Which of these statements made by an EMT student indicates that he correctly understands the use of capillary?
Capillary refill time is a simple bedside measurement that is undertaken as part of the ABCDE approach to assessing acutely ill patients. This article outlines the rationale for measurement and provides a step-by-step guide to the procedure Show
AbstractMeasurement of capillary refill time can help to confirm the presence of circulatory shock when it is used as part of the ABCDE assessment of acutely ill patients. This article outlines the procedure used to measure capillary refill time in clinical practice. Citation: Jevon P, Gallier H (2020) How to measure capillary refill time in patients who are acutely ill. Nursing Times [online]; 116: 8, 29-30. Authors: Phil Jevon is academy tutor; Hannah Gallier is academy trainer, emergency department; both at Walsall Teaching Academy, Manor Hospital, Walsall.
IntroductionCapillary refill time (CRT) is a measure of the time it takes for a distal capillary bed, such as those found in the fingers, to regain colour after pressure has been applied to cause blanching. A prolonged CRT may indicate the presence of circulatory shock. Tissue perfusion is dependent on an adequate blood pressure in the aorta which, in turn, is determined by the product of two factors:
Cardiac output is determined by the heart rate and stroke volume. Normal and prolonged CRTCRT is part of the circulation (C) component of the ABCDE approach, which is used to assess and treat patients who are acutely ill. However, its reliability has been questioned as there is very little research data to confirm validity (Shinozaki et al, 2019; Lewin and Maconochie, 2008). The normal CRT is <2 seconds; a CRT of >2 seconds suggests poor peripheral perfusion and may be an early sign of shock (Hernández et al, 2020). However, several other factors can cause a prolonged CRT, including:
Accurate timing of CRT is difficult: Fleming et al (2016) advised using a watch or clock to help measure CRT, but this can be difficult in practice as CRT is measured over a very short period of time. Some nurses count in thousands with each number (1,000, 2,000, 3,000) equating to a second but this approach may not be performed consistently between staff. It is important to interpret CRT in the context of a comprehensive assessment of circulation, which should include:
ShockShock is defined as life-threatening, generalised form of acute circulatory failure with inadequate oxygen delivery to the cells (Rhodes et al, 2016; Cecconi et al, 2014); this results in impaired basic metabolic functions of cells and organs. Hypoperfusion of the tissues triggers a systemic stress response, including tachycardia and peripheral vasoconstriction; once these physiological compensation mechanisms are overwhelmed, organ dysfunction, organ failure, irreversible organ damage and death may ensue. Shock classifications are outlined in Box 1, with clinical features given in Box 2. Box 1. Classifications of shock
Sources: Cecconi at al (2014); Soni and Watson (2011) Box 2. Shock: clinical features
Sources: Cecconi et al (2014); Jevon et al (2012) It is important to remember that hypotension is not a prerequisite for diagnosing shock because compensatory mechanisms such as vasoconstriction – which diverts blood from the peripheral circulation to the vital organs – can preserve blood pressure in the short term (Van Genderen et al, 2013). As a consequence, patients in shock may exhibit adverse changes in CRT before a fall in blood pressure is detected. CRT is a marker of peripheral perfusion and an abnormal CRT in patients with septic shock who have received resuscitation in an intensive care unit has been directly associated with poor outcomes (Lara et al, 2017). CRT can, therefore, be considered a simple monitoring tool that can help inform the triage, treatment and follow-up of patients with sepsis-related acute circulatory dysfunction (Hariri et al, 2019). Procedure for measuring CRTThis procedure is usually undertaken alongside other systemic observations.
An alternative site for measuring the CRT is the sternum (Fig 3). This site is frequently used in emergency departments, especially in winter when patients may come from a cold environment, which affects the accuracy of CRT. Professional responsibilitiesThis procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols. References Cecconi M et al (2014) Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Medicine; 40: 12, 1795-1815. Fleming S et al (2016) Capillary refill time in sick children: a clinical guide for general practice. British Journal of General Practice; 66: 652, 587-588. Hariri G et al (2019) Narrative review: clinical assessment of peripheral tissue perfusion in septic shock. Annals of Intensive Care; 9: 37. Hernández G et al (2020) Capillary refill time status could identify different clinical phenotypes among septic shock patients fulfilling Sepsis-3 criteria: a post hoc analysis of ANDROMEDA-SHOCK trial. Intensive Care Medicine; 46: 4, 816–818. Jevon P et al (2012) Monitoring the Critically Ill Patient. Chichester: Wiley-Blackwell Publishing. Lara B et al (2017) Capillary refill time during fluid resuscitation in patients with sepsis-related hyperlactatemia at the emergency department is related to mortality. PLoS One; 12: 11, e0188548. Lewin J, Maconochie I (2008) Capillary refill time in adults. Emergency Medicine Journal; 25: 6, 325-326. Rhodes A et al (2016) Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Critical Care Medicine; 45: 3, 486-552. Shinozaki K et al (2019) Comparison of point-of-care peripheral perfusion assessment using pulse oximetry sensor with manual capillary refill time: clinical pilot study in the emergency department. Journal of Intensive Care; 7: 52. Soni N, Watson D (2011) Cardiovascular support. In: Nimmo GR, Singer M (eds) ABC of Intensive Care. Chichester: Wiley-Blackwell. Van Genderen ME et al (2013) Peripheral perfusion index as an early predictor for central hypovolemia in awake healthy volunteers. Anesthesia and Analgesia; 116: 2, 351-356. Which of these statements made by an EMT indicates an accurate understanding of checking a patient's skin temperature?Which one of the following statements made by an EMT indicates an accurate understanding of checking a patient's skin temperature? "Checking the skin temperature is not precise, but it is a good estimate of abnormal high or low body temperatures."
When assessing a patient's blood pressure What does the top number indicate to the EMT?Two numbers are recorded when measuring blood pressure. The higher number is called systolic pressure. It refers to the pressure inside the artery when the heart contracts and pumps blood through the body.
When obtaining a blood pressure the EMT listens for a pulse over what blood vessel?33. To determine blood pressure, the EMT should position the cuff over the upper arm and place the stethoscope over the brachial artery.
For which one of the following conditions would the EMT most likely get an inaccurate pulse oximeter reading despite proper application of the sensor?For which one of the following conditions would the EMT most likely get an inaccurate pulse oximeter reading despite proper application of the sensor? low blood pressure.
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