Circulation Part 3, baseline vitals

The last and final part of Circulation is to get a set of baseline vitals.

This is extremely important because tracking vital signs is how we determine if our efforts to stabilize them are actually working or not.

Keep in mind that at different life stages, and even for the two genders, vital sign ranges are different. A 68-year-old man will have a different resting heart rate than a 14-year-old girl. And this isn’t including activity levels. It isn’t uncommon to see a 40 bpm resting heart rate on someone who works out regularly (cough cough, Conan). Vital signs can key us to changes but they shouldn’t be the only thing we focus on. We’re treating the casualties, not just the vital signs. We need to get 3 sets of vitals to really start to see the bigger picture than just what one set of vitals can tell us.

The vital signs we are concerned with are the Heart Rate or pulse, blood pressure, respiratory rate, pulse oximetry, and level of consciousness.

Heart Rate is the number of times your heart beats in a minute. It can be measured in any of the places you normally take a pulse, generally, we take it at the radial artery though. You want to count for at least 30 seconds. Some medical professionals will get lazy and count for 15 seconds and multiply that by 4. If at all possible we want to count for a full minute for any vital signs we take. It will give us a more accurate picture of what that vital sign actually is and allow us to be very specific in our adjustments to our treatment plan.

Blood Pressure is a combination of two pressures put together both being measured in millimeters of mercury (mmHg). The first, your Systolic (upper number, is the max pressure from one heartbeat. The second, your diastolic (lower number), is the minimum pressure between two heartbeats. The best way to get blood pressure is with a bp cuff and a stethoscope. If you don’t have that you can just see if there is a pulse at different locations and that can be used to estimate (not the best way to judge treatment efficacy) what the blood pressure might be. Those locations are the carotid (neck), Radial (wrist), femoral (just to the outside of the groin before the inner thigh), and pedal (top of the foot).  The associated numbers are 60 for carotid, 70 for femoral, 80 for radial, and 90 for a pedal. Those are the assumed Systolic values for those pulses. This means it on average requires that much pressure to push blood out to that point. These values are recorded as X/P (said over palp, which is short for palpation) so if they have a radial pulse, they have an estimated blood pressure of 80/P. This is not very accurate and the actual number for a radial can range from 60 to 100 depending on the person. See why we need to actually get a true blood pressure reading?

Respiratory Rate is just that, how many times they breathe in a minute. If they are conscious do not tell them that you are about to get their respiratory rate or they will start paying attention to their breathing and will mess up your reading. This is where a pulse oximeter can really come in handy because most will give you their pulse as well, and you can then “check” their heart rate while actually paying attention to their breathing without them noticing.

Pulse oximetry is the level of gas in your red blood cells measured in a percentage. It is measured with a Pulse Oximeter It uses red lights, optical sensors, and science to determine this. Most will also give you the heart rate as well. If that is not accessible you can try measuring their capillary refill (known as cap refill). To do this you press down on one of their nail beds until it turns white, if it takes longer than three seconds for the nail bed to return to a pink color they have an issue with peripheral perfusion which in our context is most likely because their pulse oximetry is low. You would record this as either positive or negative capillary refill.

Level of consciousness (LOC) is measured on the AVPU scale. Alert, verbal, pain, unresponsive. Alert means they are aware of what is going on and can answer basic questions correctly. Verbal means they respond to verbal stimuli but not correctly, they may grunt or look at you or even talk gibberish. Pain means they respond to pain stimuli like a sternum rub. And unresponsive means they are unresponsive to any of the before-mentioned stimuli. LOC is a very important thing to pay attention to and changes can help inform us if there are other underlying issues that we either missed in our assessment or that we cannot see (internal injuries).

This set of vitals should be taken about every 15 minutes as long as you are treating this casualty. All of this can be recorded on the bottom of the first side of the DD1380 or casualty care card. There is a spot for 4 sets of these vitals (plus the pain level on a scale of 1-10). This is because the cards were designed when the golden hour was the standard for patient transport. So every 15 minutes, four times. That makes an hour. After that, we are going to want to switch to the prolonged field care casualty card which allows recording a lot more vitals for a longer period of time. But both of those forms deserve their own posts.

Trending requires 3 sets of vitals to determine if what we are doing is working. It doesn’t matter if it is in TCCC or if we are working a clinical rotation in the guerilla hospital. Make sure you start practicing with getting these vital signs too. Getting a manual blood pressure does take a little bit of experience to do so correctly. When’s the last time you took a manual blood pressure?