# Orthostatic/postural vital signs



## Brandon O (Jul 25, 2015)

Thought this could be a worthwhile topic. How many of you are assessing postural vitals out there, and if so, how are you doing it (and to whom)?


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## akflightmedic (Jul 25, 2015)

It could be...but how many without googling could explain what orthostatic vitals signs are, how to conduct them properly and what the clinical significance is? I say this bearing in mind we are in BLS thread, so all the medics...simmer down. 

Why and when would you elect to perform orthostatics?


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## ERDoc (Jul 25, 2015)

I will hold off saying anything for now other than answering the question of when do I elect to use them.  I use them when it helps me get a patient admitted.


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## Flying (Jul 25, 2015)

_The BLS forum is now EMTLife's gladiatorial proving ground. Shower your chosen ones with praise, paragods and higher-level providers._

In recent history, I did it once out of the last three occasions I feel it would've contributed to the impression of the patient.

Patients had in common:
Dizziness/nausea as the primary complaint
Can stand or sit up on their own, preferring to lie down
We are reasonably sure he/she won't die or get worse any time soon

Cannot recall the specifics of the biomechanics, other than feeling hypotensive from the load placed on my heart every morning I wake up.

Not sure how many EMTs in this system bother to be aware of recording orthostatic changes in BP, I would like to know myself.
I habitually record the position of the patient with every set of vital signs taken given the flexibility of ePCRs.


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## Clare (Jul 25, 2015)

Never postured a pt in my life, never seen anybody else do it either and I have no plans to do it in the future.  I don't think it adds anything to be worth it.


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## DesertMedic66 (Jul 25, 2015)

I do it on a decent amount of patients.


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## Brandon O (Jul 25, 2015)

I'd say I agree with most of the above. For me, as with many things, the utility I could see was almost always in the patient considering refusal of transport. (And as noted, probably the dehydrated or otherwise lightheaded or vaguely ill.) Vitals unexciting, but they've been in their easy chair since you arrived, so let's try standing. In that respect it ends up being a safety evaluation as well (i.e. can they walk once we leave).

Other than that, one could do it out of boredom while en route to try and buff a borderline case, but in the back of the truck you're limited to Fowler's vs supine which is a pretty limited challenge.

I'm aware of the EM literature that it's of dubious predictive value, but as in many other cases, I feel this has questionable relevance for the prehospital realm where it's not always true that we have better methods available.


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## Brandon O (Jul 25, 2015)

DesertMedic66 said:


> I do it on a decent amount of patients.



Who, why, and how?


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## DesertMedic66 (Jul 25, 2015)

Brandon O said:


> Who, why, and how?


Any patient I suspect of being hypovolemic/dehydrated  who's vital signs don't reflect it. And a decent number of AMAs. For me it's hard to justify giving a fluid challenge to a patient who has a BP of 130/70 with a pulse rate of 80. Now if we stand the patient up and their BP goes to 116/70 with a pulse rate of 110 it is very easy to justify fluids. 

Since we are in a desert environment with extreme heat a lot of our patients are dehydrated. It's also something that the Docs/MICNs will ask for during a call in. 

I usually go from a sitting full fowler position to a standing position. About 30 seconds after the move record their BP and pulse rate and look for the change. Then I will just have them sit on the gurney to avoid making then move again. I believe the time limit to check vitals after a change in position is something like <3mins. 

Ortho vitals here are taught in EMT programs and medic programs and are used frequently.


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## Tigger (Jul 25, 2015)

Brandon O said:


> I'd say I agree with most of the above. For me, as with many things, the utility I could see was almost always in the patient considering refusal of transport. (And as noted, probably the dehydrated or otherwise lightheaded or vaguely ill.) Vitals unexciting, but they've been in their easy chair since you arrived, so let's try standing. In that respect it ends up being a safety evaluation as well (i.e. can they walk once we leave).
> 
> Other than that, one could do it out of boredom while en route to try and buff a borderline case, but in the back of the truck you're limited to Fowler's vs supine which is a pretty limited challenge.
> 
> I'm aware of the EM literature that it's of dubious predictive value, but as in many other cases, I feel this has questionable relevance for the prehospital realm where it's not always true that we have better methods available.


As you mention, I will use it as a way to reinforce that I think the patient should be transported. Aside from that, I might only do them if the patient is insistent that they walk, struggle, sit back down, and then try again with assistance. But if I'm presented with the typical post-syncope supine patient that wants to go to the hospital, odds are they remain supine while we extricate them from the home. I don't see enough utility to it to stand someone up just for the purposes of obtaining a set unless they are already up.


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## NomadicMedic (Jul 25, 2015)

It's always been the the proof that gets a transport from the syncope patient. That's about the only time I do it. If I think "oh, I should do orthostatics", I already know what it's going to show and it's just to get Mr "I'm not sick" to agree to the transport and a bag of fluid.


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## Brandon O (Jul 25, 2015)

So for those of you using it to convince patients they're sick, are you actually recording vitals? It seems like this would work equally well just by demonstrating their symptoms to them. (Actually, this would be more evidence based as well...)


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## Tigger (Jul 25, 2015)

Brandon O said:


> So for those of you using it to convince patients they're sick, are you actually recording vitals? It seems like this would work equally well just by demonstrating their symptoms to them. (Actually, this would be more evidence based as well...)


Yes? Doesn't take very long to throw a set into the PCR and click the "standing" stick figure.


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## Brandon O (Jul 25, 2015)

Tigger said:


> Yes? Doesn't take very long to throw a set into the PCR and click the "standing" stick figure.



Er... I didn't mean documenting it, but just whether you were bothering to actually take a blood pressure and pulse versus just seeing if they became dizzy.


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## NomadicMedic (Jul 25, 2015)

Well yeah. Otherwise it's just "stand up and tell me if you're dizzy". I found that BLS loves to take orthostatics. It gives them something to do.


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## Brandon O (Jul 25, 2015)

DEmedic said:


> I found that BLS loves to take orthostatics. It gives them something to do.



 Kinda like ALS starting IVs, right?


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## NomadicMedic (Jul 25, 2015)

Exactly.


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## Tigger (Jul 25, 2015)

Brandon O said:


> Er... I didn't mean documenting it, but just whether you were bothering to actually take a blood pressure and pulse versus just seeing if they became dizzy.


Yes, I like them to see the numbers. I also like to have them on the monitor so the can watch their rate rise with me.


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## NYBLS (Jul 25, 2015)

http://lifeinthefastlane.com/futility-orthostatic-measurements/


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## EpiEMS (Jul 29, 2015)

Curious if standing a patient up and checking a pulse (or waiting for a "I feel dizzy") would have similar predictive power as orthostatic V/S.


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## ERDoc (Jul 29, 2015)

EpiEMS said:


> Curious if standing a patient up and checking a pulse (or waiting for a "I feel dizzy") would have similar predictive power as orthostatic V/S.




Ah, but state what othostatic VS are and your source.


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## NYBLS (Jul 29, 2015)

EpiEMS said:


> Curious if standing a patient up and checking a pulse (or waiting for a "I feel dizzy") would have similar predictive power as orthostatic V/S.



I feel like thats more telling for the patient as well than saying "holy wow, your blood pressure dropped 30 points!" Especially when attempting to convince a patient to be transported.


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## Brandon O (Jul 29, 2015)

EpiEMS said:


> Curious if standing a patient up and checking a pulse (or waiting for a "I feel dizzy") would have similar predictive power as orthostatic V/S.



The literature actually suggests that provocation of symptoms ("I feel dizzy") is the most predictive -- or at least the most sensitive -- provoked tachycardia is next best, and actually BP drop is least. So if the latter is what you're referring to, yes.

Unless I'm misremembering that. It's been a while.


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## EpiEMS (Jul 29, 2015)

ERDoc said:


> Ah, but state what othostatic VS are and your source.



Not sure if I follow -- do you mean how much change in HR and/or BP would qualify as + orthostatic?




Brandon O said:


> The literature actually suggests that provocation of symptoms ("I feel dizzy") is the most predictive -- or at least the most sensitive -- provoked tachycardia is next best, and actually BP drop is least. So if the latter is what you're referring to, yes.
> 
> Unless I'm misremembering that. It's been a while.



Sounds right to me -- my (late-night) Google and PubMed search showed  the same.

Roberts and Hedges’ Clinical Procedures in Emergency Medicine (2013 ed.), pg. 16 cites this study, a meta-analysis (admittedly, an older one) which was summarized as: "When clinicians evaluate adults with suspected blood loss, the *most helpful physical findings are either severe postural dizziness (preventing measurement of upright vital signs) or a postural pulse increment of 30 beats/min or more*." I'd like to do some more digging, but I would go with Roberts and Hedges on this one (again, pg. 16): "[T]his procedure [orthostatic vital sign testing] *has limited proven value*, and clinical interpretation of orthostatic changes in blood pressure and pulse varies widely."


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## MackTheKnife (Aug 1, 2015)

Brandon O said:


> So for those of you using it to convince patients they're sick, are you actually recording vitals? It seems like this would work equally well just by demonstrating their symptoms to them. (Actually, this would be more evidence based as well...)


Are you saying sx' s are more evidenced-based than objective vital signs?


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## MackTheKnife (Aug 1, 2015)

DEmedic said:


> Well yeah. Otherwise it's just "stand up and tell me if you're dizzy". I found that BLS loves to take orthostatics. It gives them something to do.


Tongue in cheek comment, or are you being condescending towards Basics?


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## Brandon O (Aug 1, 2015)

MackTheKnife said:


> Are you saying sx' s are more evidenced-based than objective vital signs?



In this case, yes, reproduction of symptoms is more predictive than trying to pick an arbitrary cutoff for vitals aberrations.

Edit: I can dig up the references if you'd like, I have them somewhere.


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## MackTheKnife (Aug 1, 2015)

Brandon O said:


> In this case, yes, reproduction of symptoms is more predictive than trying to pick an arbitrary cutoff for vitals aberrations.
> 
> Edit: I can dig up the references if you'd like, I have them somewhere.


OK. I think you are right but are subject to attack by those on here who need to have several peer-reviewed studies before they can accept anything. Medicine is art and science.


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## teedubbyaw (Aug 1, 2015)

Absolutely do it often. I certainly don't do a textbook method. These pt's are usually already laying or sitting -- grab a BP, have them stand up and if they're dizzy/light headed, then +orthos. Get a auto BP as they're standing and moving to the stretcher. +drop +HR, boom.


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## Ewok Jerky (Aug 1, 2015)

Ortho static VS are defined as a drop in SBP of 20 or raise it HR of 30 within 5 minutes.

Routinely used in AMAs of hypovolemic cases and discharges from the hospital when admitted for hypovolemic issues.


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## Carlos Danger (Aug 1, 2015)

In what very common disease process would orthostatic VS be unreliable, and why?


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## Carlos Danger (Aug 2, 2015)

Remi said:


> In what very common disease process would orthostatic VS be unreliable, and why?



I was thinking of patients with advanced diabetes. They often have a peripheral neuropathy that results in significant autonomic dysfunction. This results in a higher resting HR and BP, and lack of compensatory hemodynamic changes in the setting of vasodilatory or hypovolemic events. You may not see a compensatory tachycardia with an orthostatic test even if they are hypovolemic.


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## Zredmond (Aug 10, 2015)

I mainly use it on syncopal episodes to decide if I am comfortable allowing pt to AMA without ALS on scene. I've had a lady at 100/68 sitting, and as soon as I stood her up it dropped to 70/40. Obviously I'm not gonna kidnap her, but you can bet I got ALS to take over.


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## MackTheKnife (Aug 10, 2015)

Did you take her standing BP right away, or wait two minutes and then take it?


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