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

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-meal History ❑ Age:Usually old individuals. ❑ Duration of symptoms: 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. ❑ Medication history: Assess the use of medications known to cause hypotension

Prolonged standing/ Stress History ❑ Source of history: 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 ❑ Systemic review: Cardiovascular, respiratory, renal, hepatic, rheumatologic, CNS (such as head injury after fall), and GI symptoms. ❑ Past medical history: Volume loss, malena. ❑ 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

Postural History ❑ Source of history: Patient and/ or a witness describing the fall. ❑ Age: Any age individuals. ❑ Duration of syncope ❑ Associated symptoms: Dizziness or lightheadedness, confusion, fatigue, nausea, blurred vision, cold clammy, and pale skin. ❑ Systemic review: Vision problems, gait problems, neck pain, cardiovascular, renal, and GI problems. ❑ 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 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,

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

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

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

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

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

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

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

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

Do's

• Educate the patient to avoid predisposing conditions such as dehydration, alcohol, etc.
• 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.

Don'ts

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