Hypotension and CV Shock
Suggested approach and Clinical Pearls
- Hypotension is considered as a deviation of >20% below usual blood pressure
- Shock is a failure to provide a perfusing blood pressure resulting in end-organ dysfunction (may be high or low-cardiac output state, with variable blood pressure)
- Consider the circulation based on pre-load, afterload, rhythm, rate, systolic and diastolic myocardial function (on both ventricles)
- If there are signs of micro-circulatory insufficiency (capillary refill >3 seconds (nose, ears, digits), mottled knees, UO <0.5mL/kg/hr), then hypotension is consistent with shock state
- Cardiac output (flow) depends on pressure and vascular resistance
- Increasing blood pressure in a low cardiac output state through vasoconstriction will compromise the patient
- Jugular venous pressure can indicate level of intravascular volume status
- Consider pre-existing right heart failure in this assessment
- To assess fluid responsiveness, consider a 'passive leg raise'
- Raise legs to 45 degrees with the body horizontal for one minute. Reassess BP for increase of the pulse pressure (difference between SBP and DBP) by 10% to demonstrate fluid responsiveness.
- Raise legs to 45 degrees with the body horizontal for one minute. Reassess BP for increase of the pulse pressure (difference between SBP and DBP) by 10% to demonstrate fluid responsiveness.