inpatient / cardiology

Hypotension - Rapid Response

Last Updated: 1/7/2023

First Impression
-- Mental Status, acute distress, general appearance
-- Tachypnea increased WOB (flaring, retraction, tripod, cyanosis) - protecting airway?
-- Check last few blood pressures and timing on the monitor; where is the BP cuff? Can we trust the readings? 
-- Current oxygenation, what are they currently hooked up to, are they getting better? Do you need to intubate?

Initial Stabilization
-- If non-responsive (GCS<8), check pulse, intubate
-- If in respiratory distress or hypoxic - NRB 100% --> HFNC --> NIPPV if COPD (BIPAP), or CHF (CPAP) --> intubate; PaO2 <60 despite NRB, get on HFNC; PaCO2 >45, put on BIPAP; pH <7.25, will likely tire out trying to blow off CO2
-- Arrhythmia - Afib - if HR >150-170 and hypotensive, its probably the HR causing the low BP, if <150, the hypotension and illness is probably causing the afib
-- GI Bleed - massive transfusion protocol (1:1:1)
-- Undifferentiated - give LR, send basic and infectious workup, start or broaden antibiotics, pressor (levo) if needed; consider calcium gluconate, SDS

Intake and Summary
-- Reason in the hospital
-- Relevant comorbidities
-- Baseline (mental status, BP range)
-- Acuity of change
-- Day events - recent meds or procedures
-- Current Access
-- Code Status and Decision-makers

-- Vitals - fevers, BP trned, HR, O2, RR
-- Exam - cap refill
-- POCUS - heart (tamponade, RV failure, LV function), Lungs (PTX, edema), IVC;
-- Red Flags for early intubation - pooling secretions, hemoptysis, respiratory distress

-- Infectious workup
- CBC with diff, CXR, UA/UCx, BCx, lactate
-- Metabolic - CMP (calcium, end-organ damage); consider TSH, cortisol
-- Toxin - check MAR for opioids, AC (bleed), BB/CCB, TCA (give bicarb)
-- Hypoxia - ABG/VBG - also check Hgb, iCal on gas
-- Ischemia - EKG, trop, NT-proBNP
-- CTPE 

-- Vasodilatory
- sepsis, anaphylaxis, neurogenic
-- Hypovolemic - hemorrhage (GI, chest, adomen, retroperitoneum, thigh), diuresis, poor PO intake, vomiting, diarrhea
-- Cardiogenic - arrhythmia, ishemia/MI, valvulopathy
-- Obstructive - tension PTX, PE, cardiac tamponade
-- Toxicologic -- opiates, sedation, BB/CCB, TCA
-- Metabolic - adrenal crisis, hypo/hyperthyroidism

Questions to Ask Yourself
1. Is this driven by loss of Cardiac Output or loss of SVR?
2. Is this Shock? Which kind? (distributive, hypovolemic, cardiogenic, obstructive)
3. What is patient’s preload? (volume, venous return, tone, obstruction to return - tension PTX, tamponade)
4. What is patient’s contractility? (squeeze)
5. What is patient’s afterload? (SVR, arterial stiffness, obstruction to flow - valves, HOCM)
6. Is this patient likely fluid responsive? (hypovolemic, sepsis)