Hypotension

 

 

Differential Diagnosis

 

  • ↓ preload:

    • Bleeding

    • Relative

  • ↓ afterload/distributive shock:

    • Anaphylaxis

    • Sepsis/SIRS

    • Neurogenic

    • Blood transfusion reaction

    • Neuraxial

    • Drugs: anethetic overdose/drug swap

    • Endocrine: Addison's, myxedema, carcinoid

    • Metabolic: hypocalcemia, hypoglycemia

  • Obstructive shock:

    • Tension pneumothorax

    • Tamponade

    • Embolic events

    • Pulmonary hypertension

  • Cardiogenic shock:

    • Rate:

      • Bradycardia

      • Tachycardia

    • Arrhythmias

    • Contractility:

      • Ischemia

      • Drugs or toxins

    • RV failure/pulmonary hypertension

    • Acute valvular pathology

 

 

Management

 

  • Emergency situation requiring simultaneous diagnosis & management

  • Inform the surgeon 

  • Call for help

  • ↓ anesthetic & hand ventilate with 100% O2

  • Vasopressor bolus +/- IV fluid bolus:

    • ​Phenylephrine 100 mcg IV PRN 

    • Norepinephrine 5 mcg IV PRN 

    • Ephedrine 5-10 mg IV PRN 

    • Epinephrine 1-10 mcg IV PRN 

  • Cycle BP & scan monitors for HR, rhythm, ST changes, SaO2, EtCO2, PAP

  • Feel for a pulse:

    • If no pulse  ACLS as per protocol

  • Ensure crash cart in room:

    • If pulse present  targeted physical exam

      • Urticaria, flushing, angioedema

      • Tracheal deviation, jugular venous distention, subcutaneous crepitus, bilateral air entry

      • JVP (jugular venous pressure) / CVP (central venous pressure) / PCWP (pulmonary capillary wedge pressure)

        • ↑ CVP / PCWP = obstructive or cardiogenic

        • ↓ CVP / PCWP = hypovolemic or distributive

      • Peripheral perfusion (↑ in distributive, ↓ in others)

      • Look at surgical field (blood loss, IVC compression, pneumoperitoneum pressure)

      • Check IV fluids, vasopressors, blood products

  • Reassess differential diagnosis based on findings

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