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Editorials |

“Vital” Sign?

Stephen Trzeciak, MD, MPH; Michael E. Chansky, MD
Author and Funding Information

Affiliations: Camden, NJ
 ,  Dr. Trzeciak is Assistant Professor, Division of Cardiovascular Disease and Critical Care Medicine and the Department of Emergency Medicine, and Dr. Chansky is Chairman of the Department of Emergency Medicine, UMDNJ-Robert Wood Johnson Medical School at Camden, Cooper University Hospital.

Correspondence to: Stephen Trzeciak, MD, MPH, UMDNJ-Robert Wood Johnson Medical School at Camden, Cooper University Hospital, One Cooper Plaza, D363, Camden, NJ 08103; e-mail: trzeciak-stephen@cooperhealth.edu



Chest. 2006;130(4):933-934. doi:10.1378/chest.130.4.933
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Imagine this: You are evaluating a 65-year-old woman who presents to the emergency department (ED) with dizziness. On arrival, her blood pressure (BP) is 80/42 mm Hg. Immediately you administer IV fluids, to which the BP promptly responds and rises to a normal range. You quietly breathe a sigh of relief, and you go about your usual diagnostic evaluation. An hour later after your workup is complete, the diagnosis for your patient remains unclear and you plan to admit her for observation. However, the nurse soon informs you that while your patient has been waiting for a bed upstairs her BP has been intermittently reading “on the low side.” You query the data recorded in the ED central monitoring station and you see that 3 of the last 10 recorded values for systolic BP (SBP) in the past hour have been < 100 mm Hg, including the most recent reading (88/46 mm Hg). In your mind you quickly run through a checklist of other clinical signs of potential tissue hypoperfusion, but the only “red flag” you can identify at this point is the arterial pressure. You ask the nurse to administer some more crystalloid, and you go back to the bedside. You are now reassured because the repeat BP is 109/64 mm Hg, and you find that the SBP remains > 100 mm Hg on all subsequent values that you obtain while the patient is in the ED. You think to yourself that perhaps those initially low values were spurious. Besides, you are a seasoned clinician, and in your judgment the patient “looks good.” How concerned should you be? Do these numbers change how you risk-stratify your patient for an adverse outcome? What you really want to know is: “what are the odds that the patient will go up to the floor and have a bad outcome or, even worse, die suddenly?” In the practice of acute care, whether you are an ED-based clinician or a consultant seeing a patient in the ED, this clinical scenario is not uncommon. Against this backdrop, Dr. Alan Jones and coworkers have made an important contribution to the literature in this issue of CHEST (see page 941).1

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