Hypotension resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ogheneochuko Ajari, MB.BS, MS [2]

Definition

Hypotension is low blood pressure, especially in the arteries of the systemic circulation. It is considered to be a systolic BP of less than 90mmHg or diastolic of less than 60mmHg.

Causes

Life Threatening Causes

• Anaphylaxis
• Bleeding
• Dehydration
• Hypothermia
• Sepsis

Common Causes

• ACE inhibitors
• Addison's disease
• Alpha blockers
• Anaphylaxis
• Beta blockers
• Bleeding
• Calcium channel blockers
• Diabetes mellitus
• Diuretics
• Hypoglycemia
• Hypothermia
• Hypovolemia
• Pregnancy
• Sepsis
• Shock
• Tricyclic antidepressants

Management

Algorithm summarizing the management of hypotension is shown below

BP measurement

Systolic BP < 90mmHg Or Diastolic BP < 60mmHg

Hypotension

History and Symptoms Detailed medication list Recent history of volume loss Dizziness or lightheadedness Syncope (fainting) Rapid, shallow breathing Nausea Blurred vision Cold clammy, pale skin

Physical Examination Heart (irregular beats) Tilt table test

Laboratory Tests CBC (anemia) Glucose (Hypoglycemia, DM) Urinalysis Blood culture Cortisol (Addison's disease) BUN

EKG Echocardiogram Stress test Valsalva maneuver

Tilt table test positive

Tilt table test negative

Neurocardiogenic syncope Continue with EKG and BP monitoring Beta blockers preferred initial treatment SSRI Fludrocortisone 0.1mg/day Midodrine 2.5-10 TID Scopolamine Dual chamber pacing may be required

Orthostatic hypotension

Postprandial hypotension Advice to eat smaller, low carbohydrate meals

Medical Therapy Fludrocortisone Pyridostigmine bromide Erythropoietin

Lifestyle Modification Regular BP monitoring with a home monitoring kit supine and prone Maintenance of an elevated salt intake of 10g/day Maintenance of proper fluid intake to prevent dehydration Blood sugar control

Do's

• Educate the patient to avoid predisposing conditions such as dehydration, alcohol etc
• Discontinue or adjust dose of medication if hypotension is caused by medication side effects
• Advice to wear compression stockings to relieve the pain and swelling of varicose veins
• Early feeding either orally or by feeding tubes to prevent ileus

Don'ts

• Avoid or limit the use of alcohol
• Avoid standing for prolonged periods of time
• Do not cross legs while in a sitting position