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EMSWORLD.com | JULY 2016 49 both numbers. In this case 50 for a diastolic pressure is below nor- mal. Diastolic hypotension indicates the patient has low systemic vascular resistance, a condition known to occur in sepsis. If your patient also complains of shortness of breath, you are probably dealing with pneumonia and sepsis. In a case like this, the vital signs plus chief complaint can give you the entire diagnosis. General impression/ventilatory effort » Evaluate the patient's level of consciousness; look for respira- tory distress. » Observe the patient's position of comfort (tripod positioning: COPD) or discomfort (CHF, COPD, asthma all worse when supine). » Conversational dyspnea: If the patient cannot speak a full sen- tence, it indicates a moderate to severe degree of respiratory distress. » Prolonged exhalation: COPD, asthma. Both COPD and asthma can result in air trapping. Air easily enters the lungs, but damaged or obstructed airways trap air, causing hyperinflation. When air is trapped, breathing transitions from passive exhalation to active exhalation with prolonged exhalation time. Observe the ratio of inspiration time to exhalation time; for patients with prolonged exhalation, consider the diagnoses of obstruction to outflow of air (i.e., COPD and asthma). Chronic air trapping is what is respon- sible for the barrel chest appearance (increased anterior/posterior diameter) of COPD patients. » Pursed-lips breathing: Found to improve the sensation of dys- pnea and reduce the work of breathing, pursed-lips breathing is often used spontaneously by COPD patients during exhalation. 3 It is possible this maneuver helps force airways to remain open during exhalation by creating an effect similar to the use of CPAP. » Accessory muscle usage: This is a sign of respiratory distress and can be seen in several conditions, including COPD, asthma, pneumonia, pulmonary embolus and pneumothorax. » Respiratory rate: Patients in general breathe fast for three reasons: They have inadequate oxygen levels, elevated blood acid levels or a psychiatric/pain reason for breathing fast. Discovering the cause for the rapid respiratory rate will aid in the diagnosis. Abnormally slow breathing can be an ominous sign of impending respiratory arrest and may be due, among other causes, to drugs or CO 2 retention in severe COPD. » Shallow respirations: Pleuritic pain will cause patients to breathe with a lower tidal volume in an effort to avoid the pain. Consider possible causes of pleuritic pain such as pneumothorax, pulmonary embolism and pneumonia. Respiratory patterns—The pattern of breathing may give a clue as to the underlying etiology of the respiratory complaint. » Normal respiration: Rate is 12–20. Most adults will have a respiratory rate of 12–16, with the upper end of normal at 20. It is important to take the first set of vital signs manually so you have a good baseline. » Kussmaul respirations: Characterized by deep, rapid respira- tions. Commonly caused by diabetic ketoacidosis or other conditions with severe metabolic acidosis. » Cheyne-Stokes respirations: Characterized by cycles of a gradual increase and decrease in respiratory depth and rate. As the respiratory rates decrease, there is a period of apnea which may For More Information Circle 37 on Reader Service Card