Baseline Vital Signs

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Baseline Vital Signs

• Sample History

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Why are vital signs so important?

• Vital signs are outward signs of what is going on
  inside the body.
• Trending
• Valuable information can be provided to the EMT-B
  when repeating vital signs which will show a
  trend in the patients condition, and allow the
  EMT to respond appropriately.

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Vitals Signs Include!

• Pulse
• Skin color
• Temperature and condition
• Capillary refill, (in infants and children).
• Pupils
• Blood pressure.

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General Information

• A. Chief complaint - Why was EMS notified.
• B. Age - years, months, days
• C. Sex - male or female
• D. Race

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Respirations

• Assess breathing by observing the patients chest
  rise and fall.
• Rate is determined by counting the number of
  breaths in in 15 seconds and multiplying by 4, or
  30 seconds and multiply by 2.
• Do not inform the patient that you are taking
  respirations.

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Quality of Respirations

• Can be determined while assessing the rate.
• Quality can be placed in 1 of 4 categories
• Normal
• Shallow
• Labored
• Noisy

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Normal Respirations

• Average chest wall motion, not using accessory
  muscles.

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Shallow

• Slight chest or abdominal wall motion.

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Labored

• An increase in the effort of breathing.
• Grunting and stridor. ( stridor - harsh, high
  pitched occurring as air passes a restriction in
  the lower part of the upper airway.
• Common in Croup.
• Often characterized by the use of accessory
  muscles.
• Nasal flaring, subclavicular and intercostal
  retractions in infants and children.
• Sometimes gasping.

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Noisy

• An increase in the audible sound of breathing.
• May include
• Snoring
• Wheezing
• Gurgling
• Crowing.

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Assessing Pulse

• Initially, a radial pulse should be assessed in
  all patients one year or older.
• In patients less than one year of age, a brachial
  pulse should be assessed.

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Note!

• In all unconscious patients, the carotid and
  radial pulses should be assessed at the same
  time.1 year or older.

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Pulse is Present

• Assess rate and quality.
• Rate is the number of beats felt in 15 seconds
  and multiplied by 4. Or 30 seconds and multiplied
  by 2.
• Quality of the can be characterized as
• Strong
• Weak
• Regular
• Irregular

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No Peripheral Pulse Present

• If peripheral pulse is not palpable assess the
  carotid pulse.
• Use caution. Avoid excess pressure on geriatrics
  patients.
• Never attempt to assess carotid pulse on both
  sides at one time.

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Skin Color

• Assess skin to determine perfusion
• The patients skin color should be assessed in the
  nail beds, lower lip mucosa, and conjunctiva.
• In infants and children, palms of hands and soles
  of feet should be assessed.
• Normal skin - pink

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Abnormal Skin Colors

• Pale - indicating poor perfusion, impaired blood
  flow.
• Cyanotic - (blue-gray) - indicating inadequate
  oxygenation or poor perfusion.
• Flushed (red) - indicating exposure to heat or
  carbon monoxide poisoning.
• Jaundice (yellow) - indicating liver
  abnormalities.

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Skin Temperature

• Assess the patients temperature by placing the
  back of your hand on the patients skin.
• Normal - warm

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Abnormal Skin Temperatures

• Hot - indicating fever or an exposure to heat.
• Cool - indicating poor perfusion or exposure to
  cold.
• Cold - indicates extreme exposure to cold.

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Skin Condition

• Assess the condition of the patients skin.
• Normal- dry.
• Abnormal - skin is wet, moist or dry.

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Capillary Refill

• Assess capillary refill in infants and children
  less than six years of age.
• Capillary refill is assessed by pressing on the
  patients skin or nail beds and determining time
  for return to initial color.
• Normal capillary refill time in infants and
  children is
• Abnormal capillary refill in infants and children
  is 2 seconds.

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Assess Pupils

• Assess pupils by briefly shining a light into the
  patients eyes, and determining size and
  reactivity.
• Dilated - (very big), normal, or constricted
  (small).
• Equal or unequal.
• Reactivity is whether or not the pupils change in
  response to light.

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P-E-A-R-L

• Pupils are equal and reactive to light.
• Reactive - change when exposed to light
• Non-reactive - do not change when exposed to
  light.
• Equally or unequally reactive.

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Assessing Blood Pressure
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Systolic Blood Pressure

• First distinction of blood flowing through the
  artery as the pressure in the blood pressure cuff
  is released.
• This is a measurement of the pressure exerted
  against the walls of the arteries during
  contraction of the ventricles.

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Diastolic blood pressure

• The point during deflation of the blood pressure
  cuff in which sounds of the pulse beat
  disappears.
• It represents the pressure exerted against the
  walls of the arteries while the ventricles relax.

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Two Methods of Obtaining Blood Pressure

• Auscultation - Listening for BP
• Palpation - Feeling for the BP.

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Other Blood Pressure Facts

• Blood pressure should be measured in all patients
  older than three years of age.
• The general assessment of the infant or child
  patient, such as sick appearing, in respiratory
  distress, or unresponsive, is more valuable than
  vital sign numbers.

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Pulse Pressure

• Difference between systolic and diastolic blood
  pressure reading.
• Useful in determining potential shock.
• A pulse pressure of 15 mmHg or lower could be
  fatal.

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Estimated Blood Pressure

• Carotid pulse only B.P. of about 60mmHg.
• Femoral pulse B.P. of about 70mmHg.
• Radial pulse B.P. of about 80mmHg.

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Reassessing Vital Signs

• Vital signs should be assessed and recorded every
  15 minutes at a minimum in a stable patient.
• Vital signs should be assessed and recorded every
  5 minutes in the unstable patient.
• Vitals should be reassessed following all medical
  interventions.

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The Sample History
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Signs/Symptoms

• Sign - any medical or trauma condition displayed
  by the patient and identifiable by the EMT-B.
• EXAMPLES - Hearing respiratory distress, Seeing
  bleeding, feeling cool skin.
• Symptom - any condition described by the patient.
  
• EXAMPLE - shortness of breath, nausea, weakness.

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Allergies

• Types
• Medications
• Food
• Environmental
• Consider medical identification tag.

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Medications

• Prescription
• Current
• Recent
• Consider birth control pills
• Nonprescription
• Current
• Recent
• Consider medical identification tag

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Pertinent Past History

• Medical
• Surgical
• Trauma
• Consider medical identification tag

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Last Oral Intake

• Solid or liquid
• Time
• Quantity

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Events Leading to Injury or Illness

• Chest pain with exertion
• Chest pain while at rest

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SWAMPLE

• This is the way it should read.
• Check for weapons while assessing your patient.
• Remember that scene safety is the 1 priority.

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Lifting and Moving Patients
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Body Mechanics

• Lifting techniques
• Carrying
• Reaching
• Pushing and pulling guidelines

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Lifting Techniques

• Safety precautions
• Use legs, not back to lift
• Keep weight as close to body as possible.

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Guidelines for Lifting

• Consider weight of patient and need for
  additional help.
• Know physical limitations and ability.
• Lift without twisting.
• Have feet positioned properly.
• Communicate clearly and frequently with partner.

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Safe Lifting of Cots and Stretchers

• When possible use a stair chair instead of a
  stretcher if medically feasible.
• Know or find out the weight to be lifted.
• Use at least two people.
• Ensure enough help available.
• Use an even number of people to lift so that
  balance is maintained.
• Know or find out weight limitations of equipment
  being used.
• Know what to do with patients who exceed weight
  limitations of equipment.

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Use Power-Lift or Squat-Lift Position

• Keep back locked into normal curvature.
• The power-lift position is useful for individuals
  with weak knees or thighs.
• The feet are a comfortable distance apart.
• The back is tight and the abdominal muscles lock
  the back in a slight inward curve.
• Straddle the object. Keep feet flat.
• Distribute weight to balls of feet or just
  behind them.
• Stand by making sure the back is locked in and
  the upper body comes up before the hips.

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Use Power-Grip to Get Maximum Force From Hands

• The palm and fingers come into complete contact
  with the object and all fingers are bent at the
  same angles.
• The power-grip should always be used in lifting.
  This allows for maximum force to be developed.
• Hands should be at least 10 inches apart.
• Lift while keeping back in locked-in position.
• When lowering cot or stretcher, reverse steps.
• Avoid bending at waist.

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Precautions for Carrying

• Whenever possible, transport patient on devices
  that can be rolled.

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Guidelines for Carrying

• Know or find out weight to be lifted.
• Know limitations of crews abilities.
• Work in coordinated manner and communicate with
  partners.
• Keep weight as close to body as possible.
• Keep back in locked-in position and refrain from
  twisting.
• Flex at the hips, not waist bend at the knees.
• Do not hyperextend the back (dont lean back from
  the waist)

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Correct Carrying Procedure

• Use correct lifting techniques to lift the
  stretcher.
• Partners should have similar strength and height.

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One-Handed Carrying Technique

• Pick up and carry with back in locked-in
  position.
• Avoid leaning to either side to compensate for
  the imbalance.

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Correct Carrying Procedure on Stairs.

• Use a stair chair instead of a stretcher, when
  possible.
• Keep back in locked-in position.
• Flex at the hips, not waist bend at the knees.
• Keep weight and arms as close to body as
  possible.

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Guidelines for Reaching

• Keep back in locked-in position.
• Avoid hyperextended position when reaching
  overhead.
• Avoid twisting the back while reaching.

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Application of Reaching Techniques

• Avoid reaching more than 15-20 inches in front of
  the body.
• Avoid situations where prolonged (more than a
  minute) strenuous effort is needed in order to
  avoid injury.

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Correct Reaching for Log Rolls

• Keep back straight while leaning over patient.
• Lean from the hips.
• Use shoulder muscles to help with roll.

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Pushing and Pulling Guidelines

• Push rather than pull, whenever possible.
• Keep back in locked-in position
• Keep line of pull through center of body by
  bending knees.
• Keep weight close to body.
• Push from area between the waist and shoulder.
• Use kneeling position if weight is below waist
  level.
• Avoid pushing or pulling from an overhead
  position if possible.
• Keep elbows bent with arms close to sides.

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Principles of Moving Patients
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Patient Moved Immediately (emergency
move) only when

• There is immediate danger to the patient if not
  moved.
• Fire or danger of fire.
• Explosives or other hazardous materials.
• Inability to protect the patient from other
  hazards at the scene.
• Inability to gain access to other patients in a
  vehicle who need life-saving care..
• Life-saving care cannot be given because of the
  patients location or position. EXAMPLE. Cardiac
  arrest patient sitting in a chair or lying on a
  bed.

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Patient Moved Quickly (urgent move)
when

• Immediate threat to life.
• Altered mental status.
• Inadequate breathing.
• Shock (hypoperfusion)
• If there is no threat to life, the patient should
  be moved when ready for transport (non-urgent
  move).

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Emergency Moves

• The greatest danger in moving a patient quickly
  is the possibility of aggravating a spinal
  injury.
• In an emergency, every effort should be made to
  pull the patient in the direction of the long
  axis of the body to provide as much protection to
  the spine as possible.
• It is impossible to remove a patient from a
  vehicle quickly and at the same time provide as
  much protection to the spine as can be
  accomplished with an interim immobilization
  device.

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Emergency Moves Cont..

• The patient on the floor or ground can be moved
  by
• Pulling on the patients clothing in the neck and
  shoulder area.
• Putting the patient on a blanket and dragging
  the blanket.
• Putting the EMTS hands under the patients
  armpits (from the back), grasping the patients
  forearms, and dragging the patient.

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Urgent Moves

• Rapid extrication of patient sitting in vehicle.
• One EMT-B gets behind the patient and brings
  cervical spine into neutral in-line position and
  provides manual immobilization.
• A second EMT applies cervical immobilization
  device as the third EMT or first responder places
  long backboard near the door and then moves to
  the passengers seat.
• The second EMT supports the thorax as the third
  person frees the patients legs from the pedals.
• At the direction of the second EMT, he and his
  partner rotate the patient in several short,
  coordinated moves until the patients back is in
  the open doorway with feet on the passengers
  seat.

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Urgent Moves Cont..

• Since the first EMT usually cannot support the
  patients head any longer, another helper
  supports the head as the first EMT gets out of
  the vehicle and takes support of the head from
  outside the vehicle.
• The end of the backboard is placed on the seat
  next to the patients buttocks. Assistants
  support the other end of the backboard as the
  EMTS lower the patient on to it.
• The EMTS slide the patient up the board into
  proper position in short, coordinated moves.
• Several variations of the technique are possible,
  including assistance from bystanders or
  firefighters. Must be accomplished without
  compromise to the spine.

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Non-urgent Moves

• Direct ground lift (no suspected spine injury)
• Two or three rescuers line up on one side of the
  patient.
• Rescuers kneel on one knee ( the same knee)
• Patients arms are placed on his chest if
  possible.
• The rescuer at the head places one arm under the
  patients neck and shoulder and cradles the
  patients head.
• He places his other arm under the patients lower
  back.

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Non-urgent Moves

• The second rescuer places one arm under the
  patients knees and one arm above the buttocks.
• If a third rescuer is available, he should place
  both arms under the waist and the other two
  rescuers slide their arms either up to the
  mid-back or down to the buttocks as appropriate.
• On signal, the rescuers lift the patient to their
  knees and roll the patient in toward their chest.
• On signal, the rescuers stand and move the
  patient to the cot.
• To lower the patient the steps are reversed.

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Extremity lift (no suspected extremity
injuries)

• One rescuer kneels at the patients head and one
  kneels at the patients side by his knees.
• The rescuer at the head places one arm under each
  of the patients shoulders while the rescuer at
  the foot grasps the patients wrists.
• The rescuer at the head slips his hands under the
  patients arms and grasps the patients wrists.
• The rescuer at the patients foot slips his hands
  under the patients knees.
• Both rescuers move up to a crouching position.
• The rescuers stand up simultaneously and move
  with the patient to the stretcher.

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Transfer of Supine Patient from Bed to Cot
66
Direct Carry

• Position cot perpendicular to the bed with head
  of cot at foot of bed.
• Unbuckle straps and remove items from cot.
• Both rescuers stand between bed and cot facing
  patient.
• First rescuer slides arm under patients neck and
  cups patients shoulder.
• Second rescuer slides hand under patients hip
  and lifts slightly.
• First rescuer slides other arm under patients
  back.
• Second rescuer places arms underneath hips and
  calves.
• Rescuers slide patient to edge of bed.
• Patient is lifted and curled toward the rescuers
  chest.
• Rescuers rotate and place patient gently onto
  cot.

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Draw Sheet Method

• Loosen bottom sheet of bed.
• Position cot next to the bed.
• Prepare cot adjust height, lower rails,
  unbuckle straps.
• Reach across cot and grasp sheet firmly at
  patients head, chest, hips, and knees.
• Slide patient gently onto cot.

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Equipment
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Stretchers/Cots

• Types
• Wheeled stretcher
• Most commonly used device.
• Rolling
• Restricted to smooth terrain
• Foot end should be pulled
• One person must guide the stretcher at head.

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Carrying

• Two rescuers
• Preferable in narrow spaces, but requires more
  strength.
• Easily unbalanced
• Rescuers should face each other from opposite
  ends of stretcher.
• Four rescuers
• One rescuer at each corner.
• More stability, requires less strength.
• Safer over rough terrain

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Loading into Ambulance

• Use sufficient lifting power
• Load hanging stretchers before wheeled cots.
• Follow manufacturers directions
• Ensure all cots and patients secured before
  moving the ambulance.
• Portable stretchers
• Stair chair

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Backboards

• Long
• Traditional wooden device
• Manufactured varieties
• Short
• Traditional wooden device
• Vest-type device
• Scoop stretcher
• Flexible stretcher
• Maintenance - follow manufacturers directions
  for inspection, cleaning, repair, and upkeep.

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Patient Positioning

• An unresponsive patient without suspected spine
  injury should be moved into the recovery position
  by rolling the patient onto his side (preferably
  the left) without twisting the body.
• A patient with chest pain or discomfort or
  difficulty breathing should sit in a position of
  comfort as long as hypotension is not present.
• A patient with suspected spine injury should be
  immobilized on a long backboard.
• A patient in shock should have his legs elevated
  8-12 inches.
• For a pregnant patient with hypotension, an early
  intervention is to position her on her left side.
• A patient who is nauseated or vomiting should be
  transported in a position of comfort however the
  EMT should be positioned appropriately to manage
  the airway.