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Hypotension Flashcards

1
Q

What is considered hypotension?

A

<90/60

Treat the patient though, not the number!

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2
Q

Using a patient-approach, what should you consider for hypotension?

A

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)?

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3
Q

When is hypotension considered pathologic?

A

If the patient is symptomatic

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4
Q

Describe the pathophysiology that leads to circulatory shock

A
  1. Lower BP
  2. Decrease O2 delivery
  3. Cellular dmg
  4. Inability to meet metabolic demands
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5
Q

What is arterial pressure determined by?

A

1)cardiac outpu
2)venous pressure
3)systemic vascular resistance

Any reduction in these variables can lead to hypotension.

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6
Q

What can cause hypotension?

A

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)

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7
Q

Why does micturition lead to hypotension in older men sometimes

A

Get up to pee, and stand up

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8
Q

What is concerning for sepsis?

A

FEVER + hypotension = worrisome for sepsis

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9
Q

What patient history is important?

A

What brought this on?
What events could have caused this
Medications
Pre-existing medical conditions
Are they symptomatic

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10
Q

What are the symptoms of hypotension

A

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

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11
Q

What are the PE do you do for hypotension?

A

Vitals
Skin (decreased perfusion, clammy skin, decreased capillary refill, pail)
Neurologic
Heart
Lungs
Abdomen
Vascular

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12
Q

What vitals do you look for in hypotension?

A

Bradycardia or Tachycardia

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13
Q

What do you look for in skin for hypotension?

A

Pallor
Diaphoresis
Cool, clammy
Prolonged capillary refill

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14
Q

What do you look for in neuro for hypotension?

A

Altered LOC (level of consciousness)

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15
Q

What 3 s/s overlaps in hypo and hypertension

A

Dizziness
Blurred vision
Nausea

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16
Q

What diagnostic testing do you order for hypotension?

A

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)

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17
Q

How do you manage hypotension initially?

A

Most (even heart attack patients) are first managed with NS

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18
Q

How do you manage hypovolemic patient

A

Fluids

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19
Q

How do you manage septic?

A

Fluids and then antibiotics

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20
Q

How do you manage aortic dissection patient?

A

Massive fluids and ER referral

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21
Q

Who do we need to make sure to be careful to give NS?

A

HF patients because we are worried about fluid overload (d/t inability to pump blood around body)

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22
Q

What is orthostatic hypotension and the BP readings? How long does it take to occur?

A

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

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23
Q

What can cause orthostatic hypotension? Who does it MC in and why?

A

Impaired autonomic reflexes
Volume depletion

MC in elderly d/t impaired baroreceptors

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24
Q

What is your normal response to standing?

A

Rapid decrease in venos return and CO detected to baroreceptors, leading to:

  1. Increase heart rate
  2. Increase peripheral vascular resistance
  3. Therefore, increasing cardiac output and limiting the actual drop in SBP
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25
Where are baroreceptors located?
In the carotids
26
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
27
What are the HTN meds that can cause orthostatic hypotension?
Alpha-1 antagonists Anti-HTN (BB, clonidine) Diuretics Antidepressants (tricylics, MAOIs) Opioids
28
How does aging lead to orthostatic hypotension?
Due to a decrease in baroreceptor sensitivity
29
What adrenal insufficiency leads to orthostatic hypotension?
Aldosterone insufficiency, leading to inability to retain fluid
30
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
31
What r/o orthostatic hypotension?
Symptoms while lying down
32
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)
33
If a bedside tilt test is not dx for orthostatic hypotension, what do you do?
Tilt table testing
34
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.
35
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.
36
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 :(
37
Management of acute orthostasis
IV fluids
38
Management of chronic orthostasis
symptoms are managed initially with nonpharmacologic measures, which the patient must strictly adhere to
39
What is the nonpharmacologic management of chronic orthostatic patients
1. Removal of any causative medication if possible 2. 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 3. Physical maneuvers: Tensing leg muscles while standing; crossing legs tightly while standing Isometric handgrip when standing
40
What are the 2 meds for hypotensive patients?
Fludrocortisone Midodrine ONLY IF SEVERELY EFFECTING THEIR LIFE
41
What is the MOA of fludrocortisone?
Promotes increased sodium reabsorption and potassium excretion from renal distal tubules
42
What are the SE of fludrocortisone?
Edema (too much fluid) Hypokalemia (BMP weekly)
43
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
44
What are the SE of midodrine?
paresthesias, piloerection (goose bumps), pruritus, GI upset, urinary retention or urgency
45
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
46
Who is the classic patient of POTS?
Teenaged female
47
What is the etiology of POTS?
Not well understood! Multifactorial Distal denervation Hypovolemia Venous dysfunction Cardiovascular deconditioning Baroreflex abnormalities Increased sympathetic activity Genetic abnormalities
48
Why does Cardiovascular deconditioning lead to POTS?
Less prone to exercise d/t symptoms, which weakens heart, worsening POTS through
49
What can trigger POTS?
STRESS infection heat surgery SITS on POTS triggers
50
What are the symptoms of POTS?
Dizziness, lightheaded Syncope Weakness/fatigue Blurry vision Nausea, abdominal cramping, diarrhea
51
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
52
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
53
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
54
How do you manage non-therapeutic POTS?
No one therapy is proven to be better 1. avoid setting it on 2. increase water intake 3. increase salt intake 4. seated aerobic exercise 5. sleep with elevated bed 6. physical maneuvers
55
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
56
What are the 4 classification of shock?
Distributive Cardiogenic Hypovolemic Obstructive Can also be mixed or unknown
57
What is the mortality of cardiogenic shock?
50% :(
58
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
59
Other than MI, what can cause cardiogenic shock?
Cardiomyopathies Infectious myocarditis Stress cardiomyopathy (sadness): Postraumatic Medication
60
What is the priniciple feature of cardiogenic shock?
hypotension with evidence of end-organ hypoperfusion
61
What is the classic patient with cardiogenic shock?
peripheral vasoconstriction (cool, moist skin) and tachycardia.
62
What is the vicious cycle of cardiogenic shock?
63
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.
64
Management of cardiogenic shock
Electrocardiogram Chest radiography Labs: CBC etc
65
Treatment of cardiogenic shock
ABC Airway, breathing,
66
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
67
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,
68
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

Cardiology (22 decks)

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