Orthostatic vital signs

[DFIB]

Here's another question I have for you guys, when do you decide to give fluids to a patient you suspect is dehydrated?

Decreased turgor = fluids

More so if i know the etiology of dehidration ie. diarrhea, vomiting etc

Edited August 16, 2011 by DFIB

[ERDoc]

So it seems there is a general consensus on the vital sign changes that make someone orthostatic. Can anyone provide a link to the literature or a textbook that says this is so?

It seems we have some discrepancy on when to check the vitals after we put the pt in a sitting or standing position.

[scubanurse]

http://www.dizziness-and-balance.com/disorders/medical/orthostatic.html

http://www.mayoclinic.com/health/orthostatic-hypotension/DS00997/DSECTION=tests-and-diagnosis

On the Mayo clinic under blood pressure monitoring, it gives the numbers 20mmHg for systolic and 10mmHg for diastolic changes.

http://www.aafp.org/afp/2003/1215/p2393.html

Very first paragraph in bold outlines the changes as

Orthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within three minutes of standing.

http://www.sciencedirect.com.dml.regis.edu/science/article/pii/S002234761000764X

This gives a general guideline to the time it takes to show a positive orthostatic sign and is from The Journal of Pediatrics.

http://journals.cambridge.org.dml.regis.edu/action/displayFulltext?type=6&fid=7854155&jid=RCG&volumeId=20&issueId=03&aid=7854154&bodyId=&membershipNumber=&societyETOCSession=&fulltextType=RV&fileId=S0959259810000201

The most commonly applied definition is that OH is present where there is a drop in systolic blood pressure of 20 mmHg or more, and/or in diastolic blood pressure of 10 mmHg or more, occurring within the first three minutes of standing (or during head-up tilt-table testing)

Seems the general consensus is that symptoms must occur within 3 minutes of position change, and that a change of 20mmHg systolic and 10mmHg diastolic results in a positive test.

I know not all will be able to access these articles.. I can e-mail them though to those who wish to read them in depth.

I know when I was diagnosed with POTS, it was through a tilt-table test... I kept passing out though and so I received a positive diagnosis without much numerical support.

[ERDoc]

Careful using pediatric literature. Kids are a whole other organism (never treat them as little adults). There seems to be some disagreement in those articles, one says 20/10 another says 25/10. One says wait at least 2 minutes and the other says within 3 minutes. Seems pretty confusing to me (no, this is not a personal attack against you Kate so please don't take it that way. It's great that you went and found these sites).

[scubanurse]

My issues started at 5 though, so kids are affected by orthostasis as well. And also why I stated a general consensus... I doubt very often in literature that you will see identical numbers from paper to paper. Hell I can't even find a consistent number of people in the world who have EDS.

The overall point I take from reading such articles is a guideline... and common sense. If someone only has a 14mmHg drop in their systolic BP, but states they are dizzy, I'm not going to rule out the possibility they might have some orthosatic issues occurring.

Hard facts combined with observation and common sense can help come to a diagnosis. Just because someone doesn't fit into the normal standard or range, does not mean they do not have an issue.

And no, I didn't take it as a personal attack, I'm really enjoying this mental stretching and discussion

[ERDoc]

I didn't mean to imply that kids can't be orthostatic. They sure can be and it should scare the hell out of you more than if an adult is.

[scubanurse]

Didn't mean to imply you thought that at all...

So what's the background on this discussion? Are we all nuts for thinking the way we do? Do you have some insider information to share?

[ERDoc]

I was thinking about the thread where we were discussing a disection and people were talking about different BPs in the arms. Orthostasis is something that is thrown around quite a bit but as we can see there is no agreed upon definition. The AAN has come up with a definition of 20/10 that is starting to be universally accepted but there is a lack of evidence. We all get a little orthostatic when we stand. I have seen a huge variation in the way VS are done between provider in the same ER. I wouldn't call it a myth or say anyone is nuts, but it is something that is almost taken as gospel but has little evidence to back it up. I'm not saying it doesn't exist (obviously it does) since lack of evidence does not me an lack of disease. I like the idea of someone being symptomatic as making them positive.

[scubanurse]

Makes sense... I remember it took a while to get a diagnosis as some doctors would just tell me to drink more water and I would be fine. I can drink all the water in the world and it wouldn't change the fact that my blood vessels don't constrict like others do.

I don't think generally in the ER it would change a treatment plan at all, nor much in the ICU/acute care but it does help in gathering more information? But if there is no universal standard on evaluating it, then it's pretty much a subjective assessment and holds little credibility.

[tniuqs]

Well just me but when working in a remote clinic setting, the couple minutes of extra time spent to evaluate is very positive for patient contact, in fact I did it yesterday on a "I have a HA, dizzy" and a resultant negative finding ... the worker was bragging to the bosses how great a paramedic they had, the treatment plan was 500 ml of H2O and a tylenol, it was a magical fix and no lost time on the job.

Not that he was wrong mind you about the great part LOL ...

Would a positive finding of orthostatic hypotension result in a different treatment plan, in a non acute patient, well not really, but I would have a tendency to "flip" to a higher level of care to investigate in far more depth just to be on the safe side for the patient.

The skin turger or tenting can be a bit misleading as well, and in a geriatric with PMHX of HTN and on meds I look more towards end organ perfusion LOC and urine output, if in an acute care setting.

Yes ERDoc those dang snot spewing, toddling virus packing alien life forms called children never follow the rule books !

cheers