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3: Initial Evaluation of the Patient: Vital Signs and Toxic Syndromes

Robert S. Hoffman; Mary Ann Howland; Neal A. Lewin; Lewis S. Nelson; Lewis R. Goldfrank

INTRODUCTION

For more than 200 years, American health care providers have attempted to standardize their approach to the assessment of patients. At the New York Hospital in 1865, pulse rate, respiratory rate, and temperature were incorporated into the bedside chart and called “vital signs.”6 It was not until the early part of the 20th century, however, that blood pressure determination also became routine. Additional components of the standard emergency assessment, such as oxygen saturation by pulse oximetry, capillary blood glucose, and pain severity, are now also beginning to be considered vital signs. Although assessment of oxygen saturation, capillary glucose, and pain severity are essential components of the clinical evaluation and are important considerations throughout this text, they are not discussed in this chapter.

In the practice of medical toxicology, vital signs play an important role beyond assessing and monitoring the overall status of a patient because they frequently provide valuable physiologic clues to the toxicologic etiology and severity of an illness. The vital signs also are a valuable parameter, which are used to assess and monitor a patient’s response to supportive treatment and antidotal therapy.

Table 3–1 presents the normal vital signs for various age groups. However, this broad range of values considered normal should serve merely as a guide. Only a complete assessment of a patient can determine whether or not a particular vital sign is truly clinically normal. This table of normal vital signs is useful in assessing children because normal values for children vary considerably with age, and knowing the range of normal variation is essential. Normal rectal temperature is defined as 95° to 100.4°F (35°–38°C).

TABLE 3–1.Normal Vital Signs by Agea,b
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TABLE 3–1. Normal Vital Signs by Agea,b
Age Systolic BP (mm Hg) Diastolic BP (mm Hg) Pulse (beats/min) Respirations (breaths/min)b
Adult ≤120 <80 60−100 16−24
16 years ≤120 <80 80 16−30
12 years 119 76 85 16−30
10 years 115 74 90 16−30
6 years 107 69 100 20−30
4 years 104 65 110 20−30
4 months 90 50 145 30−35
2 months 85 50 145 30−35
Newborn 65 50 145 35−40

aThe normal rectal temperature is defined as 95°F to 100.4°F (35°−38°C) for all ages. For children one year of age or younger, these values are the mean values for the 50th percentile. For older children, these values represent the 90th percentile at a specific age for the 50th percentile of weight in that age group. b These values were determined in the emergency department and may be ­environment and situation ­dependent.

BP = blood pressure.

The difficulty in defining what constitutes “normal” vital signs in an emergency setting is inadequately addressed and may prove to be an impossible undertaking. Published normal values may have little relevance for an acutely ill or anxious patient in the emergency setting, yet ...

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