Causes of Shy-Drager Syndrome
Shy-Drager Syndrome Causes: Book Excerpts
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Hypotension:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- 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
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Orthostatic hypotension [Postural hypotension]:
Medical causes
(Handbook of Signs & Symptoms (Third Edition))
Adrenal insufficiency
Adrenal insufficiency typically begins insidiously, with progressively severe signs and symptoms. Orthostatic hypotension may be accompanied by fatigue, muscle weakness, poor coordination, anorexia, nausea and vomiting, fasting hypoglycemia, weight loss, abdominal pain, irritability, and a weak, irregular pulse. Another common feature is hyperpigmentation — bronze coloring of the skin — which is especially prominent on the face, lips, gums, tongue, buccal mucosa, elbows, palms, knuckles, waist, and knees. Diarrhea, constipation, a decreased libido, amenorrhea, and syncope may also occur along with enhanced taste, smell, and hearing and cravings for salty food.
Alcoholism
Chronic alcoholism can lead to the development of peripheral neuropathy, which can present as orthostatic hypotension. Impotence is also a major issue in these patients. Other symptoms include numbness, tingling, nausea, vomiting, changes in bowel habits, and bizarre behavior.
Amyloidosis
Orthostatic hypotension is commonly associated with amyloid infiltration of the autonomic nerves. Associated signs and symptoms vary widely and include angina, tachycardia, dyspnea, orthopnea, fatigue, and a cough.
Hyperaldosteronism
Hyperaldosteronism typically produces orthostatic hypotension with sustained elevated blood pressure. Most other clinical effects of hyperaldosteronism result from hypokalemia, which increases neuromuscular irritability and produces muscle weakness, intermittent flaccid paralysis, fatigue, a headache, paresthesia and, possibly, tetany with positive Trousseau’s and Chvostek’s signs. The patient may also exhibit vision disturbances, nocturia, polydipsia, and personality changes. Diabetes mellitus is a common finding.
Hyponatremia
In hyponatremia, orthostatic hypotension is typically accompanied by a headache, profound thirst, tachycardia, nausea and vomiting, abdominal cramps, muscle twitching and weakness, fatigue, oliguria or anuria, cold clammy skin, poor skin turgor, irritability, seizures, and a decreased LOC. Cyanosis, a thready pulse and, eventually, vasomotor collapse may occur in a severe sodium deficit. Common causes include adrenal insufficiency, hypothyroidism, syndrome of inappropriate antidiuretic hormone secretion, and the use of thiazide diuretics.
Hypovolemia
Mild to moderate hypovolemia may cause orthostatic hypotension associated with apathy, fatigue, muscle weakness, anorexia, nausea, and profound thirst. The patient may also develop dizziness, oliguria, sunken eyeballs, poor skin turgor, and dry mucous membranes.
Other causes
Drugs
Certain drugs may cause orthostatic hypotension by reducing circulating blood volume, causing blood vessel dilation, or depressing the sympathetic nervous system. These drugs include antihypertensives (especially guanethidine monosulfate and the initial dosage of prazosin hydrochloride), tricyclic antidepressants, phenothiazines, levodopa, nitrates, monoamine oxidase inhibitors, morphine, bretylium tosylate, and spinal anesthesia. Large doses of diuretics can also cause orthostatic hypotension.
Treatments
Orthostatic hypotension is commonly associated with prolonged bed rest (24 hours or longer). It may also result from sympathectomy, which disrupts normal vasoconstrictive mechanisms.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Blood pressure decrease [Hypotension]:
Medical causes
(Handbook of Signs & Symptoms (Third Edition))
❑ Acute adrenal insufficiency. Orthostatic hypotension is characteristic with acute adrenal insufficiency, accompanied by fatigue, weakness, nausea, vomiting, abdominal discomfort, weight loss, fever, and tachycardia. The patient may also have hyperpigmentation of fingers, nails, nipples, scars, and body folds; pale, cool, clammy skin; restlessness; decreased urine output; tachypnea; and coma.
❑ Alcohol toxicity. Low blood pressure occurs infrequently; more commonly, alcohol toxicity produces distinct alcohol breath odor, tachycardia, bradypnea, hypothermia, a decreased LOC, seizures, a staggering gait, nausea, vomiting, diuresis, and slow, stertorous breathing.
❑ Anaphylactic shock. Following exposure to an allergen, such as penicillin or insect venom, a dramatic fall in blood pressure and narrowed pulse pressure signal anaphylactic reaction. Initially, anaphylactic shock causes anxiety, restlessness, a feeling of doom, intense itching (especially of the hands and feet), and pounding headache. Later, it may also produce weakness, sweating, nasal congestion, coughing, difficulty breathing, nausea, abdominal cramps, involuntary defecation, seizures, flushing, change or loss of voice due to laryngeal edema, urinary incontinence, and tachycardia.
❑ Anthrax (inhalation). Anthrax is an acute infectious disease that's caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological warfare. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in the cutaneous, inhalation, or GI form.
Inhalation anthrax is caused by inhalation of aerosolized spores. Initial signs and symptoms are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.
❑ Cardiac arrhythmias. With an arrhythmia, blood pressure may fluctuate between normal and low readings. Dizziness, chest pain, difficulty breathing, light-headedness, weakness, fatigue, and palpitations may also occur. Auscultation typically reveals an irregular rhythm and a pulse rate greater than 100 beats/minute or less than 60 beats/minute.
❑ Cardiac contusion. With cardiac contusion, low blood pressure occurs along with tachycardia and, at times, anginal pain and dyspnea.
❑ Cardiac tamponade. An accentuated fall in systolic pressure (more than 10 mm Hg) during inspiration, known as paradoxical pulse, is characteristic in patients with cardiac tamponade. This disorder also causes restlessness, cyanosis, tachycardia, jugular vein distention, muffled heart sounds, dyspnea, and Kussmaul's sign (increased venous distention with inspiration).
❑ Cardiogenic shock. A fall in systolic pressure to less than 80 mm Hg or to 30 mm Hg less than the patient's baseline because of decreased cardiac contractility is characteristic in patients with cardiogenic shock. Accompanying low blood pressure are tachycardia, narrowed pulse pressure, diminished Korotkoff sounds, peripheral cyanosis, and pale, cool, clammy skin. Cardiogenic shock also causes restlessness and anxiety, which may progress to disorientation and confusion. Associated signs and symptoms include angina, dyspnea, jugular vein distention, oliguria, ventricular gallop, tachypnea, and a weak, rapid pulse.
❑ Cholera. This acute infection, caused by the bacterium Vibrio cholerae, may be mild with uncomplicated diarrhea or severe and life-threatening. Cholera is spread by ingesting contaminated water or food, especially shellfish. Signs include abrupt watery diarrhea and vomiting. Severe fluid and electrolyte loss leads to thirst, weakness, muscle cramps, decreased skin turgor, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.
❑ Diabetic ketoacidosis. Hypovolemia triggered by osmotic diuresis in hyperglycemia is responsible for the low blood pressure associated with diabetic ketoacidosis, which is usually present in patients with type 1 diabetes mellitus. It also commonly produces polydipsia, polyuria, polyphagia, dehydration, weight loss, abdominal pain, nausea, vomiting, breath with fruity odor, Kussmaul's respirations, tachycardia, seizures, confusion, and stupor that may progress to coma.
❑ Heart failure. With heart failure, blood pressure may fluctuate between normal and low readings. However, a precipitous drop in blood pressure may signal cardiogenic shock. Other signs and symptoms of heart failure include exertional dyspnea, dyspnea of abrupt or gradual onset, paroxysmal nocturnal dyspnea or difficulty breathing in the supine position (orthopnea), fatigue, weight gain, pallor or cyanosis, sweating, and anxiety. Auscultation reveals ventricular gallop, tachycardia, bilateral crackles, and tachypnea. Dependent edema, jugular vein distention, increased capillary refill time, and hepatomegaly may also occur.
❑ Hyperosmolar hyperglycemic nonketotic syndrome (HHNS). HHNS, which is common in the patient with type 2 diabetes mellitus, decreases blood pressure — at times dramatically — if he loses significant fluid from diuresis due to severe hyperglycemia and hyperosmolarity. It also produces dry mouth, poor skin turgor, tachycardia, confusion progressing to coma and, occasionally, generalized tonic-clonic seizure.
❑ Hypovolemic shock. A fall in systolic pressure to less than 80 mm Hg or 30 mm Hg less than the patient's baseline, secondary to acute blood loss or dehydration, is characteristic in hypovolemic shock. Accompanying it are diminished Korotkoff sounds, a narrowed pulse pressure, and a rapid, weak, and irregular pulse. Peripheral vasoconstriction causes cyanosis of the extremities and pale, cool, clammy skin. Other signs and symptoms include oliguria, confusion, disorientation, restlessness, and anxiety.
❑ Hypoxemia. Initially, blood pressure may be normal or slightly elevated, but as hypoxemia becomes more pronounced, blood pressure drops. The patient may also display tachycardia, tachypnea, dyspnea, and confusion and may progress from stupor to coma.
❑ Myocardial infarction (MI). With MI, a life-threatening disorder, blood pressure may be low or high. However, a precipitous drop in blood pressure may signal cardiogenic shock. Associated signs and symptoms include chest pain that may radiate to the jaw, shoulder, arm, or epigastrium; dyspnea; anxiety; nausea or vomiting; sweating; and cool, pale, or cyanotic skin. Auscultation may reveal an atrial gallop, a murmur and, occasionally, an irregular pulse.
❑ Neurogenic shock. The result of sympathetic denervation due to cervical injury or anesthesia, neurogenic shock produces low blood pressure and bradycardia. However, the patient's skin remains warm and dry because of cutaneous vasodilation and sweat gland denervation. Depending on the cause of shock, there may also be motor weakness of the limbs or diaphragm.
❑ Pulmonary embolism. Pulmonary embolism causes sudden, sharp chest pain and dyspnea accompanied by a cough and, occasionally, a low-grade fever. Low blood pressure occurs with a narrowed pulse pressure and diminished Korotkoff sounds. Associated signs include tachycardia, tachypnea, a paradoxical pulse, jugular vein distention, and hemoptysis.
❑ Septicshock. Initially, septic shock produces fever and chills. Low blood pressure, tachycardia, and tachypnea may also develop early, but the patient's skin remains warm. Later, low blood pressure becomes increasingly severe — less than 80 mm Hg or 30 mm Hg less than the patient's baseline — and is accompanied by narrowed pulse pressure. Other late signs and symptoms include pale skin, cyanotic extremities, apprehension, thirst, oliguria, and coma.
❑ Vasovagal syncope.Vasovagal syncope is the transient loss or near-loss of consciousness that's characterized by low blood pressure, pallor, cold sweats, nausea, palpitations or slowed heart rate, and weakness following stressful, painful, or claustrophobic experiences.
Other causes
❑ Diagnostic tests.Diagnostic tests include the gastric acid stimulation test using histamine and X-ray studies using contrast media. The latter may trigger an allergic reaction, which causes low blood pressure.
❑ Drugs. Calcium channel blockers, diuretics, vasodilators, alpha- and beta-adrenergic blockers, general anesthetics, opioid analgesics, monoamine oxidase inhibitors, anxiolytics (such as benzodiazepines), tranquilizers, and most I.V. antiarrhythmics (especially bretylium tosylate) can cause low blood pressure.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Decorticate posture:
Medical causes
(Handbook of Signs & Symptoms (Third Edition))
Brain abscess
Decorticate posture may occur with brain abscess. Accompanying findings vary depending on the size and location of the abscess, but may include aphasia, hemiparesis, a headache, dizziness, seizures, nausea, and vomiting. The patient may also experience behavioral changes, altered vital signs, and a decreased LOC.
Brain tumor
A brain tumor may produce decorticate posture that's usually bilateral — the result of increased intracranial pressure (ICP) associated with tumor growth. Related signs and symptoms include a headache, behavioral changes, memory loss, diplopia, blurred vision or vision loss, seizures, ataxia, dizziness, apraxia, aphasia, paresis, sensory loss, paresthesia, vomiting, papilledema, and signs of hormonal imbalance.
Head injury
Decorticate posture may be among the variable features of a head injury, depending on the site and severity of the injury. Associated signs and symptoms include a headache, nausea and vomiting, dizziness, irritability, a decreased LOC, aphasia, hemiparesis, unilateral numbness, seizures, and pupillary dilation.
Stroke.
Typically, a stroke involving the cerebral cortex produces unilateral decorticate posture, also called spastic hemiplegia. Other signs and symptoms include hemiplegia (contralateral to the lesion), dysarthria, dysphagia, unilateral sensory loss, apraxia, agnosia, aphasia, memory loss, a decreased LOC, urine retention, urinary incontinence, and constipation. Ocular effects include homonymous hemianopsia, diplopia, and blurred vision.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Orthostatic hypotension [Postural hypotension]:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Adrenal insufficiency
This disorder typically begins insidiously, with progressively severe signs and symptoms. Orthostatic hypotension may be accompanied by fatigue, muscle weakness, poor coordination, anorexia, nausea and vomiting, fasting hypoglycemia, weight loss, abdominal pain, irritability, and a weak, irregular pulse. Another common feature is hyperpigmentation—bronze coloring of the skin—which is especially prominent on the face, lips, gums, tongue, buccal mucosa, elbows, palms, knuckles, waist, and knees. Diarrhea, constipation, decreased libido, amenorrhea, and syncope may also occur along with enhanced taste, smell, and hearing, and cravings for salty food.
Alcoholism
Chronic alcoholism can lead to the development of peripheral neuropathy, which can present as orthostatic hypotension. Impotence is also a major issue in these patients. Other symptoms include numbness, tingling, nausea, vomiting, changes in bowel habits, and bizarre behavior.
Amyloidosis
Orthostatic hypotension is commonly associated with amyloid infiltration of the autonomic nerves. Associated signs and symptoms vary widely and include angina, tachycardia, dyspnea, orthopnea, fatigue, and cough.
Diabetic autonomic neuropathy
Here, orthostatic hypotension may be accompanied by syncope, dysphagia, constipation or diarrhea, painless bladder distention with overflow incontinence, impotence, and retrograde ejaculation.
Hyperaldosteronism
This disorder typically produces orthostatic hypotension with sustained elevated blood pressure. Most other clinical effects of hyperaldosteronism result from hypokalemia, which increases neuromuscular irritability and produces muscle weakness, intermittent flaccid paralysis, fatigue, headache, paresthesia and, possibly, tetany with positive Trousseau’s and Chvostek’s signs. The patient may also exhibit visual disturbance, nocturia, polydipsia, and personality changes. Diabetes mellitus is a common finding.
Hyponatremia
In this disorder, orthostatic hypotension is typically accompanied by headache, profound thirst, tachycardia, nausea and vomiting, abdominal cramps, muscle twitching and weakness, fatigue, oliguria or anuria, cold clammy skin, poor skin turgor, irritability, seizures, and decreased LOC. Cyanosis, thready pulse, and eventually vasomotor collapse may occur in severe sodium deficit. Common causes include adrenal insufficiency, hypothyroidism, syndrome of inappropriate antidiuretic hormone secretion, and use of thiazide diuretics.
Hypovolemia
Mild to moderate hypovolemia may cause orthostatic hypotension associated with apathy, fatigue, muscle weakness, anorexia, nausea, and profound thirst. The patient may also develop dizziness, oliguria, sunken eyeballs, poor skin turgor, and dry mucous membranes.
Pheochromocytoma
Although this disorder may produce orthostatic hypotension, its cardinal sign is paroxysmal or sustained hypertension. Typically, the patient is pale or flushed and diaphoretic, and his extreme anxiety makes him appear panicky. Associated signs and symptoms include tachycardia, palpitations, chest and abdominal pain, paresthesia, tremors, nausea and vomiting, low-grade fever, insomnia, and headache.
Shy-Drager syndrome
This neurodegenerative disorder is characterized by an insidious onset of multiple autonomic failure, manifested by orthostatic hypotension, urinary and fecal incontinence, decreased sweating, and impotence. This syndrome is most common in young and middle-age adults.
Other causes
Drugs
Certain drugs may cause orthostatic hypotension by reducing circulating blood volume, causing blood vessel dilation, or depressing the sympathetic nervous system. These drugs include antihypertensives (especially the initial dosage of prazosin hydrochloride), tricyclic antidepressants, phenothiazines, levodopa, nitrates, monoamine oxidase inhibitors, morphine, bretylium tosylate, and spinal anesthesia. Large doses of diuretics can also cause orthostatic hypotension.
Treatments
Orthostatic hypotension is commonly associated with prolonged bed rest (24 hours or longer). It may also result from sympathectomy, which disrupts normal vasoconstrictive mechanisms.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Blood pressure decrease [Hypotension]:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Adrenal insufficiency (acute)
Orthostatic hypotension is characteristic in acute adrenal insufficiency and is accompanied by fatigue, weakness, nausea, vomiting, abdominal discomfort, weight loss, fever, and tachycardia. The patient may also have hyperpigmentation of fingers, nails, nipples, scars, and body folds; pale, cool, clammy skin; restlessness; decreased urine output; tachypnea; and coma.
Alcohol toxicity
Low blood pressure occurs infrequently in alcohol toxicity; more common signs and symptoms include a distinct alcohol breath odor, tachycardia, bradypnea, hypothermia, decreased LOC, seizures, staggering gait, nausea, vomiting, diuresis, and slow, stertorous breathing.
Anaphylactic shock
Following exposure to an allergen, such as penicillin or insect venom, a dramatic fall in blood pressure and narrowed pulse pressure signal this severe allergic reaction. Initially, anaphylactic shock causes anxiety, restlessness, a feeling of doom, intense itching (especially of the hands and feet), and a pounding headache. Later, it may also produce weakness, sweating, nasal congestion, coughing, difficulty breathing, nausea, abdominal cramps, involuntary defecation, seizures, flushing, urinary incontinence, tachycardia, and change or loss of voice due to laryngeal edema.
Anthrax, inhalation
Anthrax is an acute infectious disease that’s caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological agents. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in cutaneous, inhalation, or GI forms.
Inhalation anthrax is caused by inhalation of aerosolized spores. Initial signs and symptoms are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by fever, dyspnea, stridor, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetrical mediastinal widening.
Cardiac arrhythmias
In an arrhythmia, blood pressure may fluctuate between normal and low readings. Dizziness, chest pain, difficulty breathing, light-headedness, weakness, fatigue, and palpitations may also occur. Auscultation typically reveals an irregular rhythm and a pulse rate greater than 100 beats/minute or less than 60 beats/minute.
Cardiac contusion
In a cardiac contusion, low blood pressure occurs along with tachycardia and, at times, anginal pain and dyspnea.
Cardiac tamponade
An accentuated fall in systolic pressure (more than 10 mm Hg) during inspiration, known as paradoxical pulse, is characteristic in patients with cardiac tamponade. This disorder also causes restlessness, cyanosis, tachycardia, jugular vein distention, muffled heart sounds, dyspnea, and Kussmaul’s sign (increased venous distention with inspiration).
Cardiogenic shock
A fall in systolic pressure to less than 80 mm Hg, or to 30 mm Hg less than the patient’s baseline, because of decreased cardiac contractility is characteristic in patients with this disorder. Accompanying low blood pressure are tachycardia, narrowed pulse pressure, diminished Korotkoff sounds, peripheral cyanosis, and pale, cool, clammy skin. Cardiogenic shock also causes restlessness and anxiety, which may progress to disorientation and confusion. Associated signs and symptoms include angina, dyspnea, jugular vein distention, oliguria, ventricular gallop, tachypnea, and weak, rapid pulse.
Cholera
Cholera is an acute infection caused by the bacterium Vibrio cholerae that may be mild with uncomplicated diarrhea or severe and life-threatening. Cholera is spread by ingestion of contaminated water or food, especially shellfish. Signs include abrupt watery diarrhea and vomiting. Severe water and electrolyte loss leads to thirst, weakness, muscle cramps, decreased skin turgor, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.
Diabetic ketoacidosis
Hypovolemia triggered by osmotic diuresis in hyperglycemia is responsible for the low blood pressure associated with diabetic ketoacidosis, which is usually present in patients with type 1 diabetes mellitus. It also commonly produces polydipsia, polyuria, polyphagia, dehydration, weight loss, abdominal pain, nausea, vomiting, breath with fruity odor, Kussmaul’s respirations, tachycardia, seizures, confusion, and stupor that may progress to coma.
Heart failure
In heart failure, blood pressure may fluctuate between normal and low readings, but a precipitous drop in blood pressure may signal cardiogenic shock. Other signs and symptoms of heart failure include exertional dyspnea, dyspnea of abrupt or gradual onset, paroxysmal nocturnal dyspnea or difficulty breathing in the supine position (orthopnea), fatigue, weight gain, pallor or cyanosis, sweating, and anxiety. Auscultation
reveals ventricular gallop, tachycardia, bilateral crackles, and tachypnea. Dependent edema, jugular vein distention, increased capillary refill time, and hepatomegaly may also occur.
Hyperosmolar hyperglycemic nonketotic syndrome (HHNS)
HHNS, which is common in persons with type 2 diabetes mellitus, decreases blood pressure—at times dramatically, if the patient loses significant fluid from diuresis due to severe hyperglycemia and hyperosmolarity. It also produces dry mouth, poor skin turgor, tachycardia, confusion progressing to coma and, occasionally, generalized tonic-clonic seizures.
Hypovolemic shock
A fall in systolic pressure to less than 80 mm Hg, or 30 mm Hg less than the patient’s baseline, secondary to acute blood loss or dehydration is characteristic in patients with hypovolemic shock. Accompanying it are diminished Korotkoff sounds, narrowed pulse pressure, and rapid, weak, and irregular pulse. Peripheral vasoconstriction causes cyanosis of the extremities and pale, cool, clammy skin. Other signs and symptoms include oliguria, confusion, disorientation, restlessness, and anxiety.
Hypoxemia
Initially, blood pressure may be normal or slightly elevated, but as hypoxemia becomes more pronounced blood pressure drops. The patient may also display tachycardia, tachypnea, dyspnea, confusion, and stupor that may progress to coma.
Myocardial infarction
In this life-threatening disorder, blood pressure may be low or high. However, a precipitous drop in blood pressure may signal cardiogenic shock. Associated signs and symptoms include chest pain that may radiate to the jaw, shoulder, arm, or epigastrium; dyspnea; anxiety; nausea or vomiting; sweating; and cool, pale, or cyanotic skin. Auscultation may reveal an atrial gallop, a murmur and, occasionally, an irregular pulse.
Neurogenic shock
The result of sympathetic denervation due to cervical injury or anesthesia, neurogenic shock produces low blood pressure and bradycardia. However, the patient’s skin remains warm and dry because of cutaneous vasodilation and sweat gland denervation. Depending on the cause of shock, motor weakness of the limbs or diaphragm may also occur.
Pulmonary embolism
Pulmonary embolism causes sudden, sharp chest pain and dyspnea accompanied by cough and, occasionally, low-grade fever. Low blood pressure occurs with narrowed pulse pressure and diminished Korotkoff sounds. Associated signs include tachycardia, tachypnea, paradoxical pulse, jugular vein distention, and hemoptysis.
Septic Shock
Initially, septic shock produces fever and chills. Low blood pressure, tachycardia, and tachypnea may also develop early, but the patient’s skin remains warm. Later, low blood pressure becomes increasingly severe—with systolic pressure less than 80 mm Hg, or 30 mm Hg less than the baseline—and is accompanied by narrowed pulse pressure. Other late signs and symptoms include pale skin, cyanotic extremities, apprehension, thirst, oliguria, and coma.
Vasovagal syncope
Vasovagal syncope is a transient loss or near-loss of consciousness that’s characterized by low blood pressure, pallor, cold sweats, nausea, palpitations or bradycardia, and weakness following stressful, painful, or claustrophobic experiences.
Other causes
Diagnostic tests
These include the gastric acid stimulation test using histamine and X-ray studies using contrast media. The latter may trigger an allergic reaction, which causes low blood pressure.
Drugs
Calcium channel blockers, diuretics, vasodilators, alpha- and beta-adrenergic blockers, general anesthetics, opioid analgesics, monoamine oxidase inhibitors, anxiolytics (such as benzodiazepines), tranquilizers, and most I.V. antiarrhythmics (especially bretylium tosylate) can cause low blood pressure.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Decorticate posture [Decorticate rigidity, abnormal flexor response]:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Brain abscess
Decorticate posture may occur in a brain abscess. Accompanying findings vary depending on the size and location of the abscess but may include aphasia, hemiparesis, headache, dizziness, seizures, nausea, and vomiting. The patient may also experience behavioral changes, altered vital signs, and decreased LOC.
Brain tumor
A brain tumor may produce decorticate posture that’s usually bilateral—the result of increased intracranial pressure (ICP) associated with tumor growth. Related signs and symptoms include headache, behavioral changes, memory loss, diplopia, blurred vision or vision loss, seizures, ataxia, dizziness, apraxia, aphasia, paresis, sensory loss, paresthesia, vomiting, papilledema, and signs of hormonal imbalance.
Head injury
Decorticate posture may result from a head injury, depending on the site and severity of the injury. Associated signs and symptoms include headache, nausea and vomiting, dizziness, irritability, decreased LOC, aphasia, hemiparesis, unilateral numbness, seizures, and pupillary dilation.
Stroke
Typically, a stroke involving the cerebral cortex produces unilateral decorticate posture, also called spastic hemiplegia. Other signs and symptoms include hemiplegia (contralateral to the lesion), dysarthria, dysphagia, unilateral sensory loss, apraxia, agnosia, aphasia, memory loss, decreased LOC, urine retention, urinary incontinence, and constipation. Ocular effects include homonymous hemianopsia, diplopia, and blurred vision.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Orthostatic Hypotension:
Differential Overview
(Field Guide to Bedside Diagnosis)
Dysautonomia
❑ Diabetes
❑ Drugs
❑ Pernicious anemia
❑ Amyloidosis
❑ Guillain-Barré syndrome
❑ Wernicke syndrome
Other
❑ Dehydration
❑ Prolonged standing
❑ Hemorrhage
❑ Thermodilation
❑ Vasovagal response
❑ Pregnancy
❑ Addison disease
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Hypotension, orthostatic:
Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Adrenal insufficiency
Adrenal insufficiency typically begins insidiously, with progressively severe signs and symptoms. Orthostatic hypotension may be accompanied by fatigue, muscle weakness, poor coordination, anorexia, nausea and vomiting, fasting hypoglycemia, weight loss, abdominal pain, irritability, and a weak, irregular pulse. Another common feature is hyperpigmentation — bronze coloring of the skin — which is especially prominent on the face, lips, gums, tongue, buccal mucosa, elbows, palms, knuckles, waist, and knees. Diarrhea, constipation, decreased libido, amenorrhea, and syncope may also occur along with enhanced taste, smell, and hearing, and cravings for salty food.
Alcoholism
Chronic alcoholism can lead to the development of peripheral neuropathy, which can present as orthostatic hypotension. Impotence is also a major issue in these patients. Other symptoms include numbness, tingling, nausea, vomiting, changes in bowel habits, and bizarre behavior.
Amyloidosis
Orthostatic hypotension is commonly associated with amyloid infiltration of the autonomic nerves. Associated signs and symptoms vary widely and include angina, tachycardia, dyspnea, orthopnea, fatigue, and cough.
Diabetic autonomic neuropathy
Here, orthostatic hypotension may be accompanied by syncope, dysphagia, constipation or diarrhea, painless bladder distention with overflow incontinence, impotence, and retrograde ejaculation.
Hyperaldosteronism
Hyperaldosteronism typically produces orthostatic hypotension with sustained elevated blood pressure. Most other clinical effects of hyperaldosteronism result from hypokalemia, which increases neuromuscular irritability and produces muscle weakness, intermittent flaccid paralysis, fatigue, headache, paresthesia and, possibly, tetany with positive Trousseau’s and Chvostek’s signs. The patient may also exhibit vision disturbance, nocturia, polydipsia, and personality changes. Diabetes mellitus is a common finding.
Hyponatremia
In hyponatremia, orthostatic hypotension is typically accompanied by headache, profound thirst, tachycardia, nausea and vomiting, abdominal cramps, muscle twitching and weakness, fatigue, oliguria or anuria, cold clammy skin, poor skin turgor, irritability, seizures, and decreased LOC. Cyanosis, thready pulse, and eventually vasomotor collapse may occur in severe sodium deficit. Common causes include adrenal insufficiency, hypothyroidism, syndrome of inappropriate antidiuretic hormone secretion, and use of thiazide diuretics.
Hypovolemia
Mild to moderate hypovolemia may cause orthostatic hypotension associated with apathy, fatigue, muscle weakness, anorexia, nausea, and profound thirst. The patient may also develop dizziness, oliguria, sunken eyeballs, poor skin turgor, and dry mucous membranes.
Pheochromocytoma
Although pheochromocytoma may produce orthostatic hypotension, its cardinal sign is paroxysmal or sustained hypertension. Typically, the patient is pale or flushed and diaphoretic, and his extreme anxiety makes him appear panicky. Associated signs and symptoms include tachycardia, palpitations, chest and abdominal pain, paresthesia, tremors, nausea and vomiting, low-grade fever, insomnia, and headache.
Shy-Drager syndrome
Shy-Drager syndrome is a neurodegenerative disorder that’s characterized by an insidious onset of multiple autonomic failure, manifested by orthostatic hypotension, urinary and fecal incontinence, decreased sweating, and impotence. This syndrome is most common in young and middle-aged adults.
Other causes
Drugs
Certain drugs may cause orthostatic hypotension by reducing circulating blood volume, causing blood vessel dilation, or depressing the sympathetic nervous system. These drugs include antihypertensives (especially guanethidine monosulfate and the initial dosage of prazosin hydrochloride), tricyclic antidepressants, phenothiazines, levodopa, nitrates, monoamine oxidase inhibitors, morphine, bretylium tosylate, and spinal anesthesia. Large doses of diuretics can also cause orthostatic hypotension.
Medical treatments
Orthostatic hypotension is commonly associated with prolonged bed rest (24 hours or longer). It may also result from sympathectomy, which disrupts normal vasoconstrictive mechanisms.
» READ BOOK EXCERPT ONLINE »
Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Decorticate posture [Decorticate rigidity, abnormal flexor response]:
Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Brain abscess.
Decorticate posture may occur with brain abscess. Accompanying findings vary on the size and location of the abscess but may include aphasia, hemiparesis, headache, dizziness, seizures, nausea, and vomiting. The patient may also experience behavioral changes, altered vital signs, and decreased LOC.
Brain tumor
Brain tumor may produce decorticate posture that’s usually bilateral — the result of increased intracranial pressure (ICP) associated with tumor growth. Related signs and symptoms include headache, behavioral changes, memory loss, diplopia, blurred vision or vision loss, seizures, ataxia, dizziness, apraxia, aphasia, paresis, sensory loss, paresthesia, vomiting, papilledema, and signs of hormonal imbalance.
Head injury
Decorticate posture may be among the variable features of a head injury, depending on the site and severity of head injury. Associated signs and symptoms include headache, nausea and vomiting, dizziness, irritability, decreased LOC, aphasia, hemiparesis, unilateral numbness, seizures, and pupillary dilation.
Stroke.
Typically, a stroke involving the cerebral cortex produces unilateral decorticate posture, also called
spastic hemiplegia. Other signs and symptoms include hemiplegia (contralateral to the lesion), dysarthria, dysphagia, unilateral sensory loss, apraxia, agnosia, aphasia, memory loss, decreased LOC, urine retention, urinary incontinence, and constipation. Ocular effects include homonymous hemianopsia, diplopia, and blurred vision.
» READ BOOK EXCERPT ONLINE »
Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Orthostatic hypotension:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Adrenal insufficiency
In adrenal insufficiency, orthostatic hypotension may be accompanied by fatigue, muscle weakness, poor coordination, anorexia, nausea and vomiting, fasting hypoglycemia, weight loss, abdominal pain, irritability, and a weak, irregular pulse. Another common feature is hyperpigmentation — bronze coloring of the skin — which is especially prominent on the face, lips, gums, tongue, buccal mucosa, elbows, palms, knuckles, waist, and knees. Diarrhea, constipation, decreased libido, amenorrhea, and syncope may also occur along with enhanced taste, smell, and hearing, and cravings for salty food.
Amyloidosis
Orthostatic hypotension is commonly associated with amyloid infiltration of the autonomic nerves. Associated signs and symptoms vary widely and include angina, tachycardia, dyspnea, orthopnea, fatigue, and cough.
Diabetic autonomic neuropathy
Orthostatic hypotension may be accompanied by syncope, dysphagia, constipation or diarrhea, painless bladder distention with overflow incontinence, impotence, and retrograde ejaculation.
Hyperaldosteronism
Hyperaldosteronism typically produces orthostatic hypotension with sustained elevated blood pressure. Most other clinical effects of hyperaldosteronism result from hypokalemia, which increases neuromuscular irritability and produces muscle weakness, intermittent flaccid paralysis, fatigue, headache, paresthesia and, possibly, tetany with positive Trousseau’s and Chvostek’s signs. The patient may also exhibit vision disturbance, nocturia, polydipsia, and personality changes. Diabetes mellitus is a common finding.
Hyponatremia
In hyponatremia, orthostatic hypotension is typically accompanied by headache, profound thirst, tachycardia, nausea and vomiting, abdominal cramps, muscle twitching and weakness, fatigue, oliguria or anuria, cold clammy skin, poor skin turgor, irritability, seizures, and decreased LOC. Cyanosis, thready pulse, and eventually vasomotor collapse may occur in severe sodium deficit. Common causes include adrenal insufficiency, hypothyroidism, syndrome of inappropriate antidiuretic hormone secretion, and use of thiazide diuretics.
Hypovolemia
Mild to moderate hypovolemia may cause orthostatic hypotension associated with apathy, fatigue, muscle weakness, anorexia, nausea, and profound thirst. The patient may also develop dizziness, oliguria, sunken eyeballs, poor skin turgor, and dry mucous membranes.
Other causes
Drugs
Certain drugs may cause orthostatic hypotension by reducing circulating blood volume, causing blood vessel dilation, or by depressing the sympathetic nervous system. These drugs include antihypertensives (especially guanethidine and the initial dosage of prazosin), tricyclic antidepressants, phenothiazines, levodopa, nitrates, monoamine oxidase inhibitors, morphine, bretylium, and spinal anesthesia. Large doses of diuretics can also cause orthostatic hypotension.
Treatments
Orthostatic hypotension is commonly associated with prolonged bed rest (24 hours or longer). It may also result from sympathectomy, which disrupts normal vasoconstrictive mechanisms.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Decorticate posture:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Brain abscess
Decorticate posture may occur with a brain abscess. Accompanying findings vary depending on the size and location of the abscess but may include aphasia, hemiparesis, headache, dizziness, seizures, nausea, and vomiting. The patient may also experience behavioral changes, altered vital signs, and decreased LOC.
Brain tumor
A brain tumor may produce decorticate posture that’s usually bilateral — the result of increased intracranial pressure (ICP) associated with tumor growth. Related signs and symptoms include headache, behavioral changes, memory loss, diplopia, blurred vision or vision loss, seizures, ataxia, dizziness, apraxia, aphasia, paresis, sensory loss, paresthesia, vomiting, papilledema, and signs of hormonal imbalance.
Head injury
Decorticate posture may be among the variable features of a head injury, depending on its site and severity. Associated signs and symptoms include headache, nausea and vomiting, dizziness, irritability, decreased LOC, aphasia, hemiparesis, unilateral numbness, seizures, and pupillary dilation.
Stroke
Typically, a stroke involving the cerebral cortex produces unilateral decorticate posture, also called spastic hemiplegia. Other signs and symptoms include hemiplegia (contralateral to the lesion), dysarthria, dysphagia, unilateral sensory loss, apraxia, agnosia, aphasia, memory loss, decreased LOC, urine retention, urinary incontinence, and constipation. Ocular effects include homonymous hemianopsia, diplopia, and blurred vision.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Orthostatic hypotension [Postural hypotension]:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Adrenal insufficiency.Adrenal insufficiency typically begins insidiously, with progressively severe signs and symptoms. Orthostatic hypotension may be accompanied by fatigue, muscle weakness, poor coordination, anorexia, nausea and vomiting, fasting hypoglycemia, weight loss, abdominal pain, irritability, and a weak, irregular pulse. Another common feature is hyperpigmentation—bronze coloring of the skin—which is especially prominent on the face, lips, gums, tongue, buccal mucosa, elbows, palms, knuckles, waist, and knees. Diarrhea, constipation, a decreased libido, amenorrhea, and syncope may also occur along with enhanced taste, smell, and hearing and cravings for salty food.
Alcoholism.Chronic alcoholism can lead to the development of peripheral neuropathy, which can present as orthostatic hypotension. Impotence is also a major issue in these patients. Other symptoms include numbness, tingling, nausea, vomiting, changes in bowel habits, and bizarre behavior.
Amyloidosis.Orthostatic hypotension is commonly associated with amyloid infiltration of the autonomic nerves. Associated signs and symptoms vary widely and include angina, tachycardia, dyspnea, orthopnea, fatigue, and cough.
Hyperaldosteronism.Hyperaldosteronism typically produces orthostatic hypotension with sustained elevated blood pressure. Most other clinical effects of hyperaldosteronism result from hypokalemia, which increases neuromuscular irritability and produces muscle weakness, intermittent flaccid paralysis, fatigue, headache, paresthesia and, possibly, tetany with positive Trousseau's and Chvostek's signs. The patient may also exhibit vision disturbances, nocturia, polydipsia, and personality changes. Diabetes mellitus is a common finding.
Hyponatremia.With hyponatremia, orthostatic hypotension is typically accompanied by headache, profound thirst, tachycardia, nausea and vomiting, abdominal cramps, muscle twitching and weakness, fatigue, oliguria or anuria, cold clammy skin, poor skin turgor, irritability, seizures, and decreased LOC. Cyanosis, a thready pulse and, eventually, vasomotor collapse may occur with a severe sodium deficit. Common causes include adrenal insufficiency, hypothyroidism, syndrome of inappropriate antidiuretic hormone secretion, and the use of thiazide diuretics.
Hypovolemia.Mild to moderate hypovolemia may cause orthostatic hypotension associated with apathy, fatigue, muscle weakness, anorexia, nausea, and profound thirst. The patient may also develop dizziness, oliguria, sunken eyeballs, poor skin turgor, and dry mucous membranes.
Other causes
Drugs.Certain drugs may cause orthostatic hypotension by reducing circulating blood volume, causing blood vessel dilation, or depressing the sympathetic nervous system. These drugs include antihypertensives (especially guanethidine monosulfate and the initial dosage of prazosin hydrochloride), tricyclic antidepressants, phenothiazines, levodopa, nitrates, monoamine oxidase inhibitors, morphine, bretylium tosylate, and spinal anesthesia. Large doses of diuretics can also cause orthostatic hypotension.
Treatments.Orthostatic hypotension is commonly associated with prolonged bed rest (24 hours or longer). It may also result from sympathectomy, which disrupts normal vasoconstrictive mechanisms.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Blood pressure, decreased [Hypotension]:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Acute adrenal insufficiency.Orthostatic hypotension is characteristic with acute adrenal insufficiency, accompanied by fatigue, weakness, nausea, vomiting, abdominal discomfort, weight loss, fever, and tachycardia. The patient may also have hyperpigmentation of fingers, nails, nipples, scars, and body folds; pale, cool, clammy skin; restlessness; decreased urine output; tachypnea; and coma.
Anaphylactic shock.Following exposure to an allergen, such as penicillin or insect venom, a dramatic fall in blood pressure and narrowed pulse pressure signal anaphylactic reaction. Initially, anaphylactic shock causes anxiety, restlessness, a feeling of doom, intense itching (especially of the hands and feet), and pounding headache. Later, it may also produce weakness, sweating, nasal congestion, coughing, difficulty breathing, nausea, abdominal cramps, involuntary defecation, seizures, flushing, change or loss of voice due to laryngeal edema, urinary incontinence, and tachycardia.
Anthrax (inhalation).Inhalation anthrax is caused by inhalation of aerosolized spores. Initial signs and symptoms are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.
Cardiac arrhythmias.With an arrhythmia, blood pressure may fluctuate between normal and low readings. Dizziness, chest pain, difficulty breathing, light-headedness, weakness, fatigue, and palpitations may also occur. Auscultation typically reveals an irregular rhythm and a pulse rate greater than 100 beats/ minute or less than 60 beats/minute. A life-threatening arrhythmia may cause absence of a pulse and no palpable blood pressure and requires emergency resuscitation measures.
Cardiac contusion.With cardiac contusion, low blood pressure occurs along with tachycardia and, at times, anginal pain and dyspnea.
Cardiac tamponade.An accentuated fall in systolic pressure (more than 10 mm Hg) during inspiration, known as paradoxical pulse, is characteristic in patients with cardiac tamponade. This disorder also causes restlessness, cyanosis, tachycardia, jugular vein distention, muffled heart sounds, dyspnea, and Kussmaul's sign (increased venous distention with inspiration).
Cardiogenic shock.A fall in systolic pressure to less than 80 mm Hg or to 30 mm Hg less than the patient's baseline because of decreased cardiac contractility is characteristic in patients with cardiogenic shock. Accompanying low blood pressure are tachycardia, narrowed pulse pressure, diminished Korotkoff sounds, peripheral cyanosis, and pale, cool, clammy skin. Cardiogenic shock also causes restlessness and anxiety, which may progress to disorientation and confusion. Associated signs and symptoms include angina, dyspnea, jugular vein distention, oliguria, ventricular gallop, tachypnea, and a weak, rapid pulse.
Cholera.Cholera may be mild and with uncomplicated diarrhea or severe and life-threatening. Signs include abrupt watery diarrhea and vomiting. Severe fluid and electrolyte loss leads to thirst, weakness, muscle cramps, decreased skin turgor, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.
Diabetic ketoacidosis.Hypovolemia triggered by osmotic diuresis in hyperglycemia is responsible for the low blood pressure associated with diabetic ketoacidosis, which is usually present in patients with type 1 diabetes mellitus. It commonly produces polydipsia, polyuria, polyphagia, dehydration, weight loss, abdominal pain, nausea, vomiting, breath with fruity odor, Kussmaul's respirations, tachycardia, seizures, confusion, and stupor that may progress to coma.
Heart failure.With heart failure, blood pressure may fluctuate between normal and low readings. A precipitous drop in blood pressure may signal cardiogenic shock. Other signs and symptoms of heart failure include exertional dyspnea, dyspnea of abrupt or gradual onset, paroxysmal nocturnal dyspnea or difficulty breathing in the supine position (orthopnea), fatigue, weight gain, pallor or cyanosis, sweating, and anxiety. Auscultation reveals ventricular gallop, tachycardia, bilateral crackles, and tachypnea. Dependent edema, jugular vein distention, increased capillary refill time, and hepatomegaly may also occur.
Hyperosmolar hyperglycemic
nonketotic syndrome (HHNS).HHNS, which is common in the patient with type 2 diabetes mellitus, decreases blood pressure—at times dramatically—if he loses significant fluid from diuresis due to severe hyperglycemia and hyperosmolarity. It also produces dry mouth, poor skin turgor, tachycardia, confusion progressing to coma and, occasionally, generalized tonic-clonic seizure.
Hypovolemic shock.A fall in systolic pressure to less than 80 mm Hg or 30 mm Hg less than the patient's baseline, secondary to acute blood loss or dehydration, is characteristic in hypovolemic shock. Accompanying it are diminished Korotkoff sounds, a narrowed pulse pressure, and a rapid, weak, and irregular pulse. Peripheral vasoconstriction causes cyanosis of the extremities and pale, cool, clammy skin. Other signs and symptoms include oliguria, confusion, disorientation, restlessness, and anxiety.
Hypoxemia.Initially, blood pressure may be normal or slightly elevated, but as hypoxemia becomes more pronounced, blood pressure drops. The patient may display tachycardia, tachypnea, dyspnea, and confusion and may progress from stupor to coma.
Myocardial infarction (MI).With MI, a life-threatening disorder, blood pressure may be low or high. A precipitous drop in blood pressure may signal cardiogenic shock. Associated signs and symptoms include chest pain that may radiate to the jaw, shoulder, arm, or epigastrium; dyspnea; anxiety; nausea or vomiting; sweating; and cool, pale, or cyanotic skin. Auscultation may reveal an atrial gallop, a murmur and, occasionally, an irregular pulse.
Neurogenic shock.The result of sympathetic denervation due to cervical injury or anesthesia, neurogenic shock produces low blood pressure and bradycardia. The patient's skin remains warm and dry because of cutaneous vasodilation and sweat gland denervation. Depending on the cause of shock, there may also be motor weakness of the limbs or diaphragm.
Pulmonary embolism.Pulmonary embolism causes sudden, sharp chest pain and dyspnea accompanied by a cough and, occasionally, a low-grade fever. Low blood pressure occurs with a narrowed pulse pressure and diminished Korotkoff sounds. Associated signs include tachycardia, tachypnea, a paradoxical pulse, jugular vein distention, and hemoptysis.
Septic shock.Initially, septic shock produces fever and chills. Low blood pressure, tachycardia, and tachypnea may also develop early, but the patient's skin remains warm. Low blood pressure becomes increasingly severe—less than 80 mm Hg or 30 mm Hg less than the patient's baseline—and is accompanied by narrowed pulse pressure. Other late signs and symptoms include pale skin, cyanotic extremities, apprehension, thirst, oliguria, and coma.
Vasovagal syncope.Vasovagal syncope is the transient loss or near-loss of consciousness that's characterized by low blood pressure, pallor, cold sweats, nausea, palpitations or slowed heart rate, and weakness following stressful, painful, or claustrophobic experiences.
Other causes
Diagnostic tests.Diagnostic tests include the gastric acid stimulation test using histamine and X-ray studies using contrast media. The latter may trigger an allergic reaction, which causes low blood pressure.
Drugs.Calcium channel blockers, diuretics, vasodilators, alpha- and beta-adrenergic blockers, general anesthetics, opioid analgesics, monoamine oxidase inhibitors, anxiolytics (such as benzodiazepines), tranquilizers, and most I.V. antiarrhythmics (especially bretylium tosylate) can cause low blood pressure.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Decorticate posture [Decorticate rigidity, abnormal flexor response]:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Brain abscess.Decorticate posture may occur with brain abscess. Accompanying findings vary depending on the size and location of the abscess, but may include aphasia, hemiparesis, a headache, dizziness, seizures, nausea, and vomiting. The patient may also experience behavioral changes, altered vital signs, and a decreased LOC.
Brain tumor.A brain tumor may produce decorticate posture that's usually bilateral—the result of increased intracranial pressure (ICP) associated with tumor growth. Related signs and symptoms include a headache, behavioral changes, memory loss, diplopia, blurred vision or vision loss, seizures, ataxia, dizziness, apraxia, aphasia, paresis, sensory loss, paresthesia, vomiting, papilledema, and signs of hormonal imbalance.
Head injury.Decorticate posture may be among the variable features of a head injury, depending on the site and severity of the injury. Associated signs and symptoms include a headache, nausea and vomiting, dizziness, irritability, a decreased LOC, aphasia, hemiparesis, unilateral numbness, seizures, and pupillary dilation.
Stroke.Typically, a stroke involving the cerebral cortex produces unilateral decorticate posture, also called spastic hemiplegia. Other signs and symptoms include hemiplegia (contralateral to the lesion), dysarthria, dysphagia, unilateral sensory loss, apraxia, agnosia, aphasia, memory loss, a decreased LOC, urine retention, urinary incontinence, and constipation. Ocular effects include homonymous hemianopsia, diplopia, and blurred vision.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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