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Popular Search heart failurehypertensionpneumothoraxhypernatrehypernat

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  • Hypotension

Hypotension

Table of Contents
  • Overview
  • Triage
  • Causes
  • Clinical Assessment
  • Investigation
  • Management
  • Management - specific management of underlying cause
  • References

Overview #

For immediate response to hypotension that breaches MET call criteria (systolic BP < 90 mmHg) 

Key Points

  • Hypotension: blood pressure of < 90/60mmHg
  • Shock: A state of circulatory failure causing inadequate oxygen delivery to meet cellular metabolic needs and oxygen consumption requirements [1]
    • subclassified into: hypovolaemic, distributive, obstructive, cardiogenic or mixed shock
  • Hypotension can be a late sign of shock
  • Assess every hypotensive patient for signs of shock, and if present seek urgent senior review
  • A structured approach to the assessment of a hypotensive patient is provided below
  • IV fluid resuscitation is a key component of the ward management of shock, hypotension refractory to fluid resuscitation warrants urgent referral to ICU

Triage #

Immediate – should be attended immediately

Causes #

The causes of hypotension can be conceptualised as the same as the causes/classification of shock:

1. Hypovolaemic

  • Bleeding
  • Dehydration
  • Gastrointestinal losses
  • Renal losses

2. Distributive

  • Sepsis
  • Systemic inflammatory response syndrome
  • Anaphylaxis
  • Liver failure
  • Neurogenic
    • Spinal/epidural anaesthesia
    • Brain or spinal cord injury
  • Endocrine shock: Addisonian crisis, myxoedema

3. Obstructive

  • Pulmonary embolism
  • Tension pneumothorax
  • Pericardial tamponade

4. Cardiogenic

  • Myocardial infarction
  • Valvular disease (eg: stenosis, regurgitation, rupture)
  • Arrhythmia 
  • Medication effects (eg: beta-blockers, calcium channel blockers)

5. Mixed

·       A combination of the above causes

Clinical Assessment #

1. Ensure accurate blood pressure measurement

  • Take BP manually with the correct sized cuff
  • A cuff too small for the patients arm will overestimate readings, while a cuff too large will underestimate the reading
  • Automated non-invasive blood pressure measurements can be unreliable in patients with an arrythmia

2. Examine for signs of shock (if present seek urgent senior review)

  • Altered mental status
  • Tachypneoa
  • Tachycardia
  • Delayed capillary refill
  • Mottled skin
  • Oliguria (<0.5mls/kg/hr)
  • Patient reporting feeling dizzy or unwell

3. Assess for potential cause of hypotension/shock

SignSignificance
TachycardiaTachycardia is a compensatory response to hypotension/shock but may not be present:·       if the patient has received beta or calcium channel blockers, or if the cause is neurogenic or endocrine
Cardiac murmurConsider valvular disease
Absent breath soundsConsider tension pneumothorax
Tracheal deviationSuspect tension pneumothorax
JVPIf elevated consider obstructive and cardiogenic causes
Temperature of peripheriesCool peripheries can be a sign of shockWarm peripheries in a shocked patient suggests a distributive cause
Unilateral swollen limbsConsider DVT
FeverConsider sepsis
PeritonismConsider intra-abdominal sepsis or haemorrhage
Evidence of skin infectionConsider sepsis
Angiooedema, rash, wheezeSuspect anaphylaxis

4. Chart review

·       Review trend of heart rate, blood pressure and respiratory rate

·       Review notes, post-operative reports, and recent investigations

·       Review drug chart, particularly for any antihypertensive medications

Investigation #

 Initial investigations for undifferentiated shock

InvestigationSignificance
VBG/ABGMetabolic acidosis and/or lactate >2mmol/L suggests shockLow Hb – suggests haemorrhage
FBE, UEC, LFT, CRPLow Hb – suggests haemorrhageElevated urea – consider upper GI bleedingElevated inflammatory markers – consider sepsis LFT and UEC – shock can cause acute kidney and liver injury, fulminant hepatic failure can also be a cause of distributive shock
Serial troponinsCheck for myocardial injury/ischaemia
ECGCheck for:·   arrythmia·   ischaemia·   electrical alternans (tamponade)·   right heart strain (pulmonary embolus)
CXRCheck for pneumonia (sepsis), tension pneumothorax, pulmonary oedema (heart failure)

Further investigations depending on clinical suspicion

InvestigationSignificance
Group and hold Coagulation profileIf suspicion of haemorrhage
Septic screenIf suspicion of sepsis
BNPIf suscpicion of cardiac failure
Random and morning cortisolIf suspect Addisonian crisis/adrenal insufficiency[SS1] 
TFTsIf suspicion of myxoedema
Bedside TTE*If suspicion of cardiogenic shock. Looking for cardiac function,  pericardial effusions/tamponade and valvular disease.
CTPA* or VQ scan*If suspicion of PE
CT Chest/Abdomen/Pelvis*If suspicion of haemorrhage or occult infection
CT angiogram*If suspicion of bleeding or dissection

Management #

For all patients

  • Urgent escalation to a senior doctor or MET call if evidence of shock
  • Establish wide bore IV access available and draw bloods
  • Consider fluid bolus (unless evidence of pulmonary oedema)
  • Consider witholding antihypertensive and diuretic medications
  • Investigation as above

If evidence shock and not improving with one or two fluid boluses escalate to senior doctor / ICU for review and consider MET Call

Management – specific management of underlying cause #

Hypovolaemic shock

Haemorrhage

  • Apply direct pressure to external bleeding if possible
  • Arrange packed red blood cells (PRBC) transfusion and consider activating massive transfusion protocol as required
  • Arrange urgent surgical/endoscopic/interventional radiological intervention for noncompressible bleeding

References #

1. Gaieski DF, Mikkelsen ME, Evaluation of and initial approach to the adult patient with undifferentiated hypotension and shock. In: Parsons PE, Hocksberger RS, editors. UpToDate. [Internet]. UptoDate; 2020 [updated 2021 Feb 23; cited 2021 Sep 29]. Available from: https://www.uptodate.com/contents/evaluation-of-and-initial-approach-to-the-adult-patient-with-undifferentiated-hypotension-and-shock?search=hypotension&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2

2. Henry S. ATLS Advanced Trauma Life Support Student Course Manual. 10th ed. Chicago (IL): ACS American College of Surgeons; 2018. Chapter 3, p. 49.

  • Contributors

  • Reviewing Consultant/Senior Registrar

Dr Kwan Yun Lee

Dr Scott Santinon

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Updated on May 1, 2023
Table of Contents
  • Overview
  • Triage
  • Causes
  • Clinical Assessment
  • Investigation
  • Management
  • Management - specific management of underlying cause
  • References

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