Sam speaks to Intensivists Dr Jonathan Casement and Dr Rob Everitt about differentiating and managing hypotension.

Differential

* Life threatening

* Acute haemorrhage

* On the floor and four more

* Sepsis

* Arrhythmia/cardiac

* Drugs (including transfusion reaction)

* Anaphylaxis

* Dehydration (beware the accuracy of this diagnosis)

* Epidural anaesthesia

* Heart failure

* Pregnancy

* Syncope/postural

* Neurological

* Positional

* PD

* Diabetes

Approach

* Eyeball the patient / ABCDEF

* Calling a code

* 777 (or your local hospital emergency number)

* This is Sam, medical house officer I need the adult resus team to attend North Shore Hospital, ward 10, room E3.

* History

* Why are they in hospital?

* Post-op?

* Onset, timing & trend of hypotension

* Postural

* Medications

* Associated symptoms

* Pain is very concerning

* ROS

* Vitals + Examination

* End-of-bed-o-gram is probably the most important

* Peripheries for perfusion and pulse

* Manual BP

* Both arms

* Cuff size

* Urine output

* Drain output

* Consider investigations

* Keep in mind these may be of limited value

* ABG (lactate, glucose, Hb)

* ECG

* Management

* Fluid challenge only if hypovolaemic

* 250 – 500 mL stat

* Rehydrate gradually

* Transfusion

* Target Hb >70

* Use one unit then reassess

* Avoid transfusion outside daylight hours

* Catheterise and measure fluid balance

* Fix the underlying cause

* Have a low threshold to escalate to a senior

* Clear observation and escalation plan if cause is unclear

* Document

* Review past notes

* Basics (date/time/name/reason for review)

* Positives and pertinent negatives

* Impression and differential with justification.

* Have you eliminated life threatening conditions?

* Beware an impression of dehydration.

* Are they actually hypovolaemic?

* Why would they be dehydrated on the ward?

* Clear and specific plan

* Monitoring

* Consider discussion with senior and escalation, especially if called back to patient again