• Michael D. Witting
    Reprint Address: Michael D. Witting, MD, MS, University of Maryland Emergency Medicine Associates, 110 S. Paca St., 6th Floor, Baltimore, MD 21201.
    Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
    Search for articles by this author
Published:September 16, 2022DOI:



      Much controversy surrounds the use of orthostatic vital signs (OVS), including their indications, performance, and interpretation. This can lead to conflict between nurses, physicians, and consultants. This article summarizes the evidence for OVS in selected emergency department (ED) indications and the basis for a rapid measurement protocol.


      This narrative review is intended to clarify indications for OVS measurement, their performance, and interpretation.


      Phlebotomy studies indicate that OVS are more discriminating than supine vital signs in hypovolemia, but many findings, even some considered “positive,” do not provide compelling evidence in favor of or against disease. Evaluated as a diagnostic test, they have a low yield and controversial criteria for a positive test, but as vital signs, they are useful for selected patients with frequent ED presentations—blood loss, dehydration, dizziness, weakness, and falls. Available evidence supports a rapid measurement protocol, including a 1-min interval after standing.


      OVS are useful in selected patients, in a variety of frequent presentations, but their indications and implications for a patient's care are subject to physician interpretation. Given their ease of measurement and effect on decision-making, physicians may consider measuring them early in the evaluation of selected patients.


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        • Witting MD
        • Hydorn SC.
        Variation in orthostatic vital sign testing in an urban academic emergency department.
        J Emerg Nurs. 2013; 39: 619-622
        • Koziol-McClain J
        • Lowenstein SR
        • Fuller B.
        Orthostatic vital signs in emergency department patients.
        Ann Emerg Med. 1991; 20: 606-610
        • Levitt MA
        • Lopez B
        • Lieberman ME
        • Sutton M.
        Evaluation of the tilt test in an adult emergency medicine population.
        Ann Emerg Med. 1992; 21: 713-718
        • Klapper E
        • Pepkowitz SH
        • Czer L
        • Inducil C
        • Scott L
        • Goldfinger D.
        Confirmation of the safety of autologous blood donation by patients awaiting heart or lung transplantation.
        J Thorac Cardiovasc Surg. 1995; 110: 1594-1599
        • Witting MD
        • Wears RL
        • Li S.
        Defining the positive tilt test: a study of healthy adults with moderate acute blood loss.
        Ann Emerg Med. 1994; 23: 1320-1323
        • McGee S
        • Abernethy WB
        • Simel DL.
        The rational clinical examination. Is this patient hypovolemic?.
        JAMA. 1999; 281: 1022-1029
        • Knopp R
        • Claypool R
        • Leonardi D.
        Use of the tilt test in measuring acute blood loss.
        Ann Emerg Med. 1980; 9: 72-75
        • Witting MD.
        Standing shock index: an alternative to orthostatic vital signs.
        Am J Emerg Med. 2017; 35: 637-639
        • Lopez BL.
        Orthostatic vital signs.
        Ann Emerg Med. 1992; 21: 228-229
        • Long B
        • Koyfman A.
        Vascular causes of syncope: an emergency medicine review.
        J Emerg Med. 2017; 53: 322-332
        • Toarta C
        • Mukarram M
        • Arcot K
        • et al.
        Syncope prognosis based on an emergency department diagnosis: a prospective cohort study.
        Acad Emerg Med. 2018; 25: 388-396
        • Brignole M
        • Moya A
        • de Lange FJ
        • et al.
        2018 ESC Guidelines for the diagnosis and management of syncope.
        Eur Heart J. 2018; 39: 1883-1948
        • Shen WK
        • Sheldon RS
        • et al.
        • Writing Committee Members
        2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.
        Heart Rhythm. 2017; 14: e218-e254
        • Heldeweg MLA
        • Jorge PJF
        • Ligtenberg JJM
        • Ter Maaten JC
        • Harms MPM.
        Orthostatic blood pressure measurements are often overlooked during the initial evaluation of syncope in the emergency department.
        Blood Press Monit. 2018; 23: 294-296
        • Schaffer JT
        • Keim SM
        • Hunter BR
        • Kirschner JM
        • De Lorenzo RA.
        Do orthostatic vital signs have utility in the evaluation of syncope?.
        J Emerg Med. 2018; 55: 780-787
        • Bloom AS
        • Devlin JJ.
        Discriminatory value of orthostatic vital signs in the emergency department evaluation of syncope.
        Ann Emerg Med. 2017; 70: 438-439
        • Edlow JA
        • Newman-Toker D.
        Using the physical examination to diagnose patients with acute dizziness and vertigo.
        J Emerg Med. 2016; 50: 617-628
        • Navi BB
        • Kamel H
        • Shah MP
        • et al.
        Rate and predictors of serious neurologic causes of dizziness in the emergency department.
        Mayo Clin Proc. 2012; 87: 1080-1088
        • Ooi WL
        • Hossain MS
        • Lipsitz LA.
        The association between orthostatic hypotension and recurrent falls in nursing home residents.
        Am J Med. 2000; 108: 106-111
        • Graafmans WC
        • Oorns ME
        • Hofstee MA
        • Bezemer PD
        • Bouter LM
        • Lips P.
        Falls in the elderly: a prospective study of risk factors and risk profiles.
        Am J Epidemiol. 1996; 143: 1129-1136
        • Rutan GH
        • Hermanson B
        • Bild DE
        • Kittner SJ
        • LaBaw F
        • Tell GS.
        Orthostatic hypotension in older adults: the cardiovascular health study.
        Hypertension. 1992; 19: 508-519
        • McLachlan CYL
        • Yi M
        • Ling A
        • Jardine DL
        Adverse drug events are a major cause of acute medical admission.
        Intern Med J. 2014; 44: 633-638
        • American College of Emergency Physicians
        • American Geriatrics Society
        • Emergency Nurses Association
        • Society for Academic Emergency Medicine
        Geriatric Emergency Department Guidelines Task Force. Geriatric emergency department guidelines.
        Ann Emerg Med. 2014; 63: e7-25
        • Juraschek SP
        • Daya N
        • Rawlings AM.
        Association of history of dizziness and long-term adverse outcomes with early vs later orthostatic hypotension assessment times in middle-aged adults.
        JAMA Intern Med. 2017; 177: 1316-1323
        • Moore KI
        • Newton K.
        Orthostatic heart rates and blood pressures in healthy young women and men.
        Heart Lung. 1986; 15: 611-617
        • Baraff LJ
        • Schriger DL.
        Orthostatic vital signs: variation with age, specificity, and sensitivity in detecting a 450-mL blood loss.
        Am J Emerg Med. 1992; 10: 99-103
        • Kennedy M
        • Davenport KTP
        • Liu SW
        • Arendts G.
        Reconsidering orthostatic vital signs in older emergency department patients.
        Emergency Med Australasia. 2018; 30: 705-708
        • Guss DA
        • Abdelur D
        • Hemingway TJ.
        The impact of arm position on the measurement of orthostatic blood pressure.
        J Emerg Med. 2008; 34: 377-382
        • Witting MD
        • Gallagher K.
        Unique cutpoints for sitting-to-standing orthostatic vital signs.
        Am J Emerg Med. 2003; 21: 45-47