Hypotension - Exam 1

Question 1

What is considered hypotension? What is the formula for BP?

Answer 1

BP is <90/60 mmHg

Blood pressure = cardiac output x systemic vascular resistance

Question 2

Why is hypotension a problem? What is circulatory shock?

Answer 2

extent of the reduction leads to inadequate blood supply to vital organs. This can cause cellular dysfunction and damage.

When oxygen delivery is insufficient to support tissue metabolic requirements

Question 3

What medication class in particular was mentioned as a possible source of hypotension?

Answer 3

anxiolytics!!

Question 4

What 3 questions do we need to ask about specifically when working a pt up for hypotension? Name things that should be included in our ROS

Answer 4

Frequent BP changes?
Recent changes in medications?
Pre-existing medical conditions?

Dizziness, lightheadedness, syncope, nausea, confusion, vision changes, fast/shallow breathing, agitation

Question 5

What are some skin PE findings that would be consistent with hypotension? **What is the major one?

Answer 5

Pallor
Diaphoresis
Prolonged cap refill
**Decreased skin turgor

Question 6

As long as the pt does NOT have pulm edema, CHF or fluid overload, what is the generic tx for hypotension?

Answer 6

treat the underlying cause!!

fluids with NS

Question 7

Define orthostatic hypotension. In a normal person, describe what is happening that keeps BP normal.

Answer 7

Described by a significant reduction in blood pressure that typically occurs upon standing or assuming an upright posture.

In a normal patient, baroreceptors in the carotids would detect a positional change causing HR and vascular resistance to rise leading to BP correction and maintenance.

Question 8

Why is orthostatic hypotension more common in elderly people?

Answer 8

decreased baroreceptor sensitivity

Question 9

What are some common medication classes that cause hypotension?

Answer 9

Question 10

When working a pt up for hypotension, what 2 tests need to be done? What is the difference between the 2 tests? _____ also needs to be included in the measurements

Answer 10

orthostatic vitals and/or bedside tilt

passive vs active patient movement

HR/O2 stats

Question 11

Patients with frequent, very acute changes in BP such as those with suspected baroreceptor insensitivity or vasovagal syncope, consider ______. _______ should also be considered - especially in those with DELAYED symptoms.

Answer 11

continuous BP monitoring

formal tilt test

Question 12

What is the tilt table testing protocol? How long do they need to remain upright after testing?

Answer 12

Pt will lie down on a special bed or table.

IV line to inject medicine and to give IV fluids, if needed (safety).

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/high heart rate, or low/high blood pressure occur.

Question 13

During a tilt table test, the pt does NOT display any symptoms, what happens next?

Answer 13

medication (NTG Sublingual or IV) is given to increase HR.

After the medicine is given (if needed), pt will be tilted upright and monitored for symptoms of dizziness, fainting, low/high heart rate, or low/high blood pressure.

Question 14

**How much does the BP have to drop in order to be considered orthostatic hypotension?

Answer 14

At least a 20 mmHg fall in SBP
OR/Both
At least a 10 mmHg fall in DBP

Question 15

Acute orthostasis due to _______

Answer 15

volume depletion

Question 16

What are the non-pharm tx options for hypotension?

Answer 16

Question 17

What are the rx options for hypotension? ______ is a common result of the medication. How do you combat it?

Answer 17

Fludrocortisone (Florinef)
Midodrine (ProAmatine)

Supine hypertension

Elevating the head of the bed to 10-20 degrees may protect the brain when sleeping

Question 18

What is the MOA for Fludrocortisone (Florinef)? What is the monitoring? Why is the medication commonly d/c?

Answer 18

Promotes increased sodium reabsorption and potassium excretion from renal distal tubules

BMP in a week to monitor for hypokalemia

Discontinuation is common due to side effects, predominantly HTN and edema

Question 19

What is the drug class for Midodrine (ProAmatine)? What is the MOA? What is the MC cause of d/c?

Answer 19

Alpha-1 selective adrenergic agonist

Increases peripheral vascular resistance, which increases arteriolar and venous tone, resulting in increased SBP and DBP

supine hypertension

Question 20

over ___ patients do NOT find a cause for hypotension. Then what do you do?

Answer 20

1/3

we can consider sending to an autonomic specialist

Question 21

What does POTS stand for? what is the hallmark response to standing?

Answer 21

Postural Orthostatic Tachycardia Syndrome

exaggerated increase in heart rate

Question 22

T/F: In order to dx POTS, the pt must have hypotension and exaggerated increase in heart rate upon standing

Answer 22

FALSE!!! do NOT need associated hypotension. common, but not required for diagnosis

Question 23

What is the MC pt demographic for POTS?

Answer 23

Most common in young patients (14 to 45 yrs)
Much more common in females than males (5:1)

Question 24

What are 2 very common POTS coexisting conditions?

Answer 24

fibromyalgia and functional GI disorders

Question 25

What is a common presentation of POTS? What tends to make s/s worse?

Answer 25

Dizziness / Lightheadedness
Syncope
Weakness and fatigue
Blurry vision
cognitive dysfunction (difficulty concentrating, word recall problems, fuzzy, brain fog, difficulty thinking, trouble remembering)

dehydration, menstruation, prolonged standin

Question 26

**What is the gold standard dx tool and confirmatory tool for POTS?

Answer 26

FORMAL TILT TEST

Question 27

What is the diagnostic criteria for POTS? What is the requirement for pts under 20 years old? When you do need to record HR and BP?

Answer 27

30+ bpm above a resting supine/seated baseline ALONG WITH PRESENCE OF PATIENT SYMPTOMS and normal/increased BP

40 bpm increase required in patients under 20 years of age ALONG WITH PRESENCE OF PATIENT SYMPTOM

OR

Increase in HR to 120bpm within first 10 mins would also be diagnostic for all patients - symptoms not required here

baseline HR and BP should be measured after at least 5 min of rest supine and again after 1 min of standing.

Question 28

What is the non-pharm first line tx for POTS?

Answer 28

Avoid any exacerbating factors

Increase water intake (3 liters per day)

Increase salt intake (3 to 5 grams per day)

Aerobic exercise of the lower extremities / compression stockings

Question 29

What is the pharm tx for POTS? IN ORDER!!!

Answer 29

1. Beta blockers - Mostly Propranolol and Metoprolol
2. Midodrine
3. Fludrocortisone
4. Pyridostigmine

Question 30

One survey of POTS patients found that fludrocortisone improved nausea in half of 16 POTS patients but without significant improvement in _____

Answer 30

orthostatic symptoms

Question 31

______ enhances sympathetic ganglionic transmission and is given at doses of 30 to 60 mg up to three times daily.

Answer 31

Pyridostigmine

Question 32

What are the 2nd line pharm agents for POTS?

Answer 32

Ivabradine (awesome drug but expensive)

Methylphenidate

Question 33

Cardiogenic shock results in end organ _____ secondary to cardiac dysfunction. What is the MC cause of cardiogenic shock? What is the classic pt?

Answer 33

hypoperfusion

extensive cardiac damage and complications from acute MI

evidence of peripheral vasoconstriction (cool, moist skin) and tachycardia

Question 34

What are some causes of cardiogenic shock?

Answer 34

acute myocardial infarction

end stage cardiomyopathies

myocarditis due to virus, infection, toxin

stress cardiomyopathy

endocrine diseases

secondary to medications (digoxin toxicity)

posttraumatic

Question 35

Pts with recent or acute MI will have elevated ______. What other lab findings are common?

Answer 35

cardiac-specific enzymes (CK-MB, troponin)

Elevations in serum creatinine and in AST, ALT due to renal and hepatic hypoperfusion

Question 36

What is the management for a pt with cardiogenic shock?

Answer 36

1. Ventilatory support for those who qualify
2. Hemodynamic support with inotropic agents or vasopressive agents for patients with severe hypotension
3. Aspirin therapy

Question 37

What are the 2 common vasopressors used in cardiogenic shock? Which one is more common? What does a vasopressor do?

Answer 37

Norepinephrine** MC and dopamine
need to start low and go slow

increases BP

Question 38

dopamine is more _____ than NE therefore should be given in lower risk patients who have less risk of tachyarrhythmia

Answer 38

inotropic (heart pumps harder)

Question 39

What are the inotropic agents used in cardiogenic shock? Which one is a beta-1 agonist and PDE-3 inhibitor?

Answer 39

dobutamine: Beta-1 agonist

milrinone: PDE-3 inhibitor

Question 40

which inotropic agent Increases inotropy AND chronotropy - helps with cardiac function by increasing HR and force of contraction?

Answer 40

dobutamine

Question 41

which inotropic agent inotropic and lusitropic effects - increases strength of contraction and rate of relaxation?

Answer 41

milrinone

Question 42

Which inotropic agent is more likely to cause severe hypotension?

Answer 42

Milrinone