Hypotension

Hypotension: Excerpt from In a Page: Signs and Symptoms

Chronic low blood pressure is generally not a serious problem. However, a sudden drop in blood pressure is a sign of an underlying condition and may result in serious consequences secondary to cerebral and renal hypoperfusion.

Differential Diagnosis

• Orthostatic hypotension
  –Most common in elderly
  –May result in syncope or near-syncope upon standing
  –Decrease of more than 20 mmHg in systolic blood pressure, or a decrease of 10 mmHg in diastolic blood pressure within 2–5 minutes of standing

• Hypotension secondary to medications is common in elderly patients (e.g., antihypertensives; vasodilators, including nitrates, calcium channel blockers, ACE inhibitors, angiotensin receptor blockers; hypoglycemic agents; antidepressants; opiates; alcohol)
• Volume depletion
  –Often due to hyperglycemia, dehydration, hemorrhage, occult bleeding, vomiting, diarrhea, or diuretic use
• Autonomic failure
  –Absence of reflex-induced increase in heart rate as blood pressure is decreased
  –Often due to Parkinson's disease, cerebellar disorders, neuropathies, or Shy-Drager syndrome
• Postprandial hypotension (within 75 minutes of eating)
  –Very common in elderly
• Adrenal insufficiency
  –ACTH stimulation test shows inadequate increase in serum cortisol from baseline
• Diabetic autonomic neuropathy
• Shock
  –Cardiogenic shock
  –Septic shock
  –Neurogenic shock
  –Hemorrhagic shock
• Anaphylaxis
• Splenic rupture
• Ectopic pregnancy
• Hepatitis

Workup and Diagnosis

• History and physical examination
  –Compare blood pressure to patient's usual values
  –The absence of reflex-induced increase in heart rate as blood pressure falls indicates autonomic failure, which may require a workup for suspected underlying neurologic or pharmacologic conditions
  –Cardiogenic shock is often accompanied by cool, clammy extremities

• Laboratory studies may include CBC, electrolytes, BUN/creatinine, glucose, calcium, urinalysis, and ECG
• Additional studies (e.g., blood cultures, echocardiogram, blood type and cross) may be indicated based on the underlying disorder
• Swan-Ganz catheterization (right heart catheterization) may be indicated to establish the etiology (e.g., cardiogenic versus noncardiogenic) and determine patient management
• For diagnosis of adrenal insufficiency, obtain baseline cortisol level and then administer 250 µ g of ACTH (Cortrosyn); obtain serum cortisol levels 30 and 60 minutes after ACTH administration; if cortisol level increases by <7, then adrenal insufficiency is highly likely

Treatment

• Orthostatic hypotension: Increase salt and water intake; pharmacologic treatment for moderate to severe disease may include fludrocortisone acetate, sympathomimetic agents, NSAIDs, caffeine, and erythropoietin
• Volume depletion: Fluid replacement based on existing deficiencies (e.g., saline, dextrose, potassium, packed red blood cells)
• Remove offending medications, compensate for medication needs
• Adrenal insufficiency requires stress doses of IV hydrocortisone (100 mg IV every 6 hours)
• Patient education (e.g., rise slowly from sitting to standing)

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

More About Shy-Drager Syndrome

• Back to disease: Shy-Drager Syndrome: Introduction
• Next Book Extract About Shy-Drager Syndrome: HYPOTENSION AND SHOCK (Differential Diagnosis in Primary Care)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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• HYPOTENSION AND SHOCK (Differential Diagnosis in Primary Care)
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