orthostatics

[donedeal]

what is an appropriate wait time between sitting, standing, lying, when running an orthostatic assessment on a patient? won't running BPs continously cause a higher, misleading BP, but if you wait too long, between positions won't the body compensate, rendering the test useless?

[akflightmedic]

Typically for true orthostatic test, you are supposed to wait a min of 2 mins between switching postures. However in my experience, if a pt has positive orthostatic BPs, you notice it almost immediately. Many times you dont make it to standing or if they do stand they get very dizzy or near syncope. It is a good test to perform on all dizzy, weak patients and the information is very pertinent. This is an ALS assessment/diagnostic tool that can be done by any level, especially basics however it is very under utilized.

[AZCEP]

Nice reply AK.

Great tool to use, not used often enough by those that should know better.

[NREMT-Basic]

I am only a wee Basic, but what I say is true...

In my training, not so long ago,

we were taught orthostatics too.

Mares eat oats and does eat oats...

[nbsp]

Orthostatics was briefly mentioned in my class by the teacher, but we never really went over it. After a quick and unthorough google search, it seems that an orthostatics test would be only suited for dehydration, since if the patient was a victim of blood loss, you wouldn't want to wait for the 2-3 minute test, plus it would be rather obvious unless you were looking for vampire victims, in which case a simple DCAP-BTLS check on the side of the neck would be sufficient.

Perhaps Ace844 would be kind enough to post a couple of his 5-page studies.

[bassnmedic]

Orthostatics was briefly mentioned in my class by the teacher, but we never really went over it. After a quick and unthorough google search, it seems that an orthostatics test would be only suited for dehydration, since if the patient was a victim of blood loss, you wouldn't want to wait for the 2-3 minute test, plus it would be rather obvious unless you were looking for vampire victims, in which case a simple DCAP-BTLS check on the side of the neck would be sufficient.

Perhaps Ace844 would be kind enough to post a couple of his 5-page studies.

I'm sorry, but you'll have to explain to me why orthostatics would ONLY be used in dehydration patients. I use this tool on most every near syncopal patient and dizzy, weak patient i go on, most of which are not dehydrated.

[nbsp]

I'm sorry, but you'll have to explain to me why orthostatics would ONLY be used in dehydration patients. I use this tool on most every near syncopal patient and dizzy, weak patient i go on, most of which are not dehydrated.

Well going on the information I found in the quick google search above mentioned, it is indicated in patients with 1. blood/fluid loss or 2. dehydration. Blood and fluid loss would be pretty obvious in most cases, and would warrant a quick transport above a standing orthostatics test (imho), however a quick unofficial seated orthostatics test in the ambulance wouldn't hurt anyone. The only other thing that caught my attention during the quick google search was a forum post on handling syncope, not recommending taking time on scene to check for orthostatics, but recommending the lying to seated orthostatics check. Of course I speak with no authority and apologize for any misinformation.

Speaking from personal experience, I've only experienced orthostatics either after sleeping for a long time or when I was dehydrated.

[hammerpcp]

Well going on the information I found in the quick google search above mentioned, it is indicated in patients with 1. blood/fluid loss or 2. dehydration. Blood and fluid loss would be pretty obvious in most cases, and would warrant a quick transport above a standing orthostatics test (imho), however a quick unofficial seated orthostatics test in the ambulance wouldn't hurt anyone. The only other thing that caught my attention during the quick google search was a forum post on handling syncope, not recommending taking time on scene to check for orthostatics, but recommending the lying to seated orthostatics check. Of course I speak with no authority and apologize for any misinformation.

Speaking from personal experience, I've only experienced orthostatics either after sleeping for a long time or when I was dehydrated.

Ya. It is clear you don't really know what you’re talking about. Orthostatic hypotension is a sign that the pt is unable to maintain their blood pressure when vertical. This can be due to any number of factors such as heart failure, arrhythmia, and the body failing to constrict blood vessels for any umber of reasons. Anyway this information is easily obtainable on a search of the internet. .Here was the first hit and it’s a good one. As far as taking time on scene, you need to sit the pt up at some point to transfer them, so taking 20 seconds to check a BP is hardly a waste of time considering the amount of information you can obtain form this simple test.

[AZCEP]

Orthostatic vital signs: variation with age, specificity, and sensitivity in detecting a 450-mL blood loss.

Baraff LJ, Schriger DL.

Department of Pediatrics, University of California-Los Angeles School of Medicine.

The authors conducted this study to: (1) determine the effect of age on orthostatic vital signs; and (2) to define the sensitivity and specificity of alternative definitions of "abnormal" orthostatic vital signs in blood donors sustaining an acute 450-mL blood loss. The population studied were 100 healthy adult volunteer blood donors and 100 self-sufficient ambulatory citizens attending a senior citizens daytime activity center. Subjects with a history of orthostatic hypotension were excluded. Subjects were first placed in the recumbent position and their rate pulse and blood pressure were determined after 1 minute; these same parameters were measured in the same arm beginning 30 seconds after standing. In blood donors measurement of orthostatic vital signs was repeated immediately after blood donation. Blood donors served as their own controls in the determination of sensitivities and specificities. Mean orthostatic vital sign changes were as follows: pulse rate, 2 +/- 7 beats per minute; systolic blood pressure, -3 +/- 9 mm Hg; and diastolic blood pressure, 1 +/- 7 mm Hg. There was no clinically meaningful variance in orthostatic blood pressure changes with age. For a given specificity, pulse rate increase was the most sensitive of the orthostatic vital signs used alone; a pulse rise of greater than 20 beats per minute had a sensitivity of 9% with a specificity of 98%.

Normal Pathophysiology:

When a patient stands, gravity causes blood to pool in the large vessels of the legs and lower trunk (up to 500ml). Normally, baroreceptors in the aortic arch and carotids sense this change in blood pressure/volume and stimulate an endocrine, catecholamine, renin/aldosterone response. This response causes the peripheral blood vessels to constrict, the heart rate and contractility to increase, and the kidneys to hold fluids. This action pulls blood into the core circulation to supply the primary organs (heart, lungs, kidneys, liver and brain).

In patients who are volume depleted (hypovolemic), there is not enough circulating blood to be pushed into core circulation, especially when the patient moves from the supine to sitting or standing. That is why clinicians think a positive tilt is indicative of volume depletion, and institute replacement while awaiting other test results.

There is little agreement as to what indicates a significant orthostatic change and what is considered a positive tilt test. The "20-10-20" rule may be used as a guide for this. The rule refers to the expected decrease in systolic B/P (up to 20 mm Hg), a rise in diastolic B/P of 10 mm HG and an increase in heart rate by 20 beats per minute.

Measurement Techniques:

1. There is controversy as to length of wait between moving to a new position and taking VS. Most studies and experts agree that a one minute wait between movement is satisfactory.

2. For consistency the same arm with the same cuff and same location of pulse measurement should be used. This is easily accomplished by using electronic measuring devices.

Supine- The patient needs to lie supine, without pillows, for two to three minutes before measuring VS. * If supine position compromises patient’s breathing status or comfort level, assist them to a position as flat as possible. It is a good technique to obtain two sets of measurement while the patient is supine and use the second set as the baseline. This is done due to the normal sympathetic response (alerting reaction) which can cause false positives by initially raising the systolic B/P.

Sitting- Taking measurements with the patient in this position is controversial, some say the elevation is not significant enough to cause a change, other say that this in-between position causes false negatives by providing a chance for the body to adjust before changing to the standing position. * If the patient is not able to stand this is the next position after supine. Whenever measuring at this position the patient should be sitting upright, with their legs dangling at the side of the bed.

Standing- If the patient ambulated to the treatment area, and there are no signs of syncope, the sitting position can be avoided

Documentation:

Using symbols i.e., o-<--< =lying; o|_=sitting; =standing, or writing out the name of the position and the results at each position are necessary. You should also indicate whether the pulse was regular and if on a monitor, document rhythm. Also include any symptoms the patient reports as well as your clinical observations, but do not pose leading questions like, "are you dizzy?" Lastly, if fluid replacement is ordered, after infusion is completed, repeat orthostatic assessment should be performed to evaluate and document effectiveness.

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References:

Halpern, JS (1987). Clinical notebook: Assessment of orthostatic hypotension. Journal of Emergency Nursing, 13 (3), 170-171.

Roper, M (1996). Back to basics; Assessing orthostatic vital signs. American Journal of Nursing, 96 (8), 43-46.

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"Research Applied to Clinical Practice: Orthostatic Measurement"

[http://ENW.org/Research-Orthostatic.htm]

is a webarticle by Robert C. Knies, RN MSN CEN [bknies@stevenshealthcare.org]

©Robert C. Knies, RN MSN CEN

presented by Emergency Nursing World ! [http://ENW.org]

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That will have to tide you over for a while. There is a growing body of evidence that orthostatic vital signs are inaccurate in determining the volume of blood that has been lost. This is from all causes of hypovolemia, not just hemorrhage.

[Ridryder 911]

Remember to use common sense... If your patient is symptomatic and has extreme vertigo or dizziness when going from sitting or laying supine to upright this is indication that your patient is "tilt +".. with symptoms and the tilt should not be performed for potential injury to the patient falling.

Yes, like pulse points in determination of pressures, this gives approximations...

R/r 911