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

Table of Contents

 

About This Issue

Hypotension can result from myriad pathophysiologic derangements, and it falls on a continuum of severity with shock. Effective treatment depends on quickly determining the cause and initiating treatment measures appropriate for the etiology. In this issue, you will learn:

The most important likely etiologies within the 4 main categories of shock: hypovolemic, cardiogenic, obstructive, and distributive

How to analyze the relationships of systolic and diastolic blood pressure, mean arterial pressure, central venous pressure, systemic vascular resistance, and cardiac output

How to determine specific organ perfusion pressures

Specific elements of vital signs, symptoms, and history that will point to a cause for a patient’s hypotension

The high-value laboratory, imaging, and ECG results that will assist in diagnosis

Key therapeutic interventions to administer, based on the disease processes

How to manage refractory hypotension and shock

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Organ Perfusion
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
      1. Vital Signs
      2. Examination of Extremities
      3. Cardiovascular Examination
      4. Lung Examination
      5. Abdominal and Rectal Examination
10. Diagnostic Studies
    1. Laboratory Testing
    2. Imaging Studies
       1. Point-of-Care Ultrasound
       2. Other Imaging Studies
    3. Electrocardiogram
11. Treatment
    1. Intravenous Fluid Administration
    2. Hypovolemic Shock
    3. Distributive Shock
       1. Septic Shock
       2. Anaphylactic Shock
       3. Endocrinopathies
    4. Obstructive Shock
    5. Cardiogenic Shock
       1. Valvular Pathologies
    6. Refractory Hypotension
12. Special Populations
    1. Pregnant Patients
    2. Patients With Left Ventricular Assist Device
13. Controversies and Cutting Edge
    1. Use of Intravenous Vasopressin
    2. Emerging Medications for Vasodilatory Shock
       1. Methylene Blue
       2. Intravenous Hydroxocobalamin
       3. Angiotensin II
    3. Variations in Preload
    4. Other Emerging Therapies for Hypotension
14. Disposition
15. Summary
16. Time- and Cost-Effective Strategies
17. 5 Things That Will Change Your Practice
18. Risk Management Pitfalls for Hypotensive Patients in the Emergency Department
19. Case Conclusions
20. Clinical Pathway for Management of Emergency Department Patients With Hypotension
21. Tables and Figures
22. References

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 best to 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…

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for Management of Emergency Department Patients With Hypotension

Subscribe to access the complete flowchart to guide your clinical decision making.

Tables and Figures

Subscribe for full access to all Tables and Figures.

Key References

Following are the most informative references cited in this paper, as determined by the authors.

2. * Holler JG, Bech CN, Henriksen DP, et al. Nontraumatic hypotension and shock in the emergency department and the prehospital setting, prevalence, etiology, and mortality: a systematic review. PLoS One. 2015;10(3):e0119331. (Systematic review) DOI: 10.1371/journal.pone.0119331

18. * Hernandez G, Ospina-Tascon GA, Damiani LP, et al. Effect of a resuscitation strategy targeting peripheral perfusion status vs serum lactate levels on 28-day mortality among patients with septic shock. JAMA. 2019;321(7):654-664. (Randomized controlled trial; 424 patients) DOI: 10.1001/jama.2019.0071

22. * Yoshida T, Yoshida T, Noma H, et al. Diagnostic accuracy of point-of-care ultrasound for shock: a systematic review and meta-analysis. Crit Care. 2023;27(1):200. (Meta-analysis; 12 studies, 1132 patients) DOI: 10.1186/s13054-023-04495-6

32. * Gordon AC, Mason AJ, Thirunavukkarasu N, et al. Effect of early vasopressin vs norepinephrine on kidney failure in patients with septic shock. JAMA. 2016;316(5):509-518. (Randomized controlled trial; 409 patients) DOI: 10.1001/jama.2016.10485

41. * Self WH, Semler MW, Wanderer JP, et al. Balanced crystalloids versus saline in noncritically ill adults. N Engl J Med. 2018;378(9):819-828. (Crossover trial; 13,347 patients) DOI: 10.1056/NEJMoa1711586

62. * Myburgh JA, Higgins A, Jovanovska A, et al. A comparison of epinephrine and norepinephrine in critically ill patients. Intensive Care Med. 2008;34(12):2226-2234. (Randomized controlled trial; 280 patients) DOI: 10.1007/s00134-008-1219-0

85. * Crowe E, DeSantis SM, Bonnette A, et al. Whole blood transfusion versus component therapy in trauma resuscitation: a systematic review and meta-analysis. J Am Coll Emerg Physicians Open. 2020;1(4):633-641. (Systematic review and meta-analysis; 12 studies, 8431 patients) DOI: 10.1002/emp2.12089

86. * de-Madaria E, Buxbaum JL, Maisonneuve P, et al. Aggressive or moderate fluid resuscitation in acute pancreatitis. N Engl J Med. 2022;387(11):989-1000. (Randomized controlled trial; 249 patients) DOI: 10.1056/NEJMoa2202884

94. * Reitz KM, Kennedy J, Li SR, et al. Association between time to source control in sepsis and 90-day mortality. JAMA Surg. 2022;157(9):817-826. (Retrospective; 4962 patients) DOI: 10.1001/jamasurg.2022.2761

Subscribe to get the full list of 96 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: hypotension, shock, end-organ, hypovolemic, distributive, obstructive, cardiogenic, hemorrhage, sepsis, ultrasound, RUSH, ECG, POCUS, vasopressor, inotrope