What do you do when a patient's blood pressure drops from severe hypertension (180/102) to hypotension (90s/50s)?

From the Guidelines

When a patient's blood pressure drops dramatically from severe hypertension to hypotension, immediate intervention is necessary to prevent organ hypoperfusion and potential mortality. The first step is to stop any antihypertensive medications the patient is taking, as they may be contributing to the hypotension. Then, position the patient supine with legs elevated to improve venous return, as recommended by 1. Start IV fluid resuscitation with normal saline or lactated Ringer's solution, typically 500-1000 mL bolus, and reassess, considering the use of large volumes of crystalloid as suggested in 1. Some key points to consider in management include:

• Monitoring vital signs continuously, including heart rate, respiratory rate, oxygen saturation, and level of consciousness.
• If hypotension persists despite fluids, vasopressors may be needed - norepinephrine (starting at 0.05-0.1 mcg/kg/min) is often first-line, or phenylephrine (40-60 mcg/min) if tachycardia is present.
• Obtaining an ECG to rule out cardiac causes and checking for end-organ damage with laboratory tests including complete blood count, electrolytes, renal function, and cardiac enzymes. This dramatic blood pressure drop could indicate medication overdose, autonomic dysfunction, adrenal insufficiency, or volume depletion, and the goal is to gradually restore blood pressure to safe levels (typically systolic 100-120 mmHg initially) while investigating the underlying cause, as rapid correction back to hypertensive levels could cause harm, and recent guidelines such as 1 emphasize careful management of blood pressure in various clinical scenarios. Key considerations in the management of such patients include the potential need for vasodilators in hypertensive heart failure, as noted in 1, and the careful use of intravenous therapy for acute blood pressure lowering in specific conditions like intracerebral hemorrhage, as discussed in 1. Overall, the approach should prioritize the prevention of organ hypoperfusion and the careful restoration of blood pressure to safe levels, guided by the most recent and relevant clinical guidelines, such as those provided by 1.

From the FDA Drug Label

Blood volume depletion should always be corrected as fully as possible before any vasopressor is administered. When, as an emergency measure, intraaortic pressures must be maintained to prevent cerebral or coronary artery ischemia, LEVOPHED can be administered before and concurrently with blood volume replacement In previously hypertensive patients, it is recommended that the blood pressure should be raised no higher than 40 mm Hg below the preexisting systolic pressure.

When a patient's blood pressure drops from severe hypertension (180/102) to hypotension (90s/50s), blood volume depletion should be corrected as fully as possible.

• The patient should receive fluid replacement to correct blood volume depletion.
• Vasopressor administration, such as norepinephrine, may be considered if the patient remains hypotensive, but should be titrated according to the response of the patient.
• In previously hypertensive patients, the blood pressure should be raised no higher than 40 mm Hg below the preexisting systolic pressure 2.

From the Research

Immediate Action for Hypotension

When a patient's blood pressure drops from severe hypertension (180/102) to hypotension (90s/50s), immediate action is necessary to prevent further complications. The following steps can be taken:

• Administer a fluid bolus, such as lactated Ringer's solution, to help increase blood pressure 3
• Consider the use of push-dose vasopressors, such as vasopressin, to improve hemodynamics in patients with vasodilatory shock 4
• Monitor the patient's vital signs closely and adjust treatment as needed

Preventing Orthostatic Hypotension

To prevent orthostatic hypotension when moving a patient from a supine to a standing position, the following measures can be taken:

• Use dangling as an intermediary stage to help the patient adjust to the change in position 5
• Encourage leg and foot movement to help improve circulation
• Continually assess the patient during the procedure and halt if any signs of intolerance are observed

Monitoring Blood Pressure

When monitoring blood pressure, it is essential to consider the patient's position, as this can affect the readings:

• Blood pressure readings can vary depending on whether the patient is sitting or supine 6, 7
• Diastolic blood pressure and heart rate may be higher when the patient is sitting rather than supine 7
• The correlation between office blood pressure and ambulatory blood pressure can vary depending on the position in which the readings are taken 6