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Cardio Exam 3 > Hypotension and Shock > Flashcards

Hypotension and Shock Flashcards

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1
Q

Hypotension diagnostic criteria

A

SBP <90
DBP <60
● May not have any symptoms
● May still have signs/symptoms of hypotension with “normal” BP
● Treat the patient, not the number

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2
Q

Hypotension leads to:

A
  1. Reduced cardiac output
  2. Hypovolemia
  3. Reduced systemic vascular resistance
  4. Vascular obstruction
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3
Q

Nonpathologic Causes of Hypotension

A

Cardiovascular Fitness
Pregnancy
Prolonged bed rest
Alcohol

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4
Q

Presentation of Hypotension

A

Ranges from mild to severe
● Fatigue
● Dizziness
● Lightheadedness
● Headache
● Fading vision (resolves
with lying down)
● Nausea
● Tachycardia
● Syncope
● Confusion
● Pallor
● Diaphoresis
● Shock
● Seizures

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5
Q

Orthostatic Hypotension

A

A significant drop in blood pressure after rising from a seated or supine position

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6
Q

Normal blood pressure response to standing:

A
  1. Blood pools in lower extremities
  2. ↓ venous return to heart
  3. ↓ cardiac output and blood pressure
  4. Triggers ↑ sympathetic and ↓ parasympathetic stimulation
  5. ↑ sympathetic outflow raises peripheral vascular resistance, venous return,
    and cardiac output
  6. Blood pressure normalizes
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7
Q

Orthostatic Hypotension is caused by failure of _____

A

compensatory mechanisms

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8
Q

Risk Factors for Orthostatic Hypotension

A

Baroreflex dysfunction (neurogenic)
Volume depletion

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9
Q

Orthostatic Hypotension presentation

A

● Generalized weakness
● Dizziness/lightheadedness
● Visual blurring or darkening of the visual fields
● Fatigue
● Cognitive slowing
● Leg buckling
● Headache in suboccipital, posterior cervical, and
shoulder region
● Rarely MI or stroke

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10
Q

Orthostatic Hypotension diagnosis

A

● Detailed medication list, prescription and
nonprescription
● Recent medical history of potential volume loss
○ Vomiting, diarrhea, fluid restriction, fever?
● Medical history of congestive heart failure,
malignancy, diabetes, alcoholism?
● Neurologic history and examination

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11
Q

Taking Orthostatic blood pressure:

A

Compare blood pressure in supine and standing positions
1. Have the patient lie down for 5 minutes
2. Measure supine blood pressure and heart rate
3. Have the patient stand up
4. Measure standing blood pressure and heart rate at 1 and 3 minutes

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12
Q

Orthostatic Hypotension =

A

A reduction of 20 mmHg or more in systolic pressure
A reduction of 10 mmHg or more in diastolic pressure

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13
Q

T/F Heart rate should rise to compensate for postural reduction in blood pressure

A

T

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14
Q

If HR doesn’t increase, suspect ____

A

neurogenic orthostatic hypotension

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15
Q

Orthostatic Hypotension labs/diagnosis

A

● Labs (hematocrit, electrolytes, BUN,
creatinine, glucose, ferritin)
● EKG to r/o underlying heart disease
● Continuous BP monitoring (helpful for
immediate orthostatic hypotension)
● Tilt-table testing (helpful for delayed
orthostatic hypotension)

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16
Q

Orthostatic Hypotension treatment

A

No specific target BP. Goal is to prevent or reduce symptoms.
● Discontinue or reduce exacerbating
medications
● Increase salt and water intake
● Use compression socks and
abdominal binders
Modify daily activities and lifestyle

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17
Q

Lifestyle modifications for Orthostatic Hypotension

A

● Stand up slowly, in stages
● Avoid Valsalva-like maneuvers
● Avoid overheating (hot weather,
showers, saunas)
● Tense legs and contract abdominal
and buttock muscles while actively
standing
● Cross legs while standing
● Sleep w/ head of bed elevated
30-45 degrees
● Regular exercise to increase
cardiovascular fitness

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18
Q

Pharmacologic therapy for Orthostatic Hypotension

A

● Fludrocortisone (1st line)
○ Synthetic mineralocorticoid
○ Increase water and sodium
reabsorption
○ Increases intravascular volume
● Sympathomimetic agents
○ midodrine, droxidopa
● Atomoxetine
● 2nd line
○ Combo of medications
○ venlafaxine
○ pyridostigmine
○ erythropoietin
○ NSAIDs

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19
Q

Orthostatic Hypotension complications

A

● Falls
● Cardiovascular disease
● Congestive heart failure
● Atrial fibrillation

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20
Q

Vasovagal Hypotension

A

Neural reflex results in self-limited systemic hypotension characterized by bradycardia
and/or peripheral vasodilation/venodilation

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21
Q

Most common cause of syncope

A

Vasovagal Hypotension

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22
Q

Vasovagal Hypotension presentation

A

● Common prodrome: Nausea, pallor,
diaphoresis
○ Caused by increased vagal tone
● Lightheadedness
● A feeling of being warm or cold
● Palpitations
● Fatigue after recovery

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23
Q

Vasovagal Hypotension diagnosis

A

● In most cases, history and symptoms
are enough to establish diagnosis
● Physical exam usually normal
● BUT EVERYBODY GETS AN EKG

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24
Q

What history information do we need about Vasovagal Hypotension?

A

● Number, frequency, and duration of episodes
● Associated symptoms preceding syncope
● Patient position at the time of syncope
● Triggers or provocative factors
● Associated symptoms following syncope
● Witnessed signs
● Preexisting medical conditions, medications, and
family history
● Symptoms after recovery

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25
Shock = ____
Hypoperfusion 1. Cardiogenic shock 2. Distributive shock 3. Hypovolemic shock 4. Obstructive shock
26
Shock S/S
● Pt may appear obtunded or lethargic ● SBP<90 ● Tachycardia ● Confusion ● Pallor ● Decreased urinary output ● Weak peripheral pulses ● Cool, moist extremities ● Metabolic acidosis
27
Shock diagnosis
● CBC, electrolytes, glucose, ABGs, coagulation panel, lactic acid, type and cross-match, blood cultures, UA ● EKG ● Chest x ray ● Echocardiogram
28
Shock treatment
● Depends on the cause ● ABCs ● Fluid resuscitation ● Cardiac monitoring ● Monitor urine output
29
Cardiogenic Shock
● Heart is unable to maintain adequate cardiac output ● Results in hypotension and tissue hypoperfusion Nearly 50% of patients do not survive
30
_____ most common of cardiogenic shock
Myocardial infarction
31
Causes of cardiogenic shock
● Refractory arrhythmias ● End-stage cardiomyopathies ○ Ischemic, valvular, hypertrophic, restrictive, idiopathic ● Acute myocarditis ○ Infectious, toxic, rheumatologic, idiopathic ● Stress cardiomyopathy ● Endocrine abnormalities ○ Hypothyroidism, pheochromocytoma ● Trauma
32
Cardiogenic Shock history info
● Chest pain (if ischemic cause) ● Dyspnea ● Orthopnea ● Fatigue ● Malaise ● Low appetite ● Any of the previously mentioned conditions
33
Physical exam for Cardiogenic Shock
● Lung crackles (pulmonary edema) ● JVD ● Heart murmur ● Peripheral edema
34
Cardiogenic Shock labs
● Elevated cardiac enzymes if MI (CPK-MB, troponins) ● Elevated creatinine, ALT, AST if renal/hepatic hypoperfusion ● Coagulation abnormalities if hepatic congestion or hypoperfusion ● Anion gap acidosis, ↑Serum lactate, ↑BNP EKG ● Evidence of old or new infarctions ● Arrhythmias
35
Echo use in Cardiogenic shock
● Very useful! ● Look for mechanical complications of infarction ● Ventricle size/function ● Valve function ● Pericardial fluid/tamponade
36
CXR use in Cardiogenic shock
● Findings may or may not be present ● Cardiomegaly ● Pulmonary congestion
37
Coronary angiography use in cardiogenic shock
● Immediately if evidence of MI ● Identifies blockage and allows for treatment planning
38
Cardiogenic Shock treatment
● Cardiac catheterization w/ revascularization if indicated. DO NOT DELAY ● Vasopressors/inotropes (Examples?) ● Mechanical circulatory support ○ Intra-aortic balloon pump, microaxial pump, ECMO ● Ventricular Assist Device ● Heart transplant Determine cause first, then target treatment!
39
Distributive Shock
Reduction in systemic vascular resistance results in inadequate cardiac output and tissue hypoperfusion despite normal circulatory volume.
40
Causes of Distributive Shock
● Septic shock ● Neurogenic shock ● Anaphylactic shock ● Endocrine shock
41
Physical exam of Distributive Shock
● Extremities initially warm before becoming cool ● Wide pulse pressure ● Abnormal heart sounds ● Lactic acidosis - septic ● Evidence of CNS injury - neurogenic
42
Septic shock =
sepsis + fluid unresponsive hypotension + serum lactate level > 2 mmol/L + need vasopressors to keep MAP > 65 mm Hg
43
Most common cause of distributive shock
Sepsis
44
Distributive Shock - Septic treatment
● ABCs ● Fluid resuscitation ● Empiric antibiotics ○ Within the first hr ○ After cultures obtained ● Vasopressors
45
Distributive Shock - Other causes
Neurogenic shock ● Spinal cord injury ● Epidural or spinal anesthetic Drug and toxin-induced shock ● Drug overdose ● Snake bites Anaphylactic Shock ● IgE mediated Endocrine shock ● Adrenal insufficiency
46
Hypovolemic Shock
Volume is too low! ● Loss of blood ○ Trauma ○ GI bleed ● Loss of fluids/electrolytes ○ Vomiting ○ Diarrhea ○ Other dehydration
47
Hypovolemic Shock treatment
● Stop the fluid loss ● Replace volume (fluids, blood transfusion)
48
Obstructive Shock
Pump failure due to EXTRACARDIAC cause! ● Usually associated with poor right ventricular output ● Pulmonary embolism, cardiac tamponade, tension pneumothorax, severe vasoconstriction
49
Treatment of Obstructive Shock
Treatment = Remove the obstruction
50
Phenylephrine MOA
● Alpha-1 agonist ● Causes vasoconstriction ● Sympathomimetic
51
Phenylephrine indications
● Hypotension ● Shock ● Priapism ● Post-resuscitation stabilization ● PSVT conversion ● Nasal congestion (not IV form)
52
Phenylephrine contraindications
● Uncontrolled hypertension ● Ventricular tachycardia ● CAD ● Arrhythmias ● Bradycardia
53
Phenylephrine adverse effects
● Cardiac arrhythmias ● Severe hypertension
54
Vasopressin MOA
● Stimulates AVPR1 (V1) and AVPR2 (V2 receptors ● Causes vasoconstriction and antidiuresis ● Also causes smooth muscle contraction in the GI tract
55
Vasopressin indications
● Shock (specifically septic and other vasodilatory shocks) ● Central diabetes insipidus (off label)
56
Vasopressin pearls
● May cause reversible diabetes insipidus after tx d/c, monitor closely
57
Dobutamine MOA
● Stimulates beta-1 adrenergic receptors ● Chronotropic and inotropic effect ● Some vasodilation
58
Dobutamine Indications
● Shock (add if vasopressors don’t work) ● Acute decompensated heart failure ● Stress echocardiography
59
Dobutamine contraindications
● Hypertrophic cardiomyopathy w/ outflow obstruction ● HTN
60
Dopamine MOA
● Stimulates alpha and beta-1 adrenergic and dopaminergic receptors ● Inotropic and chronotropic effects ● Renal/splanchnic vasodilation (low dose) ● High doses have pressor effects
61
Dopamine indications
● Hypotension, shock (not 1st line) ● Bradycardia (ACLS) ● Symptomatic AV block
62
Dopamine BBW
Black Box Warning: If extravasation occurs, infiltrate the area with diluted phentolamine as soon as possible to prevent necrosis
63
Epinephrine MOA
● Stimulates alpha and beta adrenergic receptors ● Sympathomimetic ● Cardiac stimulation, relaxation of bronchial smooth muscle, vasoconstriction
64
Epinephrine Indications
● Hypotension, shock (septic, anaphylactic especially) ● Symptomatic bradycardia or AV block (ACLS) ● Cardiac arrest (ACLS)
65
Epinephrine Contraindications
● No absolute contraindications in life-threatening situation
66
Norepinephrine MOA
● Stimulates alpha and beta-1 adrenergic receptors ● Inotropic effect and vasoconstriction
67
Norepinephrine indications
● Cardiogenic shock ● Septic and other vasodilatory shocks ● Fluid-resistant hypotension/shock ● Post-cardiac arrest shock
68
Midodrine MOA
● Stimulates alpha-1 adrenergic receptors ● Increases arteriolar and venous tone ● Raises standing, sitting, and supine systolic and diastolic blood pressure
69
Midodrine Indications
● Orthostatic hypotension ● POTS ● Vasovagal syncope ● Prevention of hemodialysis-induced hypotension
70
Midodrine adverse effects
● Severe bradycardia ● Visual field defect ● Erythema multiforme ● Severe supine HTN
71
Midodrine BBW
Black box warning: can cause marked supine blood pressure elevation; use in pts whose lives are considerably impaired despite standard clinical care…

Cardio Exam 3 (8 decks)

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