Unmonitored Vital Signs "Disasters Waiting to Happen"

Many medical conditions aren't possible to diagnose without appropriate cardiorespiratory monitoring, vital sign reassessments, and diagnostic testing, and these are "disasters waiting to happen," warns Andrew Garlisi, MD, MPH, MBA, VAQSF, medical director for Geauga County Emergency Medical Services (EMS) and co-director of University Hospitals Geauga Medical Center's chest pain center in Chardon, OH.

Once in the ED, patients may be inadvertently ignored, unmonitored, or improperly monitored, adds Garlisi. Patients with cardiorespiratory symptoms, trauma, change in mental status, hemodynamic instability, bleeding, acute severe abdominal pain, metabolic derangement, medication or toxic overdose, sepsis, or anyone who simply looks very ill should be placed on a cardiac monitor with oximetry and continuous waveform capnography measurements, he advises.

"Waveform capnography, now a standard of care for EMS, seems not to have 'caught on' in mainstream ERs," says Garlisi. Capnography provides valuable insight into metabolism, perfusion, effectiveness of ventilation, adequacy of endotracheal tube placement, and effectiveness of cardiopulmonary resuscitation and return to spontaneous circulation in the cardiac arrest patient, he notes. Garlisi gives these examples of high-risk ED patients:

The geriatric patient with acute coronary syndrome.

Experienced emergency physicians (EPs) are acutely aware of the difficulty in evaluating geriatric patients, who often present with atypical or minimal symptoms of serious illness, says Garlisi.

"Over the decades, I have personally encountered many geriatric patients with acute STEMI [ST-elevation myocardial infarction] who only complain of weakness, not feeling right, nausea, upset stomach, and even ear pain," he says.

The geriatric patient with vague abdominal complaints.

Pain perception may be significantly altered in the geriatric patient for a variety of reasons, says Garlisi, including acute appendicitis, leaking abdominal aortic aneurysm, ischemic or perforated bowel, mesenteric thrombosis, pancreatitis, inferior wall myocardial infarction, and cholangitis.

"This can lead to catastrophic gastrointestinal emergencies being initially missed by the triage nurse or EP," he says.

The female with acute pelvic pain and normal vital signs initially.

"For the woman with ectopic pregnancy, delay in diagnosis and intervention is lethal. Unfortunately, the literature is replete with case examples," says Garlisi.

Ectopic pregnancy should be on top of the list for female patients of childbearing age with acute abdominal-pelvic pain, syncope, orthostasis, pain referred to the shoulder area, or vaginal bleeding, says Garlisi.

If there is any such suspicion, Garlisi says that aggressive treatment with intravenous (IV) crystalloid, type and cross match blood, early consultation with an obstetrician, a qualitative pregnancy test and, if positive, a quantitative HCG, and transvaginal pelvic ultrasound are key initial steps.

If the patient is hemodynamically unstable, the physician should order a bedside portable ultrasound procedure, adds Garlisi. "Torsion of the ovary causes acute pelvic pain. Pelvic ultrasound with Doppler flow studies is an essential test to rule out or rule in the diagnosis," he says.

The diabetic patient.

Type I diabetes is often associated with neuropathy and altered pain perception, says Garlisi, and patients often have subtle and atypical presentations for STEMI, epidural abscess, and serious abdominal conditions. "Diabetics have altered immunity and are prone to septic complications, he adds.

The ill infant.

Infants with bronchiolitis, meningitis, intussusceptions, urinary tract infection, and frank sepsis may not present initially with classic textbook symptoms and signs, says Garlisi.

Patients with cancer.

These patients can present with unusual complications, including pericardial effusions, metastases to the spine, pulmonary emboli, sepsis, post-radiation complications due to scarring, and fibrotic organ damage, says Garlisi.

Immunocompromised patients, including those taking immune modulators used in treatment of rheumatoid arthritis, ankylosing spondylitis, lupus, and post-transplant patients.

"These patients are prone to septic complications," says Garlisi. "Sometimes these medications are overlooked as a risk factor for sepsis, and early sepsis signs and symptoms are missed in the ED."

Hemodialysis patients.

These patients are at risk for a variety of serious medical problems, including hyperkalemia, congestive heart failure, pericardial effusion, line infections, sepsis, and respiratory complications, says Garlisi, and may present with subtle signs and symptoms.

The patient with neurological symptoms.

A patient complaining of dizziness may have a benign etiology, but subtle signs and associated symptoms of posterior cerebral circulation disorders may be missed, says Garlisi.

Subtle transient ischemic attacks, subarachnoid hemorrhage, and other intracranial bleed syndromes may present subtly, and may be missed without comprehensive evaluation, he adds.

"The ED neurological exam, in my experience, is often the most persistently missed or 'glossed over' portion of the physical examination," says Garlisi.


For more information, contact:

• Andrew Garlisi, MD, MPH, MBA, VAQSF, University Hospitals Geauga Medical Center, Chardon, OH. Phone: (330) 656-9304. Fax: (330) 656-5901. E-mail: garlisi@adelphia.net.