I was just reminded (yet again) of the usefulness of obtaining orthostatic vital signs. Recall that you obtain HR and BP with the patient supine, sitting and then standing. You must get them in that order, and they should be done after the patient has been supine for approximately 3-5 minutes with the head flat. The recommendations on how to proceed vary based on where you work (how long a patient should sit/stand), but the most important thing is to know that the BP will drop, and the HR will rise in a normal compensatory fashion. A patient with significant orthostatic hypotension will feel the effects of decreased BP almost immediately after going upright (if they are dry for instance). This will manifest in lightheadedness, wooziness etc,. – essentially near syncope. A patient is considered to have abnormal findings if:
- Systolic blood pressure drops by >20 mm Hg
- Diastolic blood pressure drops by >10 mm Hg
- HR increases >20 BPM
In general I get orthostatic VS when they will help me make a therapeutic or diagnostic decision. For example:
- An athlete who is overheated but lucid. If there are abnormal orthostatics I will give IV fluids. A change in the HR is more sensitive for volume loss in this kind of situation.
- Well appearing patient (not pale or tachycardic at baseline) with excess menstrual bleeding or bright red blood per rectum. If orthostatics are abnormal then I feel that a CBC is warranted
- Patient with syncope and reassuring cardiac, pulmonary and neuro exams with a normal EKG. This will further help my hypothesis that they had syncope from a vasovagal mechanism and also allow me to make better decisions and recommendations about fluid therapy and follow up.
- Teen with anorexia and abnormal orthostatics is concerning, and this would be supportive in addition to the EKG and electrolytes in considering inpatient admission
There is a lot more to discuss regarding orthostatic vital signs, but my main goal with this post was to get you to think about ordering and using them regularly.
