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48 Recognition of subtle tachypnea can be difficult in the emergency setting, although it can be the solitary indicator of disease. Another instance of pathology that can confuse routine measurement of the RR is diaphragmatic breathing or retractions. The variability in counting respiratory effort SECTION I VITAL SIGNS AND PATIENT MONITORING TECHNIQUES Ataxic Respiration Apneustic Respiration Kussmaul Respiration/ Hyperpnea Biot’s (Cluster) Respiration Cheyne-Stokes Respiration 4 Tidal volume (VT) with a progressive shallowdeep-shallow cycle (30 sec–2 min) Periods of rapid respirations of nearly equal depth or VT followed by regular periods of apnea Hyperventilation characterized by a consistent and deep respiratory pattern; the RR of patients with hyperpnea may be normal or rapid with increased VT CVA, trauma, or masses involving a diffuse area of the forebrain, carbon monoxide poisoning, metabolic encephalopathy, altitude sickness, opiate effect CVA or trauma involving the medulla or lower pons, mass effect on the medulla secondary to uncal or tentorial herniation, opiate effect Severe metabolic acidosis; Kussmaul respiration in diabetic ketoacidosis starts with a rapid and shallow pattern and later becomes rapid and deep CVA, trauma, or mass effect involving the pons Prolonged inspiratory phase followed by prolonged expiratory phases believed to be apneic phases CVA or trauma involving the medulla (indicates a very poor prognosis) Erratic breathing pattern with irregular pauses and increasing episodes of apnea (progresses to agonal respiration) Figure 1-1 Abnormal respiratory patterns.

The apical pulse is frequently greater than the peripheral pulse because of inadequate filling time and stroke volume, with resultant nontransmitted beats. 59 Pulse Amplitude and Contour Accurate examination and description of pulse amplitude and contour can provide additional clinical information and aid in decision making. Superimposition of one pathophysiologic state on another may modify the pulse. For example, sepsis may result in variable pulse amplitudes, depending on the stage in the development of the disease at initial evaluation of the patient.

This practice, though sometimes the only feasible method of obtaining any value in a noisy environment, poses a significant potential for error. In a study of critically ill patients transferred between hospitals, palpated systolic blood pressure values underestimated manometric values by nearly 30%. According to the American Heart Association guidelines, the sphygmomanometer cuff should be an appropriate size for the patient to ensure an accurate reading. , from the acromion process to the lateral epicondyle).