Hypotension resident survival guide: Difference between revisions

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__NOTOC__
__NOTOC__


{{CMG}}; {{AE}} {{Ochuko}}, {{JA}}<br>
{{CMG}}; {{AE}} {{Ochuko}} {{JA}} <br>
{{SK}} [[Low blood pressure resident survival guide]], [[Low blood pressure management guide]], [[guide to hypotension management]], [[hypotension management guide]], [[hypotension management algorithm]]
{{SK}} [[Low blood pressure resident survival guide]], [[Low blood pressure management guide]], [[guide to hypotension management]], [[hypotension management guide]], [[hypotension management algorithm]]
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! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Lymphadenopathy resident survival guide microchapters}}
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Hypotension resident survival guide microchapters}}
|-
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Hypotension resident survival guide#Overview|Overview]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Hypotension resident survival guide#Overview|Overview]]
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==Overview==
==Overview==
[[Hypotension]] means [[low blood pressure]] (BP). A [[systolic blood pressure|systoloc BP]] measuring less than 90mmHg and/ or [[diastolic blood pressure|diastolic BP]] of less than 60mmHg is considered [[hypotension]].
[[Hypotension]] is the term for [[low blood pressure]] (BP). A [[systolic blood pressure|systolic BP]] measuring less than 90mmHg and/ or [[diastolic blood pressure|diastolic BP]] of less than 60mmHg is considered [[hypotension]]. A difference of 20 mmHg [[systolic blood pressure|systolic BP]] and 10 mmHg [[diastolic blood pressure|diastolic BP]] is considered [[orthostatic hypotension]] (OH).  [[Orthostatic hypotension]] is the most common type of [[hypotension]], and neurogenic [[hypotension]] is demonstrated among 1/3rd of the individuals with [[Orthostatic hypotension|OH]]. A decrease in [[blood pressure]] can be life-threatening in [[conditions]] such as [[anaphylaxis]] and [[addisonian crisis]], and requires prompt treatment. It is important to access the possibility of head injury in a [[patient]] with [[syncope]] due to [[hypotension]]. [[ECG]] is an important and essential component of the evaluation of [[hypotension]]. [[Shock]] requires prompt management with fluids and [[vasopressors]]. For other causes of [[hypotension]], identifying the cause and treatment is the best strategy. Lifestyle modifications are usually the first step in management. Medications causing a drop in [[blood pressure]] should be discontinued or changed to an appropriate alternative.


==Causes==
==Causes==
===Life Threatening Causes===
===Life Threatening Causes===
Life-threatening causes include conditions that result in death or permanent disability within 24 hours if left untreated.
Life-threatening [[causes]] include [[conditions]] that result in death or permanent disability within 24 hours if left untreated.
* [[Anaphylaxis]]
* [[Anaphylaxis]]
* [[Addisonian crisis]]
* [[Addisonian crisis]]
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{{familytree/start |summary=Weight loss causes Algorithm.}}
{{familytree/start |summary=Weight loss causes Algorithm.}}
{{familytree | | | | | | | | | A01 |A01=Causes of [[hypotension]] }}  
{{familytree | | | | | | | | | A01 |A01=Causes of [[hypotension]] }}  
{{familytree | |,|-|-|v|-|-|-|-|+|-|-|-|.| | }}
{{familytree | | | | |,|-|-|-|-|+|-|-|-|.| | }}
{{familytree | B01 | | B02 | | B04 | | B03 | | |B01='''[[Vasodilation]]'''<div style="float: left; text-align: left; width: 15em; padding:1em;"><div class="mw-collapsible mw-collapsed">❑[[Fever]]<br>❑ [[Sepsis]]<br>❑ [[Anaphylaxis]]<br>❑ [[Pregnancy]]|B02='''Neurogenic'''<div style="float: left; text-align: left; width: 15em; padding:1em;"><div class="mw-collapsible mw-collapsed">❑ [[Vasovagal syncope]]/<br> Neurocardiogenic [[syncope]]<br>❑ Post-parandial hypotension |B04='''Cardiogenic'''<div style="float: left; text-align: left; width: 15em; padding:1em;"><div class="mw-collapsible mw-collapsed">❑ [[Myocardial infarction]]<br>❑ [[Arrhythmias]]<br>❑ [[aortic stenosis]]<br> ❑ [[Hypothermia]]|B03=[[Orthostatic hypotension]]}}
{{familytree | | | | B01 | | B04 | | B03 | | |B01='''[[Vasodilation]]'''<div style="float: left; text-align: left; width: 15em; padding:1em;"><div class="mw-collapsible mw-collapsed">❑[[Fever]]<br>❑ [[Sepsis]]<br>❑ [[Anaphylaxis]]<br>❑ [[Pregnancy]]|B04='''Cardiogenic'''<div style="float: left; text-align: left; width: 15em; padding:1em;"><div class="mw-collapsible mw-collapsed">❑ [[Myocardial infarction]]<br>❑ [[Arrhythmias]]<br>❑ [[aortic stenosis]]<br> ❑ [[Hypothermia]]|B03=[[Orthostatic hypotension]]}}
{{familytree | | | | | | | | | | | | | |!| }}
{{familytree | | | | | | | | | | | | | |!| }}
{{familytree | | | | | | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | | | | | | |!| | | | |}}
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==Diagnosis and Management==
==Diagnosis and Management==
Shown below is an algorithm summarizing the management of hypotension.<ref name="RicciDe Caterina2015">{{cite journal|last1=Ricci|first1=Fabrizio|last2=De Caterina|first2=Raffaele|last3=Fedorowski|first3=Artur|title=Orthostatic Hypotension|journal=Journal of the American College of Cardiology|volume=66|issue=7|year=2015|pages=848–860|issn=07351097|doi=10.1016/j.jacc.2015.06.1084}}</ref><ref name="pmid31485153">{{cite journal |vauthors= |title=Looking for Trouble: Identifying and Treating Hypotension |journal=P T |volume=44 |issue=9 |pages=563–565 |date=September 2019 |pmid=31485153 |pmc=6705478 |doi= |url=}}</ref><ref name="pmid31118743">{{cite journal |vauthors=Biswas D, Karabin B, Turner D |title=Role of nurses and nurse practitioners in the recognition, diagnosis, and management of neurogenic orthostatic hypotension: a narrative review |journal=Int J Gen Med |volume=12 |issue= |pages=173–184 |date=2019 |pmid=31118743 |pmc=6501706 |doi=10.2147/IJGM.S170655 |url=}}</ref><ref name="pmid30828233">{{cite journal |vauthors=Oommen J, Chen J, Wang S, Caraccio T, Hanna A |title=Droxidopa for Hypotension of Different Etiologies: Two Case Reports |journal=P T |volume=44 |issue=3 |pages=125–144 |date=March 2019 |pmid=30828233 |pmc=6385736 |doi= |url=}}</ref><ref name="pmid12664244">{{cite journal |vauthors=Newton JL, Kenny R, Lawson J, Frearson R, Donaldson P |title=Prevalence of family history in vasovagal syncope and haemodynamic response to head up tilt in first degree relatives: preliminary data for the Newcastle cohort |journal=Clin. Auton. Res. |volume=13 |issue=1 |pages=22–6 |date=February 2003 |pmid=12664244 |doi=10.1007/s10286-003-0077-7 |url=}}</ref><ref name="pmid6629270">{{cite journal |vauthors=Michel D |title=[Iatrogenic hypotension in the aged] |language=German |journal=Fortschr. Med. |volume=101 |issue=33 |pages=1455–8 |date=September 1983 |pmid=6629270 |doi= |url=}}</ref><ref name="pmid21431947">{{cite journal |vauthors=Freeman R, Wieling W, Axelrod FB, Benditt DG, Benarroch E, Biaggioni I, Cheshire WP, Chelimsky T, Cortelli P, Gibbons CH, Goldstein DS, Hainsworth R, Hilz MJ, Jacob G, Kaufmann H, Jordan J, Lipsitz LA, Levine BD, Low PA, Mathias C, Raj SR, Robertson D, Sandroni P, Schatz I, Schondorff R, Stewart JM, van Dijk JG |title=Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome |journal=Clin. Auton. Res. |volume=21 |issue=2 |pages=69–72 |date=April 2011 |pmid=21431947 |doi=10.1007/s10286-011-0119-5 |url=}}</ref><ref name="pmid20393093">{{cite journal |vauthors=Levine Z |title=Mild traumatic brain injury: part 1: determining the need to scan |journal=Can Fam Physician |volume=56 |issue=4 |pages=346–9 |date=April 2010 |pmid=20393093 |pmc=2860826 |doi= |url=}}</ref><ref name="pmid10891517">{{cite journal |vauthors=Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM |title=Indications for computed tomography in patients with minor head injury |journal=N. Engl. J. Med. |volume=343 |issue=2 |pages=100–5 |date=July 2000 |pmid=10891517 |doi=10.1056/NEJM200007133430204 |url=}}</ref><ref name="pmid31392227">{{cite journal |vauthors=Molaei-Langroudi R, Alizadeh A, Kazemnejad-Leili E, Monsef-Kasmaie V, Moshirian SY |title=Evaluation of Clinical Criteria for Performing Brain CT-Scan in Patients with Mild Traumatic Brain Injury; A New Diagnostic Probe |journal=Bull Emerg Trauma |volume=7 |issue=3 |pages=269–277 |date=July 2019 |pmid=31392227 |pmc=6681891 |doi=10.29252/beat-0703010 |url=}}</ref><ref name="pmid22090740">{{cite journal |vauthors=Sharif-Alhoseini M, Khodadadi H, Chardoli M, Rahimi-Movaghar V |title=Indications for brain computed tomography scan after minor head injury |journal=J Emerg Trauma Shock |volume=4 |issue=4 |pages=472–6 |date=October 2011 |pmid=22090740 |pmc=3214503 |doi=10.4103/0974-2700.86631 |url=}}</ref><ref name="pmid7825766">{{cite journal |vauthors=Jansen RW, Lipsitz LA |title=Postprandial hypotension: epidemiology, pathophysiology, and clinical management |journal=Ann. Intern. Med. |volume=122 |issue=4 |pages=286–95 |date=February 1995 |pmid=7825766 |doi=10.7326/0003-4819-122-4-199502150-00009 |url=}}</ref><ref name="pmid">{{cite journal |vauthors= |title=Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. The Consensus Committee of the American Autonomic Society and the American Academy of Neurology |journal= |volume=46 |issue=5 |pages=1470 |date=May 1996 |pmid= |doi=10.1212/wnl.46.5.1470 |url=}}</ref>
Shown below is an algorithm summarizing the management of hypotension.<ref name="RicciDe Caterina2015">{{cite journal|last1=Ricci|first1=Fabrizio|last2=De Caterina|first2=Raffaele|last3=Fedorowski|first3=Artur|title=Orthostatic Hypotension|journal=Journal of the American College of Cardiology|volume=66|issue=7|year=2015|pages=848–860|issn=07351097|doi=10.1016/j.jacc.2015.06.1084}}</ref><ref name="pmid31485153">{{cite journal |vauthors= |title=Looking for Trouble: Identifying and Treating Hypotension |journal=P T |volume=44 |issue=9 |pages=563–565 |date=September 2019 |pmid=31485153 |pmc=6705478 |doi= |url=}}</ref><ref name="pmid31118743">{{cite journal |vauthors=Biswas D, Karabin B, Turner D |title=Role of nurses and nurse practitioners in the recognition, diagnosis, and management of neurogenic orthostatic hypotension: a narrative review |journal=Int J Gen Med |volume=12 |issue= |pages=173–184 |date=2019 |pmid=31118743 |pmc=6501706 |doi=10.2147/IJGM.S170655 |url=}}</ref><ref name="pmid30828233">{{cite journal |vauthors=Oommen J, Chen J, Wang S, Caraccio T, Hanna A |title=Droxidopa for Hypotension of Different Etiologies: Two Case Reports |journal=P T |volume=44 |issue=3 |pages=125–144 |date=March 2019 |pmid=30828233 |pmc=6385736 |doi= |url=}}</ref><ref name="pmid12664244">{{cite journal |vauthors=Newton JL, Kenny R, Lawson J, Frearson R, Donaldson P |title=Prevalence of family history in vasovagal syncope and haemodynamic response to head up tilt in first degree relatives: preliminary data for the Newcastle cohort |journal=Clin. Auton. Res. |volume=13 |issue=1 |pages=22–6 |date=February 2003 |pmid=12664244 |doi=10.1007/s10286-003-0077-7 |url=}}</ref><ref name="pmid6629270">{{cite journal |vauthors=Michel D |title=[Iatrogenic hypotension in the aged] |language=German |journal=Fortschr. Med. |volume=101 |issue=33 |pages=1455–8 |date=September 1983 |pmid=6629270 |doi= |url=}}</ref><ref name="pmid21431947">{{cite journal |vauthors=Freeman R, Wieling W, Axelrod FB, Benditt DG, Benarroch E, Biaggioni I, Cheshire WP, Chelimsky T, Cortelli P, Gibbons CH, Goldstein DS, Hainsworth R, Hilz MJ, Jacob G, Kaufmann H, Jordan J, Lipsitz LA, Levine BD, Low PA, Mathias C, Raj SR, Robertson D, Sandroni P, Schatz I, Schondorff R, Stewart JM, van Dijk JG |title=Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome |journal=Clin. Auton. Res. |volume=21 |issue=2 |pages=69–72 |date=April 2011 |pmid=21431947 |doi=10.1007/s10286-011-0119-5 |url=}}</ref><ref name="pmid20393093">{{cite journal |vauthors=Levine Z |title=Mild traumatic brain injury: part 1: determining the need to scan |journal=Can Fam Physician |volume=56 |issue=4 |pages=346–9 |date=April 2010 |pmid=20393093 |pmc=2860826 |doi= |url=}}</ref><ref name="pmid10891517">{{cite journal |vauthors=Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM |title=Indications for computed tomography in patients with minor head injury |journal=N. Engl. J. Med. |volume=343 |issue=2 |pages=100–5 |date=July 2000 |pmid=10891517 |doi=10.1056/NEJM200007133430204 |url=}}</ref><ref name="pmid31392227">{{cite journal |vauthors=Molaei-Langroudi R, Alizadeh A, Kazemnejad-Leili E, Monsef-Kasmaie V, Moshirian SY |title=Evaluation of Clinical Criteria for Performing Brain CT-Scan in Patients with Mild Traumatic Brain Injury; A New Diagnostic Probe |journal=Bull Emerg Trauma |volume=7 |issue=3 |pages=269–277 |date=July 2019 |pmid=31392227 |pmc=6681891 |doi=10.29252/beat-0703010 |url=}}</ref><ref name="pmid22090740">{{cite journal |vauthors=Sharif-Alhoseini M, Khodadadi H, Chardoli M, Rahimi-Movaghar V |title=Indications for brain computed tomography scan after minor head injury |journal=J Emerg Trauma Shock |volume=4 |issue=4 |pages=472–6 |date=October 2011 |pmid=22090740 |pmc=3214503 |doi=10.4103/0974-2700.86631 |url=}}</ref><ref name="pmid7825766">{{cite journal |vauthors=Jansen RW, Lipsitz LA |title=Postprandial hypotension: epidemiology, pathophysiology, and clinical management |journal=Ann. Intern. Med. |volume=122 |issue=4 |pages=286–95 |date=February 1995 |pmid=7825766 |doi=10.7326/0003-4819-122-4-199502150-00009 |url=}}</ref><ref name="pmid">{{cite journal |vauthors= |title=Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. The Consensus Committee of the American Autonomic Society and the American Academy of Neurology |journal= |volume=46 |issue=5 |pages=1470 |date=May 1996 |pmid= |doi=10.1212/wnl.46.5.1470 |url=}}</ref><ref name="pmid8673750">{{cite journal |vauthors=El-Sayed H, Hainsworth R |title=Salt supplement increases plasma volume and orthostatic tolerance in patients with unexplained syncope |journal=Heart |volume=75 |issue=2 |pages=134–40 |date=February 1996 |pmid=8673750 |pmc=484248 |doi=10.1136/hrt.75.2.134 |url=}}</ref><ref name="pmid7100954">{{cite journal |vauthors=Robbins JM, Korda H, Shapiro MF |title=Treatment for a nondisease: the case of low blood pressure |journal=Soc Sci Med |volume=16 |issue=1 |pages=27–33 |date=1982 |pmid=7100954 |doi=10.1016/0277-9536(82)90420-8 |url=}}</ref><ref name="pmid20814408">{{cite journal |vauthors=Benvenuto LJ, Krakoff LR |title=Morbidity and mortality of orthostatic hypotension: implications for management of cardiovascular disease |journal=Am. J. Hypertens. |volume=24 |issue=2 |pages=135–44 |date=February 2011 |pmid=20814408 |doi=10.1038/ajh.2010.146 |url=}}</ref><ref name="pmid16107115">{{cite journal |vauthors=Seger JJ |title=Syncope evaluation and management |journal=Tex Heart Inst J |volume=32 |issue=2 |pages=204–6 |date=2005 |pmid=16107115 |pmc=1163473 |doi= |url=}}</ref>




{{familytree/start |summary=Hypotension Diagnosis and Management Algorithm.}}
{{familytree/start |summary=Hypotension Diagnosis and Management Algorithm.}}
{{familytree | | | | | | | | A01 | | | | | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;">[[blood pressure|Systolic BP]] < 90mmHg / [[blood pressure|Diastolic BP]] < 60mmHg OR<br>Difference of 20 mmHg systolic and 10 mmHg diastolic pressure }}
{{familytree | | | | | | | | A01 | | | | | | |A01=<div style="float: center; text-align: center; width: 20em; padding:1em;">[[blood pressure|Systolic BP]] < 90mmHg / [[blood pressure|Diastolic BP]] < 60mmHg <br>OR<br>Difference of 20 mmHg systolic and 10 mmHg diastolic pressure }}
{{familytree | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | A02 | | | | | |A02=Reassess [[blood pressure|B.P]] if unsure}}
{{familytree | | | | | | | | A02 | | | | | |A02=Reassess [[blood pressure|B.P]] if unsure}}
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{{familytree | | | | | | | | A03 | | | | | | A03=Diagnosis of [[hypotension]]}}
{{familytree | | | | | | | | A03 | | | | | | A03=Diagnosis of [[hypotension]]}}
{{familytree | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | Z01 | | | | | | |Z01=Initial tests<div style="float: left; text-align: left; width: 20em; padding:1em;"><div class="mw-collapsible mw-collapsed">❑ [[EKG]] x 24 hours<br>❑ Cardiac monitor x 24 hours till 7 days<br>❑ [[Pulse oximeter]]<br>❑ Blood pressure monitor x 24 hours<br>❑ [[TSH]]<br>❑ Serum [[electrolytes]]<br>❑ [[Hemoglobin|HB]] }}
{{familytree | | | | | | | | |)|-|-|-|.| | | }}
{{familytree | | | | | | | | Z02 | | | Z03| | | |Z02=Sinus rhythmn|Z03= [[Arrhythmia]]}}
{{familytree | | | | | | | | |!| | | | |!| | }}
{{familytree | | | | | | | | |!| | | | Z04 | | Z04=[[Holter monitor]] or <br> Long-term loop recorders <br>(may be up to a month)}}
{{familytree | | | | | | | | |!| | | | |!| | |}}
{{familytree | | | | | | | | |)|-|-|-|-|'| | }}
{{familytree | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | |,|-|-|^|-|-|-|-|v|-|-|-|.| |}}
{{familytree | | | | | |,|-|-|^|-|-|-|-|v|-|-|-|.| |}}
{{familytree | | | | | A04 | | | | | | A05 | | A06 | | |A04=Unexplained [[syncope]]/ fall/ [[dizziness]]|A05=Asymptomatic|A06=[[Shock]]}}
{{familytree | | | | | A04 | | | | | | A05 | | A06 | | |A04=Unexplained [[syncope]]/ fall/ [[dizziness]]|A05=Asymptomatic|A06=[[Shock]]}}
{{familytree | | | | | |!| | | | | | | |!| | | |!| | }}
{{familytree | | | | | |!| | | | | | | |!| | | |!| | }}
{{familytree | | | | | A07 | | | | | | |!| | | |!| | A07=[[CT scan]] head if<div style="float: left; text-align: left; width: 20em; padding:1em;"><div class="mw-collapsible mw-collapsed">
{{familytree | | | | | A07 | | | | | | |!| | | |!| | A07=<div style="float: left; text-align: left; width: 20em; padding:1em;">[[CT scan]] head if<div class="mw-collapsible mw-collapsed">
❑ Decreasing [[GCS score]] (<15)<br>
❑ Decreasing [[GCS score]] (<15)<br>
❑ [[Seizure]]<br>
❑ [[Seizure]]<br>
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{{familytree | | | | | |!| | | | | | | |!| | | |!| | }}
{{familytree | | | | | |!| | | | | | | |!| | | |!| | }}
{{familytree | |,|-|-|-|+|-|-|-|.| | | |!| | | A07 | | |A07=[[Shock resident survival guide]]}}
{{familytree | |,|-|-|-|+|-|-|-|.| | | |!| | | A07 | | |A07=[[Shock resident survival guide]]}}
{{familytree | C01 | | C02 | | C05 | | C03 | | | |C01='''Post-parandial''' <div style="float: left; text-align: left; width: 20em; padding:1em;">'''History'''<div class="mw-collapsible mw-collapsed"><br>
{{familytree | C01 | | C02 | | C03 | | C04 | | | |C01='''Post-parandial''' <div style="float: left; text-align: left; width: 20em; padding:1em;">'''History'''<div class="mw-collapsible mw-collapsed"><br>
❑ '''[[Age]]''':Usually old individuals. <br>
❑ '''[[Age]]''':Usually old individuals. <br>
❑ '''[[Symptom]]s''': [[Syncope]] or [[angina]] symptoms 15-90 minutes after meal. <br>
❑ '''[[Symptom]]s''': [[Syncope]] or [[angina]] symptoms 15-90 minutes after meal. <br>
❑ '''Associated [[symptoms]]''': [[Angina pectoris]], [[weakness]], [[dizziness]] or [[lightheadedness]], [[syncope]], [[nausea]], [[blurred vision]]/ black spots in visual field, cold clammy, or pale skin, disturbed speech. <br>  
❑ '''Associated [[symptoms]]''': [[Angina pectoris]], [[weakness]], [[dizziness]] or [[lightheadedness]], [[syncope]], [[nausea]], [[blurred vision]]/ black spots in visual field, cold clammy, or pale skin, disturbed speech. <br>  
❑ '''Past medical history''': [[Parkinson disease]], autonomic dysfunctions, [[hypertension|HTN]], [[Diabetes|diabetic autonomic neuropathy]]. <br>
❑ '''Past medical history''': [[Parkinson disease]], autonomic dysfunctions, [[hypertension|HTN]], [[Diabetes|diabetic autonomic neuropathy]]. <br>
❑ '''Medication history''': Medications administered with meal may cause [[hypotension]]. <br>|C02='''Prolonged standing/<br>Stress'''<div style="float: left; text-align: left; width: 20em; padding:1em;">'''History'''<div class="mw-collapsible mw-collapsed">
❑ '''Medication history''': Medications administered with meal may cause [[hypotension]]. <br>|C02='''Prolonged standing/ Stress'''<div style="float: left; text-align: left; width: 20em; padding:1em;">'''History'''<div class="mw-collapsible mw-collapsed">
❑ '''Source''':<br>  [[Patient]] and/ or a witness describing the fall.<br>
❑ '''Source''':<br>  [[Patient]] and/ or a witness describing the fall.<br>
❑ '''[[Age]]''': Common among young individuals.<br>
❑ '''[[Age]]''': Common among young individuals.<br>
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❑ '''Associated [[symptoms]]''': Sinking feeling, [[tachycardia]], [[sweating]] [[dizziness]] or [[lightheadedness]], [[nausea]], [[blurred vision]], cold clammy, pale skin and blaxck out preceding [[syncope]] <br>  
❑ '''Associated [[symptoms]]''': Sinking feeling, [[tachycardia]], [[sweating]] [[dizziness]] or [[lightheadedness]], [[nausea]], [[blurred vision]], cold clammy, pale skin and blaxck out preceding [[syncope]] <br>  
❑ '''Past medical history''': [[Volume loss]], [[malena]].<br>
❑ '''Past medical history''': [[Volume loss]], [[malena]].<br>
❑ '''Family history''':A positive family history has been demonstrated in the past and indicated genetic component|C05='''Postural'''<div style="float: left; text-align: left; width: 15em; padding:1em;">'''History'''<div class="mw-collapsible mw-collapsed">
❑ '''Family history''':A positive family history has been demonstrated in the past and indicated genetic component|C03=<div style="float: left; text-align: center; width: 15em; padding:1em;">'''Postural / Early morning'''<div style="float: left; text-align: left; width: 15em; padding:1em;">'''History'''<div class="mw-collapsible mw-collapsed">
❑ '''Source''': [[Patient]] and/ or a witness describing the fall.<br>
❑ '''Source''': [[Patient]] and/ or a witness describing the fall.<br>
❑ '''[[Age]]''': Any age individuals. <br>
❑ '''[[Age]]''': Any age individuals. <br>
❑ Duration of [[syncope]] <br>
❑ Duration of [[syncope]], preceding events, [[confusion]] post [[syncope]] <br>
❑ '''Associated [[symptoms]]''': [[Dizziness]] or [[lightheadedness]], [[confusion]], [[fatigue]], [[nausea]], [[blurred vision]], cold clammy, and pale skin, [[visual acuity|Vision]] problems, [[gait]] problems, and [[neck]] pain.  <br>  
❑ '''Associated [[symptoms]]''': [[Dizziness]] or [[lightheadedness]], [[confusion]], [[fatigue]], [[nausea]], [[blurred vision]], cold clammy, and pale skin, [[visual acuity|Vision]] problems, [[gait]] problems, and [[neck]] pain.  <br>  
❑ '''Past medical history''':[[Diabetes]], [[renal]] problems, [[amyloidosis]], [[heart]] [[disease]],[[hypertension|HTN]], [[autoimmune]] disease, neurodegenerative dosease. <br>
❑ '''Past medical history''':[[Diabetes]], [[renal]] problems, [[amyloidosis]], [[heart]] [[disease]],[[hypertension|HTN]], [[autoimmune]] disease, neurodegenerative dosease. <br>
❑ '''Menstrual history''': [[Menorrhagia]]<br>
❑ '''Menstrual history''': [[Menorrhagia]]<br>
❑ '''Medication history''': [[Beta-blockers]], [[aplha blockers]], [[vasodilators]], and tricyclic antidepressants.<br>
❑ '''Medication history''': [[Beta-blockers]], [[aplha blockers]], [[vasodilators]], and tricyclic antidepressants.<br>
❑ '''Social history''':[[Alcohol]] intake may cause [[dehydration]]. <br>|C03='''History'''<div class="mw-collapsible mw-collapsed"><div style="float: left; text-align: left; width: 20em; padding:1em;">❑ '''Source''': [[Patient]]<br>
❑ '''Social history''':[[Alcohol]] intake may cause [[dehydration]]. <br>|C04=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''History'''<div class="mw-collapsible mw-collapsed">❑ '''Source''': [[Patient]]<br>
❑ '''[[Age]]''':<br>  Helps determine age-specific causes. <br>
❑ '''[[Age]]''': Helps determine age-specific causes.<br>
❑ '''Associated [[symptoms]]''': [[Dizziness]] or [[lightheadedness]], [[syncope]], [[nausea]], [[blurred vision]]. <br>  
❑ '''Associated [[symptoms]]''': [[Dizziness]] or [[lightheadedness]], [[syncope]], [[nausea]], [[blurred vision]]. <br>  
❑ '''Past medical history''':<br> [[Volume loss]], [[malena]]<br>  }}
❑ '''Past medical history''':<br> [[Volume loss]], [[malena]], diagnosed conditions such as [[diabetes]], [[hypertension|HTN]], [[Addison's disease]], etc <br>  }}
{{familytree | |!| | | |!| | | |!| | | |!| | | | | }}
{{familytree | |!| | | |!| | | |!| | | |!| | | | | }}
{{familytree | D01 | | D02 | | D03 | | D04 | | | D01='''Physical exam'''<div style="float: left; text-align: left; width: 15em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>
{{familytree | D01 | | D02 | | D03 | | D04 | | | D01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Physical exam'''<div class="mw-collapsible mw-collapsed"><br>
❑ [[Vital signs]]: A decrease in [[systolic blood pressure|systolic BP]] of =/ >20 mm Hg or =/> 90 mm Hg (when the [[systolic blood pressure|systolic BP]] before the meal is > 100mmHg, within 2 hours of the start of the meal.<br>  
❑ [[Vital signs]]: [[Heart rate]], [[respiratory rate]]. A decrease in [[systolic blood pressure|systolic BP]] of =/ >20 mm Hg or =/> 90 mm Hg (when the [[systolic blood pressure|systolic BP]] before the meal is > 100mmHg, within 2 hours of the start of the meal.<br>  
❑ [[HEENT]], [[Cardiovascular examination|CVS]], [[neurological examination|neuro]], [[Respiratory examination|respiratory]], and [[Gastrointestinal system|GI]] exam.|D02='''Physical exam'''<div style="float: left; text-align: left; width: 15em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>
❑ [[HEENT]], [[Cardiovascular examination|CVS]], [[neurological examination|neuro]], [[Respiratory examination|respiratory]], and [[Gastrointestinal system|GI]] exam.|D02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Physical exam'''<div class="mw-collapsible mw-collapsed"><br>
❑ [[Vital signs]] <br>
❑ [[Vital signs]]:[[Heart rate]], [[respiratory rate]], [[blood pressure]].
❑ [[HEENT]], [[Cardiovascular examination|CVS]], [[neurological examination|neuro]], [[Respiratory examination|respiratory]], [[Gastrointestinal system|GI]] exam|D03='''Physical exam'''<div style="float: left; text-align: left; width: 15em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>
❑ [[HEENT]], [[Cardiovascular examination|CVS]], [[neurological examination|neuro]], [[Respiratory examination|respiratory]], [[Gastrointestinal system|GI]] exam.|D03=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Physical exam'''<div class="mw-collapsible mw-collapsed"><br>
❑ [[Vital signs]] <br> [[Blood pressure]]: Reduction of at least 20 mm Hg [[systolic blood pressure|systolic]] or 10 mm Hg [[diastolic blood pressure|diastolic BP]] within 3 minutes of erect standing.
❑ [[Vital signs]]:[[Heart rate]], [[respiratory rate]]. [[Blood pressure]] recording lying/ seating and standing.<br>❑ Reduction of at least 20 mm Hg [[systolic blood pressure|systolic]] or 10 mm Hg [[diastolic blood pressure|diastolic BP]] within 3 minutes of erect standing.
❑ [[HEENT]], [[Cardiovascular examination|CVS]], [[neurological examination|neuro]], [[Respiratory examination|respiratory]], [[Gastrointestinal system|GI]] exam|D04='''Physical exam'''<div style="float: left; text-align: left; width: 15em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>
❑ [[HEENT]], [[Cardiovascular examination|CVS]], [[neurological examination|neuro]], [[Respiratory examination|respiratory]], [[Gastrointestinal system|GI]] exam.|D04=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Physical exam'''<div class="mw-collapsible mw-collapsed">
❑ [[Vital signs]] <br>
❑ [[Vital signs]]:[[Heart rate]], [[respiratory rate]]. [[Blood pressure]] recording lying/ seating and standing.
❑ [[HEENT]], [[Cardiovascular examination|CVS]], [[neurological examination|neuro]], [[Respiratory examination|respiratory]], [[Gastrointestinal system|GI]] exam}}
❑ [[HEENT]], [[Cardiovascular examination|CVS]], [[neurological examination|neuro]], [[Respiratory examination|respiratory]], [[Gastrointestinal system|GI]] exam.}}
{{familytree | |!| | | |!| | | |!| | | |!| | | | | }}
{{familytree | |!| | | |!| | | |!| | | |!| | | | | }}
{{familytree | |!| | | |!| | | |!| | | |!| | | | | }}
{{familytree | |!| | | |!| | | |!| | | |!| | | | | }}
{{familytree | E01 | | E02 | | E03 | | E04 | | | E01=Labs<div style="float: left; text-align: left; width: 20em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>[[CBC]]<br>[[Glucose]]/ [[HbA1c]]<br>[[Urinalysis]]<br>[[Comprehensive metabolic panel|CMP]]<br>[[EKG]]<br>[[Stress test]]|E02=Labs<div style="float: left; text-align: left; width: 20em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>[[CBC]] ([[anemia]]<br>[[Glucose]] ([[Hypoglycemia]], [[hyperglycemia]], [[DM]])<br>[[Urinalysis]]<br>[[Blood culture]]<br>[[Cortisol]] ([[Addison's disease]])<br>[[BUN]]<br>[[EKG]]<br>[[Echocardiogram]]<br>[[Stress test]]<br>[[Valsalva maneuver]]|E03=Labs<div style="float: left; text-align: left; width: 20em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>[[CBC]] ([[anemia]]<br>[[Glucose]] ([[Hypoglycemia]], [[hyperglycemia]], [[DM]])<br>[[Urinalysis]]<br>[[Blood culture]]<br>[[Cortisol]] ([[Addison's disease]])<br>[[BUN]]<br>[[EKG]]<br>[[Echocardiogram]]<br>[[Stress test]]<br>[[Valsalva maneuver]]|E04=Labs<div style="float: left; text-align: left; width: 20em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>[[CBC]] ([[anemia]]<br>[[Glucose]] ([[Hypoglycemia]], [[hyperglycemia]], [[DM]])<br>[[Urinalysis]]<br>[[Blood culture]]<br>[[Cortisol]] ([[Addison's disease]])<br>[[BUN]]<br>[[EKG]]<br>[[Echocardiogram]]<br>[[Stress test]]<br>[[Valsalva maneuver]]}}
{{familytree | E01 | | E02 | | E03 | | E04 | | | | E01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Labs'''<div class="mw-collapsible mw-collapsed">[[CBC]]<br>[[BSL]]/ [[HbA1c]]<br>[[Urinalysis]]<br>[[Comprehensive metabolic panel|CMP]]<br>[[Holter monitor]], [[CXR]], [[stress test]] (high risk individuals)|E02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Labs'''<div class="mw-collapsible mw-collapsed">[[CBC]]<br>
{{familytree | |!| | | |!| | |!| | | | | | | | | }}
[[BSL]]<br>
{{familytree | |`|-|-| K01 |-|'| | | | |K01=[[Tilt table test]]}}
[[Holter monitor]], [[CXR]], [[stress test]] (high risk individuals)|E03=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Labs'''<div class="mw-collapsible mw-collapsed">
{{familytree | | | | | |!| | | | | | |}}
[[CBC]]<br>
{{familytree | | |,|-|-|^|-|-|-|.| | | | | | | | | | | | | | }}
[[Anemia]] workup: [[Ferritin]], [[total iron-binding capacity]], [[reticulocyte count]], [[vitamin B12]] and [[folic acid]] levels.<br>
{{familytree | | C01 | | | | | | C02 | | | | | | | | | | | | | | C01=[[tilt table test|Tilt table test positive]]| C02=[[tilt table test|Tilt table test negative]]}}
[[BSL]]/ [[HbA1c]]<br>
{{familytree |,|-|^|-|-|.| | | | |!| | | | | | | | | | | | | | | }}
[[Urinalysis]]<br>
{{familytree |!| | | | |!| | | | |!| | | | | | | | | | | | | }}
[[FOBT]]<br>
{{familytree | E01 | | E02 | | | E03 | | | | | | | | | | E01=[[Neurocardiogenic syncope]]<br>Orthostatic hypotension after 3 minutes of standing|E02=[[Orthostatic hypotension]]<br>Diagnosed in 1 minute of standing<br> Severity estimated in 2 minutes of standing| E03=[[postprandial|Postprandial hypotension]]}}
[[Comprehensive metabolic panel|CMP]]<br>
❑ [[Brain natriuretic peptide|proBNP]] and [[echocardiography]]<br>
[[Holter monitor]], [[CXR]], [[stress test]] (high risk individuals)|E04=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Labs'''<div class="mw-collapsible mw-collapsed">[[CBC]]<br>
[[Urinalysis]]<br>[[Cortisol]] ([[Addison's disease]])<br>[[Comprehensive metabolic panel|CMP]]<br>[[Echocardiogram]]<br>[[Holter monitor]], [[CXR]], [[stress test]] (high risk individuals)}}
{{familytree | |!| | | |!| | |!| | | | |!| | | | }}
{{familytree | |`|-|-| K01 |-|'| | | | K02 | | | | |K01=[[Tilt table test]]|K02='''Lifestyle Modification'''<div class="mw-collapsible mw-collapsed"><div style="float: left; text-align: left; width: 20em; padding:1em;">❑ Regular [[blood pressure]] monitoring both supine and [[prone]].<br>
❑ Maintain fluid intake.}}
{{familytree | | | | | |!| | | | | | | |!| | | | |}}
{{familytree | | |,|-|-|^|-|-|-|.| | | |!| | | | | | | | | | }}
{{familytree | | C01 | | | | | | C02 | | C03 | | | | | | | | | | | C01=[[tilt table test|Tilt table test positive]]| C02=[[tilt table test|Tilt table test negative]]|C03=❑ Cardiac journal<br>❑ Follow-up}}
{{familytree | |,|^|-|-|.| | | | |!| | | | | | | | | | | | | | | }}
{{familytree | |!| | | |!| | | | |!| | | | | | | | | | | | | }}
{{familytree | E01 | | E02 | | | |!| | | | | | | | | | E01=<div style="float: left; text-align: left; width: 20em; padding:1em;">Orthostatic hypotension after 3 minutes of standing|E02=<div style="float: left; text-align: left; width: 20em; padding:1em;">Diagnosed in 1 minute of standing<br>Severity estimated in 2 minutes of standing<br>❑  [[Valsalva maneuve|Valsalva test]] or carotid massage may be utilized to confirm the diagnosis}}
{{familytree | |!| | | |!| | | | |!| | | | | | | | | | | | |}}
{{familytree | E04 | | E05 | | | E03 | | | | | | | | | | E03=[[postprandial|Postprandial hypotension]]|E04=[[Neurocardiogenic syncope]]|E05=[[Orthostatic hypotension]] }}
{{familytree | |!| | | |!| | | | |!| | | | | | | | | | | | |}}
{{familytree | |!| | | |!| | | | |!| | | | | | | | | | | | |}}
{{familytree | F08 | | F01 | | | F03 | | | | | | | | | | |  F08='''Lifestyle Modification'''<div class="mw-collapsible mw-collapsed"><div style="float: left; text-align: left; width: 20em; padding:1em;">❑ Regular [[blood pressure]] monitoring both supine and [[prone]].<br>
{{familytree | F08 | | F01 | | | F03 | | | | | | | | | | |  F08='''Lifestyle Modification'''<div class="mw-collapsible mw-collapsed"><div style="float: left; text-align: left; width: 20em; padding:1em;">❑ Regular [[blood pressure]] monitoring both supine and [[prone]].<br>
❑ [[salt|elevated salt intake]] of no more than 10g/day.<br>
❑ [[salt|elevated salt intake]] of no more than 10g/day.<br>
Mainten fluid intake.|F01='''Lifestyle Modification'''<div class="mw-collapsible mw-collapsed"><div style="float: left; text-align: left; width: 20em; padding:1em;">
Maintain fluid intake.|F01='''Lifestyle Modification'''<div class="mw-collapsible mw-collapsed"><div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ Regular [[blood pressure]] monitoring both supine and [[prone]].<br>
❑ Regular [[blood pressure]] monitoring both supine and [[prone]].<br>
❑ [[salt|elevated salt intake]] of no more than 10g/day.<br>
❑ Maintain fluid intake.<br>
Mainten fluid intake.<br>
❑ Postural [[orthostatic hypotension|OH]]:
❑ [[blood sugar|Blood sugar control]]|F03='''Lifestyle Modification'''<div class="mw-collapsible mw-collapsed"><div style="float: left; text-align: left; width: 20em; padding:1em;">
:❑ [[salt|Elevated salt intake]]
❑ Lifestyle modifications to optimise [[blood pressure]] post meal.<br>
:❑  ''Mild cases'': 2 g salt tablets thrice a day (minimum eight 8-ounce servings of fluid/ day). Maximum of no more than 10g/day.<br>
:''Acute cases'': Salty soups and about five 8-ounce servings of fluid/ half day.
:❑ [[Abdominal]] binder<br>
Early morning [[orthostatic hypotension|OH]]
:❑ Care on awakening with gradual shift from supine to upright.<br>
:❑ Drinking two cups of cold water 30 min before arising from the bed.<br>
:❑ Elevation of the head end of the bed.|F03='''Lifestyle Modification'''<div class="mw-collapsible mw-collapsed"><div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ Counsel the [[patient]] and caregiver about the risk and timing post meal.<br>
❑ Counsel the [[patient]] and caregiver about the risk and timing post meal.<br>
❑ Discontinue unnecessary medications.<br>
❑ Discontinue unnecessary medications.<br>
❑ Pre and post parandial [[blood pressure|B.P.]] monitoring.<br>
❑ Pre and post parandial [[blood pressure|B.P.]] monitoring.<br>
❑ Medications between the meals rather with the meal.<br>
❑ Medications between the meals rather with the meal.<br>
❑ Meal: Smaller, low [[carbohydrate]] meals. Liberal salt, water intake. Avoid meal during [[hemodialysis]].}}
❑ Meal: Smaller, low [[carbohydrate]] meals. Liberal salt, water intake. Avoid hot drinks, hot foods, meals during [[hemodialysis]], and reduce [[alcohol]] intake.}}
{{familytree | |!| | | |!| | | | |!| | | | | | | | | | | |}}
{{familytree | |!| | | |!| | | | |!| | | | | | | | | | | |}}
{{familytree | F07 | | F02 | | | F04 | | | | | | | | | | | | |F07='''Medical therapy'''<div style="float: left; text-align: left; width: 20em; padding:1em;"><div class="mw-collapsible mw-collapsed">
{{familytree | F07 | | F02 | | | F04 | | | | | | | | | | | | |F07='''Medical therapy'''<div style="float: left; text-align: left; width: 20em; padding:1em;"><div class="mw-collapsible mw-collapsed">
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❑ [[Midodrine]] 2.5-10 TID<br>
❑ [[Midodrine]] 2.5-10 TID<br>
❑ [[Scopolamine]]<br>
❑ [[Scopolamine]]<br>
❑ [[pacemaker|Dual chamber pacing]] may be required.|F02='''Medical therapy'''<div style="float: left; text-align: left; width: 20em; padding:1em;"><div class="mw-collapsible mw-collapsed">❑ [[Fludrocortisone]] 0.1-1.0 mg / day<br>❑ [[Pyridostigmine bromide]]<br>❑ [[Erythropoietin]]|F04='''Medical therapy'''<div class="mw-collapsible mw-collapsed"><div style="float: left; text-align: left; width: 20em; padding:1em;"> ❑ Caffeine 250mg before meal<br> ❑[[Octreotide]] 50 microgram [[subcutaneous|S/C]] before each meal.<br>  
❑ [[pacemaker|Dual chamber pacing]] may be required.|F02='''Medical therapy'''<div style="float: left; text-align: left; width: 20em; padding:1em;"><div class="mw-collapsible mw-collapsed">❑ Severe acute  cases: hospital management with [[intravenous fluid|IV fluid]]s<br>❑ [[Fludrocortisone]] 0.1-1.0 mg / day<br>❑ [[Pyridostigmine bromide]]<br>❑ [[Erythropoietin]] 50 units/kg [[subcutaneously|S/C]] thrice a week (monitoring [[reticulocyte count]] and [[hematocrit|Hct]])|F04='''Medical therapy'''<div class="mw-collapsible mw-collapsed"><div style="float: left; text-align: left; width: 20em; padding:1em;"> ❑ [[Caffeine]] 250mg before meal<br> ❑ [[Octreotide]] 50 microgram [[subcutaneous|S/C]] before each meal.<br>  
❑[[Indomethacin]] 25-50 mg thrice a day<br> ❑[[Midodrine]] 2.5 -10 mg thrice a day/ 60 mg 6 or 12 hourly.}}
❑ [[Indomethacin]] 25-50 mg thrice a day<br> ❑[[Midodrine]] 2.5 -10 mg thrice a day/ 60 mg 6 or 12 hourly.}}
{{familytree | |!| | | |!| | | | | |!| | | | |}}
{{familytree | |`| G01 |'| | | | G02 | | | | | | | | | | | | | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> FDA approved pharmacotherapy for neurogenic [[orthostatic hypotension|OH]]<br>
 ❑  Droxidopa<br>
 ❑  Midodrine|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">❑ Cardiac journal<br>❑ Follow-up}}
{{familytree | | | |!| | | | | | | | | | | | | | | | | | |}}
{{familytree | | | G03 | | | | | | | | | | | | | | | | | |G03=<div style="float: left; text-align: left; width: 20em; padding:1em;">❑ Cardiac journal<br>❑ Follow-up}}
{{familytree/end}}
{{familytree/end}}


==Do's==
==Do's==
*Educate the [[patient]] to avoid predisposing conditions such as [[dehydration]], [[alcohol]], etc.
*Educate the [[patient]] to avoid predisposing conditions such as [[dehydration]], [[alcohol]], etc.<ref name="pmid16107115">{{cite journal |vauthors=Seger JJ |title=Syncope evaluation and management |journal=Tex Heart Inst J |volume=32 |issue=2 |pages=204–6 |date=2005 |pmid=16107115 |pmc=1163473 |doi= |url=}}</ref>
*Discontinue or adjust the dose of medication if hypotension is caused by medication side effects.
* Educate the [[patient]] of [[orthostatic hypotension|OH]] for counter maneuvers such as:<ref name="pmid20439562">{{cite journal |vauthors=Figueroa JJ, Basford JR, Low PA |title=Preventing and treating orthostatic hypotension: As easy as A, B, C |journal=Cleve Clin J Med |volume=77 |issue=5 |pages=298–306 |date=May 2010 |pmid=20439562 |pmc=2888469 |doi=10.3949/ccjm.77a.09118 |url=}}</ref>
*Advice to wear compression stockings to relieve the pain and swelling from [[varicose veins]].
** Leg elevation, thigh muscle co-contraction, toe-raising, crossing and contracting the legs, waist bending, and slow marching.
*Counsel the caregivers of elder patients with postprandial hypotension.
*Discontinue or adjust the dose of medication if hypotension is caused by medication side effects.<ref name="pmid20439562">{{cite journal |vauthors=Figueroa JJ, Basford JR, Low PA |title=Preventing and treating orthostatic hypotension: As easy as A, B, C |journal=Cleve Clin J Med |volume=77 |issue=5 |pages=298–306 |date=May 2010 |pmid=20439562 |pmc=2888469 |doi=10.3949/ccjm.77a.09118 |url=}}</ref>
*Advice to wear compression stockings to relieve the pain and swelling from [[varicose veins]].<ref name="pmid16107115">{{cite journal |vauthors=Seger JJ |title=Syncope evaluation and management |journal=Tex Heart Inst J |volume=32 |issue=2 |pages=204–6 |date=2005 |pmid=16107115 |pmc=1163473 |doi= |url=}}</ref>
*Counsel the caregivers of elder patients with postprandial hypotension.<ref name="pmid16107115">{{cite journal |vauthors=Seger JJ |title=Syncope evaluation and management |journal=Tex Heart Inst J |volume=32 |issue=2 |pages=204–6 |date=2005 |pmid=16107115 |pmc=1163473 |doi= |url=}}</ref>
*A multidisciplinary approach to [[patient]] management is necessary. Involve [[cardiologist]], [[endocrinologist]], [[otolaryngologist]], [[geriatician]], [[neurologist]], and [[dietitian]].


==Don'ts==
==Don'ts==
*Do not over treat [[hypotension]]. Symptomatic [[hypotension|low BP]] or decreased organ perfusion is a treatable entity.
*Do not over treat [[hypotension]]. Symptomatic [[hypotension|low BP]] or decreased organ perfusion is a treatable entity.
*Do not forget to follow up with the [[patient]] and monitor the [[blood pressure]] to titrate the management strategy.


==References==
==References==
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[[Category:Intensive care medicine]]
[[Category:Intensive care medicine]]
[[Category: Physical examination]]
[[Category: Physical examination]]
 
[[Category:Up-To-Date]]
{{WH}}
{{WS}}

Latest revision as of 18:10, 11 March 2021


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ogheneochuko Ajari, MB.BS, MS [2] Javaria Anwer M.D.[3]
Synonyms and keywords: Low blood pressure resident survival guide, Low blood pressure management guide, guide to hypotension management, hypotension management guide, hypotension management algorithm

Hypotension resident survival guide microchapters
Overview
Causes
Diagnosis and Management
Do's
Don'ts

Overview

Hypotension is the term for low blood pressure (BP). A systolic BP measuring less than 90mmHg and/ or diastolic BP of less than 60mmHg is considered hypotension. A difference of 20 mmHg systolic BP and 10 mmHg diastolic BP is considered orthostatic hypotension (OH). Orthostatic hypotension is the most common type of hypotension, and neurogenic hypotension is demonstrated among 1/3rd of the individuals with OH. A decrease in blood pressure can be life-threatening in conditions such as anaphylaxis and addisonian crisis, and requires prompt treatment. It is important to access the possibility of head injury in a patient with syncope due to hypotension. ECG is an important and essential component of the evaluation of hypotension. Shock requires prompt management with fluids and vasopressors. For other causes of hypotension, identifying the cause and treatment is the best strategy. Lifestyle modifications are usually the first step in management. Medications causing a drop in blood pressure should be discontinued or changed to an appropriate alternative.

Causes

Life Threatening Causes

Life-threatening causes include conditions that result in death or permanent disability within 24 hours if left untreated.

Common Causes

The algorithm illustrates common causes of hypotension based upon the etiology.[1][2][3][4]

 
 
 
 
 
 
 
 
Causes of hypotension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Vasodilation
 
Cardiogenic
 
Orthostatic hypotension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Neurogenic
 
 
 
 
Iatrogenic
 
 
 
 
Non-neurgenic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medications
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Peripheral autonomic

Diabetic autonomic neuropathy
❑ Acquired non-diabetic autonomic neuropathy

Hereditary autonomic neuropathy
 
Neurodegenerative

❑ Pure autonomic failure
Parkinson disease
❑ Diffuse lewy body disease

❑ Multiple system atrophy
 
Post-traumatic
Spinal cord injury
 
 
 
 
 
Hypovolemia

Dehydration/ low intravascular volume: Vomiting, diarrhea, Addison's disease
Polyuria such as in diabetes mellitus
❑ Third-spacing: Burns, sepsis

Bleeding: Wounds, menorrhagia
 
Venous pooling
Prolonged bed rest
Heat stroke
 
Others

❑ Aging
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Diagnosis and Management

Shown below is an algorithm summarizing the management of hypotension.[5][6][1][7][8][9][10][11][12][13][14][15][16][17][18][19][2]


 
 
 
 
 
 
 
Systolic BP < 90mmHg / Diastolic BP < 60mmHg
OR
Difference of 20 mmHg systolic and 10 mmHg diastolic pressure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Reassess B.P if unsure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnosis of hypotension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initial tests
EKG x 24 hours
❑ Cardiac monitor x 24 hours till 7 days
Pulse oximeter
❑ Blood pressure monitor x 24 hours
TSH
❑ Serum electrolytes
HB
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sinus rhythmn
 
 
Arrhythmia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Holter monitor or
Long-term loop recorders
(may be up to a month)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unexplained syncope/ fall/ dizziness
 
 
 
 
 
Asymptomatic
 
Shock
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CT scan head if

❑ Decreasing GCS score (<15)
Seizure
❑ > 1 episode of vomiting
❑ Skull fracture evidence
❑ Age >60 years
❑ Abnormal neurological examination

❑ High-risk mechanism injury
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Shock resident survival guide
 
 
 
 
 
 
 
 
 
 
 
 
 
Post-parandial
History

Age:Usually old individuals.
Symptoms: Syncope or angina symptoms 15-90 minutes after meal.
Associated symptoms: Angina pectoris, weakness, dizziness or lightheadedness, syncope, nausea, blurred vision/ black spots in visual field, cold clammy, or pale skin, disturbed speech.
Past medical history: Parkinson disease, autonomic dysfunctions, HTN, diabetic autonomic neuropathy.

Medication history: Medications administered with meal may cause hypotension.
 
Prolonged standing/ Stress
History

Source:
Patient and/ or a witness describing the fall.
Age: Common among young individuals.
Duration of symptoms: Frequency, triggering or relieving factors.
Associated symptoms: Sinking feeling, tachycardia, sweating dizziness or lightheadedness, nausea, blurred vision, cold clammy, pale skin and blaxck out preceding syncope
Past medical history: Volume loss, malena.

Family history:A positive family history has been demonstrated in the past and indicated genetic component
 
Postural / Early morning
History

Source: Patient and/ or a witness describing the fall.
Age: Any age individuals.
❑ Duration of syncope, preceding events, confusion post syncope
Associated symptoms: Dizziness or lightheadedness, confusion, fatigue, nausea, blurred vision, cold clammy, and pale skin, Vision problems, gait problems, and neck pain.
Past medical history:Diabetes, renal problems, amyloidosis, heart disease,HTN, autoimmune disease, neurodegenerative dosease.
Menstrual history: Menorrhagia
Medication history: Beta-blockers, aplha blockers, vasodilators, and tricyclic antidepressants.

Social history:Alcohol intake may cause dehydration.
 
History
Source: Patient

Age: Helps determine age-specific causes.
Associated symptoms: Dizziness or lightheadedness, syncope, nausea, blurred vision.

Past medical history:
Volume loss, malena, diagnosed conditions such as diabetes, HTN, Addison's disease, etc
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical exam

Vital signs: Heart rate, respiratory rate. A decrease in systolic BP of =/ >20 mm Hg or =/> 90 mm Hg (when the systolic BP before the meal is > 100mmHg, within 2 hours of the start of the meal.

HEENT, CVS, neuro, respiratory, and GI exam.
 
 
Physical exam

Vital signs:Heart rate, respiratory rate. Blood pressure recording lying/ seating and standing.
❑ Reduction of at least 20 mm Hg systolic or 10 mm Hg diastolic BP within 3 minutes of erect standing.

HEENT, CVS, neuro, respiratory, GI exam.
 
Physical exam

Vital signs:Heart rate, respiratory rate. Blood pressure recording lying/ seating and standing.

HEENT, CVS, neuro, respiratory, GI exam.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Labs
CBC
BSL/ HbA1c
Urinalysis
CMP
Holter monitor, CXR, stress test (high risk individuals)
 
Labs
CBC

BSL

Holter monitor, CXR, stress test (high risk individuals)
 
Labs
 
Labs
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tilt table test
 
 
 
 
 
 
Lifestyle Modification
❑ Regular blood pressure monitoring both supine and prone.
❑ Maintain fluid intake.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tilt table test positive
 
 
 
 
 
Tilt table test negative
 
❑ Cardiac journal
❑ Follow-up
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Orthostatic hypotension after 3 minutes of standing
 
❑ Diagnosed in 1 minute of standing
❑ Severity estimated in 2 minutes of standing
Valsalva test or carotid massage may be utilized to confirm the diagnosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Neurocardiogenic syncope
 
Orthostatic hypotension
 
 
Postprandial hypotension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lifestyle Modification
❑ Regular blood pressure monitoring both supine and prone.

elevated salt intake of no more than 10g/day.

❑ Maintain fluid intake.
 
Lifestyle Modification

❑ Regular blood pressure monitoring both supine and prone.
❑ Maintain fluid intake.
❑ Postural OH:

Elevated salt intake
Mild cases: 2 g salt tablets thrice a day (minimum eight 8-ounce servings of fluid/ day). Maximum of no more than 10g/day.
Acute cases: Salty soups and about five 8-ounce servings of fluid/ half day.
Abdominal binder

❑ Early morning OH

❑ Care on awakening with gradual shift from supine to upright.
❑ Drinking two cups of cold water 30 min before arising from the bed.
❑ Elevation of the head end of the bed.
 
 
Lifestyle Modification

❑ Counsel the patient and caregiver about the risk and timing post meal.
❑ Discontinue unnecessary medications.
❑ Pre and post parandial B.P. monitoring.
❑ Medications between the meals rather with the meal.

❑ Meal: Smaller, low carbohydrate meals. Liberal salt, water intake. Avoid hot drinks, hot foods, meals during hemodialysis, and reduce alcohol intake.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical therapy

Beta blockers preferred initial treatment
SSRI
Fludrocortisone 0.1mg/day
Midodrine 2.5-10 TID
Scopolamine

Dual chamber pacing may be required.
 
Medical therapy
❑ Severe acute cases: hospital management with IV fluids
Fludrocortisone 0.1-1.0 mg / day
Pyridostigmine bromide
Erythropoietin 50 units/kg S/C thrice a week (monitoring reticulocyte count and Hct)
 
 
Medical therapy
Caffeine 250mg before meal
Octreotide 50 microgram S/C before each meal.
Indomethacin 25-50 mg thrice a day
Midodrine 2.5 -10 mg thrice a day/ 60 mg 6 or 12 hourly.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FDA approved pharmacotherapy for neurogenic OH

 ❑ Droxidopa

 ❑ Midodrine
 
 
 
 
 
❑ Cardiac journal
❑ Follow-up
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Cardiac journal
❑ Follow-up
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Do's

Don'ts

  • Do not over treat hypotension. Symptomatic low BP or decreased organ perfusion is a treatable entity.
  • Do not forget to follow up with the patient and monitor the blood pressure to titrate the management strategy.

References

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