Hypotension Flashcards
What is considered hypotension?
<90/60
Treat the patient though, not the number!
Using a patient-approach, what should you consider for hypotension?
Is this low for them?
Are they having s/s of hypotension?
Is this an acute episode?
How long have you been symptomatic?
What is the patient’s baseline?
Showing signs of hypoperfusion?
What is the CC of the patient (is it related to their BP)?
When is hypotension considered pathologic?
If the patient is symptomatic
Describe the pathophysiology that leads to circulatory shock
- Lower BP
- Decrease O2 delivery
- Cellular dmg
- Inability to meet metabolic demands
What is arterial pressure determined by?
1)cardiac outpu
2)venous pressure
3)systemic vascular resistance
Any reduction in these variables can lead to hypotension.
What can cause hypotension?
Cardiogenic
Hypovolemia
Orthastasis
Sepsis
Endo (aldosterone def, diabetes typically autonomic neuropathy)
Vascular (PE, aortic disection)
Drug induced
Neurogenic (vasomotor emotional, micturition gets up to pee and then passes out men)
Why does micturition lead to hypotension in older men sometimes
Get up to pee, and stand up
What is concerning for sepsis?
FEVER + hypotension = worrisome for sepsis
What patient history is important?
What brought this on?
What events could have caused this
Medications
Pre-existing medical conditions
Are they symptomatic
What are the symptoms of hypotension
Lightheadedness, dizziness, syncope (d/t decreased perfusion to brain)
Nausea
Confusion
Fatigue
These are d/t hypoperfusion to brian, organs, and skin and vary based on what cause the episode, their age, health
What are the PE do you do for hypotension?
Vitals
Skin (decreased perfusion, clammy skin, decreased capillary refill, pail)
Neurologic
Heart
Lungs
Abdomen
Vascular
What vitals do you look for in hypotension?
Bradycardia or Tachycardia
What do you look for in skin for hypotension?
Pallor
Diaphoresis
Cool, clammy
Prolonged capillary refill
What do you look for in neuro for hypotension?
Altered LOC (level of consciousness)
What 3 s/s overlaps in hypo and hypertension
Dizziness
Blurred vision
Nausea
What diagnostic testing do you order for hypotension?
Based on dx
EKG (if heart problems)
echocardiogram (valves)
CBC (losing blood ask if there are stools)
CMP
UA
Urine drug screen
CT head (if AMS)
How do you manage hypotension initially?
Most (even heart attack patients) are first managed with NS
How do you manage hypovolemic patient
Fluids
How do you manage septic?
Fluids and then antibiotics
How do you manage aortic dissection patient?
Massive fluids and ER referral
Who do we need to make sure to be careful to give NS?
HF patients because we are worried about fluid overload (d/t inability to pump blood around body)
What is orthostatic hypotension and the BP readings? How long does it take to occur?
Drop of one or both of the following upon standing from a lying position:
At least a 20 mmHg fall in SBP
At least a 10 mmHg fall in DBP
Usually occurs within 2 to 5 minutes
What can cause orthostatic hypotension? Who does it MC in and why?
Impaired autonomic reflexes
Volume depletion
MC in elderly d/t impaired baroreceptors
What is your normal response to standing?
Rapid decrease in venos return and CO detected to baroreceptors, leading to:
- Increase heart rate
- Increase peripheral vascular resistance
- Therefore, increasing cardiac output and limiting the actual drop in SBP
Where are baroreceptors located?
In the carotids
What typically causes orthostatic hypotension?
Prolonged lying or sitting
Volume depletion (from sweating)
Autonomic failure (especially in elderly)
Neurodegenerative disease, such as Parkinson’s
Neuropathies, as a result of DM, B12 deficiency, amyloidosis, sarcoidosis, Lyme disease
Medications:
A common side effect due to a variety of mechanisms, including peripheral vasodilation, autonomic dysfunction, and volume depletion
What are the HTN meds that can cause orthostatic hypotension?
Alpha-1 antagonists
Anti-HTN (BB, clonidine)
Diuretics
Antidepressants (tricylics, MAOIs)
Opioids
How does aging lead to orthostatic hypotension?
Due to a decrease in baroreceptor sensitivity
What adrenal insufficiency leads to orthostatic hypotension?
Aldosterone insufficiency, leading to inability to retain fluid
What are the symptoms of orthostatic hypotension and how do they improve?
Vary in severity
Result of hypoperfusion to the brain
Classic symptoms include:
Generalized weakness
Dizziness or lightheadedness
Blurry vision or darkening of the visual fields
Syncope
What r/o orthostatic hypotension?
Symptoms while lying down
How do you evaluate orthostatic hypotension?
Laying down, sitting up, standing
Bedside tilt test /Orthostatic BP measurement (Immediately, at 2 minutes, and at 5 minutes)
If a bedside tilt test is not dx for orthostatic hypotension, what do you do?
Tilt table testing
Describe the tilt table testing
Pt will lie down on a special bed or table.
IV line to inject medicine and to give IV fluids, if needed.
ECG electrodes, BP cuff for monitoring (can use Arterial line of needed) and straps across chest and legs
Pt will lie flat on the bed initially, then raised to an almost standing angle while on the bed.
Pt will remain upright for up to 45 minutes to determine if symptoms such as dizziness, fainting, low heart rate, or low blood pressure occur.
If there are no symptoms in tilt table testing, what do you do?
If no symptoms occur, medication (NTG Sublingual or IV) is given to increase HR. This is given while laying flat.
After the medicine is given (if needed), pt will be tilted upright and monitored for symptoms of dizziness, fainting, low heart rate, or low blood pressure.
Once enough information is obtained, pt is lowered to a flat position and allowed to rest. HR and BP will be monitored.
When stable, the IV line, blood pressure cuff, and ECG electrodes are removed and test is complete.
What is the remaining testing of orthostatic hypotension?
CBC, BMP
EKG
EMG
Over 1/3 of patients will have no identifiable cause discovered, even after an extensive work-up :(
Management of acute orthostasis
IV fluids
Management of chronic orthostasis
symptoms are managed initially with nonpharmacologic measures, which the patient must strictly adhere to
What is the nonpharmacologic management of chronic orthostatic patients
- Removal of any causative medication if possible
- Lifestyle modifications:
Get up slowly
Straining, coughing and exertion in hot weather can exacerbate sx’s
Maintain hydration
Elastic compression stockings
Increase salt and water intake
6 to 10 g of sodium per day
At least 3 liters of water a day - Physical maneuvers:
Tensing leg muscles while standing; crossing legs tightly while standing
Isometric handgrip when standing
What are the 2 meds for hypotensive patients?
Fludrocortisone
Midodrine
ONLY IF SEVERELY EFFECTING THEIR LIFE
What is the MOA of fludrocortisone?
Promotes increased sodium reabsorption and potassium excretion from renal distal tubules
What are the SE of fludrocortisone?
Edema (too much fluid)
Hypokalemia (BMP weekly)
What is the MOA midodrine and why is it not preferred?
Increases peripheral vascular resistance, which increases arteriolar and venous tone, resulting in increased SBP and DBP
Does not cross the blood-brain barrier
Must be taken 3 times a day
What are the SE of midodrine?
paresthesias, piloerection (goose bumps), pruritus, GI upset, urinary retention or urgency
What does POTS stand for and what is the difference between this and orthostasis?
Postural Orthostatic Tachycardia Syndrome
It is d/t to exaggerated increase in HR
Who is the classic patient of POTS?
Teenaged female
What is the etiology of POTS?
Not well understood! Multifactorial
Distal denervation
Hypovolemia
Venous dysfunction
Cardiovascular deconditioning
Baroreflex abnormalities
Increased sympathetic activity
Genetic abnormalities
Why does Cardiovascular deconditioning lead to POTS?
Less prone to exercise d/t symptoms, which weakens heart, worsening POTS through
What can trigger POTS?
STRESS
infection
heat
surgery
SITS on POTS triggers
What are the symptoms of POTS?
Dizziness, lightheaded
Syncope
Weakness/fatigue
Blurry vision
Nausea, abdominal cramping, diarrhea
What is the diagnostic criteria of POTS?
Correlation of symptoms with a SUSTAINED increase in upright heart rate by at least 30 beats/minute (40 beats/minute for patients under the age of 20 years) within 10 minutes of standing or head-up tilt, without orthostatic hypotension
What is the gold-standard of dx POTS?
Formal tilt table test
Must see a sustained increase in HR of greater than 30 bpm OR
An increase to 120 bpm or higher in the first 10 minutes of the test
There should be no drop in blood pressure
What additional labs should you order for POTS?
Basic workup
Initial evaluation, due to vague symptoms, should include CBC, CMP, EKG, and thyroid function tests
How do you manage non-therapeutic POTS?
No one therapy is proven to be better
- avoid setting it on
- increase water intake
- increase salt intake
- seated aerobic exercise
- sleep with elevated bed
- physical maneuvers
What are the pharm treatments of POTS?
Fludrocortisone
Midodrine
Beta blockers, such as Propranolol (20 to 30 mg tid or qid)
SSRI/SNRI – rarely used but have been shown to be beneficial in some
Trial and error :(
Prognosis – most patients have good prognosis with improved symptoms after 1-2 years
What are the 4 classification of shock?
Distributive
Cardiogenic
Hypovolemic
Obstructive
Can also be mixed or unknown
What is the mortality of cardiogenic shock?
50% :(
What causes cardiogenic shock and the MC of this?
Result of the failure of the heart in its function as a pump, resulting in inadequate cardiac output.
MI is MC
Other than MI, what can cause cardiogenic shock?
Cardiomyopathies
Infectious myocarditis
Stress cardiomyopathy (sadness):
Postraumatic
Medication
What is the priniciple feature of cardiogenic shock?
hypotension with evidence of end-organ hypoperfusion
What is the classic patient with cardiogenic shock?
peripheral vasoconstriction (cool, moist skin) and tachycardia.
What is the vicious cycle of cardiogenic shock?
What are the lab findings of cardiogenic shock?
Patients with recent or acute
MIs
Elevations in cardiac-specific enzymes (CK-MB, troponin)
Renal and hepatic hypoperfusion
Elevations in serum creatinine and in AST, ALT
Hepatic congestion or hepatic hypoperfusion
Coagulation abnormalities may be present. An anion gap acidosis may be present, and the serum lactate level may be elevated.
Management of cardiogenic shock
Electrocardiogram
Chest radiography
Labs: CBC etc
Treatment of cardiogenic shock
ABC Airway, breathing,
Ms. M is a 70-year-old woman who arrives at the emergency department complaining of shortness of breath and dizziness.
On physical exam, her pulse is 105 bpm, BP 75/45 mm Hg, and her skin exam is notable for hives. She is warm and has bounding pulses. The patient recently underwent surgery to have a mechanical mitral valve placed and took amoxicillin for the first time as prophylaxis for an upcoming dental procedure.
What is at the top of your dx?
What should you give her?
Anaphylactic shock d/t new meds
Administer EPI
Mrs. G is a 24 y/o female with 2 children. She comes to the clinic today with the CC of “I feel like I am in a brain fog.”
What are we going to be asking for ROS survey?
What should we order?
Sleep
When does it happen
Thyroid disease
Depression /anxiety
Dehydration
Medications she on
Should order thyroid studies, CBC,
Pt is a 16 y/o male brought it by his mom.
States he has been nauseated and light headed all morning and feels like his “heart is racing” at times. He also ℅ headache.
Vitals:
Temp: 98.6 HR: 90 RR: 16 BP: 80/55
Upon further questioning….
Pt states he started football 2 a days this past week.
On PE:
Pt appears pale and diaphoretic
Heart: tachycardic
Lungs: WNL
Abdomen: WNL
Neurovascular: WNL
What is the top of dx?
Hypotension d/t dehydration
No diagnostics warranted
