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

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

Overview

Hypotension means low blood pressure (BP). A systoloc BP measuring less than 90mmHg and/ or diastolic BP of less than 60mmHg is considered hypotension.

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 ❑ Sepsis ❑ Anaphylaxis ❑ Pregnancy

Neurogenic ❑ Vasovagal syncope/ Neurocardiogenic syncope ❑ Post-parandial hypotension

Cardiogenic ❑ Arrhythmias ❑ 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 volume: Vomiting, diarrhea ❑ Polyuria such as in diabetes mellitus ❑ Third-spacing: Burns, sepsis ❑ Bleeding: Wounds, menorrhagia

Venous pooling Prolonged bed rest Heat stroke

Others ❑ Addison's disease ❑ 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

Diagnosis of hypotension

Syncope/ fall/ dizziness

Asymptomatic

Post-meal History ❑ Patient age:Usually demostrated among old individuals. ❑ Duration of symptoms: In chronic causes access the frequency of episodes, trigerring factors (such as specific meals), and relieving factors. ❑ Associated symptoms:Dizziness or lightheadedness, syncope, nausea, blurred vision, cold clammy, or pale skin. ❑ Systemic review: Cardiovascular, respiratory, renal, hepatic, rheumatologic, and GI exam. ❑ Past medical history:Parkinsons disease, autonomic dysfunctions. ❑ Past surgical history: ❑ Medication history: Assess the use of medications known to cause hypotension ❑ Family history:

Prolonged standing/ Stress History ❑ Source of history: Patient and/ or the witnesses' description of the fall. ❑ Patient 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 ❑ Systemic review: Cardiovascular, respiratory, renal, hepatic, rheumatologic, and GI exam. ❑ Past medical history: Volume loss, malena, ❑ Past surgical history: ❑ Medication history: Assess the use of medications known to cause hypotension ❑ Family history:A positive family history has been demonstrated in the past and indicated genetic component

Upon standing up History ❑ Source of history: Patient or well-informed caregiver. ❑ Patient age: Helps determine age-specific causes, ❑ Duration of symptoms: (weeks in acute/severe versus years in chronic conditions). ❑ Associated symptoms:dizziness or lightheadedness, syncope, nausea, blurred vision, cold clammy, pale skin ❑ Systemic review: Cardiovascular, respiratory, renal, hepatic, rheumatologic, and GI exam. ❑ Past medical history: Volume loss, malena, ❑ Past surgical history:Recent surgery leading to volume loss ❑ Menstrual history: Menorrhagia ❑ Medication history: Assess the use of medications known to cause vasodilation ❑ Family history: ❑ Social history:Alcohol intake may cause dehydration

History ❑ Source of history: Patient or well-informed caregiver. ❑ Patient age: Helps determine age-specific causes, ❑ Duration of symptoms: (weeks in acute/severe versus years in chronic conditions). ❑ Associated symptoms:dizziness or lightheadedness, syncope, nausea, blurred vision, cold clammy, pale skin ❑ Systemic review: Cardiovascular, respiratory, renal, hepatic, rheumatologic, and GI exam. ❑ Past medical history: Volume loss, malena, ❑ Past surgical history: ❑ Menstrual history: ❑ Medication history: Assess the use of medications known to cause hypotension ❑ Family history: ❑ Social history: ❑ Sexual history: ❑ Exposure:

Tilt table test

Tilt table test positive

Tilt table test negative

Neurocardiogenic syncope Continue with EKG and blood pressure 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

Lifestyle Modification ❑ Regular blood pressure 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

Medical Therapy ❑ Fludrocortisone ❑ Pyridostigmine bromide ❑ Erythropoietin

History ❑ Source of history: Patient or well-informed caregiver. ❑ Patient age: Helps determine age-specific causes, ❑ Duration of symptoms: (weeks in acute/severe versus years in chronic conditions). ❑ Associated symptoms:dizziness or lightheadedness, syncope, nausea, blurred vision, cold clammy, pale skin ❑ Systemic review: Cardiovascular, respiratory, renal, hepatic, rheumatologic, and GI exam. ❑ Past medical history: Volume loss, malena, ❑ Past surgical history: ❑ Menstrual history: ❑ Medication history: Assess the use of medications known to cause hypotension ❑ Family history: ❑ Social history: ❑ Sexual history: ❑ Exposure:

Characterise the severity of the condition

Physical exam ❑ Appearance of the patient: ❑ Vital signs ❑ Temperature: ❑ Heart rate: Tachycardia, irregular pulse ❑ Respiratory rate: Tachypnea ❑ Blood pressure: ❑ Oxygen saturation: ❑ HEENT ❑ Cardiovascular examination ❑ Respiratory examination ❑ Gastrointestinal system exam includes oral examination, abdominal examination, and digital rectal exam

Labs and tests CBC (anemia Glucose (Hypoglycemia, hyperglycemia, DM) Urinalysis Blood culture Cortisol (Addison's disease) BUN EKG Echocardiogram Stress test Valsalva maneuver

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 from varicose veins.

Don'ts

• Do not over treat hypotension. Symptomatic low BP or decreased organ perfusion is a treatable entity.