Literature That Changes Practice: Abnormal Vitals That Predict Death

You’re called out late one afternoon during the heaviest snowstorm of the year to a 32-year-old female complaining of abdominal pain. She doesn’t seem to have any difficulty walking to the door to let you in. She agrees to a full assessment: the offending section of the abdomen is neither tender nor distended, though the patient does hunch over it protectively.

Her vitals are as follows:

• Heart rate: 108
• Respiratory rate: 22
• Blood pressure: 122/ 83
• Oxygen saturation: 98% on room air
• Temperature: 98
• Blood sugar: 104

She seems a little agitated, but that could easily be due to your partner’s bedside manner.

“If everything seems normal then I’ll just stay home,” she says. “Sorry to bother y’all.  It just felt like something was wrong.”

“Well,” you say, “Your exam wasn’t completely normal.”

Your partner sighs and rolls his eyes. “It’s because she’s upset.”

That barely fast heart rate could be because this patient is anxious or in pain or dehydrated or just finished drinking two energy drinks with a name like “Assault.” It would be an enormous pain to get her to definitive care, today of all days, with three inches of snow already on the ground and almost none of the roads plowed yet. And maybe that mild tachycardia is completely psychological. But also, maybe not.

We go to EMT or paramedic school to learn normal vital sign ranges. A lot of in-field practice is learning which ones are clinically relevant or even emergent.

A patient with a blood pressure of 208 deserves a thorough and exhaustive neurologic assessment. He also needs a 12-lead EKG and real consideration of various life-threatening causes hypertensive crises. However, assuming the absence of any of those relevant symptoms, this blood pressure value alone does not actually indicate an emergency. He should follow up with his primary care doctor for a medication adjustment and perhaps some bloodwork as this hypertension will shorten his life.¹

Then we have the readings that are emergent even if a patient insists they feel normal: blood pressure, blood oxygen, or respiratory rate that is too low. After all, in some patients, a single episode of hypoxia or hypotension can kill. But there’s also a heart rate or a respiratory rate that is too rapid.

Those two vital signs—tachycardia and tachypnea—are dangerous and worth noting, even in the absence of any other concerning exam findings.²

In 2016, a study was done looking at 4,878 patients who entered the emergency room. Patients under 18 who were transferred to the hospital, those who bypassed the emergency department and/or had trauma to the torso were excluded. Patients with any tachycardia or tachypnea were included.

This study further divided these patients based on whether they continued to have that abnormal vital in the emergency room, whether it normalized (possibly in response to treatment), and whether they still had it when they were admitted. Then they measured how many of these patients were still alive in 30 days.

The results were striking: patients with these abnormal findings had a 30-day in-hospital mortality of 3% to 8%. This is dramatically higher than the random chance a not-terminally ill person has of not surviving the month.

“Well, obviously patients with heart rates in the 160s are way more likely to die than other people,” you might say. They are. But it’s important to remember that patients with a heart rate or respiratory rate that was even slightly too fast were included. A patient breathing 21 times a minute is in the same, too-likely-to-die for comfort bucket as someone who’s breathing 58 times a minute. An adult with a heart rate of 102 is also in the group that is much likelier to die, with people whose heart rates are in the 190s.

“Obviously patients that are hypotensive are more likely to die.” Also, yes. But about 78% of the patients included in this study were never hypotensive. Their blood pressures remained normal. Also, even if you remove all the patients with a low blood pressure, you’re still looking at eerily high mortalities within the month: 1.5% of the tachycardia group and 5.5% of the tachypnea group. When you do add in hypotension, the mortality rate doubles.

These numbers only apply to people who arrived at the ER. Since people EMTs encounter during an average shift have called 9-1-1, it seems likely to be a similar group of people. Why do these abnormalities matter so much when others matter so little? The study authors make no attempt to tackle this question. I would guess that patients with these vitals are more likely to have deadly but difficult to diagnose problems, such as sepsis, pulmonary embolism, heart infection, or unknown internal bleeding.

What makes this so complicated is that there are plenty of relatively benign reasons for a rapid heart rate and respiratory rate: Pain, anxiety, heat exhaustion, dehydration, recent inhaler use, passionate love for espresso shots, to name only a few.

EMS has very limited tools to try and tell the difference. Also, depending on the tolerance of your protocol and own judgement, it’s more than reasonable to simply inform the person that their vitals indicate that they would benefit from having a definitive assessment from a doctor. These changes don’t necessarily require a fluid bolus or an ambulance ride. Indisputably, however, they mandate an investigation.

You ask your partner to go get a kit that you both know you don’t need and recheck the vitals while calmly chatting with the patient. Everything else is normal, but still: respiratory rate 22, heart rate 107. You explain that, while nothing present mandates a field intervention, it would be best for her to discuss her symptoms with an individual who went to medical school.

You end up on the wall at the ER for three hours. Did you save a life or misuse an ER workup? If you do this 20 times, on average it will be the first one once. And often, for a particular patient, we never get to know.

Work Cited

1. Donaldson, R., Young, N., Sanchez, F., Heston, T., Cunningham, R., Simpson, B., & Lu, K. (2021). Asymptomatic hypertension. WikEM. https://wikem.org/wiki/Asymptomatic_hypertension

2. Puskarich, M. A., Nandi, U., Long, B. G., & Jones, A. E. (2017). Association between persistent tachycardia and tachypnea and in-hospital mortality among non-hypotensive emergency department patients admitted to the hospital. Clinical and experimental emergency medicine, 4(1), 2–9. https://doi.org/10.15441/ceem.16.144