Checking Posturals, ALS indicators

[BAM123]

Hello! I have a question in regards to checking for postural changes in a Pt's BP. I'm almost finished with EMT class, and the checking for posturals has a become a big thing all of the sudden. We have been instructed to check posturals in Pts who are dizzy/weak, ab pain, or any Pt with suspected volume issues -unless they're already hypotensive, have cardiac issues, trauma, or 3rd Tri vaginal bleed-. SO, If there's a change of at least 20 mm/Hg in their systolic, does this indicate the need to call for ALS? I know this may depend on where you are, but I'm interested in what others have been taught. Thanks!

[zippyRN]

Hello! I have a question in regards to checking for postural changes in a Pt's BP. I'm almost finished with EMT class, and the checking for posturals has a become a big thing all of the sudden. We have been instructed to check posturals in Pts who are dizzy/weak, ab pain, or any Pt with suspected volume issues -unless they're already hypotensive, have cardiac issues, trauma, or 3rd Tri vaginal bleed-. SO, If there's a change of at least 20 mm/Hg in their systolic, does this indicate the need to call for ALS? I know this may depend on where you are, but I'm interested in what others have been taught. Thanks!

other than the fact that this will add up to 20 minutes to your scene time ...

[spenac]

You not only have to consider BP but also pulse. Yes a 20 point change would warrent ALS. But honestly ALS should be on all calls.

[Dustdevil]

SO, If there's a change of at least 20 mm/Hg in their systolic, does this indicate the need to call for ALS? I know this may depend on where you are, but I'm interested in what others have been taught.

Welcome aboard!

The above statement addresses the crux of your question. Unfortunately, we don't know anything about your system. Are ALS the first responders, or are they on an ambulance? Are you are a first responder or on an ambulance? What is the typical wait time for ALS? Are they co-dispatched with you, or must you request them from the scene before they are even dispatched? What the typical transport time to an appropriate facility? Those are all important factors necessary to intelligently address your question about the operational implications of orthostatic findings.

Moving on to the procedure itself, orthostatic changes can indicate much more than simple volume issues. Cardiogenic, neurogenic, septic, and pharmacological causes are all common, and require a lot more than simple volume replacement to manage. Only a well educated and experienced paramedic (which your system may or may not even have) can competently determine which is the cause of the orthostatic hypotension and manage it. Simple volume issues are the least of your worries. They need little more than rapid transportation, as volume replacement is not likely to make a significant difference in their outcome. It is all those other, non-volume issues that need immediate paramedic intervention.

ZippyRN is correct. Competent orthostatic vital sign measurement takes a good ten minutes at the very minimum to perform. If ALS is responding with you, they're going to be on scene before you ever finish. If they are not already responding, then you have just burned up way too much valuable time doing the procedure to continue to wait around for ALS. That 's why, as Spenac pointed out, ALS should have been responding in the first place. If they are not, then you should face the fact that your system sucks. Not all patients need ALS care. However, those that do need it NOW, not after an EMT has wasted fifteen minutes figuring it out. And every patient needs an ALS examination to determine that.

If your instructors are telling you only about orthostatic blood pressure changes, and not about measuring the pulse, then you should suspect that they don't know what they are doing (an unfortunately common occurrence in EMT education). As well, it is not just the systolic reading that is considered. You should also be considering the diastolic reading. As well, you'll want to understand exactly which positions should be used for measuring orthostatics and why. If you'll Google "orthostatic vital signs" there are many great resources on the net that lay out the exact procedure, as well as the clinical considerations involved. I encourage you to visit several of them to get an in-depth understanding of them. Remember that the things covered in any EMT course are just the bare minimum, entry level bits of knowledge necessary to have a very basic understanding. There is MUCH, much more you need to learn through independent study in order to have a competent understanding of what you are doing and why. That's why it is such a positive sign that you are here and doing such research. Never stop that quest! Good luck, and please stick around to let us know how the class is going!

[FL_Medic]

If there is a 10 point change in BP, or HR you should consider this patient positive for your tilt(orthostatic) test. ALS should be called, and this patient should probably be transported in a position that will keep them from being dizzy, and SBP > 100mmHg (or normal for patient). This patient should be placed on a cardiac monitor and have a 12-lead EKG. IV should be established and a thourough physical exam and PMHx.

*******Administrator, please move this post to "students" thread********

[Dustdevil]

*******Administrator, please move this post to "students" thread********

Good recommendation, but this isn't strictly a student issue, dealing with the learning process. It is relevant to all practitioners, so the Patient Care forum would seem more appropriate.

[FL_Medic]

10-4, and agreed.

[BAM123]

Thanks all for the replies on this, it certainly helped to google orthostatic vital signs for much much more info on this topic. The text book didn't seem to cover this procedure very well (if at all). This website seems like a great resource for the future, I'm sure I'll continue to use it. Thanks again!

[Dustdevil]

The text book didn't seem to cover this procedure very well (if at all).

Be aware that this also applies to almost every single other thing covered (or not covered) in your course, except for the monkey skills like bandaging and splinting. The content requirements of the EMT course have grown exponentially in the last twenty years, with the addition of pharmacology and defibrillation, yet NO hours have been added to the course to cover them. Consequently, today's EMT students are being given a LOT less actual education than they once did. That puts you behind the 8-ball from the get-go, so I would encourage you to spend a lot of time digging deeper into the topics that are covered in your class, in order to achieve a greater, more thorough understanding. Going out into the field to perform medical skills that you do not have a true understanding of is unforgivable. Never accept the bare minimum amount of knowledge. Be a professional. Always continue to educate yourself.

[ERDoc]

There is no good evidence to support the use of orthostatic vital signs. As you can see from the few posts in this thread already, there is no consensus on what constitutes abnormal. One person has said a 10 point drop in BP, another has said 20. Some literature will say 30. There is also no consensus to support a specific increase in pulse. The only reliable measure of true orthostasis is the pt's symptoms. Do they become lighthead? That being said, do I do them in the ER? Of coourse. Despite the lack of EBM to establish a set criteria, it helps when dealing with the bean counters to show some drop in BP to support a hospital admission. Here are a few studies for everyone's enjoyment.

http://www.ncbi.nlm.nih.gov/pubmed/1927355...Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/pubmed/1583476...ogdbfrom=pubmed