# Orthostatic Vital Signs



## EMSrush (Dec 14, 2011)

I would like to find out what everyone's opinion is on the usefulness/sensitivity/specificity of obtaining orthostatic vital signs in the field. If you do use orthos, which conditions do you use them for and how do they affect your treatment plan?


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## usafmedic45 (Dec 14, 2011)

> everyone's opinion is on the usefulness/sensitivity/specificity of obtaining orthostatic vital signs in the field



Rather than relying on people's "opinions", why not actually look it up on PubMed and see what the actual specificity and sensitivity is?


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## KellyBracket (Dec 14, 2011)

If you want to start looking at the Pubmed stuff, a good place to start would be the meta-analysis that was published in JAMA a few years ago. It was titled Is This Patient Hypovolemic? 

One pearl I appreciated from this review - researchers do not use the seated position for BP and HR assessment. It's just supine and standing!


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## EMSrush (Dec 14, 2011)

usafmedic45 said:


> Rather than relying on people's "opinions", why not actually look it up on PubMed and see what the actual specificity and sensitivity is?



Specificity and sensitivity will vary, depending on the types of patients that the test is used on, and the many "variations" in testing technique. I was curious to know who uses orthostats in the field and how they are used by individual EMS providers; I am familiar with their use in the hospital. I came to a forum for opinions because I wanted just that. 

Directing me to PubMed wasn't quite what I was looking for, but thanks for the resource.


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## usafmedic45 (Dec 14, 2011)

Sorry....it's just one of those sorts of questions we get on here that is often asked because someone doesn't know exactly how to word what they are looking for.  I only used it rarely in the field, usually when I suspected someone might be a little volume depleted/dehydrated but wasn't frankly hypotensive.  I also would use it if the patient was reporting symptoms similar to what one might expect to be orthostatic in nature.


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## mycrofft (Dec 14, 2011)

*Orthostatics: yield versus time and risk.*

Risk of falling or initiating syncope or arrhythmia.
TIME: how long to equilibrate? How many iterations? How long to try to puzzle out the results and record them?
YIELD: what difference will it make to your initial treatment?

I liked monitoring the pulse for rhythm and consistency of strength, not just rate, while in the act of tilting/sitting up or down for the orthostatic in the exam room. Now, what are we looking at when the pt sits up rapidly or squats to stand, and the rate becomes faster, irregularly irregular and with irregularly palpable strength? (Syncope follows). One of our MD's had this, kept trying to get back up and passing out.


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## Brandon O (Dec 14, 2011)

I shared some thoughts on it here: http://emsbasics.com/2011/05/08/get-up-stand-up-orthostatics/

Like many advanced exam techniques, I find it mainly useful when things look pretty normal and you're trying to dig deeper to "rule in" some badness -- perhaps because you've got a long transport and you're bored, but in particular, when the patient wants to sign a refusal.

But they need to be pretty orthostatic to show clear changes between supine and high Fowler's. So the practicalities can be a challenge.


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## mycrofft (Dec 14, 2011)

*HAHA love the AMA thing*

They refuse sitting down, make 'em stand up fast, pass out, implied consent...just kidding as usual.


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## Brandon O (Dec 14, 2011)

mycrofft said:


> They refuse sitting down, make 'em stand up fast, pass out, implied consent...just kidding as usual.



Yeh, but whatcha gonna do, transport 'em standing?


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## mycrofft (Dec 14, 2011)

*Trendelenburg STAT*

Ride 'em feet first and jam on the brakes when they start to wake up?


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## Brandon O (Dec 14, 2011)

The Human Centrifuge, eh? I can dig it.


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## bstone (Dec 14, 2011)

Orthostatic hypotension can be a mystery for it's underlying pathology and the patient likes it even less.


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## mycrofft (Dec 15, 2011)

*Oh, answer to the question I posed above:*

He sucked a heart valve. I recount more of his tale under the prehospital ECMO thread.


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## Thriceknight (Dec 18, 2011)

Brandon Oto said:


> I shared some thoughts on it here: http://emsbasics.com/2011/05/08/get-up-stand-up-orthostatics/
> 
> Like many advanced exam techniques, I find it mainly useful when things look pretty normal and you're trying to dig deeper to "rule in" some badness -- perhaps because you've got a long transport and you're bored, but in particular, when the patient wants to sign a refusal.
> 
> But they need to be pretty orthostatic to show clear changes between supine and high Fowler's. So the practicalities can be a challenge.



This was a great article!! Definitely should take a look at it.. h34r:


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## Tigger (Dec 19, 2011)

My ATC is of the school of thought that they can help confirm that someone is dehydrated and is in need of some fluid replenishment...I take them when he asks but I can't say that obtaining them is some sort of be all-end all assessment technique...


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## mycrofft (Dec 21, 2011)

*Pinch test for hypohydration (skinn tenting).*

Also obvious xerostomia, c/o thirst, sunken eyes, oliguria. For conversation's sake orthostatic could reveal dehydration, but many other signs are faster and more sure.
Like starting an IV and sand comes out.


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## Brandon O (Dec 21, 2011)

In my personal experience, obvious clinical signs are often absent in younger/healthier dehydration patients.


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## mycrofft (Dec 21, 2011)

*...who are better able to resist it's influences.*

HOw about thirst (not a good indicator in itself) and viscosity of oral secretions?

Actually, thirst isn't a bad one if you are not going to be making demands that can rapidly increase the dehydration. IOW, if I get thirsty doing EMTLIFE, I could need a drink now or later; if I get thirsty running a race, I need more than a sip or two and right now, because my water loss curve is too steep.

I know, thirst can be allayed by rinsing out the mouth....


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## Too Old To Work (Dec 23, 2011)

Useless in EMS for the most part. Especially since very few people at the BLS or ALS level are taught what they mean or how to interpret them. 

I've seen many cases where people who should know better will sit or stand up a patient who is already hypotensive to see if they are "postural". They find out that they are when the patient loses consciousness. 

If the patient is hypotensive lying down, they are going to be hypotensive sitting or standing. 

If the patient is normotensive lying down, and has a pulse rate in the normal range, you aren't going to learn much by checking postural vital signs. 

Just more long taught and essentially useless EMS knowledge along with looking for battle sign, Raccoon eyes, and of course blown pupils. All of which are late signs and the absence of minutes or hours after an injury tell you nothing about the patient's condition.


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## Brandon O (Dec 23, 2011)

Too Old To Work said:


> I've seen many cases where people who should know better will sit or stand up a patient who is already hypotensive to see if they are "postural". They find out that they are when the patient loses consciousness.
> 
> If the patient is hypotensive lying down, they are going to be hypotensive sitting or standing.



Patient: [hypotensive, lying lateral in a pool of blood from his butt]
Us: [help him sit up to move him to a stairchair]
Patient: [immediately seizes]
Us: Hmm... whoops.


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## Too Old To Work (Dec 23, 2011)

Brandon Oto said:


> Patient: [hypotensive, lying lateral in a pool of blood from his butt]
> Us: [help him sit up to move him to a stairchair]
> Patient: [immediately seizes]
> Us: Hmm... whoops.



Yeah, something like that. Or the guy who is cold, pale, wet, pressure of 60/p, and had syncope. Same thing, sit him up, watch him pass out. 

Which is why I condemn it.


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## EMSrush (Dec 24, 2011)

Too Old To Work said:


> Useless in EMS for the most part. Especially since very few people at the BLS or ALS level are taught what they mean or how to interpret them.
> 
> I've seen many cases where people who should know better will sit or stand up a patient who is already hypotensive to see if they are "postural". They find out that they are when the patient loses consciousness.
> 
> ...



Thank you so much. This is the type of feedback that I was looking for when I posted the original thread.


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## Niccigsu (Jan 13, 2012)

We just started going over this in class and according to our book you should use orthostatic vitals when you suspect shock.


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## rescue1 (Jan 13, 2012)

You're supposed to have your (presumably) critically injured trauma patients stand up for a series of vital signs? That's the most absurd thing I've ever heard.


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## dixie_flatline (Jan 13, 2012)

I've only really seen it used when we are posted up at concerts (especially all-day events) and knuckle-heads spend all day in the sun and have a beer and a shot of tequila as Breakfast, Lunch, and Dinner.  As has been mentioned, a lot of the other signs & symptoms of dehydration seem to be absent from idiotic twenty-somethings.


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## medichopeful (Jan 13, 2012)

Not sure if it's been mentioned, but one test for dehydration is a drop in BP, especially upon standing.

Edit: Apparently it has been!


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## Veneficus (Jan 13, 2012)

rescue1 said:


> You're supposed to have your (presumably) critically injured trauma patients stand up for a series of vital signs? That's the most absurd thing I've ever heard.



Forgive them...

They know not what they do...

I would point out that there are 4 classes of shock.

Class I (15% or less total blood volume) being largely asymptomatic.

Class II ( 15-30% total blood volume with an estimated blood loss of between 800-1500ml) will be discovered by orthostatic pressure changes. Urine output maintained

Class III (30-40% total blood volume estimated 2000ml) anxious or combative with decompensation and drop in urine output.

Class IV (>40% blood volume) imminent circulatory collapse.

In EMT class, the curriculum focuses on class III and class IV. Identifying a patient is these states is rather a no brainer. But they are not nearly as common as Class I and II.

The purpose of orthostatics in a potential shock patient, which for the purposes of this discussion, we will just call hypovolemic for simplicity, is meant to distinguish class I (do nothing) from Class II (compensation benefitted by supportive care.)

From the EMS standpoint, the practicality is:

Would the patient benefit from supportive therapy? (IV infusion) or just a ride (turf to BLS, BLS rides call, or not call for ALS)


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## rescue1 (Jan 13, 2012)

Ah, OK. I stand corrected. 

My course, unsurprisingly, never even mentioned Class I and II shock.


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## johnrsemt (Jan 13, 2012)

Whatever you do:  when pts BP dropped 44 points from supine to sitting  do NOT stand them up.   an Engine crew did that while waiting for us to getting there;   hard to write in the report how someone with a GI bleed needed sutures in their forehead


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