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], 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

 
 
 
 
 
 
 
 
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.


 
 
 
 
 
 
 
Systolic BP < 90mmHg
Or
Diastolic BP < 60mmHg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Reassess B.P
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnosis of hypotension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Syncope/ fall/ dizziness
 
 
 
 
 
Asymptomatic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Post-meal
History

 
 
 
Upon standing up
History

 
 
History
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Labs and tests
 
 
 
 
 

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.

References

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