Orthostatic vital signs in emergency department patients

doi:10.1016/S0196-0644(05)82376-5

Annals of Emergency Medicine

Volume 20, Issue 6, June 1991, Pages 606-610

https://doi.org/10.1016/S0196-0644(05)82376-5 Get rights and content

Study objective:

To examine the variability and define the normal ranges of orthostatic vital signs in an emergency department population.

Design:

Descriptive.

Setting:

The ED of an urban teaching hospital in Denver, Colorado.

Type of participants:

Adult ED patients with no history of recent blood or fluid losses.

Measurements:

Lying and standing heart rate and blood pressure measured by an automated instrument.

Results:

In 132 presumed euvolemic patients, the statistical normal ranges (mean ± 2 SD), of orthostatic vital signs were wide: on standing, the heart rate range was from ↓ 5.0 to ↑ 39.4 beats per minute; for systolic blood pressure, the range was ↓ 20 to ↑ 25.7 mm Hg; and for diastolic blood pressure, the range was ↓ 6.4 to ↑ 24.9 mm Hg. In this sample, 43% had “positive” orthostatic vital signs according to currently accepted values.

Conclusion:

The data from this study indicate that there is a wider than expected variation in orthostatic vital signs among presumed euvolemic ED patients.

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WHEN AND HOW TO USE ORTHOSTATIC VITAL SIGNS
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Much controversy surrounds the use of orthostatic vital signs (OVS), including their indications, performance, and interpretation. This can lead to conflict between nurses, physicians, and consultants. This article summarizes the evidence for OVS in selected emergency department (ED) indications and the basis for a rapid measurement protocol.
This narrative review is intended to clarify indications for OVS measurement, their performance, and interpretation.
Phlebotomy studies indicate that OVS are more discriminating than supine vital signs in hypovolemia, but many findings, even some considered “positive,” do not provide compelling evidence in favor of or against disease. Evaluated as a diagnostic test, they have a low yield and controversial criteria for a positive test, but as vital signs, they are useful for selected patients with frequent ED presentations—blood loss, dehydration, dizziness, weakness, and falls. Available evidence supports a rapid measurement protocol, including a 1-min interval after standing.
OVS are useful in selected patients, in a variety of frequent presentations, but their indications and implications for a patient's care are subject to physician interpretation. Given their ease of measurement and effect on decision-making, physicians may consider measuring them early in the evaluation of selected patients.
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Citation Excerpt :
It is estimated that greater than 40% of euvolemic adolescents have positive orthostatic vital signs.6 In a study of euvolemic adult ED patients it was estimated that 43% met criteria for positive orthostatic vital signs.7 The presence or absence of positive orthostatic vital signs should not be the sole driver of diagnostic and disposition decisions.
Hydration in advanced cancer: Can bioelectrical impedance analysis improve the evidence base? A systematic review of the literature
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Decisions surrounding the administration of clinically assisted hydration to patients dying of cancer can be challenging because of the limited understanding of hydration in advanced cancer and a lack of evidence to guide health care professionals. Bioelectrical impedance analysis (BIA) has been used to assess hydration in various patient groupings, but evidence for its use in advanced cancer is limited.
To critically appraise existing methods of hydration status assessment in advanced cancer and review the potential for BIA to assess hydration in advanced cancer.
Searches were carried out in four electronic databases. A hand search of selected peer-reviewed journals and conference abstracts also was conducted. Studies reporting (de)hydration assessment (physical examination, biochemical measures, symptom assessment, and BIA) in patients with advanced cancer were included.
The results highlight how clinical examination and biochemical tests are standard methods of assessing hydration, but limitations exist with these methods in advanced cancer. Furthermore, there is disagreement over the evidence for some commonly associated symptoms with dehydration in cancer. Although there are limitations with using BIA alone to assess hydration in advanced cancer, analysis of BIA raw measurements through the method of bioelectrical impedance vector analysis may have a role in this population.
The benefits and burdens of providing clinically assisted hydration to patients dying of cancer are unclear. Bioelectrical impedance vector analysis shows promise as a hydration assessment tool but requires further study in advanced cancer. Innovative methodologies for research are required to add to the evidence base and ultimately improve the care for the dying.
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Citation Excerpt :
Unfortunately, the results do not withstand scientific validation. In a prospective study of 132 euvolemic patients, using the standard definition of a significant change, 43% would have been considered “positive.”29 In another study of 502 hospitalized geriatric patients with orthostatic vital signs obtained three times daily, 68% had significant changes documented daily.30
Cardio-Renal syndrome may occur as a result of either primarily renal or cardiac dysfunction. This complex interaction requires a tailored approach to manage the underlying pathophysiology while optimizing the patient's symptoms and thus providing the best outcomes. Patients often are admitted to the hospital for signs and symptoms of congestion and fluid overload is the most frequent cause of subsequent re-admission. Fluid management is of paramount importance in the strategy of treatment for heart failure patients. Adequate fluid status should be obtained but a target value should be set according to objective indicators and biomarkers. Once the fluid excess is identified, a careful prescription of fluid removal by diuretics or extracorporeal therapies must be made. While delivering these therapies, adequate monitoring should be performed to prevent unwanted effects such as worsening of renal function or other complications. There is a very narrow window of optimal hydration for heart failure patients. Overhydration can result in myocardial stretching and potential decompensation. Inappropriate dehydration or relative reduction of circulating blood volume may result in distant organ damage caused by inadequate perfusion. We suggest consideration of the “5B” approach. This stands for balance of fluids (reflected by body weight), blood pressure, biomarkers, bioimpedance vector analysis, and blood volume. Addressing these parameters ensures that the most important issues affecting symptoms and outcomes are addressed. Furthermore, the patient is receiving the best possible care while avoiding unwanted side effects of the treatment.

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: Presented at the Emergency Nurses Association Scientific Assembly in Washington, DC, September 1989.

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Original contributionOrthostatic vital signs in emergency department patients

Study objective:

Design:

Setting:

Type of participants:

Measurements:

Results:

Conclusion:

Ann Emerg Med

Ann Emerg Med

J Emerg Med

Am Heart J

Ann Emerg Med

Ann Emerg Med

The early assessment of hypovolemia: Postural vital signs

JEN

The clinical use of orthostatic vital signs

Assessment and Intervention in Emergency Nursing

Syncope and dizziness

Approach to syncope

J Gen Int Med

Dizziness

Renal diseases, fluid and electrolyte disorders, and hypertension

Metabolism and endocrinology

Disorders of potassium metabolism

Metabolic and endocrinologic problems

Upright body tilt for evaluation of patients with recurrent, unexplained syncope

PACE

Survey of Studies Involving the Dinamap Vital Signs Monitor

A comparison of time intervals after posture change when measuring pulse and blood pressure in healthy elderly and nonelderly subjects

Original contribution
Orthostatic vital signs in emergency department patients