Orthostatic/postural vital signs

Brandon O

Brandon O

Puzzled by facies
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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)?
 
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?
 
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.
 
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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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.
 
I do it on a decent amount of patients.
 
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.
 
Brandon O said:
Who, why, and how?
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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.
 
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.
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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.
 
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.
 
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...)
 
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...)
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Yes? Doesn't take very long to throw a set into the PCR and click the "standing" stick figure.
 
Tigger said:
Yes? Doesn't take very long to throw a set into the PCR and click the "standing" stick figure.
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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.
 
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.
 
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.
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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.
 
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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