Hypotension

  • What are the Pt's VS?

  • Is the Pt. conscious, confused, or disoriented?

  • What has the Pt's BP been?

  • What was the reason for admission?

  • If impending or established shock is suspected, ensure IV access and have the Pt placed in Trendelenburg's position (head of bed down). Hypotension requires that you see the patient immediately.

Major Causes of Hypotension

  • Cardiogenic shock (rate or pump problem)

  • Hypovolemic

  • Septic Shock

  • Anaphylaxis

Things you don't want to miss:

Shock, which is evidence of inadequate perfusion. This is best assessed by looking at end organs: brain (mental status), heart (chest pain), and kidneys (urine output). Shock is a clinical diagnosis defined as a systolic BP <90, with evidence of inadequate tissue perfusion.

Key History:

  • Check BP, pulse, respirations, O2 saturations, and temperature.

  • Quickly look at the patient and review chart. Get an ECG.

Focused Examination:

  • General: How distressed does or sick the patient look?

  • VS: Repeat. Elevated temp and hypotension suggest sepsis.

  • Neurologic: Mentation

  • CVS: HR, JVP, skin temp, and color. Capillary refill.

  • Lungs: Listen for crackles. Breath sounds on both sides.

  • GI: Any evidence of blood loss?

Laboratory Data:

Troponins, ECG, ABG, CBC, Electrolytes, CXR, Sr. cortisol levels

Management:

  • Examine the ECG and take the pulse yourself.

  • Check BP in both arms. Think Aortic dissection if there is a differential.

  • A compensatory tachycardia is expected appropriate response to hypotension. However, check the ECG to ensure that the patient does not have atrial fibrillation, SVT, or V. tach, which may cause hypotension because of decreased diastolic filling.

  • Bradycardia may be seen in autonomic dysfunction or heart block.

  • Wide open initially (use large bore IV cannulae in two veins - both arms) or central line (CVC), NS or lactated Ringer's. Exception is cardiogenic shock, which may require preload reduction and transfer to a unit.

    • Caution in patient with CHF, low EF

  • O2: >2L O2 via NC; keep oxygen sats >92%

  • Hypovolemic, anaphylactic, and septic shock require fluids. Use small boluses (e.g., 500 mL). If no response, repeat bolus or leave fluids open.

  • Anaphylactic shock requires epinephrine, 0.3 mg IV immediately and repeated every 10 - 15 min as required. Hydrocortisone, 250 mg IV, and diphenhydramine (Benadryl), 25 mg IV, should be administered.

  • In septic shock, IV fluids and ABx can resolve the shock. However, continuing hypotension requires ICU admission for vasopressors.

    • Epinephrine (Levophed): ACLS dosing range of 2- 10 mcg/min, initally start at 4 mcg/min. In ICU settings maintain drip rate at 0.06 to 0.47 mcg/kg/min.

    • Dopamine 0.5 - 20 mcg/kg/min.

  • Cardiogenic shock can be the result an acute MI or worsening CHF. However, other causes of hypotension and elevated JVP include acute cardiac tamponade, PE, and tension PTx. These always need to be considered.