How to Manage a Hypotensive Patient on the Floor

Buckle up, PGY-1’s! Intern year is starting whether you’re ready or not. Don’t fret, BTK has your back to make sure you dominate the first year of residency. 

Today, we’re hitting the wards and tackling some of the scary clinical scenarios you will see as an intern.

Hosts: Shanaz Hossain, Nina Clark

Tips for new interns:
THINGS TO REMEMBER
·       BREATHE. In most cases, you have a little bit of time – at least enough to take a breath and calm down outside the room before heading into an emergency. Panic doesn’t help anybody.
·       See the patient. Getting a bunch of pages? Worried about someone? Confused as to what’s going on? Go see the patient and chat with the bedside team.
·       Know your toolbox. There are a ton of people around who can help you in the hospital, and knowing the basic labs/imaging studies and when to use them can help you to triage even the sickest patients.
·       Load the boat. You’ve heard this one from us all week! Loop senior level residents in early.

HYPOTENSION
·       Differential: measurement error, patient’s baseline, and don’t miss – SHOCK.
           - Etiologies of shock: hemorrhagic, hypovolemic,
·       On the phone: full set of vitals, accurate I/Os,
·       On the way: recent notes, PMH/PSH including from this hospital stay, and vitals/I&Os/studies from earlier in the day
·       In the room: ABCDs – rapidly gives you a sense of how high acuity the patient is
·       Get more info: labs, consider imaging, work up specific types of shock based on clinical concern.
·       Initial management: depends on etiology of hypotension; don’t forget to consider peripheral or central access, foley catheterization for close monitoring of urine output, and level of care

 HYPOXEMIA
·       Differential: atelectasis, baseline pulmonary disease, pneumonia, PE, hemo/pneumothorax, volume overload
·       On the phone: full set of vitals, amount of supplemental oxygen required and delivery device, rate of escalation in oxygen requirement
·       On the way: review PMH/PSH, known injuries (known hemothorax/pneumothorax? Rib fractures? Chest tubes in already?), risk factors for DVT/PE, review I/Os for evidence of volume status, vitals and labs for evidence of infection
·       In the room: ABCDs, pulmonary and cardiac exam, volume status exam
·       Get more info: basic labs, ABG if worried about oxygenation, CXR, consider bedside US of the lungs/heart, if high suspicion for PE consider CTA chest
·       Initial Management: supplemental O2, higher level of care, consider intubation or other supplemental oxygenation adjuncts, additional management dependent on suspected etiology
·       ABG Vs VBG (IBCC): https://emcrit.org/ibcc/vbg/ 

ALTERED MENTAL STATUS
·       Differential: stroke, medication effect, hypoxemia or hypercarbia, toxic or medication effect, endocrine/metabolic, stroke or MI, psychiatric illness, or infections, delirium
·       On the way: review PMH/PSH, recent notes for evidence of altered mentation or agitation, or signs hinting at above etiologies
·       In the room: ABCDs, focal neuro deficits?, alert/oriented? Be sure the patient’s mental status is adequate for airway protection!
·       Get more info: basic labs, blood gas/lactate, CT head noncontrast if concerned for stroke.
·       Initial management: rule out above; if concerned about delirium, optimize sleep/wake cycles, pain control, and lines/drains/tubes. 

OLIGURIA
·       Differential: prerenal due to hypovolemia or low effective circulating volume, intrinsic renal disease, post-renal obstruction
·       On the phone: clarify functional foley or bladder scan results, full set of vitals
·       On the way: review PMH/PSH, known injuries (known hemothorax/pneumothorax? Rib fractures? Chest tubes in already?), risk factors for DVT/PE, review I/Os for evidence of volume status, vitals and labs for evidence of infection
·       In the room: ABCDs, confirm functioning foley catheter
·       Get more info: basic labs, urine electrolytes, consider fluid challenge to evaluate responsiveness, consider adjuncts including renal US
·       Initial management: typically consider IVF bolus initially, but if patient not volume responsive, don't overload them -- look for other etiologies! 

TACHYCARDIA
·       Differential: sinus tachycardia (pain, hypovolemia, agitation, infection), cardiac arrhythmia, MI, PE
·       On the phone: full set of vitals, acuity of change in heart rate, updated I/Os
·       On the way: Review PMH/PSH, known cardiac history, cardiac and PE risk factors, volume resuscitation, signs concerning for infection, updated I/Os
·       In the room: ABCDs, cardiac/pulmonary exam, evaluate for any localizing signs for infection
·       Get more info: basic labs, EKG, consider CXR, troponins
·       Initial management: depends heavily on etiology

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