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.A difference of 20 mmHg systoloc BP and 10 mmHg diastolic BP is considered orthostatic hypotension (OH). Orthostatic hypotension is the most common type of hypotension. Neurogenic hypotension is demonstrated among 1/3rd of the individuals with OH. A decrease in blood pressure can be life-threatening in conditions such as anaphylaxis and addisonian crisis, and requires prompt management. It is important to access the possibility of head injury in a patient with syncope due to hypotension. ECG is an important and essential component of the evaluation of hypotension. Shock requires prompt management with fluids and vasopressors. For other causes of hypotension identifying the cause and treatment is the best strategy. Lifestyle modifications are usually the first step in management. Medications causing a drop in blood pressure should be discontinued or changed to an appropriate alternative. Monitoring with a cardiac journal and follow up is essential to effective management.

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 ❑Fever ❑ Sepsis ❑ Anaphylaxis ❑ Pregnancy

Cardiogenic ❑ Myocardial infarction ❑ Arrhythmias ❑ aortic stenosis ❑ 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 intravascular volume: Vomiting, diarrhea, Addison's disease ❑ Polyuria such as in diabetes mellitus ❑ Third-spacing: Burns, sepsis ❑ Bleeding: Wounds, menorrhagia

Venous pooling Prolonged bed rest Heat stroke

Others ❑ 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 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: Parkinson disease, autonomic dysfunctions, HTN, diabetic autonomic neuropathy. ❑ 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, and GI exam.

Physical exam ❑ Vital signs ❑ HEENT, CVS, neuro, respiratory, GI exam.

Physical exam ❑ Vital signs Blood pressure: Reduction of at least 20 mm Hg systolic or 10 mm Hg diastolic BP within 3 minutes of erect standing. ❑ HEENT, CVS, neuro, respiratory, GI exam.

Physical exam ❑ Vital signs ❑ HEENT, CVS, neuro, respiratory, GI exam.

Labs ❑ CBC ❑ EKG❑ Serum electrolytes ❑ Glucose/ HbA1c ❑ Urinalysis ❑ CMP ❑ Stress test

Labs CBC Serum electrolytes Glucose Urinalysis Cortisol (Addison's disease) BUN EKG Echocardiogram Stress test

Labs ❑ EKG ❑ CBC ❑ Serum electrolytes ❑ Anemia workup: Serum ferritin, iron binding capacity, reticulocyte count, vitamin B12 and folic acid levels. ❑ Glucose/ HbA1c ❑ Urinalysis ❑ FOBT ❑ CMP ❑ Stress test

Labs ❑ CBC ❑ Serum electrolytes ❑ Urinalysis ❑ Cortisol (Addison's disease) ❑ CMP ❑ EKG ❑ Echocardiogram ❑ Stress test

Tilt table test

Tilt table test positive

Tilt table test negative

Neurocardiogenic syncope Orthostatic hypotension after 3 minutes of standing

Orthostatic hypotension Diagnosed in 1 minute of standing Severity estimated in 2 minutes of standing

Postprandial hypotension

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

Lifestyle Modification ❑ Regular blood pressure monitoring both supine and prone. ❑ Elevated salt intake of no more than 10g/day. ❑ Maintain fluid intake. ❑ Blood sugar control

Lifestyle Modification ❑ 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 hot drinks, hot foods,meals during hemodialysis, and reduce alcohol intake.

Medical therapy ❑ Beta blockers preferred initial treatment ❑ SSRI ❑ Fludrocortisone 0.1mg/day ❑ Midodrine 2.5-10 TID ❑ Scopolamine ❑ Dual chamber pacing may be required.

Medical therapy ❑ Fludrocortisone 0.1-1.0 mg / day ❑ Pyridostigmine bromide ❑ Erythropoietin 50 units/kg S/C thrice a week (monitoring reticulocyte count and [[hematocrit}Hct]])

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.
• Do not forget to follow up with the patient and monitor the blood pressure to titrate the management strategy.