EMT: Assessment, Vital Signs and Special Patients

In depth

The one-page summary above is what the PDF prints. These sections go further.

Respiratory rate and pulse

Hill and colleagues randomized 82 adults: those told their breathing was being counted breathed about 2.1 breaths per minute slower than those who were not told, and shortening the count from 60 to 15 seconds underestimated the rate by about 2.2 breaths per minute (about 1 for 30-second counts). The practical method is to keep the fingers on the radial pulse after counting it and watch the chest for 30 to 60 seconds without saying so. One breath is one rise and one fall.

An irregularly irregular pulse suggests atrial fibrillation. Merck explains that some beats, especially those that follow closely after the previous one, do not eject enough blood to produce a wave at the wrist, so the apical rate can exceed the radial rate (a pulse deficit). Open RN calls the apical pulse the most accurate and recommends a full 60-second count, especially when the rhythm is irregular. The EMT reports both numbers, because the true ventricular rate may be fast while the wrist count looks normal, and acquires a 12-lead per protocol (NASEMSO: promptly for cardiac complaints).

Blood pressure: cuffs and the pulse-location rule

Open RN: the cuff bladder should be about 40% of the arm circumference wide and 80–100% of it long. An undersized cuff gives an artificially high reading and an oversized cuff an artificially low one, and automatic monitors should not be relied on in a rapid or irregular rhythm; confirm an unexpected automatic reading manually. A child whose pressure reads far above her recent baseline with an infant cuff that reaches less than halfway round is most likely showing cuff error, and a falsely high number could hide the fall that matters: NASEMSO calls hypotension a late and ominous sign in pediatric shock. Spastic limbs may give unreliable readings (EMS World 2012).

The old teaching that a palpable radial pulse means a systolic pressure of at least 80 mm Hg (femoral 70, carotid 60) was tested by Deakin and Low in 20 hypovolemic patients with arterial lines: of 12 with all three pulses, 10 had a systolic below 80, and the rule generally overestimated pressure. A rapid radial pulse with cool, pale skin remains a useful sign of poor perfusion, but it is not a number. Measure the BP early, en route if needed, and trend it.

Capillary refill and skin color

Anderson and colleagues measured capillary refill in 1,000 healthy adults: median 1.9 seconds, 95th percentile 3.5 seconds, slightly longer with age, and longer with cooler skin and a cooler room; together these factors explained little of the variation, and the authors doubted its reliability as a test. In an older patient found on a cold floor, a slow fingertip refill with normal mental status, a strong radial pulse, normal BP and warm trunk skin does not mean shock. NASEMSO assesses perfusion with pulse rate and quality, skin color and temperature, and refill together.

Pallor in darker skin: a health assessment text describes it as a grey shade to the lips, mucous membranes and skin, notes that pale conjunctivae look white or very pale pink in any skin color, and suggests the palms, which tend to be lighter. Kelly and colleagues' 2025 scoping review advises looking at areas of low pigmentation and cites one study of children with anemia in which conjunctival and palmar pallor were the most accurate sites and nail beds the least; pallor was recommended for screening, not diagnosis. Compare with the patient's own normal, not the EMT's skin.

Unresponsive patients and painful stimuli

Functional (psychogenic) unresponsiveness: Bacchi and Slee describe bedside signs that support it, such as a modified hand drop test (the hand avoids the face) and resisted eyelid opening, and warn against stimuli that can cause tissue damage. Merck notes that psychogenic unresponsiveness is separated from true coma by a full neurologic examination, with video EEG when doubt remains, and that stabilization of airway, breathing and circulation and a bedside glucose come first. A hint is not a diagnosis: overdose after an argument, hypoglycemia, a seizure or a head injury can look the same. NASEMSO checks glucose in every altered patient and discourages the sternal rub.

Stimulus choice: Nallaluthan and colleagues class trapezius squeeze, supraorbital pressure and jaw pressure as central stimuli and nail-bed pressure as peripheral, and for a cervical cord level recommend central stimuli; the same paper notes that supraorbital and jaw pressure use the trigeminal (fifth cranial nerve) pathway and recommends central stimuli at a cervical cord level; that a face stimulus stays testable above a cord injury is a reviewer reading of that table. After a diving injury with paralysis and lost sensation in all four limbs, a fingertip, chest or thigh stimulus may never be felt, so no response there would be misread as coma. Use supraorbital pressure and record the limb findings as a spinal finding. The graded stimulus sequence is on Neuro: ICP and Stroke.

Dementia: Merck notes that behavioral disturbances may be triggered by a physical problem, such as pain, that the patient cannot communicate; a change in behavior calls for a physical examination, and explaining care before giving it helps. NASEMSO uses observational pain scales (for example FLACC) when cognitive impairment prevents self-report, and its spinal care pearls warn that dementia can prevent accurate assessment. A calm man who now shouts and pulls one arm away after a fall has an arm injury until proven otherwise; examine and splint it, and still look for the cause of the fall.

Arrest with equipment, ICDs and wearable defibrillators

Position: the Korean 2025 adult BLS guideline says CPR is most effective when the patient is immediately placed supine, on a firm surface where possible. A slumped, belted driver cannot receive compressions of adequate depth, so a rapid pull to the ground with the head supported in line is the fastest route to effective CPR and AED analysis. A witness who saw him slump before a walking-speed roll points to a medical arrest, so full spinal packaging would only delay compressions.

Athletes: Malik and colleagues treat any athlete who collapses without head trauma as sudden cardiac arrest until proven otherwise, warn that occasional gasping is mistaken for breathing, and aim for an AED within 3 minutes of collapse (survival 74% with defibrillation within 3 minutes versus 49% later in one study). In Tanaka's manikin study of 18 rescuers, depth over football shoulder pads (median 5.0 cm) did not differ significantly from baseline (5.7 cm), and the authors advise compressing over the pads without hesitation while others cut the jersey and open the pads, then placing the AED. Blanchard 2025: helmet and shoulder pads come off together, by the people most familiar with them, when CPR or AED placement needs the chest; the face mask alone can be removed for airway access.

ICD shocks: NHLBI tells patients to call their provider after any shock, to arrange a visit that day or the next after one or two shocks if they feel well, and to call 9-1-1 for several strong shocks in a short time, which can mean repeated dangerous rhythms or a device problem. An awake patient with a regular pulse is not in arrest: no compressions; keep the AED ready, request ALS and transport. If he becomes pulseless, start CPR and place the pads off the device (see BLS, High-Quality CPR and Choking).

Wearable cardioverter-defibrillator (IAED Journal 2021): a red alarm (two-tone siren rising to about 100 dB) means the vest has detected a dangerous rhythm and is preparing to shock, with prompts such as press response buttons to delay treatment, electrical shock possible do not touch patient, and bystanders do not interfere. Only a conscious wearer should press the buttons; anyone else pressing them delays a needed shock. The vest shocks within about a minute without help. Bystander CPR is appropriate except while those prompts are sounding. NHLBI also tells wearers to warn others to step back during a warning.

Pregnancy: asthma and uterine inversion

NASEMSO titrates oxygen to 94–98%. Powrie and colleagues advise keeping maternal saturation above 95% if possible for fetal well-being, treating acute exacerbations as in non-pregnant patients, and note that inhaled beta-agonists appear very well tolerated by the fetus; the commonest cause of worsening asthma in pregnancy is likely stopping medication. So a pregnant woman with an SpO₂ of 93% speaking in short phrases gets oxygen now and help with her own inhaler, sitting upright, with ALS and transport.

NASEMSO: the placenta delivers by itself, often within 5–15 minutes; do not force it or pull the cord. Merck names excessive cord traction as the most common cause of uterine inversion, which presents with hemorrhage and hypotension, a fundus that cannot be felt or is lower than expected, and the inverted fundus at or beyond the vaginal opening. In hospital the uterus is replaced before an attached placenta is removed, and a uterotonic follows. The EMT stops traction, leaves the placenta attached, gives high-flow oxygen and shock care, contacts medical direction and transports rapidly. Fundal massage is impossible (there is no fundus in the abdomen) and replacement is not EMT care.

Infants and single-ventricle children

Meningitis in infants starts with nonspecific signs: lethargy, irritability, poor feeding, fever. Merck calls paradoxical irritability (comforting by a parent irritates rather than soothes) more specific for meningitis in neonates, attributing it to painful movement of inflamed meninges, and the University of Hawaii pediatrics text describes infants who are worse when carried, rocked or bounced and prefer to lie still as highly suggestive, while noting no single sign is diagnostic. In children younger than 12 months a supple neck does not exclude meningitis (Merck); in neonates a bulging fontanelle or neck stiffness occurs in only about 20%. The EMT classes the infant as sick, uses a mask per local protocol, handles her gently and transports promptly.

Single-ventricle hearts: Merck describes the staged repair for hypoplastic left heart syndrome. Before the first operation, newborns get as little oxygen as possible, aiming for saturations of 70–80%. The Glenn at 3 to 6 months sends about half the body's venous return passively to the lungs; the Fontan follows at 18 to 36 months. In a 2026 survey of cardiac intensive care clinicians, the most common post-Glenn target was 81–85% (23 of 35), without consensus. The EMT reads the number against the child's documented baseline. A reading far below it with grunting, drowsiness and mottled skin is respiratory failure with poor perfusion: give oxygen, avoid needless positive pressure while she breathes adequately, and go to the closest appropriate emergency department (NASEMSO), with the cardiac center advising by phone.

Functional needs, frequent callers and refusals

NASEMSO Functional Needs: the physical exam and care are never intentionally abbreviated, only modified; identify the need from the patient, family, alert jewelry or devices; the family is an excellent source of information and can calm the patient; use interpreters, communication boards, writing and the patient's own methods, and document them. Service animals accompany the patient except in narrow cases.

Cerebral palsy: an EMS World practice article advises never straightening a spastic limb for any reason, splinting in the baseline position and placing pads under high-pressure areas and in gaps between body and stretcher; it also notes baclofen pumps and orthoses. Mughal 2014: children with moderate to severe cerebral palsy have low bone density and fracture after minimal trauma, with contractures among the risk factors. A child with pneumonia is transported semi-sitting with the limbs supported as found and the belts over padding, never unrestrained.

Frequent callers: LaCalle and Rabin's systematic review found frequent ED users make up 4.5–8% of patients but 21–28% of visits, on average have higher-acuity complaints and greater risk of admission than occasional users (the very highest-frequency users may differ), and many present with true medical needs. Anchoring on the call history is the danger. NASEMSO Patient Refusals requires a complete set of vital signs and an initial assessment, a capacity determination (medical direction if in doubt) and a documented discussion of risks before any refusal; a patient who cannot respond cannot refuse.

Exam pearls

• Count respirations covertly for 30–60 seconds
• Irregular pulse: apical for a full minute; report the deficit
• Small cuff high, large cuff low
• A radial pulse is not a blood pressure
• Slow refill in cold old fingers alone is not shock
• Dark skin pallor: conjunctivae, mouth, palms
• Above a neck injury, test pain at the face
• ICD shocks with a pulse: no CPR, AED ready, transport
• Vest siren: hands off, let it shock
• Never pull the cord; no fundus plus a mass is inversion
• Infant worse when held: think meningitis
• Single ventricle: compare with her own baseline