• The first set of vital signs measured on a patient.

Vital Signs and Measurements

• Breathing: observing chest rise and fall. Count the number of breaths in 30 sec. Multiply by 2 for breaths per min.
• Pulse: palpate the artery with the index and middle finger tips. Count the number of beats in 30 sec. Multiply by 2 for beats per min.
• Skin: observing color, feel for temperature and condition using the back of your hand without glove covering, and measure capillary refill by depressing on the patient's nail bed and observe for return of color.
• Pupils: observe size and reaction to penlight.
• Blood Pressure: Taken using a sphygmomanometer and a stethoscope.
• Pulse Oximetry: Measured using a pulse oximeter.

Normal Vital Signs

• Breathing
  • 12-20 per min for adults. 20-30 for small children. >30 for infants and newborns.
  • Adequate chest expansion (1 in.).
  • Clear and effortless.
• Pulse
  • 60-80 per min for adults. Faster for children and the elderly.
  • Strong and regular.
• Skin
  • Pink (palm and sole), Warm and dry.
  • Fast Capillary refill (under 2 sec male adults and children, 3 for females, and 4 in the elderly).
• Pupils
  • Normal and equal in size.
  • Respond to light.
• Blood Pressure: 120 / 80 (systolic / diastolic) in adults. Higher in the elderly and lower in children.
• Pulse Oximetry: 97-100%

Detailed Vital Signs and Symptoms

Breathing

Detailed Normal Rates of Breathing
Rate per min	12-20	15-30	20-30	25-40	30-60
Age group	11+ years	6 - 10 years	6 months - 5 years	30 days - 5 months	0 - 30 days

• Shallow breathing: inadequate chest or abdominal wall (children) expansion.
• Labored breathing: use of accessory muscles.
• Noisy breathing Snoring: tongue obstruction of the upper airway at the pharynx. Wheezing: constriction of the bronchioles. Gurgling: fluid in the upper airway. Crowing or Stridor (harsh high pitched sound): obstruction of the upper airway at the larynx.

Pulse

Patient	Slow (bradycardia) if below	Normal (at rest)	Rapid (tachycardia) if above
Adult	60	60-80	100
Elderly		90
Adolescent	50	60-105	105
Child (5-12 years)	60	60-120	120
Child (1-5 years)	80	80-150	150
Infant	120	120-150	150




Pulse characteristic	Possible problems / diagnosis
Normal rate, regular rate, and strong (full) pulse	Normal person at rest
Rapid, regular and strong	Exertion, fright, fever, high blood pressure, initial response to injury and bleeding
Rapid, regular and weak (also called regular and thready)	Indication of shock
Slow	Head injury, drug use (barbiturate or narcotic), poisons, possible cardiac problem
No pulse	Cardiac arrest
Pulsus paradoxus (decrease in pulse strength during inhalation)	Severe cardiac or respiratory injury, illness or blood loss

• Pulses can be located in the major arteries- Carotid (neck), Femoral (groin), Radial (wrist), Brachial (arm), Popliteal (behind knee), Posterior Tibial (ankle), Dorsalis Pedis (foot).

Skin

• Temperature
  • Hot: fever, exposure to heat, localized infection.
  • Warm: normal.
  • Cool: inadequate circulation, shock, or exposure to cold.
  • Cold: extreme exposure to cold.
• Condition
  • Abnormally Dry: severe dehydration or spinal injury.
  • Dry: normal.
  • Wet or Moist: shock, or heat, cardiac, or diabetic emergencies.
  • Clammy (cool and wet / diaphoretic): indication of shock.
• Color
  • Pale or mottled: onset of shock.
  • Cyanotic: late sign of shock.
  • Red: anaphylactic or vasogenic shock, poisoning, overdose or other medical condition.
  • Yellow: jaundice, liver problems.
• Capillary Refill: more reliable for children under 6.
  • Slow cap refill = possible hypoperfusion.

Pupils

• Dilated: cardiac arrest, use of stimulant drugs like cocaine, amphetamine, LSD.
• Constricted: central nervous system disorder, use of narcotics.
• Unequal: Stroke, head injury, artificial eye, eye drops.
• Nonreactive: Cardiac arrest, brain injury, drug influence.

Blood Pressure

Normal blood pressures
Patient	Systolic (mmHg)	Diastolic (mmHg)
Adult Male	100 + age up to 40	60-85
Adult female	90 + age up to 40	60-85
Adolescent	90 and above	2/3 systolic
Child (1-10 yrs)	80 + (2 x age) +/- 10	2/3 systolic
Infant (1-12 mo)	70 and above	2/3 systolic

• Hypertension: high blood pressure in an adult is considered over 140 / 85.
• Pulse pressure: the difference between systolic and diastolic pressure. Normally falls between 25 % and 50 % of systolic pressure.
• Narrow (low) pulse pressure: shock, cardiac tamponade (blood filling the pericardial sac, compressing the heart), tension pneumothorax (injury to one lung, causing pressure on the heart and the other lung).
• Wide (high) pulse pressure: head injury.
• Measuring blood pressure: Using a sphygmomanometer (wrapped around the arm), applying pressure (by pumping) over the brachial artery until a radial pulse can no longer be detected. Over pump 30 mmHg, then slowly release the pressure. Detect for a return of pulse by either auscultation or palpation.
• Auscultation: listening with a stethoscope for the return of the brachial pulse. The first sound marks the systolic pressure and the last sound (either a disappearance or a notable drop in volume) marks the diastolic pressure.
• Palpation: palpating for the radial pulse. When the radial pulse returns, this is the systolic pressure. The palpation technique cannot measure diastolic pressure (a "P" is noted in place of the diastolic pressure). The systolic pressure measured is approximately 7 mmHg lower than those obtained by auscultation.
• Do not over pump more than what is needed- it can be very painful for the patient.
• Orthostatic Vital Signs Test (Tilt Test): Measures heart rate and blood pressure for a patient while supine and while standing up. A positive result occurs when the heart rate increases 10-20 bpm and the blood pressure decreases 10-20 mmHg up standing up. This indicates significant blood loss.

Pulse Oximetry

• Measured over the tip of the index finger, can detect hypoxia, which can be treated by applying oxygen via a nonrebreather mask.
• Limitations: Directly measures hemoglobin saturation, not oxygen level. Therefore, false readings can occur during carbon monoxide poisoning. Errors in reading can also occur from nail polish and excessive finger movement.

Vital Sign Reassessment

• Stable patients: every 15 min
• Unstable patients: every 5 min

The SAMPLE History

Medical history obtained from the patient, family and bystanders

• Signs and Symptoms
  • Signs: what you can observe and measure about the patient, such as the vital signs.
  • Symptoms: what the patient describes to you- pain, numbness...etc. You cannot observe these, so you must ask OPQRST
    • Onset: "what were you doing when it started?"
    • Provocation or Palliation: "does anything make it worse? Anything makes it better?"
    • Quality of pain: "can you describe it to me? Is it sharp, dull, constant, intermittent?"
    • Region and Radiation: "where exactly does it hurt? Does the pain extend anywhere else?" (Myocardial infarction produces pain that radiates to the arms and jaw)
    • Severity: "on a scale of 1 to 10, how much does it hurt?"
    • Time: "how long has this been going on? How has this progressed over time?"
• Allergies: "Do you have any allergies?" This includes medication, food, or other environmental factors. Check for medical alert tags.
• Medications: "Are you on any medications? Have you taken medications recently?" This includes prescriptions, over-the-counter, birth control pills, illicit drugs (be tactful, indicate that you are not an EMT, not a police officer, and you need the information for treatment purposes), or herbal medicine. Look for medical tags.
• Pertinent past history: "Have you ever had any illnesses? Operations? Have you ever been admitted to a hospital?" Find out medical problems and past surgical procedures.
• Last oral intake: "When did you last eat or drink something? What was it?" A diabetic patient who hasn't consumed anything for 8 hours may be hypoglycemic.
• Events leading up to the injury or illness: "What happened? How did this happen?" The events leading up to the injury provide clues for the underlying cause.
  
  What's a normal resting heart rate?
  
  A normal resting heart rate for adults ranges from 60 to 100 beats a minute.
  
  Generally, a lower heart rate at rest implies more efficient heart function and better cardiovascular fitness. For example, a well-trained athlete might have a normal resting heart rate closer to 40 beats a minute.
  
  To measure your heart rate, simply check your pulse. Place your index and third fingers on your neck to the side of your windpipe. To check your pulse at your wrist, place two fingers between the bone and the tendon over your radial artery — which is located on the thumb side of your wrist.
  
  When you feel your pulse, count the number of beats in 15 seconds. Multiply this number by 4 to calculate your beats per minute.
  
  Keep in mind that many factors can influence heart rate, including:
  
  •Activity level
  •Fitness level
  •Air temperature
  •Body position (standing up or lying down, for example) •Emotions
  •Body size
  •Medications
  
  Although there's a wide range of normal, an unusually high or low heart rate may indicate an underlying problem. Consult your doctor if your resting heart rate is consistently above 100 beats a minute (tachycardia) or below 60 beats a minute (bradycardia) — especially if you have other signs or symptoms, such as fainting, dizziness or shortness of breath.
  
  Your heart rate changes from minute to minute. It depends on whether you are standing up or lying down, moving around or sitting still, stressed or relaxed. Your resting heart rate, though, tends to be stable from day to day. The usual range for resting heart rate is anywhere between 60 and 90 beats per minute. Above 90 is considered high.
  
  Many factors influence resting heart rate. Genes play a role. Aging tends to speed it up. Regular exercise tends to slow it down. (In his prime, champion cyclist Lance Armstrong had a resting heart rate of just 32 beats per minute.) Stress, medications, and medical conditions also influence the heart rate.