Hypotension

1. Gopi Prithviraj Intern Boot Camp July 7th, 2010 Hypotension

2. It’s 3 AM, and you are the on-call intern for Carpenter, admitting your last patient on Tower 7 (that was not geographically localized by the NACR) Kristina, RN from Lakeside 65, calls to tell you there is a Cherniack patient with a BP of 60/30. What is the first thing you want to know?

3. Common symptoms Mental status changes Lethargy, weakness Cool, clammy skin Oliguria Orthostatic hypotension Laying ? Standing (No need for sitting) 2-5 minutes before retaking blood pressure At least 20 mm Hg fall in SBP At least 10 mm Hg fall in DBP

4. She tells you the patient is sleeping comfortably. Are you done?

5. Other initial information you should find out: Is this BP accurate? What are the other vital signs? GO SEE ANY PATIENT WITH ABNORMAL VITALS! Check ABCs. If you can’t measure the BP, what is the next step? Check Pulse Radial Pulse present suggests SBP > 80 Carotid or Femoral Pulse present suggests SBP > 60 BP is relative! Why was the patient admitted? What comorbidities could explain low BP? What has their BP been running? Call your senior!

6. She tells you the patient got up to go to the bathroom and became very dizzy. Your sign-out states that this is an elderly patient who was admitted today with nausea, vomiting and diarrhea.

7. Hypovolemia (decreased preload) Volume depletion (Poor PO intake) 3rd spacing Post-dialysis Overdiuresis GI losses Vascular dissection Hemorrhage

8. A word about fluids and IV access What IV fluids would you give, and how? Always bolus with normal saline! Be very aggressive with IV hydration If clinically unstable or evidence of GI bleed, need at least two large bore peripheral IVs (16-gauge or 18-gauge) What do you do if the floor nurse cannot establish IV access?

9. You are the on-call intern for Hellerstein and Chris, RN from T5, calls to tell you a patient that you are covering has a BP of 60/30.Your sign-out states that this is a 58 year old patient with CAD s/p recent CABG. On exam his HR is 150. Admission ECG showed NSR at 75 bpm. 

15. Cardiogenic (pump failure) Acute MI Arrhythmia Valvular dysfunction CHF/cardiomyopathy

17. You are the on-call VA Blue intern and a nurse on 4A calls to tell you there is a Green team patient became acutely SOB and hypotensive with a systolic BP in the 50s.Your sign-out states that this a patient with a left hip fracture that is being “co-managed” with the orthopedic service.

18. Obstructive Causes of Hypotension Pulmonary Embolism Cardiac Tamponade Atrial Myxoma Tension Pneumothorax

19. A word about PE Most common signs/symptoms: dyspnea, pleuritic chest pain, tachypnea, tachycardia, JVD, hypoxia, hypotension If you suspect PE as the cause of hypotension, it is likely massive (segmental) Increased PVR (from impedence of RV outflow) and decreased preload causes decreased CO, which leads to hypotension Massive PE frequently causes RV failure

20. PE You can always get a CT Chest with contrast or VQ scan (even if it is the middle of the night at the VA) If there is no evidence of dissection or other contraindication to anticoagulation, start heparin drip (with bolus) immediately ¼ of patients with proven PE have no changes in their ECG from baseline.

21. ECG Findings in PE

22. A word about cardiac tamponade Fluid accumulating in the pericardium faster than the pericardium can stretch, leading to accumulation of pressure on the cardiac chambers Decreased venous return ? Decreased CO ? Hypotension Usually as a result of chest trauma, myocardial infarction, malignancy, uremia, pericarditis, or cardiac surgery Beck’s Triad: Hypotension Elevated JVP (from impaired venous return to the heart) Diminished heart sounds (from fluid inside the pericardium) May also see chest pain, tachycardia, dyspnea, decreased level of consciousness, pulsus paradoxus

23. Cardiac Tamponade How do you check for pulsus paradoxus? Using a manual BP cuff, inflate about 20 mm Hg above SBP, then slowly release until you first hear Korotkoff sounds (at first, you will only hear with expiration) Slowly release until you hear a sound with every beat (inspiration and expiration) The difference is the pulsus (abnormal > 10 mm Hg) EKG: low voltage QRS complexes, electrical alternans Echo: diastolic collapse of RA (end-diastole) and RV (early diastole), LA collapse (in 25%), reciprocal changes in LV and RV volume, pericardial effusion, enlarged pericardium Treatment: IVFs, call cards fellow for stat TTE and ?pericardiocentesis (check for pulsus and measure JVP first!) At end-diastole- RA volume is minimal but pericardial pressure is maximalAt end-diastole- RA volume is minimal but pericardial pressure is maximal

25. A word about tension pneumothroax… MEDICAL EMERGENCY! Present with sudden dyspnea, tachypnea, chest pain, hyperresonance on affected side, tracheal deviation (towards UNaffected side), and hypotension Usually from blunt/penetrating trauma; can occur from spontaneous pneumothorax Don’t wait for the CXR to treat! Treatment: 14-16 gauge angiocath into 2nd intercostal space, midclavicular line. Call CT surgery or pulmonary fellow for chest tube placement.

27. Neutropenic Fever A single temperature of > 38.3°C (100.4°F) or a sustained temperature > 38°C for more than one hour Neutropenia: ANC < 500 cells/µL OR < 1000 cells/µL with a predicted nadir of < 500 cells/microL ANC = (total WBC count in mm3)(%neutrophils + %bands) Physical exam: look for s/s of infection, including mucous membranes, all indwelling catheter sites. Avoid rectal exams in the neutropenic patient- but must examine perianal area for abscesses. Panculture, Chest X-Ray

28. Initial Neutropenic Fever Management MEDICAL EMERGENCY! Requires broad spectrum antibiotics ASAP VA: Neutropenic fever protocol Antibiotic choice directed at likely source Zosyn 4.5 gm IV q6h or Cefipime 2 gm IV q8h Vancomycin 1 gm q12h if concern for line infection, mucositis, MRSA, or if clinically deteriorating If continues to spike fevers after 5 days on broad spectrum antibiotics, consider antifungal coverage High mortality if initiation of antibiotics is delayed Gram negative: Also ceftazidine, imipenem, meropenemGram negative: Also ceftazidine, imipenem, meropenem

29. You are the Eckel intern and you get a call from Odessa, the secretary on Lakeside 40, who says “Your patient just came back from dialysis with a low blood pressure and fever. Oookaaay, byyyye””

30. Distributive causes of hypotension Severe decrease in SVR with an increase in CO Sepsis Anaphylaxis Adrenal insufficiency Medications (narcotics, anesthetics, paralytics) Thyroid storm End-stage Liver Disease Sepsis induced hypotension SBP of < 90mm Hg or mean arterial pressure < 70mm Hg or a SBP decrease > 40 mm Hg or < 2 SD below normal for age in the absence of other causes of hypotension

31. SIRS and Sepsis syndromes

32. Hemodynamics of Shock Syndromes

33. Early Goal-Directed Therapy of Sepsis Fluids, fluids, fluids; pressors if needed Norepinephrine or dopamine are initial pressors of choice in sepsis 2nd line: epinephrine, phenylephrine, or vasopressin Initial resuscitation goals (First 6 hours): Central venous pressure (CVP): 8–12 mm Hg Higher target in mechanically ventilated patients: 12-15 mm Hg Mean arterial pressure (MAP) = 65 mm Hg Urine output = 0.5mL/kg/hr Central venous (superior vena cava) or mixed venous oxygen saturation = 70% or = 65%, respectively If not at goal mixed venous oxygen saturation, consider more IVF, prbcs with goal Hct > 30%, or dobutamine Pan-culture, then broad spectrum antibiotics

34. Pressors

35. Additional Therapies in Sepsis Management Consider steroids if hypotension doesn’t respond to the previous interventions Hydrocortisone 50 mg IV q6h Wean steroids once pressors are no longer required Consider recombinant human activated protein C [Xigris] if high mortality risk (APACHE II = 25 or multiple organ failure) and no contraindications APACHE II = Acute Physiology and Chronic Health Evaluation II: severity of disease classification system

38. Other Distributive Causes of Hypotension: Medications Narcotics Narcan (Naloxone) 0.4-2 mg IV/IM/SQ/ETT q2-3 min PRN Benzodiazepines Flumazenil 0.2 mg – 0.5 mg IV qmin: Start 0.2 mg IV x 1, wait 30 seconds, then 0.3 mg IV x 1, wait 30 seconds, then 0.5 mg IV qmin PRN up to 6 doses. Max 5 mg total; doses should be given IV push over 30 seconds Paralytics Anesthetics

39. Other Distributive Causes of Hypotension: Anaphylaxis Acute multi-system type I hypersensitivity reaction Anaphylactic shock: anaphylaxis associated with systemic vasodilation which subsequently causes hypotension, patient also develops severe bronchoconstriction Can develop: hives, swelling of lips, tongue, and throat, shortness of breath, wheezes, stridor, loss of consciousness, coronary artery spasm Treatment: Epinephrine 0.5mg (1:1000) SQ/IM q5-15 mins prn, Benadryl 50mg IV, Zantac 50mg IV

40. Other Distributive Causes of Hypotension: Adrenal Insufficiency in Critically Ill Patients Inadequate amount of steroid hormone production by adrenal glands Causes: Sudden withdrawal of long-term corticosteroid therapy Stress in patients with chronic adrenal insuffiency Waterhouse-Friedrichsen syndrome Symptoms: Hypotension, hypoglycemia, dehydration, mental status changes, weakness, fatigue, dizziness, N/V/D Treatment: Stress dose steroids (hydrocortisone 50 mg IV q6h)

41. Summary of specific interventions Narcotics ? Narcan (Naloxone) 0.4-2 mg IV/IM/SQ/ETT q2-3 min PRN Benzodiazepines ? Flumazenil 0.2 mg – 0.5 mg IV qmin: Start 0.2 mg IV x 1, wait 30 seconds, then 0.3 mg IV x 1, wait 30 seconds, then 0.5 mg IV qmin PRN up to 6 doses. Max 5 mg total; doses should be given IV push over 30 seconds Anaphylaxis ? Epinephrine 0.5mg (1:1000) SQ q5-15 mins prn, Benadryl 50mg IV, Zantac 50mg IV Arrythmia ? appropriate ACLS algorithm Hemorrhage ? prbcs (can give O-neg unmatched blood in case of emergency) Tension PTX ? 14-16 gauge angiocath into 2nd intercostal space midclavicular line. Call pulmonary fellow or surgery for chest tube. Sepsis ? IVFs, draw cultures, antibiotics, start pressors if needed STEMI ? ACS protocol, call cardiology fellow to review ECGs and activate cath lab if appropriate Neutropenic fever ? stat antibiotics, neutropenic precautions Adrenal insufficiency ? Stress dose steroids (hydrocortisone 50 mg IV q6h)

42. Final words of wisdom Hypotension (SBP < 90) or a drop in SBP > 40 suggests impending shock Always review medications (overdiuresis, anti-hypertensives) and events of the day (procedures?, new meds?) STAT labs to consider: comprehensive metabolic panel, magnesium, CBC, coags, cardiac enzymes, blood cultures, amylase/lipase, type and screen, lactate, tox screen Get an ABG and portable CXR IV access: fluids, fluids, fluids; and antibiotics if appropriate Place the patient in Trendelenberg position If the patient is unstable or if you have any concerns regarding the patient, call your senior resident and also realize that the Code White nurse is your friend! Notify the appropriate ICU if transfer is needed. At the VA, utilize the Rapid Response team if needed.

43. Thanks to Brooke Decker and Brian Southern…

44. Questions?