Hypotension resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ogheneochuko Ajari, MB.BS, MS [2] Javaria Anwer M.D.[3]
Synonyms and keywords: Low blood pressure resident survival guide, Low blood pressure management guide, guide to hypotension management, hypotension management guide, hypotension management algorithm

Hypotension resident survival guide microchapters
Overview
Causes
Diagnosis and Management
Do's
Don'ts

Overview

Hypotension is the term for low blood pressure (BP). A systolic BP measuring less than 90mmHg and/ or diastolic BP of less than 60mmHg is considered hypotension. A difference of 20 mmHg systolic BP and 10 mmHg diastolic BP is considered orthostatic hypotension (OH). Orthostatic hypotension is the most common type of hypotension, and neurogenic hypotension is demonstrated among 1/3rd of the individuals with OH. A decrease in blood pressure can be life-threatening in conditions such as anaphylaxis and addisonian crisis, and requires prompt treatment. It is important to access the possibility of head injury in a patient with syncope due to hypotension. ECG is an important and essential component of the evaluation of hypotension. Shock requires prompt management with fluids and vasopressors. For other causes of hypotension, identifying the cause and treatment is the best strategy. Lifestyle modifications are usually the first step in management. Medications causing a drop in blood pressure should be discontinued or changed to an appropriate alternative.

Causes

Life Threatening Causes

Life-threatening causes include conditions that result in death or permanent disability within 24 hours if left untreated.

• Anaphylaxis
• Addisonian crisis
• Excessive bleeding
• Severe dehydration
• Severe hypothermia

Common Causes

The algorithm illustrates common causes of hypotension based upon the etiology.

Causes of hypotension

Vasodilation ❑Fever ❑ Sepsis ❑ Anaphylaxis ❑ Pregnancy

Cardiogenic ❑ Myocardial infarction ❑ Arrhythmias ❑ aortic stenosis ❑ Hypothermia

Orthostatic hypotension

Neurogenic

Iatrogenic

Non-neurgenic

Medications ❑Diurectis ❑ Vasodilators ❑ Nitrates ❑ PDE5 inhibitors ❑ ACE inhibitors ❑ Alpha blockers ❑ Calcium channel blockers ❑ Beta blockers ❑ Antidepressants ❑ Tricyclic antidepressants ❑ MAO inhibitors ❑ Piribedil

Peripheral autonomic ❑ Diabetic autonomic neuropathy ❑ Acquired non-diabetic autonomic neuropathy ❑ Hereditary autonomic neuropathy

Neurodegenerative ❑ Pure autonomic failure ❑ Parkinson disease ❑ Diffuse lewy body disease ❑ Multiple system atrophy

Post-traumatic Spinal cord injury

Hypovolemia ❑ Dehydration/ low intravascular volume: Vomiting, diarrhea, Addison's disease ❑ Polyuria such as in diabetes mellitus ❑ Third-spacing: Burns, sepsis ❑ Bleeding: Wounds, menorrhagia

Venous pooling Prolonged bed rest Heat stroke

Others ❑ Aging

Diagnosis and Management

Shown below is an algorithm summarizing the management of hypotension.

Systolic BP < 90mmHg / Diastolic BP < 60mmHg OR Difference of 20 mmHg systolic and 10 mmHg diastolic pressure

Reassess B.P if unsure

Diagnosis of hypotension

Initial tests ❑ EKG x 24 hours ❑ Cardiac monitor x 24 hours till 7 days ❑ Pulse oximeter ❑ Blood pressure monitor x 24 hours ❑ TSH ❑ Serum electrolytes ❑ HB

Sinus rhythmn

Arrhythmia

Holter monitor or Long-term loop recorders (may be up to a month)

Unexplained syncope/ fall/ dizziness

Asymptomatic

Shock

CT scan head if ❑ Decreasing GCS score (<15) ❑ Seizure ❑ > 1 episode of vomiting ❑ Skull fracture evidence ❑ Age >60 years ❑ Abnormal neurological examination ❑ High-risk mechanism injury

Shock resident survival guide

Post-parandial History ❑ Age:Usually old individuals. ❑ Symptoms: Syncope or angina symptoms 15-90 minutes after meal. ❑ Associated symptoms: Angina pectoris, weakness, dizziness or lightheadedness, syncope, nausea, blurred vision/ black spots in visual field, cold clammy, or pale skin, disturbed speech. ❑ Past medical history: Parkinson disease, autonomic dysfunctions, HTN, diabetic autonomic neuropathy. ❑ Medication history: Medications administered with meal may cause hypotension.

Prolonged standing/ Stress History ❑ Source: Patient and/ or a witness describing the fall. ❑ Age: Common among young individuals. ❑ Duration of symptoms: Frequency, triggering or relieving factors. ❑ Associated symptoms: Sinking feeling, tachycardia, sweating dizziness or lightheadedness, nausea, blurred vision, cold clammy, pale skin and blaxck out preceding syncope ❑ Past medical history: Volume loss, malena. ❑ Family history:A positive family history has been demonstrated in the past and indicated genetic component

Postural / Early morning History ❑ Source: Patient and/ or a witness describing the fall. ❑ Age: Any age individuals. ❑ Duration of syncope, preceding events, confusion post syncope ❑ Associated symptoms: Dizziness or lightheadedness, confusion, fatigue, nausea, blurred vision, cold clammy, and pale skin, Vision problems, gait problems, and neck pain. ❑ Past medical history:Diabetes, renal problems, amyloidosis, heart disease,HTN, autoimmune disease, neurodegenerative dosease. ❑ Menstrual history: Menorrhagia ❑ Medication history: Beta-blockers, aplha blockers, vasodilators, and tricyclic antidepressants. ❑ Social history:Alcohol intake may cause dehydration.

History ❑ Source: Patient ❑ Age: Helps determine age-specific causes. ❑ Associated symptoms: Dizziness or lightheadedness, syncope, nausea, blurred vision. ❑ Past medical history: Volume loss, malena, diagnosed conditions such as diabetes, HTN, Addison's disease, etc

Physical exam ❑ Vital signs: Heart rate, respiratory rate. A decrease in systolic BP of =/ >20 mm Hg or =/> 90 mm Hg (when the systolic BP before the meal is > 100mmHg, within 2 hours of the start of the meal. ❑ HEENT, CVS, neuro, respiratory, and GI exam.

Physical exam ❑ Vital signs:Heart rate, respiratory rate, blood pressure. ❑ HEENT, CVS, neuro, respiratory, GI exam.

Physical exam ❑ Vital signs:Heart rate, respiratory rate. Blood pressure recording lying/ seating and standing. ❑ Reduction of at least 20 mm Hg systolic or 10 mm Hg diastolic BP within 3 minutes of erect standing. ❑ HEENT, CVS, neuro, respiratory, GI exam.

Physical exam ❑ Vital signs:Heart rate, respiratory rate. Blood pressure recording lying/ seating and standing. ❑ HEENT, CVS, neuro, respiratory, GI exam.

Labs ❑ CBC ❑ BSL/ HbA1c ❑ Urinalysis ❑ CMP ❑ Holter monitor, CXR, stress test (high risk individuals)

Labs ❑ CBC ❑ BSL ❑ Holter monitor, CXR, stress test (high risk individuals)

Labs ❑ CBC ❑ Anemia workup: Ferritin, total iron-binding capacity, reticulocyte count, vitamin B12 and folic acid levels. ❑ BSL/ HbA1c ❑ Urinalysis ❑ FOBT ❑ CMP ❑ proBNP and echocardiography ❑ Holter monitor, CXR, stress test (high risk individuals)

Labs ❑ CBC ❑ Urinalysis ❑ Cortisol (Addison's disease) ❑ CMP ❑ Echocardiogram ❑Holter monitor, CXR, stress test (high risk individuals)

Tilt table test

Lifestyle Modification ❑ Regular blood pressure monitoring both supine and prone. ❑ Maintain fluid intake.

Tilt table test positive

Tilt table test negative

❑ Cardiac journal ❑ Follow-up

❑ Orthostatic hypotension after 3 minutes of standing

❑ Diagnosed in 1 minute of standing ❑ Severity estimated in 2 minutes of standing ❑ Valsalva test or carotid massage may be utilized to confirm the diagnosis

Neurocardiogenic syncope

Orthostatic hypotension

Postprandial hypotension

Lifestyle Modification ❑ Regular blood pressure monitoring both supine and prone. ❑ elevated salt intake of no more than 10g/day. ❑ Maintain fluid intake.

Lifestyle Modification ❑ Regular blood pressure monitoring both supine and prone. ❑ Maintain fluid intake. ❑ Postural OH: ❑ Elevated salt intake ❑ Mild cases: 2 g salt tablets thrice a day (minimum eight 8-ounce servings of fluid/ day). Maximum of no more than 10g/day. ❑ Acute cases: Salty soups and about five 8-ounce servings of fluid/ half day. ❑ Abdominal binder ❑ Early morning OH ❑ Care on awakening with gradual shift from supine to upright. ❑ Drinking two cups of cold water 30 min before arising from the bed. ❑ Elevation of the head end of the bed.

Lifestyle Modification ❑ Counsel the patient and caregiver about the risk and timing post meal. ❑ Discontinue unnecessary medications. ❑ Pre and post parandial B.P. monitoring. ❑ Medications between the meals rather with the meal. ❑ Meal: Smaller, low carbohydrate meals. Liberal salt, water intake. Avoid hot drinks, hot foods, meals during hemodialysis, and reduce alcohol intake.

Medical therapy ❑ Beta blockers preferred initial treatment ❑ SSRI ❑ Fludrocortisone 0.1mg/day ❑ Midodrine 2.5-10 TID ❑ Scopolamine ❑ Dual chamber pacing may be required.

Medical therapy ❑ Severe acute cases: hospital management with IV fluids ❑ Fludrocortisone 0.1-1.0 mg / day ❑ Pyridostigmine bromide ❑ Erythropoietin 50 units/kg S/C thrice a week (monitoring reticulocyte count and Hct)

Medical therapy ❑ Caffeine 250mg before meal ❑ Octreotide 50 microgram S/C before each meal. ❑ Indomethacin 25-50 mg thrice a day ❑Midodrine 2.5 -10 mg thrice a day/ 60 mg 6 or 12 hourly.

FDA approved pharmacotherapy for neurogenic OH  ❑ Droxidopa  ❑ Midodrine

❑ Cardiac journal ❑ Follow-up

❑ Cardiac journal ❑ Follow-up

Do's

• Educate the patient to avoid predisposing conditions such as dehydration, alcohol, etc.
• Educate the patient of OH for counter maneuvers such as:
  • Leg elevation, thigh muscle co-contraction, toe-raising, crossing and contracting the legs, waist bending, and slow marching.
• Discontinue or adjust the dose of medication if hypotension is caused by medication side effects.
• Advice to wear compression stockings to relieve the pain and swelling from varicose veins.
• Counsel the caregivers of elder patients with postprandial hypotension.
• A multidisciplinary approach to patient management is necessary. Involve cardiologist, endocrinologist, otolaryngologist, geriatician, neurologist, and dietitian.

Don'ts

• Do not over treat hypotension. Symptomatic low BP or decreased organ perfusion is a treatable entity.
• Do not forget to follow up with the patient and monitor the blood pressure to titrate the management strategy.