Orthostatic changes.

[PSYCtest040]

Got a gig on my chart documenting orthostatic check and want to run it by you all.

A few days ago had a 15 yo female feeling ill for a few days and presenting with fever, pale diaphoretic skin and general body aches. My field diagnosis was flu with possiable dehydration and I decided to check for orthostatic changes. Supine vitals were P 112 bpm, BP 118/60 and RR 26 slightly labored. We sat her up and and there was no change in pulse so I concluded there were no orthostatic changes.

the gig I received asked why I didn't document a repeat BP. What I know of orthostatic changes due to the fluid shift if there is an increase in the pulse rate there will be a drop in BP and since there was no change in pulse I concluded no orthostatic changes.

What are ya'alls thoughts?

[fdnyemt5330]

Got a gig on my chart documenting orthostatic check and want to run it by you all.

A few days ago had a 15 yo female feeling ill for a few days and presenting with fever, pale diaphoretic skin and general body aches. My field diagnosis was flu with possiable dehydration and I decided to check for orthostatic changes. Supine vitals were P 112 bpm, BP 118/60 and RR 26 slightly labored. We sat her up and and there was no change in pulse so I concluded there were no orthostatic changes.

the gig I received asked why I didn't document a repeat BP. What I know of orthostatic changes due to the fluid shift if there is an increase in the pulse rate there will be a drop in BP and since there was no change in pulse I concluded no orthostatic changes.

What are ya'alls thoughts?

I would have checked the BP anyhow to be on the safe side.

[wvditchdoc]

"Normally, when a person moves to an upright position, blood pressure and heart rate change so quickly that continuous electronic monitoring is required to detect the differences,9 and ordinary clinical observations lag behind the physiologic changes. The line between normal and pathologic changes in blood pressure and heart rate is not easy to define clinically. Although heart rate measurement is not included in the AAS/AAN definition of orthostatic hypotension, it can be determined easily and may be helpful, especially in patients who do not meet the blood pressure criteria of orthostatic hypotension. An elevation in heart rate that occurs when a patient moves from recumbency to standing may indicate compensation for decreased stroke volume. However, clinical decisions should be guided more by symptoms of decreased cerebral perfusion than by absolute blood pressure or heart rate measurements."

http://www.aafp.org/afp/20031215/2393.html

The article says HR is a "Helpful" tool but all S&S should be taken in account. Sounds like the gig was righteous. Sorry for the bad news.

[Cthippo]

Agreed. You were probably right, but to not take the second BP feels like you half-assed it.

[screaming pizza]

We're all hanging you out to dry! The zing what correct. As long as you weren't told to bend over...

[Philly Medic]

If you went through all that what is an extra minute to get a second BP.

[PSYCtest040]

The reason behind my post was not the gig I received but the etiology behind orthostatic hypotention. I read somewhere (for the life of me I can't remember where) that due to the fluid shifts between supine and sitting, a 10 BPM rise in pulse rate was a better indication of a positive tilt test than blood pressure alone. Since there was no changes in pulse rate between supine and sitting i assumed (that probably did me in right there) the tilt test was negative and saw no need for repeat blood pressure. Has anybody else heard of this or am I just loosing my mind?

[fdnyemt5330]

The reason behind my post was not the gig I received but the etiology behind orthostatic hypotention. I read somewhere (for the life of me I can't remember where) that due to the fluid shifts between supine and sitting, a 10 BPM rise in pulse rate was a better indication of a positive tilt test than blood pressure alone. Since there was no changes in pulse rate between supine and sitting i assumed (that probably did me in right there) the tilt test was negative and saw no need for repeat blood pressure. Has anybody else heard of this or am I just loosing my mind?

:yernuts:


Just kidding. I've got to go do my laundry. I'll dig the books out when I get home and look it up.

[GaHazMedic]

The reason behind my post was not the gig I received but the etiology behind orthostatic hypotention. I read somewhere (for the life of me I can't remember where) that due to the fluid shifts between supine and sitting, a 10 BPM rise in pulse rate was a better indication of a positive tilt test than blood pressure alone. Since there was no changes in pulse rate between supine and sitting i assumed (that probably did me in right there) the tilt test was negative and saw no need for repeat blood pressure. Has anybody else heard of this or am I just loosing my mind?

You are correct in the 10bpm. Blood pressure tends to recover rather quickly and is therefor a bad indicator of orthostatic hypotension. I still take a BP just so that the nurses have less to gripe about, but it really makes no difference if you have no change in heart rate.

[screaming pizza]

The reason behind my post was not the gig I received but the etiology behind orthostatic hypotention. I read somewhere (for the life of me I can't remember where) that due to the fluid shifts between supine and sitting, a 10 BPM rise in pulse rate was a better indication of a positive tilt test than blood pressure alone. Since there was no changes in pulse rate between supine and sitting i assumed (that probably did me in right there) the tilt test was negative and saw no need for repeat blood pressure. Has anybody else heard of this or am I just loosing my mind?

It sounds good, but what does med control have to say? It may be accurate, but before you start operating off of things like that make sure that its a kosher practice.