What are the management steps for a patient with a diastolic blood pressure of 0, indicating severe hypotension?

Management of Diastolic Blood Pressure of 0 mmHg

A diastolic blood pressure of 0 mmHg represents a life-threatening emergency requiring immediate aggressive fluid resuscitation, vasopressor support, and identification of the underlying cause—this is not hypotension but rather impending cardiovascular collapse or cardiac arrest.

Immediate Resuscitation Priorities

Verify the Reading and Assess Patient Status

• Confirm the blood pressure measurement is accurate by checking equipment function, cuff size, and obtaining measurements from multiple sites or using arterial line monitoring if available 1
• Assess for signs of life: pulse, consciousness, and breathing—a true diastolic pressure of 0 suggests either severe shock, aortic regurgitation, or measurement error 1
• If the patient is pulseless or in cardiac arrest, initiate ACLS protocols immediately rather than treating as isolated hypotension 1

Aggressive Volume Resuscitation

• Initiate aggressive fluid resuscitation with 0.9% sodium chloride or balanced crystalloid solution as first-line therapy, with the goal of maintaining target arterial pressure 2
• Establish large-bore intravenous access for rapid fluid and medication administration 2
• Blood volume depletion should always be corrected as fully as possible before any vasopressor is administered 3

Vasopressor Support

• Add norepinephrine infusion to maintain target arterial pressure while continuing volume replacement if systolic blood pressure remains below 80 mmHg despite fluid resuscitation 2, 3
• Norepinephrine should be diluted in 5% dextrose injection and administered via central venous access when possible 3
• Initial norepinephrine dosing: 2-3 mL per minute (8-12 mcg of base), then titrate to maintain systolic blood pressure of 80-100 mmHg 3
• Avoid vasopressors if systolic blood pressure of 80-90 mmHg can be achieved with fluids alone, as premature vasopressor use may worsen organ perfusion in hemorrhagic states 2

Identify and Treat Underlying Causes

Critical Differential Diagnosis

• Hemorrhagic shock: Assess for occult bleeding sources, particularly intra-abdominal or thoracic hemorrhage 1
• Cardiogenic shock: Evaluate for acute myocardial infarction, cardiac arrhythmias, or decreased cardiac output 1
• Aortic dissection: Consider in patients with severe chest or back pain 1
• Severe aortic regurgitation: Can present with wide pulse pressure and low diastolic pressure 1
• Septic shock: Look for signs of infection and systemic inflammatory response 2

Diagnostic Workup

• Perform immediate bedside ultrasound (FAST exam) to assess for free fluid and cardiac function 1
• Obtain ECG to evaluate for myocardial ischemia or arrhythmias 1
• Serial hemoglobin/hematocrit measurements have low sensitivity for detecting acute hemorrhage and should not be used as isolated markers for bleeding severity 1, 2
• Central venous pressure monitoring is helpful in detecting and treating occult blood volume depletion 3

Supportive Care Measures

Airway and Oxygenation

• Secure the airway if the patient has impaired consciousness or is unable to protect the airway 2
• Administer high-flow oxygen to maintain adequate oxygenation 2

Temperature Management

• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 2

Monitoring

• Continuous blood pressure monitoring in an intensive care unit is essential 4, 5
• Avoid transporting hemodynamically unstable patients to imaging until stabilized 2

Critical Pitfalls to Avoid

• Do not delay resuscitation to obtain imaging studies—stabilization takes priority over diagnostic workup 2
• Do not rely on single hematocrit measurements to guide resuscitation as they do not accurately reflect acute blood loss 1, 2
• Occult blood volume depletion should always be suspected and corrected when patients remain hypotensive despite vasopressor therapy 3
• A diastolic blood pressure approaching zero is incompatible with adequate tissue perfusion and represents imminent cardiovascular collapse requiring the most aggressive interventions 6