Hypotension

Question 1

Why is NEWS chart not always an accurate representation of organ perfusion in hypotensive?

Answer 1

If they are naturally very hypertensive then body adapts to a new sitting baseline and therefore a drop by 25% or more in BP can still be very dangerous regardless of NEWS

Question 2

What does DBP contribute to?

Answer 2

Coronary perfusion

Question 3

What does MAP contribute to? What is low?

Answer 3

Organ perfusion pressure - below 60 is low

Question 4

How do you calculate MAP?

Answer 4

MAP = DBP + (SBP - DBP)/3

Question 5

How do you calculate pulse pressure?

Answer 5

SBP - DBP

Question 6

Difference between stroke volume and ejection fraction?

Answer 6

Stroke volume is the volume ejected from the left ventricle in systole and ejection fraction is the % of the ventricle that empties on systole

Question 7

What 3 factors effect stroke volume?

Answer 7

Preload
Contractility
Afterload

Question 8

How do you optimise preload?

Answer 8

IV fluids due to frank starling law

Question 9

What negatively effects contractility?

Answer 9

Ischaemia, scarring, beta blockers, hypoxia, severe acidosis

Question 10

What causes an increased afterload?

Answer 10

Afterload increased by stenosis, constricted vessels, PE

Question 11

In hypotensive patient what 6 aspects do you need to take into account in order to modify it?

Answer 11

Heart rate
Rhythm 
Preload
Contractility 
Afterload
SVR

Question 12

In hypotension what are you looking for regarding a HR or rhythm cause? What do you palpate? tests?

Answer 12

Bradycardia, arrhythmia, very tachycardic not allowing filling time
Palpate central pulses
12 lead ECG

Question 13

How do you assess the preload in a patient? what signs? what do you need to ask about in their recent history?

Answer 13

Preload = dehydrated
Signs - mucous membranes, skin turgour, CRT, thirst, UO
History = recent surgery, blood loss, vomiting, diarrhoea, drains with lots in

Question 14

How do you assess contractility?

Answer 14

ECHO

Question 15

What 2 detrimental effects on the heart does increased afterload have?

Answer 15

Increased afterload causes hypertrophy meaning increased oxygen requirements by the heart
Also decreases coronary filling which means less perfusion to heart muscle

Question 16

If someone is in AF why is this a risk if their SVR drops?

Answer 16

Vasodilation cannot be compensated by an increased HR as the atrial component is lost

Question 17

If someone already has an increased afterload and you give high volume IV fluids what do you risk?

Answer 17

Acute left ventricular failure

Question 18

What kind of shock is caused by PE?

Answer 18

Obstructive shock

Question 19

What are the 5 (approx) stages from a PE to cardiac arrest?

Answer 19

PE causes massive rise in pulmonary venous resistance and pressure which causes huge rise in RV afterload, obstructive shock, the ventricular septum bows towards the LV, causes LV function decline, hypotension and cardiac arrest

Question 20

As well as cardiac arrest what other symptoms of PE will be seen due to pulmonary congestion?

Answer 20

SOB
Distended neck veins
Hypoxia

Question 21

Difference in clinical appearance of a patient with low SVR vs high?

Answer 21

Low SVR = warm peripheries

High SVR = cold peripheries, clammy, mottled

Question 22

What is the main type of shock that appears with a high SVR?

Answer 22

Cardiogenic shock

Question 23

What is the main cause of shock that leads to low SVR?

Answer 23

Distributive shock - sepsis

Question 24

If you have hypotension, how can you tell if it is a cardiogenic shock or distributive shock?

Answer 24

If the peripheries are warm or not

Question 25

Causes of distributive shock?

Answer 25

``` Sepsis Pancreatitis Anaphylaxis Burns Drugs and toxins (transfusion, bites, beta blockers, vasodilators) Addisonian crisis Thyrotoxicosis ```

Question 26

What are the classic 3 signs of addisonian crisis?

Answer 26

Hyponatraemia Hyperkalaemia Pigmentation

Question 27

Symptoms of severe thyrotoxicosis? What is it often mistaken for?

Answer 27

``` High output cardiac failure low SVR increased temperature increased HR Often mistaken for early sepsis ```

Question 28

How can you monitor the extend of peripheral vasoconstriction on clinical exam?

Answer 28

transition points between hot and cold peripheries | Mark and use as monitor for therapy effectiveness

Question 29

What areas of mottling reveal a severe mortality risk?

Answer 29

Truncal, upper thigh and genital mottling suggest imminent cardiac arrest