Vital Signs & SAMPLE History

           What is your diagnosis of this patient?   See EMT challenge questions for more information.

The assessment of vital signs and obtaining an accurate medical history are the foundation on which the EMT's treatment of a patient is based. Life-threatening problems must be taken care of first, but the vitals and history generally dictate the course of treatment for the remaining time the EMT is with the patient. 

If the patient's condition does not match the vital signs (patient looks poor but the vitals are normal) treat the patient, not the vitals! Always err on the side of caution. 

Symptoms are things the patient must tell the EMT. They are subjective in nature because they have to be related to the patient. For example, nausea, chills, or pain cannot be seen, felt, heard, or measured by the EMT. Signs are things the EMT can determine by observation. They are objective in nature since they are things that can be seen, heard, measured, or felt about a patient's injury or illness. 

Pulse

The pulse is the wave of blood through the vessels as the heart contracts. Pulses are mostly assessed in the radial artery in the wrist at the base of the thumb or in the carotid artery on either side of the front of the neck. Pulse may also be assessed in the femoral artery located in the leg near the groin.

Pulses should be evaluated for rate, character, and rhythm. Pulse rate is the number of beats per minute and varies among patients. The normal resting pulse rates are:

Pulse rates above the normal range is called tachycardia. A pulse rate below the normal range is called bradycardia.

Pulse character refers to the force of the wave as the blood is pumped through the system. A strong pulse is called a full pulse and an extremely strong pulse is bounding. Generally, the faster the heart beats, the weaker the pulse.

Pulse rhythm refers to the intervals between beats. If the beats are constant, the pulse is regular. If the beats are not constant, the pulse is irregular. Character and rhythm are as important as rate and should be recording in patient notes.

To assess the radial pulse, use 2-3 fingers and place them in the middle on the anterior side of the arm just above the wrist. NEVER use your thumb to detect pulse as it has its own pulse! Count the number of beats for 30 seconds and multiply that number by 2. If anything is abnormal with the pulse, always count for the full minute. 

The carotid artery can be used to assess pulse by placing the fingers on the cricoid in the patient's neck. Slide the fingers to the same side of the patient as the assessor is positioned until the groove between the cricoid and tendons is felt. The carotid pulse should be felt in this groove just lateral of the cricoid. Do not assess pulse bilaterally at the same time. Never assess pulse on the opposite side of the neck from where you are as this may compromise the airway and breathing by compression on the neck from your hand.

The femoral artery can be located by placing the fingers just lateral to the pubis where the leg and hip are attached. More pressure may have to be applied to assess pulse from this artery than the others as the artery is deeper below the skin surface. This location is not often used also because of clothing which makes assessment more difficult. 

Respirations

A single respiration includes one cycle of inhalation (inspiration) and exhalation (expiration). 

The respiratory rate is the number of respirations in 1 minute. The normal respiratory rates are:

adults: 12 - 24 rpm
children: variable
infants: 30 - 50 rpm

The respiratory character includes the depth and ease of breathing. Respiratory depth refers to the amount of air that is exchanged with each breath. The ease of breathing depends on whether or not a patient exhibits labored, difficult, or painful breathing. Respiratory rhythm will be regular or irregular. Constant intervals between breaths is regular. Anything else is irregular. See lesson on airway management for more detailed information.

Blood Pressure

    Blood pressure is the pressure that the blood exerts on the walls of the arteries as blood is forced through the circulatory system by heart contractions. It is measure in mm Hg (Mercury). The pressure that is created by the contraction of the left ventricle forcing blood into the body system is called the systolic pressure. The systolic pressure is heard first. The diastolic pressure is heard second and occurs when the left ventricle is relaxed and refilling with blood. Blood pressure is usually measure in even numbers with the systolic stated first and diastolic second. The difference between the systolic and diastolic pressure is the pulse pressure. Pulse pressure is usually 30-40 mm Hg.

The two instruments used to measure blood pressure are the stethoscope which consists of a bell on one end of rubber or vinyl tubing and ear pieces on the other end. The bell is used to pick up sounds within the body which are transferred to the ear pieces via the tubing. The sphygmomanometer (blood pressure cuff) consists of a vinyl or rubber bladder surrounded by a material sleeve. A gauge and pump are attached to the bladder with hoses.

Blood pressure may be assessed by palpation by placing the blood pressure cuff around the patient's upper arm. The radial pulse is palpated. The release valve on the bulb pump is closed and the pump is squeezed repeatedly, filling the bladder with air until approximately 200 mm Hg is realized. As the bladder tightens around the arm, the radial pulse will disappear. If the pulse can be felt, more air needs to be pumped into the cuff until the radial pulse cannot be felt. The valve on the bulb pump is turned to slowly release the pressure in the bladder until the radial pulse can be felt. This pressure reading should be recorded as the systolic pressure. The rest of the pressure can then be released. Diastolic pressure is not recorded. Blood pressure is recorded as systolic/P.

    The most accurate method for assessing blood pressure is auscultation. The brachial artery is found on the inside of the elbow. With the ear pieces in the ears, the bell of the stethoscope is placed over the brachial artery. Air is added to the bladder of the cuff in the same manner as described above until the beat cannot be heard. The valve is slowly opened until the heart beat can be heard again. This pressure is recorded as the systolic pressure. The pressure is continued to be released slowly until the heart beat cannot be heard or it changes from loud to soft. This pressure is recorded as diastolic pressure.

Make sure that the proper size blood pressure cuff is used. The cuff should completely circle the patient's arm with the bladder covering about half of the arm. Automatic blood pressure monitors are available but may not work well in a moving vehicle.

Skin Color and Temperature

Pale skin may indicate shock, heart attack, or emotional distress. Cyanosis may indicate poor oxygen levels in the blood. Redness may be caused by high blood pressure, fever, or some types of poisoning. Skin temperature is assessed by placing the back of your hand against the patient's skin. Normal skin is warm and dry. Very hot skin may indicate fever. Cold skin may result from shock, heat exhaustion, or exposure to cold. Tympanic thermometers are frequently used which rapidly assess body temperature by placing sensors in the patient's ear.

Level of Consciousness

The patient's level of consciousness is assessed to determine if the patient is awake, alert, or confused. The AVPU system is used to determine the patient's state of consciousness. 

A-Alert and awake; aware of person, place, time, condition, etc.

V-Responds to verbal stimuli

P-Responds to painful stimuli; does not respond to verbal stimuli

U-Unconscious; does not respond to verbal or painful stimuli

Pupil Reaction

When too much light enters the eye, the pupil constricts to limit the amount of light that can enter. When lighting is poor, the pupils dilate to allow more light into the eyes. Both pupils normally constrict and dilate together and the same amount. Pupils that react differently may indicate injury.

SAMPLE History

It is important for the EMT to get an accurate medical history if possible. Use the acronym SAMPLE to obtain thorough information. 

S - Signs and Symptoms. May include the vital signs.

A - Allergies. Is the patient allergic to anything? medication? food? insectstings? bites? other substances?

M - Medication. What is patient taking? For what condition? Are they prescription? OTC? Illegal?

P - Pertinent medical history. Has the patient experienced any problems? How long? Obtain names of PCP, etc.

L - Last meal. When was last meal eaten? What was eaten? Anyone else that ate same meal get sick?

E - Events. What lead to calling EMS? Look for medical alert bracelets or necklaces.

Review Questions:

1. The patient must relay signs to the EMT because they cannot be observed. (True or False)

2. Which of the following locations is NOT used to take the pulse of an adult?

    a. femoral artery        c. carotid artery

    b. brachial artery        d. radial artery

3. When taking blood pressure, the higher reading is the __________.

4. Normally, the patient's pupils will react how when exposed to bright light?

5. List all the vital signs.

6. What do the letters SAMPLE mean?

7. Why should vital signs be taken more than once?

8. Write a SAMPLE history on yourself.

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