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Cross Cover 101: Hypotension Jennifer Best, MD Consultative

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Cross Cover 101: Hypotension Jennifer Best, MD Consultative and Hospital Medicine Program Harborview Medical Center Case 1 Welcome to internship! You are awakened ... – PowerPoint PPT presentation

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Title: Cross Cover 101: Hypotension Jennifer Best, MD Consultative


1
Cross Cover 101 Hypotension
  • Jennifer Best, MD
  • Consultative and Hospital Medicine Program
  • Harborview Medical Center

2
Case 1
  • Welcome to internship!
  • You are awakened from sleep by a call from a RN
    regarding a cross-cover patients blood pressure
    112/58.
  • Hes just called you twice once about a patient
    who wont take his docusate and a second to tell
    you that a patient who is leaving the day after
    tomorrow doesnt have a discharge order written

3
Case 1 (continued)
  • You review your signout sheet
  • Admitting dx PNA
  • PMH HTN, OA and GERD
  • Meds Atenolol 100mg qd
  • Lisinopril 40mg qd
  • HCTZ 25mg qd
  • Blood pressures in the hospital have been
    running between 160-170 systolic
  • Thoughts?

4
Pearls
  • Hypotension is defined as a BP that is lt90/60 or
    one that is symptomatic
  • Normal blood pressure in a poorly controlled
    hypertensive is not just dumb luck
  • Hypotension can be life-threatening

5
What would you like to know?
6
Things you need to know
  • ABC how sick are they?
  • Why is the patient in the hospital?
  • Is the value real? Has the reading been
    rechecked?
  • What are the patients baseline blood pressures?
  • What are the other vitals?
  • Beta blockers
  • When did the patient last have meds?
  • How does the patient look? Symptomatic?

7
Im on my way upcan you
  • Increase monitoring
  • Position patient in Trendelenberg
  • Start O2
  • Check status of IV access
  • Call Rapid Response Team if applicable

8
Other elevator thoughts
  • Do I need HELP handling this patient?
  • What is the patients code status?
  • Review signout for clues about volume status
  • Review signout for indicators of infection
  • Review medication list
  • Procedures today?
  • Is this person in SHOCK?

9
What is shock?
  • Hypotension resulting in impairment of tissue
    perfusion
  • Altered mental status
  • Chest pain
  • Decreased urine output
  • Metabolic acidosis
  • SHOCK SICK ACT FAST!

10
Some quick physiology
  • mean arterial pressure (MAP)
  • 2(DBP)SBP / 3
  • cardiac output (CO) x systemic vascular
    resistance (SVR) central venous pressure (CVP)
  • MAP lt60 results in tissue hypoperfusion shock

11
Examination
  • Mental status
  • Full heart, lung, abdominal exam
  • Temperature of extremities warm vs. cool
  • Capillary refill
  • Full skin exam
  • Volume status/review of I/O
  • Stool guaiac

12
Early interventions Workup
  • Full labs CBC, Chem 10, coags, type and screen
    if concern for bleeding
  • Consider cardiac enzymes
  • Looking for infection UA/urine culture, blood
    cultures x 2, sputum cx
  • EKG and telemetry
  • CXR
  • ABG
  • Foley catheter

13
Early interventions IV access
  • Anticipate decompensation and work quickly
  • Large-bore PIVs or Cordis is best (over TLC)
  • PICC lines inadequate

14
Early interventions IV Fluids
  • In general, most causes of hypotension should be
    treated initially with fluids
  • Normal saline/Lactated Ringers isotonic
  • Give fluid as bolus 500 cc fine to start in most
    patients. If concern for CHF, start with 250cc.
  • If patient is unstable, fluid needs to go in fast
    (wide open)
  • CHF is special case avoid fluids/diurese or
    consider inotropes

15
Early interventions Sepsis
  • Fluid!
  • Send cultures right away
  • If no obvious source, tap untapped fluid
  • Broad antibiotic coverage. Consider likelihood
    of hospital acquired organisms (e.g. Pseudomonas,
    MRSA).
  • Look at what theyve been getting what DOESNT
    it cover

16
Pressors
  • Pressors should only be initiated when it is felt
    that the patient has had enough volume
  • Must be administered through central line and
    monitored with A-line
  • Usually titrated to MAP of 60
  • Initial choices
  • Dopamine Common first line
  • Dobutamine Cardiogenic shock or refractory CHF
  • Norepinephrine (Levophed) Sepsis
  • Phenylephrine Sepsis or neurogenic shock,
    tachycardia
  • Vasopressin Adjunctive role in sepsis
  • Epinephrine Anaphylaxis

17
Act fast pattern recognition
  • HYPOTENSION WITH
  • Wheezing after initiation of antibiotic

18
Anaphylaxis
  • Epinephrine 0.4mg IM of 11000 solution
    (different from code epi)
  • Benadryl 50mg IV q6 hours
  • Ranitidine 50mg IV
  • Solu-Medrol 125mg IV
  • Consider early intubation if airway compromised

19
Act fast pattern recognition
  • HYPOTENSION
  • In the context of surgery/acute stressor
  • In the setting of chronic steroid use
  • Refractory to IVF

20
Adrenal insufficiency
  • Vague symptoms
  • Consider adrenal hemorrhage in setting of
    anticoagulation or coagulopathy
  • Pretreat with Hydrocortisone 50-100mg IV on call
    to OR and then q8H x 24 hours
  • Use dexamethasone while obtaining ACTH
    stimulation test

21
Act fast pattern recognition
  • HYPOTENSION WITH
  • Elevated neck veins and muffled heart tones

22
Cardiac tamponade
  • Risk factors MI, malignancy, heart surgery,
    anticoagulation
  • STAT echo and cardiology evaluation
  • Pulsus paradoxus Listen for the point at which
    Korotkoff sounds disappear with inspiration and
    subtract the point at which sounds are heard with
    inspiration and expiration. A difference of gt10
    is considered pathologic.
  • Give fluids CO dependent on preload
  • Pericardiocentesis 18 gauge needle 45 degrees to
    plane of skin, angle at 45 degrees toward L
    shoulder in subxiphoid space

23
Act fast pattern recognition
  • HYPOTENSION WITH
  • Tracheal deviation and absent breath sounds

24
Tension pneumothorax
  • Never wait for a CXR if you suspect tension PTX!
  • Insert 18 gauge needle in anterior second
    intercostal space at midclavicular line.
  • REMEMBER Trachea will deviate away from affected
    side

25
Hypotension in the hospital
  • Infection present on admission or acquired,
    invasive lines and catheters, etc.
  • Medication changes increases or omissions
  • Antihypertensives
  • Diuretics
  • Vasodilators
  • Narcotics
  • Steroids?
  • Immobility risk for orthostasis, PE
  • Anticoagulation risk for new bleeding
  • First do no harm! HOLD ANTIHYPERTENSIVES

26
When to transfer?
  • Hypotension refractory to initial fluid
    resuscitation
  • Hypotension of unknown origin
  • Active bleeding GI or otherwise
  • Evidence of end-organ compromise
  • Pressor requirement
  • 5 or more people in the room is probably
    suggestive ?
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