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hypotension Flashcards

1
Q

what is considered hypotension

A

<90/60

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2
Q

pathophys of hypotension

A
  1. Hypotension reduces blood flow
  2. Decreasing oxygen delivery to organs and tissues
  3. Causing cellular damage and dysfunction.
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3
Q

When oxygen delivery is insufficient to support tissue metabolic requirements, a person is said to be in what state?

A

circulatory shock

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4
Q

Arterial pressure is determined by:
(3)

A

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

Any reduction in these variables can lead to hypotension

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5
Q

causes of hypotension

A
  1. cardiogenic
    - Acute coronary syndrome
    - Arrhythmias
    - Cardiomyopathy
    - Congestive heart failure
    - Valvulopathy
    - Pulmonary embolism
    - Pulmonary hypertension
    - Cardiac tamponade
    - Tension pneumothorax
  2. hypovolemia
    - Hemorrhage
    - Dehydration
    - Dialysis
  3. orthostatic
  4. sepsis
  5. endocrinologic
    - Adrenal insufficiency
    - Diabetes
    - Hypothyroidism
  6. vascular
    - Aortic dissection or rupture
    - Peripheral vascular dz
    - Pulmonary embolism
  7. drugs
    - Alcohol
    - Anesthesia
    - Antidepressants
    - Antihypertensives
    - Antipsychotics
    - Anxiolytics
    - General anesthesia
    - Narcotics
  8. neurogenic
    - Age-related
    - Medullary stroke
    - Parkinsonism
    - Postprandial
    - Peripheral neuropathy
    - Syphilis
    - Vasomotor - Emotional, Micturition
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6
Q

Important Historical Information to ask for hypotension

A

Acute change in BP?
Precipitating events/symptoms?
Medications, including any recent changes?
Pre-existing medical conditions?
Are they symptomatic?

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7
Q

sx of hypotension

A

Depends on the patient, underlying cause, existing comorbidities, age, etc.
1. Lightheadedness, dizziness, HA
2. Syncope
3. Nausea
4. Confusion, Fatigue
5. chest pain
6. SOB
7. blurred vision

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8
Q

signs of hypotension

A

Bradycardia or Tachycardia
Skin - Pallor, Diaphoresis, Cool/clammy, Prolonged capillary refill
Altered LOC
Other signs depend on underlying mechanism

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9
Q

diagnostic testing/labs for hypotension

A

Testing should reflect your differential diagnosis!!
EKG
CBC, CMP, UA
Echocardiogram
Urine drug screen
CT head

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10
Q

management for hypotension

A

Depends on the underlying cause and patient presentation!
Typically, IV bolus of normal saline

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11
Q

Described as a drop in blood pressure upon standing, leading to symptoms of hypotension

A

Orthostasis or Postural hypotension

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12
Q

Orthostatics can occur due to ?

A

impairment of autonomic reflexes
volume depletion
Occurs more frequently in the elderly

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13
Q

criteria for orthostatic hypotension

A
  1. 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
  2. Usually occurs within 2 to 5 minutes

However, delayed orthostasis may occur after 5 or even 10 minutes

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14
Q

Normal BP Response to Standing

A

Rapid decrease in venous return and cardiac output
Detected by baroreceptors in carotids

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15
Q

Standing stimulates sympathetic nervous system to: (3)

A
  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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16
Q

causes of orthostatics

A
  1. Prolonged lying or sitting
  2. Volume depletion
  3. Autonomic failure
  4. Neurodegenerative disease, such as Parkinson’s
  5. Neuropathies, as a result of DM, B12 deficiency, amyloidosis, sarcoidosis, Lyme disease
  6. Med SE - peripheral vasodilation, autonomic dysfunction, volume depletion
  7. Aging - Due to a decrease in baroreceptor sensitivity
  8. Adrenal insufficiency
  9. Cardiogenic
    - CHF
    - AS
    - Arrhythmias
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17
Q

medications that cause orthostatics

A
  1. alpha-1 antagonists - terazosin, prazosin, doxazosin
  2. antiHTN - ACEi BB, clonidine
  3. diuetics - loops, HCTZD
  4. phosphodiesterase type 5 inhibitors - sildenafil, vardenafil
  5. antidepressants - TCA, trazodone, MAOi
  6. opioids - morphine, oxycodone, tramadol
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18
Q

sx of orthostatics

A
  1. Vary in severity
    - Result of hypoperfusion to the brain
  2. Classic symptoms include:
    - Generalized weakness
    - Dizziness or lightheadedness
    - Blurry vision or darkening of the visual fields
    - Syncope
  3. Atypical presentations include:
    - Fatigue, cognitive slowing and nausea
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19
Q

ways to evaluate orthostatics

A
  1. Bedside tilt test /Orthostatic BP measurement
  2. Formal tilt table test
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20
Q

how to perform tilt table testing

A
  1. Pt lie down on a special bed/table
  2. IV line to inject medicine and to give IV fluids, if needed.
  3. ECG electrodes, BP cuff for monitoring (can use Arterial line of needed) and straps across chest and legs
  4. bed raised to an almost standing angle
  5. Pt will remain upright for up to 45 minutes to determine if sx occur
  6. If no sx, meds (NTG Sublingual or IV) is given to increase HR. This is given while laying flat.
  7. After the meds is given (if needed), pt will be tilted upright and monitored for sx
  8. pt is lowered to a flat position and allowed to rest. HR and BP will be monitored.
21
Q

diagnostic evaluation for othostatics

A

Remaining testing should be focused on identifying treatable conditions:
CBC, BMP
EKG
EMG

22
Q

Over how many of patients will have no identifiable cause discovered, even after an extensive work-up.

A

1/3

23
Q

management for acute orthostatics

A

MC due to volume depletion – IV fluids

24
Q

management for chronic orthostatics

A

sx are managed initially with nonpharmacologic measures, which the patient must strictly adhere to
Pharm therapy is added with severe sx refractory to nonpharmacologic therapies

25
Q

nonpharm management for chronic orthostatics

A
  1. Removal of any causative medication
  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
    — 6-10 g of sodium per day
    — At least 3 L/day
  3. Physical maneuvers:
    - Tensing leg muscles while standing; crossing legs tightly while standing
    - Isometric handgrip when standing
26
Q

pharm management for chronic orthostatics

A
  1. Fludrocortisone (Florinef)
  2. Midodrine (ProAmatine)
    Patients should monitor and record BP at home several times a day, including while lying, sitting and standing
    Elevating the head of the bed to 10-20 degrees may protect the brain when sleeping
27
Q

____, a common result of medications for orthostatics, is a difficult treatment conundrum

A

Supine hypertension

28
Q

drug class of Fludrocortisone (Florinef)

A

Potent mineralocorticoid with high glucocorticoid activity

29
Q

MOA - Promotes increased sodium reabsorption and potassium excretion from renal distal tubules
what drug

A

Fludrocortisone

30
Q

considerations of Fludrocortisone

A
  1. monitored for edema, supine/sitting HTN
  2. BMP in a week to monitor for hypokalemia
  3. d/c is common due to SE, predominantly HTN and edema
31
Q

Midodrine (ProAmatine) drug class

A

Alpha-1 selective adrenergic agonist

32
Q

MOA - Increases peripheral vascular resistance, which increases arteriolar and venous tone, resulting in increased SBP and DBP
Does not cross the blood-brain barrier
Short half-life of 30 minutes, so must be dosed TID
what drug?

A

Midodrine

33
Q

considerations for midodrine

A

Supine hypertension is MC cause of d/c
Other SE include: paresthesias, piloerection, pruritus, GI upset, urinary retention or urgency

34
Q

Another form of orthostatic intolerance, but the hallmark response to standing is an exaggerated increase in heart rate

A

Postural Orthostatic Tachycardia Syndrome (POTS)

35
Q

POTS is MC in who?

A

young patients (14 - 45 yrs)
females (5:1)

36
Q

causes of POTS

A

Distal denervation
Hypovolemia
Venous dysfunction
CV deconditioning
Baroreflex abnormalities
Increased sympathetic activity
Genetic abnormalities
Triggered by infectious illness or post-surgical
Often co-exists with many non-orthostatic symptoms

37
Q

s/s of POTS

A

MC sx (occur with standing):
- Dizziness / Lightheadedness
- Syncope
- Weakness and fatigue
- Blurry vision
Other possible symptoms:
-Nausea, abdominal cramping, diarrhea or constipation

abruptly or insidiously

38
Q

POTS sx can worsen with times of what?

A

dehydration, menstruation, prolonged standing

39
Q

criteria for POTS

A
  1. hx orthostatic intolerance with or without systemic sx
  2. increase in upright HR by >30 bpm (40 bpm for pts <20 y/o) <10 mins of standing/head-up tilt, without orthostatic hypotension
  3. Autonomic testing to correlate sx with HR changes, confirm the diagnosis, and assess the degree of objective signs of orthostatic intolerance
  4. Other diagnostic testing to exclude alternative diagnoses or confounding concomitant conditions
40
Q

gold standard to confirm POTS

A

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

41
Q

diagnostic evaulations for POTS

A

Additional workup geared toward other DDx - autonomic neuropathies, med SE dehydration
CBC, CMP, EKG, and thyroid function tests

42
Q

nonpharm management for POTS

A
  1. Avoid any exacerbating factors
  2. Increase water intake (2 liters per day)
  3. Increase salt intake (3 to 5 grams per day)
  4. Aerobic exercise of the lower extremities / compression stockings
43
Q

pharm tx for POTS

A

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

44
Q

prognosis for POTS

A

most have good prognosis with improved symptoms after 1-2 years

45
Q

Result of the failure of the heart in its function as a pump, resulting in inadequate cardiac output.

A

Cardiogenic Shock

46
Q

MC cause of Cardiogenic Shock

A
  1. Extensive myocardial damage from an acute MI
  2. Mechanical complications of an acute MI - valve lesions, arrhythmias, and cardiomyopathies
47
Q

The principle feature of shock is ___ with ___

A

hypotension
evidence of end-organ hypoperfusion

occurs as a consequence of inadequate cardiac function

48
Q

The classic patient with cardiogenic shock has sx evidence of ___ and ___

A

peripheral vasoconstriction (cool, moist skin)
tachycardia.

49
Q

lab findings for cardiogenic shock

A
  1. Patients with recent or acute MIs
    - Elevations in cardiac-specific enzymes (CK-MB, troponin)
  2. Renal and hepatic hypoperfusion
    - Elevations in serum creatinine
    - elevated AST, ALT
  3. Hepatic congestion or hepatic hypoperfusion
    - Coagulation abnormalities
    - anion gap acidosis
    - elevated serum lactate level

Cardiovascular (24 decks)

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