As part of your ongoing assessment of the patient, and in preparation for the arrival of any assistance you have called, it is important to keep a check on a patient's vital signs to establish a baseline.
If possible, these recordings should be written down so that you can keep a record of any changes, and hand this over to the ambulance crew who take the patient from you. Ideally, it should be recorded on a report, which should form part of every first aid kit. Alternatively, you can write it on any piece of paper, or often first aiders end up writing on their protective glove.
The vital signs you are looking to record relate to the body's essential functions. It starts with the airway and breathing already covered in basic life support (although you should look for additional detail) and continues with circulation, look of the skin, level of consciousness and pupil reaction.
While maintaining an open airway, ensure that the victim is breathing and count the rate of breathing. The easiest way to do this is to count the number of breaths taken in a given time period (15 or 30 seconds are common time frames), and then multiply up to make a minute. The longer the time period, the more accurate it is, however you are likely to want the patient not to converse (as this disrupts their breathing pattern), and it is important not to tell them that you are watching their breathing, as this is likely to make them alter the pattern, so a shorter period is likely to be more useful and reduce worry for the patient.
In addition to rate, you should note if the breathing is heavy or shallow, and importantly if it is regular. If it is irregular, see if there is a pattern to it (such as breathing slowly, getting faster, then suddenly slower again). Note whether breathing is noisy (wheezing could be a sign of asthma, rattling (also called 'stridor') a sign of fluid in the throat or lungs).
Whereas in the primary survey, we did not check the circulation of the victim to see if the heart was beating (we assumed that if the victim was breathing, their heart was working and if they were not breathing, their heart was also stopped), it is important in monitoring the breathing victim to check their circulation.
The two main checks are:
- Capillary Refill - The capillaries are the smallest type of blood vessel, and are responsible for getting blood in to all the body tissues. If the blood pressure is not high enough, then not enough blood will be getting to the capillaries. It is especially important to check capillary refill if the victim has suffered an injury to one of their limbs. You check capillary refill by taking the victim's hand, lifting it above the level of the heart, and squeezing reasonably hard for about a second on the nailbed. This should move the blood out, and the nail bed will appear white. If the pink colour returns quickly (and in a healthy victim, it may return before you even move your fingers away to look!), then this is normal. Victims who have poor peripheral circulation, especially the elderly and hypothermia victims, may not demonstrate adequate capillary refill due to general lack of blood flow, making this test less valuable on these patients. A normal time for the pink colour to return is less than two seconds. If it takes longer than two seconds for colour to return, then this could indicate a problem and you should seek medical advice.
- Pulse check - As a first aider, you can also check a victim's heart rate by feeling for their pulse. There are three main places you might wish to check for a pulse:
- Radial pulse - This is the best pulse to look for a first aider, on a conscious victim, as it is non-invasive and relatively easy to find. It is located on the wrist (over the radial bone). To find it, place the victim's hand palm up and take the first two fingers of your hand (NEVER use your thumb, as it contains a pulse of its own) and on the thumb side of the victim's wrist you will feel a rounded piece of bone, move in from here 1-2cm in to a shallow dip at the side of the bone, and press your fingers in (gently), where you should be able to feel a pulse. Taking a pulse here can be a skill that takes practice, so it is worth frequently testing this skill. Should there be no pulse in a victim who is pale and unwell, you are advised to seek medical assistance urgently.
- Carotid Pulse - This is in the main artery which supplies the head and brain, and is located in the neck. This is best used on unconscious victims, or those victims where you are unable to find a radial pulse (because the carotid pulse, being closer to the heart, is stronger than the radial pulse). To locate it, place your two fingers in to the indentation to the side of the windpipe, in line with the Adam's apple (on men), or approximately the location a Adam's Apple would be on women.
- Pedal Pulse - The pedal pulse can be found in several locations on the foot, and this is used when you suspect a broken leg, in order to ascertain if there is blood flowing to the foot.
When measuring a pulse you should measure the pulse rate. This is best achieved by counting the number of beats in 15 seconds, and then multiplying the result by four. You should also check if the pulse is regular or irregular.
Related to circulation, is the colour of the skin. Changes in circulation will cause the skin to be different colours, and you should note if the victim is flushed, pale, ashen, or blue tinged.
It should also be noted if the victim's skin is clammy, sweaty or very dry, and this information should be passed on to the ambulance crew.
Level of Consciousness
You can continue to use the acronym AVPU to assess if the victim's level of consciousness changes while you are with them. To recap, the levels are:
- Voice induces response
- Pain induces response
- Unresponsive to stimuli
Valuable information can be gained from looking at a victim's pupils. For this purpose, first aid kits should have a penlight or small torch in them.
Ideally, the pupils of the eye should be equal and reactive to light (mydriasis), usually written down as PEARL:
- Reactive to
To check this, ask the victim to look straight at you with both eyes. Look to see if both pupils are the same size and shape (be sensitive to those who may be blind in one eye, or may even have a glass eye, although they will usually tell you).
To check if they are reactive, take the penlight, and ask the victim to look at your nose. Briefly (5 seconds or so) shield their eye with your hand from the light source where they are (sunlight, room lighting etc.), and then turn on the penlight, positioning it off to the side of their head. Move the penlight in over their eye quickly, and watch to see the size change. A normal reaction would be the pupil getting smaller quickly as the light is shone in to it. Repeat on the other eye.
If both pupils are the same, and both react, note this on your form as PEARL, or else note down what you did, or did not see.