What is the initial step in managing a patient with hypotension (low blood pressure)?

Initial Management of Hypotension

The first step in managing a patient with hypotension is to establish the etiology by measuring blood pressure in both supine and standing positions, while simultaneously assessing for symptoms and signs of organ hypoperfusion. 1

Diagnostic Assessment

Initial Evaluation

• Measure BP in both supine and standing positions
  • A drop of ≥20 mmHg in systolic BP or ≥10 mmHg in diastolic BP within 3 minutes of standing suggests orthostatic hypotension 1, 2
• Document symptoms that correlate with hypotension:
  • Dizziness, lightheadedness, fatigue, visual disturbances
  • Assess if symptoms occur when standing or in upright position 1
• Evaluate for signs of organ hypoperfusion:
  • Altered mental status
  • Cool extremities
  • Decreased urine output
  • Tachycardia (compensatory mechanism)

Essential Tests

• Urine analysis (Dipstix)
• Serum electrolytes and renal function (urea/creatinine)
• Blood glucose
• ECG (for evidence of myocardial ischemia or left ventricular hypertrophy)
• Full blood count 1

Management Algorithm

Step 1: Identify and Address Reversible Causes

• Discontinue or reduce medications that may cause hypotension:
  • Non-HF cardiovascular treatments (calcium channel blockers, centrally acting antihypertensives, alpha-blockers)
  • Excessive diuretic therapy 1, 2
• Correct transient medical conditions:
  • Dehydration (from diarrhea, fever, etc.)
  • Bleeding
  • Infection 1

Step 2: Immediate Management Based on Severity

For Severe Hypotension (SBP <90 mmHg with signs of organ hypoperfusion)

• Ensure adequate IV access (large vein, preferably antecubital fossa) 3, 4
• Administer IV fluids:
  • Crystalloid fluid challenge (30 mL/kg) 5
  • Whole blood or plasma if indicated for volume replacement 3
• If hypotension persists despite fluid resuscitation, initiate vasopressors:
  • Norepinephrine: Initial dose 2-3 mL/min (8-12 mcg/min), titrate to maintain SBP 80-100 mmHg 3
  • Dopamine: Alternative option at 5-15 mcg/kg/min 4

For Orthostatic Hypotension

• Lifestyle modifications:
  • Elevate head of bed 6-9 inches during sleep
  • Physical counter-pressure maneuvers (leg crossing, squatting)
  • Compression garments (thigh-high or abdominal)
  • Increased salt and fluid intake (2-2.5 L/day) if not contraindicated
  • Small, frequent meals to reduce postprandial hypotension 2
• Pharmacological treatment if needed:
  • Midodrine (2.5-10 mg three times daily)
  • Fludrocortisone (0.1-0.3 mg daily) - use cautiously due to risk of supine hypertension
  • Droxidopa for neurogenic orthostatic hypotension 2

Step 3: Monitoring and Follow-up

• Continuous monitoring of vital signs during acute management 3
• Document neurological status before and after interventions 1
• For patients with chronic hypotension, regular follow-up every 3 months once stabilized 1

Special Considerations

Heart Failure Patients with Hypotension

• Prioritize medications with mortality benefit:
  • SGLT2 inhibitors and MRAs have the least effect on BP
  • Start with low doses and gradually titrate 1, 2
• Focus on symptom improvement rather than BP normalization 2

When to Refer for Specialist Advice

• Malignant or accelerated phase hypertension (emergency referral)
• Suspected secondary causes of hypotension
• Refractory hypotension despite initial management
• Hypotension with multiple cardiovascular risk factors 1

Common Pitfalls to Avoid

• Don't rely on single hematocrit measurements as an isolated marker for bleeding-induced hypotension 1
• Avoid excessive sedation during monitoring of neurological status 1
• Don't abruptly withdraw vasopressors; taper gradually 3
• Avoid administering vasopressors into small peripheral veins due to risk of extravasation and tissue necrosis 3, 4
• For patients on chronic medications for heart failure, don't discontinue guideline-directed medical therapy without careful consideration of risks and benefits 1

By following this structured approach to hypotension management, you can effectively identify the underlying cause and provide appropriate treatment to improve patient outcomes and reduce morbidity and mortality.