Hypotension

Evaluation

Decreased SVR: Exam = warm extremities, sometimes flushing

• Sepsis: common cause. Obtain blood culture x2, CXR, UA/micro/culture, and lactate. Rapid administration of IVF and antibiotic
• Medications: Look for antiHTN, pain meds, sedative, if concern for opioate overdose, give naloxone
• Adrenal insufficiency: Is the patient on chronic steroids and unable to mount a stress response? consider stress dose steroids
• Anaphylaxis: Give epinephrine 0.2-0.5ml SC/IM q20mins, benadyrl 50mg IV, hydrocortisone 100mg IV
  

Decreased preload: Exam= cold extremities

• Hypovolemia: STAT CBC, consider central venous pressure monitoring. Give IVF
• Pulm emboli
• Tension pneumothorax: Unequal breath sounds on examination. DO not wait for CXR. Insert 14 or 16 gauge needle into the second intercostal space at the midclavicular line ASAP
• Tamponade: elevated JVP, muffled heart sound and hypotension
• Right ventricular infact
• Pulmonary hypertension

Decreased contractility

• MI
• Medication
• Aortic dissection: Get STAT chest CT

Management

1. Is the patient stable?
2. Have low threshold to transfer a hypotensive patient to the ICU for better nursing support, pressors and/or intubation
3. Treatment is aimed at the underlying cause but almost all cases call for fluid resuscitation. If suspicion of CHF is low then give rapid isotonic fluid resuscitation
4. If there is concern for mixed cardiogenic and septic shock, let your volume exam guide treatment. Keep fluid boluses small (i.e 200ml and reassess). Trend lactate.
5. In general, start O2, additional large bore peripheral IVs, put patient in trendelenburg, draw basic STAT labs (CBC, lytes, BUN, creatinine, glucose, LFTs blood/urine culture), STAT EKG, CXR, ABG/lactate

If the patient stable then ask this question

1. Is this BP real?
2. Is the BP different from prior values? if the patient usually has a BP 80/40 then the acuity may be decreased somewhat
3. Is there associated hypoxemia, AMS, or increased RR (reasons for intubation)?
4. Is the MAP <60? MAP less than 60 results in significant risk of hypoperfusion to vital organs