apart they are. If you can do this, then you can continue to mentally tap out that pace — hopefully, while continuing to feel, see, or hear the true beats, which will help you to maintain the right speed, but even if you miss some, you’ll still have your mental beat to count. Even if you miss most of them!

So you feel for the pulse, and you palpate the first couple beats. Then you hit a tortuous section of road that throws you around the cabin, and you’re unable to feel anything for several seconds. But you already had the rhythm in your head, so when you pick up the pulse again, you haven’t lost the count — and you’ll end up with an accurate number.

Now, in sick people these rhythms aren’t always regular. And if you observe that a pulse or respiratory cycle isn’t regular, then this system won’t be as effective — for instance, there’s not much point in trying to find the “beat” to an A-Fib pulse. But small irregularities or breaks in the rhythm are okay, as long as there’s still a regular cycle underlying it; for instance, occasional dropped (or extra) beats won’t change the basic rate.

Give it a try. If you got rhythm, vital signs will never give you trouble again.

What it Looks Like: Agonal Respirations

See also what Jugular Venous Distention, Seizures, and Cardiac Arrest and CPR look like

Education and experience are both important to making a well-rounded provider, and each of the two have distinct advantages. Perhaps the greatest advantage of experience is that it gives you the best ability to recognize situations you’d otherwise only know by description or by photograph.

Nowadays, though, with the Wonders of Modern Technology, we have some tools that can help bridge this gap. Experience is still essential — but there’s no reason that the first time you see a seizure or cyanosis should be in a situation with real stakes.

So let’s go through some of the common medical events and conditions we talk about, learn about, but may not truly know the presentation of until we encounter it.

Today, it’s:

Agonal Respirations

Agonal respirations are an inadequate pattern of breathing associated with extreme physiological distress, particularly periarrest states (that is, it is usually seen just prior to cardiac arrest, as well as during and for some time after). Although not always seen during arrest, it is not uncommon, and there is some evidence that it may be associated with better outcomes than arrests without agonal breathing. Whatever the case, it can easily be confused for ordinary respiration, leading to the mistaken impression that the “breathing” patient must also have a pulse; this confusion is part of why the American Heart Association no longer recommends checking for breathing as part of layperson’s CPR.

As for healthcare providers, whether we’re able to put the label of “agonal” on it or not, we should be able to recognize from the rate and depth that this is not adequate respiration to sustain oxygenation, and ventilatory assistance (as well as a check of hemodynamic status) is in order. But recognizing the specific nature of this breathing can be a very useful red flag to set your “code” wheels in motion.

Here are a few simulated examples, performed by medical actors. They range in presentation and context.

http://www.youtube.com/watch?v=M99bRjmsC7E

Finally, here’s a treat — this is a video of a real-life cardiac arrest at a beach in Australia. Starting after the first shock, from 2:39 onward, you can see a great example of agonal breathing. The rest of the video is also a nice example of an honest code being worked in the field — not perfect, but real. (For bonus points, how could their CPR and other treatment have been improved?)

(Thanks to Dave Hiltz for inspiring today’s topic.)

Vital Signs: Blood Pressure

For other Vital Signs posts, see: Respirations and Pulse

In the grand scheme of medical skills, taking a manual blood pressure is far from difficult, but sick people and austere conditions can combine to make it another thing entirely. Obtaining a BP on an ill patient while rattling down the road is legitimately one of the most difficult psychomotor skills an EMT-Basic has to master.

Mastering it starts with stacking the odds in your favor. A good stethoscope is better than a lousy one — you don’t need a $500 cardiology model, but something with good insulation and tight-fitting earpieces can make a real difference. Of course, you’ll also want to try to take your blood pressures at times of peace: on scene, before the rig starts moving, or even shoehorned in while stopped at traffic lights.

The elbow-supported technique for finding the brachial pulse is also ideal for taking a BP; trying to hear anything when the arm is slightly flexed is a recipe for frustration. But ensure that however you arrange things, the arm is completely relaxed, because muscular tension can radically throw a measurement; this will require fully supporting the arm and sometimes reassuring the patient. “Just relax” is the line I always deliver while busily pumping the bulb.

Where to put the gauge? Wherever. I’ll usually clip it to one of the stretcher straps, but you can find a bit of blanket that it’ll nestle into, secure it to a shirt, clip it to your watchband or the edge of the cuff, or just ask the patient to hold it for you. The built-in strap on the cuff is only a good location if you’re at the patient’s right side, which is typically not where we sit while we’re transporting. There’s probably a huge market niche out there for “EMS style” cuffs with their handedness reversed… but I digress.

Although I don’t always follow all of these steps, here’s the basic approach I recommend for a routine blood pressure check:

Support the arm, ideally at a position that is horizontally level with the heart.
Palpate the antecubital fossa until you find the pulse point. Note this location.
Palpating at the radial or the AC, pump up the cuff until you lose the pulse. Note this number and deflate the cuff.
Place your scope on the AC and inflate the cuff past the previous number. Obtain your pressure in the ordinary fashion.

Starting with a palpated pressure may seem redundant, and it can be, but it has two advantages: first, it gives you a rough sense of what systolic to look for, and second, if you’re unable to auscultate a pressure, you’ll still have a palpated one to record. This is actually the officially recommended method, although it seems rarely done nowadays.

Palpated pressures are legitimate, although when they start becoming the norm it can be a sign of lazy care. The diastolic can be a valuable number, though, particularly in traumatic or cardiac cases, so remember that auscultating is still the default standard of care. And remember, particularly if you’re mixing methods, that palpated pressures often will differ from auscultated pressures (including those taken by machine), usually by 10-15 points on the low side.

What if you’re not getting anything from the arm? Well, you can try the other arm, of course. But really, the thing to remember is that you can take a blood pressure anywhere there’s a pulse, although it’s much easier when that pulse is strong and the artery proximal to it can be easily occluded. Remember that although you can palpate a pressure from any distal spot on the same artery, near or far (barring anastamoses), auscultation — which is essentially listening to the turbulence created immediately downstream of the occlusion — requires placing your scope just below the cuff, and will not be successful farther downstream. Putting the cuff (pedi cuffs when needed) on the forearm and measuring at the radial is effective; thigh cuffs work too, although the popliteal can be an evasive pulse to locate. You can even cuff the lower calf and palpate a pedal or tibial pulse, if you’re daring. Go nuts, and try to experiment before the call when you actually need it. Do make an effort, though, to use an appropriate sized cuff for the extremity; mis-sized cuffs can actually yield significantly erroneous readings. For the morbidly obese, I usually prefer to place a regular cuff on the forearm than to use a thigh cuff on the upper arm, but see what works for you.

As a final note, remember that cuffing the neck and palpating the temporal pulse is never an appropriate method of patient assessment, no matter how little blood you may suspect is reaching their brain.

On maintenance: during your morning checkout, pump some air into the cuff, close the valve and give the whole thing a squeeze to check for leaks. There’s nothing better than discovering these after you’ve wrapped it around a critical patient’s arm.

On sphygmomanometers: for obvious reasons, the resting point for the needle should be at zero. (Very cheap cuffs sometimes have a pin-stop here for the needle to rest against; this is a problem because the dial can be miscalibrated without showing it. Pin-stop gauges shouldn’t be used unless your service is seriously broke.) If you have one that needs zeroing, most cuffs can be adjusted by pulling the tubing off the dial, grasping the metal nipple with some pliers (or very strong fingers), and twisting it in either direction until the needle is zeroed. Alternately, fans of mental math can just add or subtract the false “zero” number each time they take a pressure.

And finally, on tourniquets: the immortal Dr. Scott Weingart of Emcrit has described his practice of using BP cuffs as tourniquets. You’ll hear about this from time to time, but there’s always someone who points out the damned things leak like sieves and that’s the last property you want in a tourniquet. Dr. Weingart’s solution is to pump up the cuff until bleeding is controlled (or 250mmHg, whichever is sooner), then clamp both tubes with locking hemostats. (He uses smooth ones to avoid damaging the rubber; he recommends padding with a 4×4 if you’re using a ridged hemostat.) My hemostats are all in the shop, and this may or may not fly with your agency — modifying equipment for “off-label” use is always somewhat shaky ground for us field peons — but I think it’s a splendid idea if you can swing it.

Vital Signs: Pulse

For other Vital Signs posts, see: Respirations and Blood Pressure

Ah, the almighty pulse. If I have a favorite vital sign, this is it; let me lay hands on a patient and take a pulse and my assessment is already well under way.

On the conscious patient our go-to point is the radial pulse, and like golf, mastering the radial is all in the grip. Techniques may vary here, but I always find the radial easier to palpate if you approach from the ulnar side of the arm, coming “underneath” rather than over the top of the radius. This also lets you take a pulse while easily holding onto their limb, rather than forcing you to find a place to rest it, or supporting the arm with one hand while you palpate with the other. Just grab and count, very natural. If you have no luck, you can always keep hold of their arm while using your other hand to do some searching.

The textbooks always seem to show this being done with two delicate fingers, which is silly; more fingers means more coverage, so I always use at least three. (Your little finger is kinda short, otherwise it’d be four.) Use a moderate pressure, but if you’re having trouble, try pressing both lighter and firmer, as well as moving to different spots. (While I usually wear my watch in the normal position, you’ll notice here that when taking a pulse this way, I flip it around my wrist so I can see the face.)

The main way to ensure you’re never baffled by the pulse, however, is by always being willing to look elsewhere. Some people simply won’t have a radial, and this fact may or may not have significance — it may mean they’re hypotensive, or that their arm is locally hypoperfused, but it also may be a chronic condition. Hemodialysis patients with arterio-venous fistulas in their arm are especially notorious for having peculiar or absent radial pulses, as the arteries near the fistula have been scavenged and rerouted. Make like a picky renter — go elsewhere!

Your next attempt after the radial should be the brachial. Now, in classes and textbooks I have always been taught to look for a radial in the upper arm, beneath the bicep, but I’ve never had luck with this. Rather, my target is the antecubital fossa, the same territory made popular by blood pressures and large-bore IV sticks.

Again, positioning is key here. To effectively feel this pulse, the elbow should be in full extension, but relaxed. Depending on the patient’s position, you may accomplish this by wrapping your arm around theirs and holding their elbow in your hand, but from your bench seat in the truck, an easier way to do it is to simply rest their elbow on your knee. (Either way, it’s important to support them at the elbow, because this allows gravity to force their arm into extension.) The brachial can be a real lifesaver when a radial isn’t forthcoming, and I go to it readily and often.

Logically, the next step would be a carotid pulse, but the truth is that on conscious, alert patients, this is always a little awkward; people don’t like having their neck touched. If they need it, they need it, but for the routine pulse check, I try to steer clear. The same goes for a femoral pulse, for the same reasons; there was a story at my old service of a brash young EMT who got canned for “feeling a femoral” on an inebriated coed from a campus we served.

Instead, if I can’t find a radial or brachial on either arm, I’ll often take an apical “pulse,” simply auscultating at the chest for heart sounds. This is not, strictly speaking, a pulse, insofar as it’s not counting actual perfusing beats so much as counting any cardiac noise (it therefore tells you nothing about blood pressure), but it’s a good fallback — and if you’re very suave it can even yield additional clinical information, regarding murmurs, rubs, etc.

Here are a some other tricks that can be useful:

Inflate a BP cuff and count the bounces on the sphygmomanometer needle. Although this is not an indicator of systolic or diastolic pressure, it is a legitimate way to measure a pulse.
If pulse oximetry is available, the device will usually calculate a pulse for you, and if there’s a displayed waveform you can also confirm it from that.
The aforementioned AV fistulas can be used to your advantage. Gentle palpation of visible, active fistulas should let you feel a pulsing vibration called a thrill (an indicator of healthy flow), and this is easily counted for an accurate pulse rate. (Auscultating at the fistula should reveal a buzzing sound called bruit, which can be used similarly.)
If you’re able to locate a difficult pulse point, such as a dorsalis pedis, X’ng the spot with a pen can make subsequent checks much easier.
Lowering the arm below the level of the heart can occasionally make a radial more readily palpable, especially in hypotensive situations.

Finally, when all else fails, remember your perpetual fallback: skin signs. A patient with no available pulses and no obtainable blood pressure can still give you a general sense of perfusion, both centrally and to each extremity, if you assess the color and temperature of his skin. (This is especially valuable for infants, for whom proper pulse checks can be difficult, and blood pressures even more so.) And then there’s the sidekick to this, which is capillary refill. Current teaching is that cap refill is not a meaningful sign except in the very young, because numerous chronic conditions can cause delayed refill without poor arterial pressure, and this is true; a slow cap refill in an adult shouldn’t mean much to you. However, a rapid refill is still a pretty specific sign of good perfusion, because there’s not many conditions that can fake that (with the possibly exception of distributive shocks, such as septic or anaphylactic). A quick pat-down is an ever-ready way to rapidly assess anyone’s hemodynamic status within a couple seconds.

Vital Signs: Respirations

In the eyes of many EMTs, taking vital signs is BLS bread and butter. I’m not sure if I agree, since there’s other butter I’d hate losing more, but unquestionably vitals are something we do an awful lot of and probably ought be good at. Mainly, it’s the big three: pulse, pressure, and respiratory rate (the fourth vital sign is temperature, which is not considered vital prehospitally, and the de facto fifth sign is O2 saturation, which is not always available).

But woe unto the poor freshly-anointed Basic who enters the field and discovers that taking a blood pressure off his classmate at a quiet desk has almost nothing in common with playing hunt-the-Korotkoff on an elderly PVD patient in the back of a vehicle that sounds, to the layman, almost indistinguishable from a steam locomotive. With experience, we figure it out and we get by, but I’m always interested in the tricks that people have come to rely on, and here are some of my own. Let’s start with…

Respirations

The man who said that any blind monkey can count respirations has never tried it on sick people.

The first challenge here is getting away with staring at someone’s chest without giving them the skeevs. Women may be a little more wary about this, but if you’re unsubtle enough even men may ask if you “like what you see.” One method is a classic: while taking a pulse, count your beats and then start counting respirations without looking away or dropping their wrist. It gives you an excuse to stare blankly, and the patient is rarely the wiser. Good multitaskers can even count a pulse while simultaneously counting respirations over the same interval of time, although this is a bit much for my own second-tier brain.

Alternately, you can place yourself out of the patient’s field of vision, a technique that girl-oglers will recognize. In the back of the rig, you can usually pull this off by simply moving behind the stretcher — the captain’s chair is often too far, blocking your vision unless the stretcher is very reclined, but moving to the end of the bench seat is usually far enough and more convenient anyway.

How about the shallow respirations that virtually can’t be seen? You can put a hand on their chest to feel, but this is a little weird in the conscious patient and again betrays your intentions. You’re better off maximizing your visibility. Make sure there are no piles of blankets or folds of clothing in the way, and try watching both the abdomen and the thorax, as different people breathe in different fashions. If you’re still having no luck, auscultate! Place your stethoscope and count from the lung sounds. In fact, respiratory distress patients will sometimes produce wheezes or crackles that are audible from the bedside, allowing you to get a count with the naked ear.

Some texts recommend counting for at least 30 seconds; this is accurate, but feels like a geological epoch. Unless respirations are highly irregular, I count for 15. That does mean that your results will always be a multiple of 4, but here’s a way to improve it: count partial breaths as well. If you start with the chest “up” and 15 seconds later end on a “down,” call it a half stroke — so 4.5 x 4 would mean a respiratory rate of 18. You can get even fancier with quarter-strokes but that may be a little silly unless their rate is very slow.

A final note: “ehhh, looks normal” is not a valid method for counting respirations. There are times for estimation, but one hospital-based study showed that an overwhelming number of patients were documented at triage as breathing exactly 16 times a minute. A statistical miracle! In other words, you’re not as good at eyeballing as you think; take a few seconds and do your job.

For other Vital Signs posts, see: Pulse and Blood Pressure

Cheat Sheets

Now and then you see someone with one of those little spiral-bound EMS “pocket guides.” They make sense for paramedics, who have drug dosages and other information-dense (and in some cases, rarely used) protocols that need remembering; but they always seemed a little silly for the EMT-B, who mostly needs to remember not to drop anyone.

There are a handful of things that would be useful to me in a reference, however, and therein lies the rub: preprinted field guides invariably consist 75% of what you already know and are missing 50% of what you actually need. For instance, when I moved two years ago, one of my main concerns was learning the different points-of-entry in the Boston metro area (trauma, STEMI, etc.), a service area which runneth over with so much healthcare that even your hairdresser might be an RN. But I’m not going to find that information in any book I can find on a shelf.

The answer? Homemade references! I made my own cheatsheet by laying out what I needed on the computer (I used Adobe InDesign, but a word processor would work), printing it in foldable handbook size, and gluing and stapling it together into a booklet. This fits unnoticeably in my back pocket and goes everywhere with me during my shift, and it works great — it’s full of exactly what I need and nothing else. My original one has been falling to pieces, so I just recently revised it and made up a new one. I’ve considered laminating it, but I don’t want to make it any thicker, and that would make it difficult to write on for any revisions.

I recommend making your own cheat sheet if you get a chance. You can check out mine here; here’s a couple sample pages as an example.

And the final product: