Hypotension resident survival guide

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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

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

Overview

Hypotension means low blood pressure (BP). A systoloc BP measuring less than 90mmHg and/ or diastolic BP of less than 60mmHg is considered hypotension.

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
 
Neurogenic
Vasovagal syncope/
Neurocardiogenic syncope
❑ Post-parandial hypotension
 
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]


 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
History

Source: Patient and/ or a witness describing the fall.
Age: Any age individuals.
❑ Duration of 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.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical exam

Vital signs: 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
 
Physical exam

Vital signs
Blood pressure: 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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Labs
CBC

EKG❑ Serum electrolytes
Glucose/ HbA1c
Urinalysis
CMP
Stress test
 
Labs
 
Labs
 
Labs
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tilt table test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tilt table test positive
 
 
 
 
 
Tilt table test negative
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Neurocardiogenic syncope
Orthostatic hypotension after 3 minutes of standing
 
Orthostatic hypotension
Diagnosed in 1 minute of standing
Severity estimated in 2 minutes of standing
 
 
Postprandial hypotension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lifestyle Modification
❑ Regular blood pressure monitoring both supine and prone.

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

❑ Mainten fluid intake.
 
Lifestyle Modification

❑ Regular blood pressure monitoring both supine and prone.
elevated salt intake of no more than 10g/day.
❑ Mainten fluid intake.

Blood sugar control
 
 
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
Fludrocortisone 0.1-1.0 mg / day
Pyridostigmine bromide
Erythropoietin 50 units/kg S/C thrice a week (monitoring reticulocyte count and [[hematocrit}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.
 
 
 
 
 
 
 
 
 
 
 
 

Do's

  • Educate the patient to avoid predisposing conditions such as dehydration, alcohol, etc.
  • Discontinue or adjust the dose of medication if hypotension is caused by medication side effects.
  • Advice to wear compression stockings to relieve the pain and swelling from varicose veins.
  • Counsel the caregivers of elder patients with postprandial hypotension.

Don'ts

  • Do not over treat hypotension. Symptomatic low BP or decreased organ perfusion is a treatable entity.

References

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  2. Seger JJ (2005). "Syncope evaluation and management". Tex Heart Inst J. 32 (2): 204–6. PMC 1163473. PMID 16107115.
  3. Vanamoorthy P, Pandia MP, Bithal PK, Valiaveedan SS (January 2010). "Refractory hypotension due to intraoperative hypothermia during spinal instrumentation". Indian J Anaesth. 54 (1): 56–8. doi:10.4103/0019-5049.60500. PMC 2876912. PMID 20532075.
  4. Zhang P, Li Y, Nie K, Wang L, Zhang Y (December 2018). "Hypotension and bradycardia, a serious adverse effect of piribedil, a case report and literature review". BMC Neurol. 18 (1): 221. doi:10.1186/s12883-018-1230-1. PMC 6307137. PMID 30591018.
  5. Ricci, Fabrizio; De Caterina, Raffaele; Fedorowski, Artur (2015). "Orthostatic Hypotension". Journal of the American College of Cardiology. 66 (7): 848–860. doi:10.1016/j.jacc.2015.06.1084. ISSN 0735-1097.
  6. "Looking for Trouble: Identifying and Treating Hypotension". P T. 44 (9): 563–565. September 2019. PMC 6705478 Check |pmc= value (help). PMID 31485153.
  7. Oommen J, Chen J, Wang S, Caraccio T, Hanna A (March 2019). "Droxidopa for Hypotension of Different Etiologies: Two Case Reports". P T. 44 (3): 125–144. PMC 6385736. PMID 30828233.
  8. Newton JL, Kenny R, Lawson J, Frearson R, Donaldson P (February 2003). "Prevalence of family history in vasovagal syncope and haemodynamic response to head up tilt in first degree relatives: preliminary data for the Newcastle cohort". Clin. Auton. Res. 13 (1): 22–6. doi:10.1007/s10286-003-0077-7. PMID 12664244.
  9. Michel D (September 1983). "[Iatrogenic hypotension in the aged]". Fortschr. Med. (in German). 101 (33): 1455–8. PMID 6629270.
  10. 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 (April 2011). "Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome". Clin. Auton. Res. 21 (2): 69–72. doi:10.1007/s10286-011-0119-5. PMID 21431947.
  11. Levine Z (April 2010). "Mild traumatic brain injury: part 1: determining the need to scan". Can Fam Physician. 56 (4): 346–9. PMC 2860826. PMID 20393093.
  12. Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM (July 2000). "Indications for computed tomography in patients with minor head injury". N. Engl. J. Med. 343 (2): 100–5. doi:10.1056/NEJM200007133430204. PMID 10891517.
  13. Molaei-Langroudi R, Alizadeh A, Kazemnejad-Leili E, Monsef-Kasmaie V, Moshirian SY (July 2019). "Evaluation of Clinical Criteria for Performing Brain CT-Scan in Patients with Mild Traumatic Brain Injury; A New Diagnostic Probe". Bull Emerg Trauma. 7 (3): 269–277. doi:10.29252/beat-0703010. PMC 6681891 Check |pmc= value (help). PMID 31392227.
  14. Sharif-Alhoseini M, Khodadadi H, Chardoli M, Rahimi-Movaghar V (October 2011). "Indications for brain computed tomography scan after minor head injury". J Emerg Trauma Shock. 4 (4): 472–6. doi:10.4103/0974-2700.86631. PMC 3214503. PMID 22090740.
  15. Jansen RW, Lipsitz LA (February 1995). "Postprandial hypotension: epidemiology, pathophysiology, and clinical management". Ann. Intern. Med. 122 (4): 286–95. doi:10.7326/0003-4819-122-4-199502150-00009. PMID 7825766.
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