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
• Dehydration
• Hypothermia

Common Causes

• Vasovagal syncope
• Hypovolemia: Excessive vomiting, diarrhea, polyuria such as in diabetes mellitus,burns, bleeding and/ or dehydration.
• Medications: ACE inhibitors, alpha blockers, beta blockers, diuretics, calcium channel blockers and tricyclic antidepressants.
• Vasodilation: Anaphylaxis, sepsis, and pregnancy.
• Addison's disease
• Hypothermia
• Prolonged bed rest
• Arrhythmias

Diagnosis and Management

Shown below is an algorithm summarizing the management of hypotension.

Blood pressure 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, hyperglycemia, 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 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

Medical Therapy Fludrocortisone Pyridostigmine bromide Erythropoietin

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

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

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