Evaluation and Management of Hypotensive Patients in the Emergency Department (Pharmacology CME)

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Delivery Method:	Online
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Publication Date: December 2023 (Volume 25, Number 12)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 12/01/2026.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 1 Pharmacology CME credit, subject to your state and institutional approval.

Authors

Peer Reviewers

Abstract

Hypotension can be a sign of significant underlying pathology, and if it is not rapidly identified and addressed, it can contribute to organ injury. Treatment of hypotension is best targeted at the underlying etiology, although this can be difficult to discern early in a patient’s disease course. Expedited bedside evaluation with rapid initiation of treatment based on the most likely underlying etiology is paramount, followed by serial reassessment of the patient’s condition. This review synthesizes the key aspects of the presentation and evaluation of a patient with hypotension, including salient historical features, physical examination findings, and diagnostic tests that can help guide treatment.

Case Presentations

A 60-year-old woman with fever and flank pain is brought in by EMS…

• The patient reports that she has been experiencing flank pain for the last 2 days and called EMS today because she had a fever and felt so weak that she was unable to walk.
• The patient appears tired, tachypneic, and in mild distress. Her vital signs are: temperature, 38.5ºC; heart rate, 145 beats/min; blood pressure, 87/33 mm Hg; respiratory rate, 31 breaths/min; and oxygen saturation, 96% on room air. Her pulse is thready and irregular, and the monitor shows that she is in atrial fibrillation. She is delirious and has right costovertebral tenderness.
• You suspect the patient is septic from a urinary tract source, but you wonder whether the atrial fibrillation is also contributing to her hypotension. What additional diagnostic tests could be performed at the bedside to evaluate for urinary tract obstruction and help guide hemodynamic management?

A 23-year-old man who is on warfarin for a mechanical mitral valve is brought in by friends after sustaining a gunshot wound to the abdomen…

• He is in severe distress, is diaphoretic, and pulling off his nonrebreather mask. His vital signs are: temperature, 35ºC; heart rate, 160 beats/min; blood pressure, 71/57 mm Hg; and respiratory rate, 35 breaths/min. You are unable to obtain oxygen saturation due to poor waveform on pulse oximetry.
• His examination reveals 1 penetrating injury just to the right of his umbilicus.
• His vital signs remain unchanged after being given 1 unit of packed red blood cells and 1 unit of fresh frozen plasma.
• You are most concerned about hemorrhagic shock, and you consider how to best incorporate point-of-care ultrasound into his assessment, whether he would benefit from activation of the massive transfusion protocol, and how to best address his coagulopathy…

A 35-year-old woman who is 2 weeks post partum presents with increasing fatigue, generalized weakness, and shortness of breath with exertion…

• Her breathing is labored, and she is speaking in short sentences.
• Her vital signs are: temperature, 37ºC; heart rate, 120 beats/min; blood pressure, 93/81 mm Hg; respiratory rate, 28 breaths/min; and oxygen saturation, 76% on room air.
• Her examination reveals a jugular venous pulse of 15 cm H2O, crackles throughout both lung fields, an S3 gallop, a holosystolic murmur radiating to the axilla, cool extremities, and moderate bilateral lower extremity edema.
• You identify that the patient is currently in shock, and consider the therapeutic interventions that will be needed…

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.