Hypotension resident survival guide: Difference between revisions

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==Diagnosis and Management==
==Diagnosis and Management==
Shown below is an algorithm summarizing the management of hypotension.<ref name="RicciDe Caterina2015">{{cite journal|last1=Ricci|first1=Fabrizio|last2=De Caterina|first2=Raffaele|last3=Fedorowski|first3=Artur|title=Orthostatic Hypotension|journal=Journal of the American College of Cardiology|volume=66|issue=7|year=2015|pages=848–860|issn=07351097|doi=10.1016/j.jacc.2015.06.1084}}</ref><ref name="pmid31485153">{{cite journal |vauthors= |title=Looking for Trouble: Identifying and Treating Hypotension |journal=P T |volume=44 |issue=9 |pages=563–565 |date=September 2019 |pmid=31485153 |pmc=6705478 |doi= |url=}}</ref><ref name="pmid31118743">{{cite journal |vauthors=Biswas D, Karabin B, Turner D |title=Role of nurses and nurse practitioners in the recognition, diagnosis, and management of neurogenic orthostatic hypotension: a narrative review |journal=Int J Gen Med |volume=12 |issue= |pages=173–184 |date=2019 |pmid=31118743 |pmc=6501706 |doi=10.2147/IJGM.S170655 |url=}}</ref><ref name="pmid30828233">{{cite journal |vauthors=Oommen J, Chen J, Wang S, Caraccio T, Hanna A |title=Droxidopa for Hypotension of Different Etiologies: Two Case Reports |journal=P T |volume=44 |issue=3 |pages=125–144 |date=March 2019 |pmid=30828233 |pmc=6385736 |doi= |url=}}</ref><ref name="pmid12664244">{{cite journal |vauthors=Newton JL, Kenny R, Lawson J, Frearson R, Donaldson P |title=Prevalence of family history in vasovagal syncope and haemodynamic response to head up tilt in first degree relatives: preliminary data for the Newcastle cohort |journal=Clin. Auton. Res. |volume=13 |issue=1 |pages=22–6 |date=February 2003 |pmid=12664244 |doi=10.1007/s10286-003-0077-7 |url=}}</ref><ref name="pmid6629270">{{cite journal |vauthors=Michel D |title=[Iatrogenic hypotension in the aged] |language=German |journal=Fortschr. Med. |volume=101 |issue=33 |pages=1455–8 |date=September 1983 |pmid=6629270 |doi= |url=}}</ref><ref name="pmid21431947">{{cite journal |vauthors=Freeman R, Wieling W, Axelrod FB, Benditt DG, Benarroch E, Biaggioni I, Cheshire WP, Chelimsky T, Cortelli P, Gibbons CH, Goldstein DS, Hainsworth R, Hilz MJ, Jacob G, Kaufmann H, Jordan J, Lipsitz LA, Levine BD, Low PA, Mathias C, Raj SR, Robertson D, Sandroni P, Schatz I, Schondorff R, Stewart JM, van Dijk JG |title=Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome |journal=Clin. Auton. Res. |volume=21 |issue=2 |pages=69–72 |date=April 2011 |pmid=21431947 |doi=10.1007/s10286-011-0119-5 |url=}}</ref><ref name="pmid20393093">{{cite journal |vauthors=Levine Z |title=Mild traumatic brain injury: part 1: determining the need to scan |journal=Can Fam Physician |volume=56 |issue=4 |pages=346–9 |date=April 2010 |pmid=20393093 |pmc=2860826 |doi= |url=}}</ref><ref name="pmid10891517">{{cite journal |vauthors=Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM |title=Indications for computed tomography in patients with minor head injury |journal=N. Engl. J. Med. |volume=343 |issue=2 |pages=100–5 |date=July 2000 |pmid=10891517 |doi=10.1056/NEJM200007133430204 |url=}}</ref><ref name="pmid31392227">{{cite journal |vauthors=Molaei-Langroudi R, Alizadeh A, Kazemnejad-Leili E, Monsef-Kasmaie V, Moshirian SY |title=Evaluation of Clinical Criteria for Performing Brain CT-Scan in Patients with Mild Traumatic Brain Injury; A New Diagnostic Probe |journal=Bull Emerg Trauma |volume=7 |issue=3 |pages=269–277 |date=July 2019 |pmid=31392227 |pmc=6681891 |doi=10.29252/beat-0703010 |url=}}</ref><ref name="pmid22090740">{{cite journal |vauthors=Sharif-Alhoseini M, Khodadadi H, Chardoli M, Rahimi-Movaghar V |title=Indications for brain computed tomography scan after minor head injury |journal=J Emerg Trauma Shock |volume=4 |issue=4 |pages=472–6 |date=October 2011 |pmid=22090740 |pmc=3214503 |doi=10.4103/0974-2700.86631 |url=}}</ref>
Shown below is an algorithm summarizing the management of hypotension.<ref name="RicciDe Caterina2015">{{cite journal|last1=Ricci|first1=Fabrizio|last2=De Caterina|first2=Raffaele|last3=Fedorowski|first3=Artur|title=Orthostatic Hypotension|journal=Journal of the American College of Cardiology|volume=66|issue=7|year=2015|pages=848–860|issn=07351097|doi=10.1016/j.jacc.2015.06.1084}}</ref><ref name="pmid31485153">{{cite journal |vauthors= |title=Looking for Trouble: Identifying and Treating Hypotension |journal=P T |volume=44 |issue=9 |pages=563–565 |date=September 2019 |pmid=31485153 |pmc=6705478 |doi= |url=}}</ref><ref name="pmid31118743">{{cite journal |vauthors=Biswas D, Karabin B, Turner D |title=Role of nurses and nurse practitioners in the recognition, diagnosis, and management of neurogenic orthostatic hypotension: a narrative review |journal=Int J Gen Med |volume=12 |issue= |pages=173–184 |date=2019 |pmid=31118743 |pmc=6501706 |doi=10.2147/IJGM.S170655 |url=}}</ref><ref name="pmid30828233">{{cite journal |vauthors=Oommen J, Chen J, Wang S, Caraccio T, Hanna A |title=Droxidopa for Hypotension of Different Etiologies: Two Case Reports |journal=P T |volume=44 |issue=3 |pages=125–144 |date=March 2019 |pmid=30828233 |pmc=6385736 |doi= |url=}}</ref><ref name="pmid12664244">{{cite journal |vauthors=Newton JL, Kenny R, Lawson J, Frearson R, Donaldson P |title=Prevalence of family history in vasovagal syncope and haemodynamic response to head up tilt in first degree relatives: preliminary data for the Newcastle cohort |journal=Clin. Auton. Res. |volume=13 |issue=1 |pages=22–6 |date=February 2003 |pmid=12664244 |doi=10.1007/s10286-003-0077-7 |url=}}</ref><ref name="pmid6629270">{{cite journal |vauthors=Michel D |title=[Iatrogenic hypotension in the aged] |language=German |journal=Fortschr. Med. |volume=101 |issue=33 |pages=1455–8 |date=September 1983 |pmid=6629270 |doi= |url=}}</ref><ref name="pmid21431947">{{cite journal |vauthors=Freeman R, Wieling W, Axelrod FB, Benditt DG, Benarroch E, Biaggioni I, Cheshire WP, Chelimsky T, Cortelli P, Gibbons CH, Goldstein DS, Hainsworth R, Hilz MJ, Jacob G, Kaufmann H, Jordan J, Lipsitz LA, Levine BD, Low PA, Mathias C, Raj SR, Robertson D, Sandroni P, Schatz I, Schondorff R, Stewart JM, van Dijk JG |title=Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome |journal=Clin. Auton. Res. |volume=21 |issue=2 |pages=69–72 |date=April 2011 |pmid=21431947 |doi=10.1007/s10286-011-0119-5 |url=}}</ref><ref name="pmid20393093">{{cite journal |vauthors=Levine Z |title=Mild traumatic brain injury: part 1: determining the need to scan |journal=Can Fam Physician |volume=56 |issue=4 |pages=346–9 |date=April 2010 |pmid=20393093 |pmc=2860826 |doi= |url=}}</ref><ref name="pmid10891517">{{cite journal |vauthors=Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM |title=Indications for computed tomography in patients with minor head injury |journal=N. Engl. J. Med. |volume=343 |issue=2 |pages=100–5 |date=July 2000 |pmid=10891517 |doi=10.1056/NEJM200007133430204 |url=}}</ref><ref name="pmid31392227">{{cite journal |vauthors=Molaei-Langroudi R, Alizadeh A, Kazemnejad-Leili E, Monsef-Kasmaie V, Moshirian SY |title=Evaluation of Clinical Criteria for Performing Brain CT-Scan in Patients with Mild Traumatic Brain Injury; A New Diagnostic Probe |journal=Bull Emerg Trauma |volume=7 |issue=3 |pages=269–277 |date=July 2019 |pmid=31392227 |pmc=6681891 |doi=10.29252/beat-0703010 |url=}}</ref><ref name="pmid22090740">{{cite journal |vauthors=Sharif-Alhoseini M, Khodadadi H, Chardoli M, Rahimi-Movaghar V |title=Indications for brain computed tomography scan after minor head injury |journal=J Emerg Trauma Shock |volume=4 |issue=4 |pages=472–6 |date=October 2011 |pmid=22090740 |pmc=3214503 |doi=10.4103/0974-2700.86631 |url=}}</ref><ref name="pmid7825766">{{cite journal |vauthors=Jansen RW, Lipsitz LA |title=Postprandial hypotension: epidemiology, pathophysiology, and clinical management |journal=Ann. Intern. Med. |volume=122 |issue=4 |pages=286–95 |date=February 1995 |pmid=7825766 |doi=10.7326/0003-4819-122-4-199502150-00009 |url=}}</ref>




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{{familytree | C01 | | C02 | | C05 | | C03 | | | |C01='''Post-parandial''' <div style="float: left; text-align: left; width: 20em; padding:1em;">'''History'''<div class="mw-collapsible mw-collapsed"><br>
{{familytree | C01 | | C02 | | C05 | | C03 | | | |C01='''Post-parandial''' <div style="float: left; text-align: left; width: 20em; padding:1em;">'''History'''<div class="mw-collapsible mw-collapsed"><br>
❑ '''[[Age]]''':Usually old individuals. <br>
❑ '''[[Age]]''':Usually old individuals. <br>
❑ '''[Symptom]]s''':[[Syncope]] or [[angina]] symptoms 15-90 minutes after meal. <br>
❑ '''[[Symptom]]s''': [[Syncope]] or [[angina]] symptoms 15-90 minutes after meal. <br>
❑ '''Associated [[symptoms]]''': [[Angina pectoris]], [[weakness]], [[dizziness]] or [[lightheadedness]], [[syncope]], [[nausea]], [[blurred vision]]/ black spots in visual field, cold clammy, or pale skin, disturbed speech. <br>  
❑ '''Associated [[symptoms]]''': [[Angina pectoris]], [[weakness]], [[dizziness]] or [[lightheadedness]], [[syncope]], [[nausea]], [[blurred vision]]/ black spots in visual field, cold clammy, or pale skin, disturbed speech. <br>  
❑ '''Systemic review''': [[Cardiovascular system|CVS]], [[respiratory system|respiratory]], [[renal system|renal]], [[liver|hepatic]], [[Rheumatology|rheumatologic]], and [[Gastrointestinal system|GI]] system review.<br>
❑ '''Past medical history''': [[Parkinsons disease]], autonomic dysfunctions, [[hypertension|HTN]], <br>
❑ '''Past medical history''':[[Parkinsons disease]], autonomic dysfunctions, [[hypertension|HTN]], <br>
❑ '''Medication history''': Medications administered with meal may cause [[hypotension]]. <br>|C02='''Prolonged standing/<br>Stress'''<div style="float: left; text-align: left; width: 20em; padding:1em;">'''History'''<div class="mw-collapsible mw-collapsed">
❑ '''Medication history''': Medications administered with meal that may cause [[hypotension]] <br>|C02='''Prolonged standing/<br>Stress'''<div style="float: left; text-align: left; width: 20em; padding:1em;">'''History'''<div class="mw-collapsible mw-collapsed">
❑ '''Source''':<br>  [[Patient]] and/ or a witness describing the fall.<br>
❑ '''Source''':<br>  [[Patient]] and/ or a witness describing the fall.<br>
❑ '''[[Age]]''': Common among young individuals.<br>
❑ '''[[Age]]''': Common among young individuals.<br>
❑ '''Duration of [[symptoms]]''': Frequency, triggering or relieving factors.<br>
❑ '''Duration of [[symptoms]]''': Frequency, triggering or relieving factors.<br>
❑ '''Associated [[symptoms]]''': Sinking feeling, [[tachycardia]], [[sweating]] [[dizziness]] or [[lightheadedness]], [[nausea]], [[blurred vision]], cold clammy, pale skin and blaxck out preceding [[syncope]] <br>  
❑ '''Associated [[symptoms]]''': Sinking feeling, [[tachycardia]], [[sweating]] [[dizziness]] or [[lightheadedness]], [[nausea]], [[blurred vision]], cold clammy, pale skin and blaxck out preceding [[syncope]] <br>  
❑ '''Systemic review''':<br> [[Cardiovascular system|Cardiovascular]], [[respiratory system|respiratory]], [[renal system|renal]], [[liver|hepatic]], [[Rheumatology|rheumatologic]], [[CNS]] (such as head injury after fall), and [[Gastrointestinal system|GI]] symptoms. <br>
❑ '''Past medical history''': [[Volume loss]], [[malena]].<br>
❑ '''Past medical history''': [[Volume loss]], [[malena]].<br>
❑ '''Medication history''': Assess the use of medications known to cause [[hypotension]] <br>
❑ '''Family history''':A positive family history has been demonstrated in the past and indicated genetic component|C05='''Postural'''<div style="float: left; text-align: left; width: 15em; padding:1em;">'''History'''<div class="mw-collapsible mw-collapsed">
❑ '''Family history''':A positive family history has been demonstrated in the past and indicated genetic component|C05='''Postural'''<div style="float: left; text-align: left; width: 15em; padding:1em;">'''History'''<div class="mw-collapsible mw-collapsed">
❑ '''Source''': [[Patient]] and/ or a witness describing the fall.<br>
❑ '''Source''': [[Patient]] and/ or a witness describing the fall.<br>
❑ '''[[Age]]''': Any age individuals. <br>
❑ '''[[Age]]''': Any age individuals. <br>
❑ Duration of [[syncope]] <br>
❑ Duration of [[syncope]] <br>
❑ '''Associated [[symptoms]]''': [[Dizziness]] or [[lightheadedness]], [[confusion]], [[fatigue]], [[nausea]], [[blurred vision]], cold clammy, and pale skin. <br>
❑ '''Associated [[symptoms]]''': [[Dizziness]] or [[lightheadedness]], [[confusion]], [[fatigue]], [[nausea]], [[blurred vision]], cold clammy, and pale skin, [[visual acuity|Vision]] problems, [[gait]] problems, and [[neck]] pain. <br>  
❑ '''Systemic review''': [[Visual acuity|Vision]] problems, [[gait]] problems, [[neck]] pain, [[Cardiovascular system|cardiovascular]], [[renal system|renal]], and [[Gastrointestinal system|GI]] problems.<br>
❑ '''Past medical history''':[[Diabetes]], [[renal]] problems, [[amyloidosis]], [[heart]] [[disease]],[[hypertension|HTN]], [[autoimmune]] disease, neurodegenerative dosease. <br>
❑ '''Past medical history''':[[Diabetes]], [[renal]] problems, [[amyloidosis]], [[heart]] [[disease]],[[hypertension|HTN]], [[autoimmune]] disease, neurodegenerative dosease. <br>
❑ '''Menstrual history''': [[Menorrhagia]]<br>
❑ '''Menstrual history''': [[Menorrhagia]]<br>
❑ '''Medication history''': [[Beta-blockers]], [[aplha blockers]], [[vasodilators]], and tricyclic antidepressants.<br>
❑ '''Medication history''': [[Beta-blockers]], [[aplha blockers]], [[vasodilators]], and tricyclic antidepressants.<br>
❑ '''Social history''':[[Alcohol]] intake may cause [[dehydration]]. <br>|C03='''History'''<div class="mw-collapsible mw-collapsed"><div style="float: left; text-align: left; width: 20em; padding:1em;">❑ '''Source''': [[Patient]]<br>
❑ '''Social history''':[[Alcohol]] intake may cause [[dehydration]]. <br>|C03='''History'''<div class="mw-collapsible mw-collapsed"><div style="float: left; text-align: left; width: 20em; padding:1em;">❑ '''Source''': [[Patient]]<br>
❑ '''[[Age]]''':<br>  Helps determine age-specific causes, <br>
❑ '''[[Age]]''':<br>  Helps determine age-specific causes. <br>
❑ '''Associated [[symptoms]]''': [[Dizziness]] or [[lightheadedness]], [[syncope]], [[nausea]], [[blurred vision]], cold clammy, pale skin irrespective to change in blood pressure. <br>
❑ '''Associated [[symptoms]]''': [[Dizziness]] or [[lightheadedness]], [[syncope]], [[nausea]], [[blurred vision]]. <br>  
❑ '''Systemic review''':<br> [[Cardiovascular system|Cardiovascular]], [[respiratory system|respiratory]], [[renal system|renal]], [[liver|hepatic]], [[Rheumatology|rheumatologic]], and [[Gastrointestinal system|GI]].<br>
❑ '''Past medical history''':<br> [[Volume loss]], [[malena]].  <br>  }}
❑ '''Past medical history''':<br> [[Volume loss]], [[malena]].  <br>  }}
{{familytree | |!| | | |!| | | |!| | | |!| | | | | }}
{{familytree | |!| | | |!| | | |!| | | |!| | | | | }}
{{familytree | D01 | | D02 | | D03 | | D04 | | | D01='''Physical exam'''<div style="float: left; text-align: left; width: 15em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>
{{familytree | D01 | | D02 | | D03 | | D04 | | | D01='''Physical exam'''<div style="float: left; text-align: left; width: 15em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>
❑ [[Vital signs]]: A decrease in [[systolic blood pressure|systolic BP]] of =/ >20 mm Hg or =/> 90 mm Hg (when the [[systolic blood pressure|systolic BP]] before the meal is > 100mmHg, within 2 hours of the start of the meal.<br>  
❑ [[Vital signs]]: A decrease in [[systolic blood pressure|systolic BP]] of =/ >20 mm Hg or =/> 90 mm Hg (when the [[systolic blood pressure|systolic BP]] before the meal is > 100mmHg, within 2 hours of the start of the meal.<br>  
❑ [[HEENT]], [[Cardiovascular examination|CVS]], [[neurological examination|neuro]], [[Respiratory examination|respiratory]], [[Gastrointestinal system|GI]] exam|D02='''Physical exam'''<div style="float: left; text-align: left; width: 15em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>
❑ [[HEENT]], [[Cardiovascular examination|CVS]], [[neurological examination|neuro]], [[Respiratory examination|respiratory]], [[Gastrointestinal system|GI]] exam|D02='''Physical exam'''<div style="float: left; text-align: left; width: 15em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>
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{{familytree | |!| | | |!| | | |!| | | |!| | | | | }}
{{familytree | |!| | | |!| | | |!| | | |!| | | | | }}
{{familytree | |!| | | |!| | | |!| | | |!| | | | | }}
{{familytree | |!| | | |!| | | |!| | | |!| | | | | }}
{{familytree | E01 | | E02 | | E03 | | E04 | | | E01=Labs<div style="float: left; text-align: left; width: 20em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>[[CBC]] ([[anemia]]<br>[[Glucose]] ([[Hypoglycemia]], [[hyperglycemia]], [[DM]])<br>[[Urinalysis]]<br>[[Blood culture]]<br>[[Cortisol]] ([[Addison's disease]])<br>[[BUN]]<br>[[EKG]]<br>[[Echocardiogram]]<br>[[Stress test]]<br>
{{familytree | E01 | | E02 | | E03 | | E04 | | | E01=Labs<div style="float: left; text-align: left; width: 20em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>[[CBC]]<br>[[Glucose]]/ [[HbA1c]]<br>[[Urinalysis]]<br>[[Comprehensive metabolic panel|CMP]]<br>[[EKG]]<br>[[Stress test]]|E02=Labs<div style="float: left; text-align: left; width: 20em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>[[CBC]] ([[anemia]]<br>[[Glucose]] ([[Hypoglycemia]], [[hyperglycemia]], [[DM]])<br>[[Urinalysis]]<br>[[Blood culture]]<br>[[Cortisol]] ([[Addison's disease]])<br>[[BUN]]<br>[[EKG]]<br>[[Echocardiogram]]<br>[[Stress test]]<br>[[Valsalva maneuver]]|E03=Labs<div style="float: left; text-align: left; width: 20em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>[[CBC]] ([[anemia]]<br>[[Glucose]] ([[Hypoglycemia]], [[hyperglycemia]], [[DM]])<br>[[Urinalysis]]<br>[[Blood culture]]<br>[[Cortisol]] ([[Addison's disease]])<br>[[BUN]]<br>[[EKG]]<br>[[Echocardiogram]]<br>[[Stress test]]<br>[[Valsalva maneuver]]|E04=Labs<div style="float: left; text-align: left; width: 20em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>[[CBC]] ([[anemia]]<br>[[Glucose]] ([[Hypoglycemia]], [[hyperglycemia]], [[DM]])<br>[[Urinalysis]]<br>[[Blood culture]]<br>[[Cortisol]] ([[Addison's disease]])<br>[[BUN]]<br>[[EKG]]<br>[[Echocardiogram]]<br>[[Stress test]]<br>[[Valsalva maneuver]]}}
[[Valsalva maneuver]]|E02=Labs<div style="float: left; text-align: left; width: 20em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>[[CBC]] ([[anemia]]<br>[[Glucose]] ([[Hypoglycemia]], [[hyperglycemia]], [[DM]])<br>[[Urinalysis]]<br>[[Blood culture]]<br>[[Cortisol]] ([[Addison's disease]])<br>[[BUN]]<br>[[EKG]]<br>[[Echocardiogram]]<br>[[Stress test]]<br>[[Valsalva maneuver]]|E03=Labs<div style="float: left; text-align: left; width: 20em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>[[CBC]] ([[anemia]]<br>[[Glucose]] ([[Hypoglycemia]], [[hyperglycemia]], [[DM]])<br>[[Urinalysis]]<br>[[Blood culture]]<br>[[Cortisol]] ([[Addison's disease]])<br>[[BUN]]<br>[[EKG]]<br>[[Echocardiogram]]<br>[[Stress test]]<br>[[Valsalva maneuver]]|E04=Labs<div style="float: left; text-align: left; width: 20em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>[[CBC]] ([[anemia]]<br>[[Glucose]] ([[Hypoglycemia]], [[hyperglycemia]], [[DM]])<br>[[Urinalysis]]<br>[[Blood culture]]<br>[[Cortisol]] ([[Addison's disease]])<br>[[BUN]]<br>[[EKG]]<br>[[Echocardiogram]]<br>[[Stress test]]<br>[[Valsalva maneuver]]}}
{{familytree | |!| | |`| | |!| | | | | | | | | | }}
{{familytree | |!| | | | | |!| | | | | | | | | | }}
{{familytree | |`|-|-| K01 |'| | | | | |K01=[[Tilt table test]]}}
{{familytree | |`|-|-| K01 |'| | | | | |K01=[[Tilt table test]]}}
{{familytree | | | | | |!| | | | | | |}}
{{familytree | | | | | |!| | | | | | |}}
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❑ [[salt|elevated salt intake]] of no more than 10g/day.<br>
❑ [[salt|elevated salt intake]] of no more than 10g/day.<br>
❑ Mainten fluid intake.<br>
❑ Mainten fluid intake.<br>
❑ [[blood sugar|Blood sugar control]]|F03=''Lifestyle Modification'''<div class="mw-collapsible mw-collapsed"><div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[blood sugar|Blood sugar control]]|F03='''Lifestyle Modification'''<div class="mw-collapsible mw-collapsed"><div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ Lifestyle modifications to optimise [[blood pressure]] post meal.<br>
❑ Lifestyle modifications to optimise [[blood pressure]] post meal.<br>
❑ Counsel the [[patient]] and caregiver about the risk and timing post meal.<br>
❑ Counsel the [[patient]] and caregiver about the risk and timing post meal.<br>

Revision as of 20:16, 15 September 2020


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.

Common Causes

The algorithm illustrates common causes of hypotension based upon the etiology.[1][2][3][4]

 
 
 
 
 
 
 
 
Causes of hypotension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Vasodilation
 
Neurogenic
Vasovagal syncope/
Neurocardiogenic syncope
❑ Post-parandial hypotension
 
Cardiogenic
 
Orthostatic hypotension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Neurogenic
 
 
 
 
Iatrogenic
 
 
 
 
Non-neurgenic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medications
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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.[5][6][1][7][8][9][10][11][12][13][14][15]


 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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: Parkinsons disease, autonomic dysfunctions, HTN,

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
History

Source: 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, 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.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical exam

Vital signs: 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, GI exam
 
Physical exam

❑ Appearance of the patient:

Vital signs

HEENT, CVS, neuro, respiratory, GI exam
 
Physical exam

❑ Appearance of the patient:

Vital signs

HEENT, CVS, neuro, respiratory, GI exam
 
Physical exam

❑ Appearance of the patient:

Vital signs

HEENT, CVS, neuro, respiratory, GI exam
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Labs
 
Labs
 
Labs
 
Labs
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lifestyle Modification

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

Blood sugar control
 
 
 
Lifestyle Modification

❑ Lifestyle modifications to optimise blood pressure post meal.
❑ 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 meal during hemodialysis.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical therapy
 
 
 
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.
 
 
 
 
 
 
 
 
 
 
 
 

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.

References

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