On Call: Hypotension

Definitions

Definitions

  • Hypotension: Low Blood Pressure; SBP < 90 mmHg or MAP < 65 mmHg
    • Relative Hypotension: Drop in SBP > 40 mmHg from Baseline
    • Orthostatic Hypotension: Drop in SBP > 20 mmHg or DBP > 10 mmHg When Standing
  • Shock: State of Cellular & Tissue Hypoxia Due to Reduced Oxygen Delivery or Increased Demand
    • Most Often Associated with Hypotension but Can Be Hypertensive

Shock – Classification

Evaluation

Vitals

  • ABC’s – Airway, Breathing & Circulation
  • Vital Signs
  • Repeat Blood Pressure Reading to Ensure Accuracy

Signs of Shock

  • Hypotension
  • Tachycardia
  • Tachypnea
  • Altered Mental Status
  • Diaphoresis
  • Cyanosis
  • Oliguria/Anuria

Work-Up to Consider

  • Labs:
    • Arterial Blood Gas (ABG)
    • Lactate
    • Complete Blood Count (CBC)
    • Complete Metabolic Panel (CMP)
    • Troponin
    • B-Type Natriuretic Peptide (BNP)
  • EKG
  • Chest X-Ray
  • Echocardiogram

Treatment

Initial Managements

  • Always Ensure that ABC’s are Secured
  • Consider Getting the Placing “Lined Up”
    • Central Venous Catheter for Fluid/Pressor Administration
    • Arterial Line for Continuous Blood Pressure Monitoring
  • In General, Stop Any Antihypertensives or Diuretics

Management of Undifferentiated Shock (Uncertain Cause)

  • Start with a Bolus of Crystalloid Fluid – 1 Liter Lactated Ringer
    • Consider Smaller Boluses (500 cc) in CHF
  • Postoperative Patient May Require Multiple Fluid Boluses if Under-Resuscitated in the OR
  • Consider Starting Vasopressors if Fluid Boluses Do Not Stabilize
  • Ongoing Management Should Be Directed Based on Further Work-Up

Management of Differentiated Shock

Vasopressor Pharmacology