Hypotension and Shock Flashcards

1
Q

Hypotension diagnostic criteria

A

SBP <90
DBP <60
● May not have any symptoms
● May still have signs/symptoms of hypotension with “normal” BP
● Treat the patient, not the number

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2
Q

Hypotension leads to:

A
  1. Reduced cardiac output
  2. Hypovolemia
  3. Reduced systemic vascular resistance
  4. Vascular obstruction
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3
Q

Nonpathologic Causes of Hypotension

A

Cardiovascular Fitness
Pregnancy
Prolonged bed rest
Alcohol

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4
Q

Presentation of Hypotension

A

Ranges from mild to severe
● Fatigue
● Dizziness
● Lightheadedness
● Headache
● Fading vision (resolves
with lying down)
● Nausea
● Tachycardia
● Syncope
● Confusion
● Pallor
● Diaphoresis
● Shock
● Seizures

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5
Q

Orthostatic Hypotension

A

A significant drop in blood pressure after rising from a seated or supine position

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6
Q

Normal blood pressure response to standing:

A
  1. Blood pools in lower extremities
  2. ↓ venous return to heart
  3. ↓ cardiac output and blood pressure
  4. Triggers ↑ sympathetic and ↓ parasympathetic stimulation
  5. ↑ sympathetic outflow raises peripheral vascular resistance, venous return,
    and cardiac output
  6. Blood pressure normalizes
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7
Q

Orthostatic Hypotension is caused by failure of _____

A

compensatory mechanisms

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8
Q

Risk Factors for Orthostatic Hypotension

A

Baroreflex dysfunction (neurogenic)
Volume depletion

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9
Q

Orthostatic Hypotension presentation

A

● Generalized weakness
● Dizziness/lightheadedness
● Visual blurring or darkening of the visual fields
● Fatigue
● Cognitive slowing
● Leg buckling
● Headache in suboccipital, posterior cervical, and
shoulder region
● Rarely MI or stroke

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10
Q

Orthostatic Hypotension diagnosis

A

● Detailed medication list, prescription and
nonprescription
● Recent medical history of potential volume loss
○ Vomiting, diarrhea, fluid restriction, fever?
● Medical history of congestive heart failure,
malignancy, diabetes, alcoholism?
● Neurologic history and examination

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11
Q

Taking Orthostatic blood pressure:

A

Compare blood pressure in supine and standing positions
1. Have the patient lie down for 5 minutes
2. Measure supine blood pressure and heart rate
3. Have the patient stand up
4. Measure standing blood pressure and heart rate at 1 and 3 minutes

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12
Q

Orthostatic Hypotension =

A

A reduction of 20 mmHg or more in systolic pressure
A reduction of 10 mmHg or more in diastolic pressure

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13
Q

T/F Heart rate should rise to compensate for postural reduction in blood pressure

A

T

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14
Q

If HR doesn’t increase, suspect ____

A

neurogenic orthostatic hypotension

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15
Q

Orthostatic Hypotension labs/diagnosis

A

● Labs (hematocrit, electrolytes, BUN,
creatinine, glucose, ferritin)
● EKG to r/o underlying heart disease
● Continuous BP monitoring (helpful for
immediate orthostatic hypotension)
● Tilt-table testing (helpful for delayed
orthostatic hypotension)

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16
Q

Orthostatic Hypotension treatment

A

No specific target BP. Goal is to prevent or reduce symptoms.
● Discontinue or reduce exacerbating
medications
● Increase salt and water intake
● Use compression socks and
abdominal binders
Modify daily activities and lifestyle

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17
Q

Lifestyle modifications for Orthostatic Hypotension

A

● Stand up slowly, in stages
● Avoid Valsalva-like maneuvers
● Avoid overheating (hot weather,
showers, saunas)
● Tense legs and contract abdominal
and buttock muscles while actively
standing
● Cross legs while standing
● Sleep w/ head of bed elevated
30-45 degrees
● Regular exercise to increase
cardiovascular fitness

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18
Q

Pharmacologic therapy for Orthostatic Hypotension

A

● Fludrocortisone (1st line)
○ Synthetic mineralocorticoid
○ Increase water and sodium
reabsorption
○ Increases intravascular volume
● Sympathomimetic agents
○ midodrine, droxidopa
● Atomoxetine
● 2nd line
○ Combo of medications
○ venlafaxine
○ pyridostigmine
○ erythropoietin
○ NSAIDs

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19
Q

Orthostatic Hypotension complications

A

● Falls
● Cardiovascular disease
● Congestive heart failure
● Atrial fibrillation

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20
Q

Vasovagal Hypotension

A

Neural reflex results in self-limited systemic hypotension characterized by bradycardia
and/or peripheral vasodilation/venodilation

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21
Q

Most common cause of syncope

A

Vasovagal Hypotension

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22
Q

Vasovagal Hypotension presentation

A

● Common prodrome: Nausea, pallor,
diaphoresis
○ Caused by increased vagal tone
● Lightheadedness
● A feeling of being warm or cold
● Palpitations
● Fatigue after recovery

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23
Q

Vasovagal Hypotension diagnosis

A

● In most cases, history and symptoms
are enough to establish diagnosis
● Physical exam usually normal
● BUT EVERYBODY GETS AN EKG

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24
Q

What history information do we need about Vasovagal Hypotension?

A

● Number, frequency, and duration of episodes
● Associated symptoms preceding syncope
● Patient position at the time of syncope
● Triggers or provocative factors
● Associated symptoms following syncope
● Witnessed signs
● Preexisting medical conditions, medications, and
family history
● Symptoms after recovery

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25
Q

Shock = ____

A

Hypoperfusion
1. Cardiogenic shock
2. Distributive shock
3. Hypovolemic shock
4. Obstructive shock

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26
Q

Shock S/S

A

● Pt may appear obtunded or
lethargic
● SBP<90
● Tachycardia
● Confusion
● Pallor
● Decreased urinary output
● Weak peripheral pulses
● Cool, moist extremities
● Metabolic acidosis

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27
Q

Shock diagnosis

A

● CBC, electrolytes, glucose, ABGs, coagulation panel,
lactic acid, type and cross-match, blood cultures, UA
● EKG
● Chest x ray
● Echocardiogram

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28
Q

Shock treatment

A

● Depends on the cause
● ABCs
● Fluid resuscitation
● Cardiac monitoring
● Monitor urine output

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29
Q

Cardiogenic Shock

A

● Heart is unable to maintain
adequate cardiac output
● Results in hypotension and
tissue hypoperfusion
Nearly 50% of patients do not survive

30
Q

_____ most common of cardiogenic shock

A

Myocardial infarction

31
Q

Causes of cardiogenic shock

A

● Refractory arrhythmias
● End-stage cardiomyopathies
○ Ischemic, valvular, hypertrophic,
restrictive, idiopathic
● Acute myocarditis
○ Infectious, toxic, rheumatologic,
idiopathic
● Stress cardiomyopathy
● Endocrine abnormalities
○ Hypothyroidism, pheochromocytoma
● Trauma

32
Q

Cardiogenic Shock history info

A

● Chest pain (if ischemic cause)
● Dyspnea
● Orthopnea
● Fatigue
● Malaise
● Low appetite
● Any of the previously
mentioned conditions

33
Q

Physical exam for Cardiogenic Shock

A

● Lung crackles (pulmonary edema)
● JVD
● Heart murmur
● Peripheral edema

34
Q

Cardiogenic Shock labs

A

● Elevated cardiac enzymes if MI (CPK-MB, troponins)
● Elevated creatinine, ALT, AST if renal/hepatic
hypoperfusion
● Coagulation abnormalities if hepatic congestion or
hypoperfusion
● Anion gap acidosis, ↑Serum lactate, ↑BNP
EKG
● Evidence of old or new infarctions
● Arrhythmias

35
Q

Echo use in Cardiogenic shock

A

● Very useful!
● Look for mechanical complications of
infarction
● Ventricle size/function
● Valve function
● Pericardial fluid/tamponade

36
Q

CXR use in Cardiogenic shock

A

● Findings may or may not be present
● Cardiomegaly
● Pulmonary congestion

37
Q

Coronary angiography use in cardiogenic shock

A

● Immediately if evidence of MI
● Identifies blockage and allows for
treatment planning

38
Q

Cardiogenic Shock treatment

A

● Cardiac catheterization w/ revascularization if indicated. DO NOT DELAY
● Vasopressors/inotropes (Examples?)
● Mechanical circulatory support
○ Intra-aortic balloon pump, microaxial pump, ECMO
● Ventricular Assist Device
● Heart transplant
Determine cause first, then target treatment!

39
Q

Distributive Shock

A

Reduction in systemic vascular resistance
results in inadequate cardiac output and
tissue hypoperfusion despite normal
circulatory volume.

40
Q

Causes of Distributive Shock

A

● Septic shock
● Neurogenic shock
● Anaphylactic shock
● Endocrine shock

41
Q

Physical exam of Distributive Shock

A

● Extremities initially warm before becoming cool
● Wide pulse pressure
● Abnormal heart sounds
● Lactic acidosis - septic
● Evidence of CNS injury - neurogenic

42
Q

Septic shock =

A

sepsis + fluid unresponsive hypotension + serum lactate level > 2 mmol/L
+ need vasopressors to keep MAP > 65 mm Hg

43
Q

Most common cause of distributive
shock

A

Sepsis

44
Q

Distributive Shock - Septic treatment

A

● ABCs
● Fluid resuscitation
● Empiric antibiotics
○ Within the first hr
○ After cultures obtained
● Vasopressors

45
Q

Distributive Shock - Other causes

A

Neurogenic shock
● Spinal cord injury
● Epidural or spinal anesthetic
Drug and toxin-induced shock
● Drug overdose
● Snake bites
Anaphylactic Shock
● IgE mediated
Endocrine shock
● Adrenal insufficiency

46
Q

Hypovolemic Shock

A

Volume is too low!
● Loss of blood
○ Trauma
○ GI bleed
● Loss of fluids/electrolytes
○ Vomiting
○ Diarrhea
○ Other dehydration

47
Q

Hypovolemic Shock treatment

A

● Stop the fluid loss
● Replace volume (fluids, blood transfusion)

48
Q

Obstructive Shock

A

Pump failure due to
EXTRACARDIAC cause!
● Usually associated with poor
right ventricular output
● Pulmonary embolism,
cardiac tamponade, tension
pneumothorax, severe
vasoconstriction

49
Q

Treatment of Obstructive Shock

A

Treatment = Remove the obstruction

50
Q

Phenylephrine MOA

A

● Alpha-1 agonist
● Causes vasoconstriction
● Sympathomimetic

51
Q

Phenylephrine indications

A

● Hypotension
● Shock
● Priapism
● Post-resuscitation stabilization
● PSVT conversion
● Nasal congestion (not IV form)

52
Q

Phenylephrine contraindications

A

● Uncontrolled hypertension
● Ventricular tachycardia
● CAD
● Arrhythmias
● Bradycardia

53
Q

Phenylephrine adverse effects

A

● Cardiac arrhythmias
● Severe hypertension

54
Q

Vasopressin MOA

A

● Stimulates AVPR1 (V1) and AVPR2 (V2
receptors
● Causes vasoconstriction and antidiuresis
● Also causes smooth muscle contraction
in the GI tract

55
Q

Vasopressin indications

A

● Shock (specifically septic and other
vasodilatory shocks)
● Central diabetes insipidus (off label)

56
Q

Vasopressin pearls

A

● May cause reversible diabetes
insipidus after tx d/c, monitor
closely

57
Q

Dobutamine MOA

A

● Stimulates beta-1 adrenergic receptors
● Chronotropic and inotropic effect
● Some vasodilation

58
Q

Dobutamine Indications

A

● Shock (add if vasopressors don’t work)
● Acute decompensated heart failure
● Stress echocardiography

59
Q

Dobutamine contraindications

A

● Hypertrophic
cardiomyopathy w/ outflow
obstruction
● HTN

60
Q

Dopamine MOA

A

● Stimulates alpha and beta-1 adrenergic
and dopaminergic receptors
● Inotropic and chronotropic effects
● Renal/splanchnic vasodilation (low dose)
● High doses have pressor effects

61
Q

Dopamine indications

A

● Hypotension, shock (not 1st line)
● Bradycardia (ACLS)
● Symptomatic AV block

62
Q

Dopamine BBW

A

Black Box Warning: If
extravasation occurs, infiltrate
the area with diluted
phentolamine as soon as
possible to prevent necrosis

63
Q

Epinephrine MOA

A

● Stimulates alpha and beta adrenergic receptors
● Sympathomimetic
● Cardiac stimulation, relaxation of bronchial
smooth muscle, vasoconstriction

64
Q

Epinephrine Indications

A

● Hypotension, shock (septic, anaphylactic
especially)
● Symptomatic bradycardia or AV block (ACLS)
● Cardiac arrest (ACLS)

65
Q

Epinephrine Contraindications

A

● No absolute contraindications
in life-threatening situation

66
Q

Norepinephrine MOA

A

● Stimulates alpha and beta-1 adrenergic
receptors
● Inotropic effect and vasoconstriction

67
Q

Norepinephrine indications

A

● Cardiogenic shock
● Septic and other vasodilatory shocks
● Fluid-resistant hypotension/shock
● Post-cardiac arrest shock

68
Q

Midodrine MOA

A

● Stimulates alpha-1 adrenergic receptors
● Increases arteriolar and venous tone
● Raises standing, sitting, and supine
systolic and diastolic blood pressure

69
Q

Midodrine Indications

A

● Orthostatic hypotension
● POTS
● Vasovagal syncope
● Prevention of hemodialysis-induced
hypotension

70
Q

Midodrine adverse effects

A

● Severe bradycardia
● Visual field defect
● Erythema multiforme
● Severe supine HTN

71
Q

Midodrine BBW

A

Black box warning: can cause
marked supine blood pressure
elevation; use in pts whose lives
are considerably impaired
despite standard clinical care…