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Hypotension on the Ward Definitions Systolic < 90mmHg or Mean < 60 mmHg or Systolic fall > 40mmHg ? Evidence of Organ Hypoperfusion Oliguria / Confusion / Skin cold-clammy ? normally hypotensive Physiology of Normal Blood Pressure Bp = Cardiac Output x Systemic Vascular Resistance Bp = CO x SVR CO = Stroke Volume x Heart rate Remember: normal valves sinus rhythm no hypovolaemia obstruction BP sensed by: baroreceptors carotid sinus/ aorta atrial stretch receptors BP controlled by Endocrine: Adren/Noradenaline Angiotensin II Local Reflexes incl Nitric Oxide, Kinins etc Causes / Classification Hypovolemia Low Cardiac Output Stroke Volume: Pre / Afterload / Contractility /dysrhythmias Low Heart rate Low SVR Sepsis / Anaphylaxis / Drugs Valvular MR / AR Assessment + Treatment Call for help A B C ? pulse ? breathing I/V access at least 18g (green) Is it low CO / high SVR or high CO / low SVR - guides diagnosis and Rx Consider likely causes Brief History: ?Blood - fluid loss ?surgery Pain to localise cause Eg Pneumothorax/ GI bleed PMHx Drug Hx ?allergy Examination: ? Hr + Bp + Temp + RR Are they ‘ill” Skin cold + shut down( low CO, Hi SVR) Skin warm + dilated ( Hi CO, Lo SVR) CVS ? sinus rhythem Postural hypotension ? CVP elevated or low Heart examination RS GI +GU + NS ?Investigations Treatment: General approach Most have Hypovolemia Consider specifics Give fluid until filled: 200 ml colloid in 15 mins Hr returning to normal Bp rising CVP rises by 3mmHg = 5cm H2o When filled (need CVP or Left sided monitors) Inotropes: to CO - need ITU Vasopressors: to SVR - need ITU Specific Treatments Reassure - Get Help - Oxygen - IV Access Low CO Pneumothorax: decompress + drain LVF: If Hypotensive call ITU GTN +? Diuretics + inotropes Bradycardia- depends on rhythm Atropine 0.5mg –1mg iv Isoprenaline ivi Pacing – external or intravenous Tachycardia - depends on rhythm drug / DC Cardioversion / overdrive pacing High CO Sepsis - From where ? Drain - debride Fluid / Antibiotics / Vasopressors / cool Anaphylaxis - Adrenaline im 0.3 - 0.5mg + fluid Nebs if bronchospasm Hydrocortisone 200mg iv Chlorpheniramine 10mg iv (H1 Blocker) ? Ranitidine 50mg iv (H2 Blocker) Case Histories 23 Yr male Arrived on ward from recovery post appendicectomy The nurses call you immediately as his BP is 60/20 Differential? What would you do in the 1st 15 minutes ? 78 Yr female Arrived on ward from Casualty post MI The nurses call you immediately as his BP is 78/40 Differential? What would you do ? 56 Yr male 5 Days post laparotomy T = 39.50c confused Differential? What would you do ? 86 Yr male 1/2 hour post CVP insertion Progressive SOB Differential? Bp = 80/45 What would you do ?
