Hypotension
Sam speaks to Intensivists Dr Jonathan Casement and Dr Rob Everitt about differentiating and managing hypotension.
Differential
- Life threatening
- Acute haemorrhage
- On the floor and four more
- Sepsis
- Arrhythmia/cardiac
- Drugs (including transfusion reaction)
- Anaphylaxis
- Acute haemorrhage
- Dehydration (beware the accuracy of this diagnosis)
- Epidural anaesthesia
- Heart failure
- Pregnancy
- Syncope/postural
- Neurological
- Positional
- PD
- Diabetes
Approach
- Eyeball the patient / ABCDEF
- Calling a code
- 777 (or your local hospital emergency number)
- This is Sam, medical house officer I need the adult resus team to attend North Shore Hospital, ward 10, room E3.
- History
- Why are they in hospital?
- Post-op?
- Onset, timing & trend of hypotension
- Postural
- Medications
- Associated symptoms
- Pain is very concerning
- ROS
- Vitals + Examination
- End-of-bed-o-gram is probably the most important
- Peripheries for perfusion and pulse
- Manual BP
- Both arms
- Cuff size
- Urine output
- Drain output
- Consider investigations
- Keep in mind these may be of limited value
- ABG (lactate, glucose, Hb)
- ECG
- Management
- Fluid challenge only if hypovolaemic
- 250 – 500 mL stat
- Rehydrate gradually
- Transfusion
- Target Hb >70
- Use one unit then reassess
- Avoid transfusion outside daylight hours
- Catheterise and measure fluid balance
- Fix the underlying cause
- Have a low threshold to escalate to a senior
- Clear observation and escalation plan if cause is unclear
- Fluid challenge only if hypovolaemic
- Document
- Review past notes
- Basics (date/time/name/reason for review)
- Positives and pertinent negatives
- Impression and differential with justification.
- Have you eliminated life threatening conditions?
- Beware an impression of dehydration.
- Are they actually hypovolaemic?
- Why would they be dehydrated on the ward?
- Clear and specific plan
- Monitoring
- Consider discussion with senior and escalation, especially if called back to patient again
