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 ?