Hypotension

Etiology

Cardiogenic Shock (see Cardiogenic Shock)

Arrhythmia/Conduction Disturbance

Cardiomyopathy (see Congestive Heart Failure)

Increased Afterload

Increased Intrathoracic Pressure (with Impaired Right-Sided Venous Return)

Intracardiac Shunt (see Intracardiac and Extracardiac Shunt)

Valvular Disease/Mechanical Disturbance

Distributive Shock (Vasodilatory Shock)

Anaphylaxis/Anaphylactic Shock

Septic Shock/Toxic Shock

Systemic Inflammatory Response Syndrome (SIRS) (see Sepsis)

Endocrine/Metabolic-Associated Hypotension

Hematologic Disease-Associated Hypotension

Neurogenic Shock (see Neurogenic Shock)

  • Neuroaxial Anesthesia (see xxxx)
    • Physiology: xxxx
  • Acute Spinal Cord Injury (see Acute Spinal Cord Injury)
    • Physiology
      • Interruption of Autonomic Pathways, Resulting in Decreased Systemic Vascular Resistance and Altered Vagal Tone: probably the predominant mechanism
      • Myocardial Depression: may also play a role
  • Traumatic Brain Injury (TBI) (see Traumatic Brain Injury)
    • Physiology: xxxx

Drug/Toxin-Associated Hypotension

  • α-Blockers (Non-Selective)
  • α1-Blockers (see xxxx)
    • Alfuzosin (Uroxatral) (see Alfuzosin, [[Alfuzosin]])
    • Doxazosin (Cardura) (see Doxazosin, [[Doxazosin]])
    • Prazosin (Minipress, Vasoflex, Pressin, Hypovase) (see Prazosin, [[Prazosin]])
    • Silodosin (Rapaflo) (see Silodosin, [[Silodosin]])
    • Tamsulosin (Flomax) (see Tamsulosin, [[Tamsulosin]])
    • Terazosin (Hytrin) (see Terazosin, [[Terazosin]])
  • Abacavir-Hypersensitivity Reaction (see Abacavir, [[Abacavir]])
  • All-Trans Retinoic Acid (ATRA)/Retinoic Acid Syndrome (see All-Trans Retinoic Acid, [[All-Trans Retinoic Acid]])
  • Alpha-1 Antitrypsin (Aralast, Glassia, Prolastin, Zemaira) (see Alpha-1 Antitrypsin, [[Alpha-1 Antitrypsin]]): occurs in 0-0.3% of cases
  • Amiodarone (see Amiodarone, [[Amiodarone]])
  • Angiotensin Converting Enzyme (ACE) Inhibitors (see Angiotensin Converting Enzyme (ACE) Inhibitors, [[Angiotensin Converting Enzyme Inhibitors]])
    • Captopril (Capoten) (see Captopril, [[Captopril]])
    • Enalapril (Vasotec, Enalaprilat) (see Enalapril, [[Enalapril]])
    • Fosinopril (Monopril) (see Fosinopril, [[Fosinopril]])
    • Lisinopril (Zestril) (see Lisinopril, [[Lisinopril]])
    • Moexipril (Univasc) (see Moexipril, [[Moexipril]])
    • Perindopril (Coversyl, Coversum, Preterax, Aceon) (see Perindopril, [[Perindopril]])
    • Quinapril (Accupril) (see Quinapril, [[Quinapril]])
    • Ramipril (Altace) (see Ramipril, [[Ramipril]])
    • Trandolapril (Mavik) (see Trandolapril, [[Trandolapril]])
  • Angiotensin II Receptor Blockers (ARB) (see Angiotensin II Receptor Blockers, [[Angiotensin II Receptor Blockers]])
    • Candesartan (Atacand) (see Candesartan, [[Candesartan]])
    • Fimasartan (Kanarb) (see Fimasartan, [[Fimasartan]])
    • Irbesartan (Avapro, Aprovel, Karvea) (see Irbesartan, [[Irbesartan]])
    • Losartan (Cozaar) (see Losartan, [[Losartan]])
    • Olmesartan (Benicar, Olmecip) (see Olmesartan, [[Olmesartan]])
    • Telmisartan (Micardis) (see Telmisartan, [[Telmisartan]])
    • Valsartan (Diovan) (see Valsartan, [[Valsartan]])
  • Atypical Anti-Psychotic Agents
    • Olanzapine (Zyprexa) (see Olanzapine, [[Olanzapine]])
    • Quetiapine (Seroquel) (see Quetiapine, [[Quetiapine]])
    • Risperidone (Risperdal) (see Risperidone, [[Risperidone]])
  • β-Blockers (see β-Adrenergic Receptor Antagonists, [[β-Adrenergic Receptor Antagonists]])
    • Non-Selective Beta Blockers
      • Carteolol
      • Nadolol (Corgard, Anabet, Solgol, Corzide, Alti-Nadolol, Apo-Nadol, Novo-Nadolol) (see Nadolol, [[Nadolol]])
      • Penbutolol
      • Pindolol (Visken, Betapindol, Blockin L, Blocklin L, Calvisken, Cardilate, Decreten, Durapindol, Glauco-Visken, Pectobloc, Pinbetol, Prindolol, Pynastin) (see Pindolol, [[Pindolol]])
      • Propafenone (Rhythmol) (see Propafenone, [[Propafenone]]): with additional Class 1C antiarrhythmic properties (inhibits sodium channels)
      • Propanolol (Inderal) (see Propanolol, [[Propanolol]])
      • Sotalol (Betapace, Betapace AF, Sotalex, Sotacor) (see Sotalol, [[Sotalol]]): with additional Class III antiarrhythmic properties (inhibits potassium channels)
      • Timolol (Blocadren, Timoptic) (see Timolol, [[Timolol]])
    • Cardioselective (β1-Selective) Beta Blockers
      • Acebutolol (Sectral, Prent) (see Acebutolol, [[Acebutolol]])
      • Atenolol (Tenormin) (see Atenolol, [[Atenolol]])
      • Betaxalol (Betoptic, Lokren, Kerlone) (see Betaxalol, [[Betaxalol]])
      • Bisoprolol (Concor, Zebeta) (see Bisoprolol, [[Bisoprolol]])
      • Esmolol (Brevibloc) (see Esmolol, [[Esmolol]])
      • Metoprolol (Lopressor) (see Metoprolol, [[Metoprolol]])
      • Nebivolol (Bystolic) (see Nebivolol, [[Nebivolol]])
      • Practolol: although structurally similar to propanolol, it is no longer used in humans (due to adverse effect of oculomucocutaneous syndrome)
    • β-Blockers with Intrinsic Sympathomimetic Activity (β-Adrenergic Receptor Antagonism + Low Level β-Adrenergic Receptor Agonism)
      • Acebutolol (see Acebutolol, [[Acebutolol]])
      • Carteolol
      • Celiprolol
      • Mepindolol
      • Oxprenolol
      • Penbutolol
      • Pindolol (Visken, Betapindol, Blockin L, Blocklin L, Calvisken, Cardilate, Decreten, Durapindol, Glauco-Visken, Pectobloc, Pinbetol, Prindolol, Pynastin) (see Pindolol, [[Pindolol]])
    • β-Blockers with α1-Blocking Activity
      • Carvedilol (Coreg) (see Carvedilol, [[Carvedilol]])
      • Labetalol (Normodyne, Trandate) (see Labetalol, [[Labetalol]])
  • Benzodiazepines (see Benzodiazepines, [[Benzodiazepines]])
    • Alprazolam (Xanax) (see Alprazolam, [[Alprazolam]])
    • Chlordiazepoxide (Librium) (see Chlordiazepoxide, [[Chlordiazepoxide]])
    • Diazepam (Valium) (see Diazepam, [[Diazepam]])
    • Lorazepam (Ativan) (see Lorazepam, [[Lorazepam]])
    • Midazolam (Versed) (see Midazolam, [[Midazolam]])
    • Temazepam (Restoril, Normison) (see Temazepam, [[Temazepam]])
  • Calcium Channel Blockers (see Calcium Channel Blockers, [[Calcium Channel Blockers]])
    • Amlodipine (Norvasc) (see Amlodipine, [[Amlodipine]])
    • Diltiazem (Cardizem) (see Diltiazem, [[Diltiazem]])
    • Felodipine (Plendil) (see Felodipine, [[Felodipine]])
    • Isradipine (DynaCirc, Prescal) (see Isradipine, [[Isradipine]])
    • Nicardipine (Cardene) (see Nicardipine, [[Nicardipine]])
    • Nifedipine (Procardia) (see Nifedipine, [[Nifedipine]])
    • Nimodipine (Nimotop) (see Nimodipine, [[Nimodipine]])
    • Verapamil (Calan, Isoptin, Verelan, Verelan PM, Bosoptin, Covera-HS) (see Verapamil, [[Verapamil]])
  • Carbon Monoxide Intoxication (Carboxyhemoglobinemia) (see Carboxyhemoglobinemia, [[Carboxyhemoglobinemia]]): results in mitochondrial dysfunction
  • Cholinergic Intoxication (see Cholinergic Intoxication, [[Cholinergic Intoxication]])
    • Carbamate Intoxication (see Carbamates, [[Carbamates]])
    • Organophosphate Intoxication (see Organophosphates, [[Organophosphates]])
  • Cigua Toxin Poisoning (see Cigua Toxin Poisoning, [[Cigua Toxin Poisoning]])
  • Cyanide Intoxication (see Cyanide, [[Cyanide]]): results in mitochondrial dysfunction -> hypotension occurs late in course
  • Cytokine Release Syndrome (see Cytokine Release Syndrome, [[Cytokine Release Syndrome]])
    • Alemtuzumab (Campath, MabCampath, Campath-1H, Lemtrada) (see Alemtuzumab, [[Alemtuzumab]]): anti-CD52 monoclonal antibody
    • TGN1412: anti-CD28 superagonist
    • Anti-Thymocyte Globulin (ATG) (see Anti-Thymocyte Globulin, [[Anti-Thymocyte Globulin]])
    • Basiliximab (Simulect) (see Basiliximab, [[Basiliximab]])
    • Bi-Specific Antibodies in Treatment of Leukemia
    • Haploidentical Mononuclear Cells in Treatment of Refractory Leukemia
    • Lenalidomide (Revlimid) (see Lenalidomide, [[Lenalidomide]])
    • Muromonab-CD3 (Orthoclone OKT3) (see Muromonab-CD3, [[Muromonab-CD3]]): anti-CD3 monoclonal antibody
    • Oxaliplatin (Eloxatin, Oxaliplatin Medac) (see Oxaliplatin, [[Oxaliplatin]])
    • Rituximab (Rituxan) (see Anti-CD20 Therapy, [[Anti-CD20 Therapy]]): chimeric monoclonal anti-CD20 antibody
    • T-Cells Engineered to Express CD19–Chimeric Antigen Receptor (CAR)
  • Dexmedetomidine (Precedex) (see Dexmedetomidine, [[Dexmedetomidine]])
  • Endothelin Receptor Antagonists (see Endothelin Receptor Antagonists, [[Endothelin Receptor Antagonists]])
    • Ambrisentan (Letairis) (see Ambrisentan, [[Ambrisentan]])
    • Atrasentan (Xinlay) (see Atrasentan, [[Atrasentan]])
    • Bosentan (Tracleer) (see Bosentan, [[Bosentan]])
    • Macitentan (Opsumit) (see Macitentan, [[Macitentan]])
    • Sitaxentan (Thelin) (see Sitaxentan, [[Sitaxentan]])
    • Tezosentan
    • Zibotentan (see Zibotentan, [[Zibotentan]])
  • Ethylene Glycol Intoxication (see Ethylene Glycol, [[Ethylene Glycol]])
  • Fosphenytoin (Cerebyx) (see Fosphenytoin, [[Fosphenytoin]])
  • Glyphosate Ingestion (see Glyphosate, [[Glyphosate]])
  • Hydralazine (see Hydralazine, [[Hydralazine]])
  • Hydrogen Sulfide Gas Inhalation (see Hydrogen Sulfide Gas, [[Hydrogen Sulfide Gas]])
  • Intravenous Immunoglobulin (IVIG) (see Intravenous Immunoglobulin, [[Intravenous Immunoglobulin]])
  • Isopropanol Intoxication (see Isopropanol, [[Isopropanol]])
  • Magnesium Sulfate (see Magnesium Sulfate, [[Magnesium Sulfate]]): with rapid infusion
  • Metal Intoxication
    • Arsenic Intoxication (see Arsenic, [[Arsenic]])
    • Iron Intoxication (see Iron, [[Iron]])
    • Manganese Intoxication (see Manganese, [[Manganese]])
    • Selenium Intoxication (see Selenium, [[Selenium]])
    • Thallium Intoxication (see Thallium, [[Thallium]])
  • Methanol Intoxication (see Methanol, [[Methanol]])
  • Methemoglobinemia (see Methemoglobinemia, [[Methemoglobinemia]])
  • N-Acetylcysteine (Mucomyst, Acetadote, Fluimucil, Parvolex) (see N-Acetylcysteine, [[N-Acetylcysteine]]): associated with oral administration
  • Nerium Oleander Intoxication (see Nerium Oleander, [[Nerium Oleander]])
  • Neuroleptic Malignant Syndrome (NMS) (see Neuroleptic Malignant Syndrome, [[Neuroleptic Malignant Syndrome]])
    • Physiology: due to autonomic instability
  • Ocrelizumab (Ocrevus) (see Ocrelizumab, [[Ocrelizumab]])
    • Epidemiology: may occur as a component of infusion reaction
  • Opiates (see Opiates, [[Opiates]])
    • Hydromorphone (Dilaudid) (see Hydromorphone, [[Hydromorphone]])
    • Meperidine (Demerol) (see Meperidine, [[Meperidine]])
    • Methadone (Dolophine) (see Methadone, [[Methadone]])
    • Morphine (see Morphine, [[Morphine]])
    • Opiate Intoxication (see Opiates, [[Opiates]])
    • Oxycodone (see Oxycodone, [[Oxycodone]])
  • Phenytoin (Dilantin) (see Phenytoin, [[Phenytoin]])
  • Phosphodiesterase Type 5 (PDE5) Inhibitors (see Phosphodiesterase Type 5 Inhibitors, [[Phosphodiesterase Type 5 Inhibitors]])
    • Sildenafil (Viagra, Revatio) (see Sildenafil, [[Sildenafil]])
    • Tadalafil (Adcirca, Cialis) see Tadalafil, [[Tadalafil]])
    • Vardenafil (Levitra, Staxyn) (see Vardenafil, [[Vardenafil]])
  • Propofol (Diprivan) (see Propofol, [[Propofol]])
  • Prostaglandins with Vasodilatory Properties
    • Epoprostenol (PGI2, Prostacyclin, Flolan, Veletri) (see Epoprostenol, [[Epoprostenol]])
    • Iloprost (Ilomedin, Ventavis) (see Iloprost, [[Iloprost]])
    • Prostaglandin E1 (Alprostadil) (see Prostaglandin E1, [[Prostaglandin E1]])
  • Protamine (see Protamine, [[Protamine]])
  • Rasburicase (Elitek) (see Rasburicase, [[Rasburicase]])
  • Rattlesnake Bite (see Rattlesnake Bite, [[Rattlesnake Bite]])
  • Ruxolitinib (Jakafi) Withdrawal Syndrome (see Ruxolitinib, [[Ruxolitinib]])
    • Epidemiology: occurs 1 day-3 wks after drug withdrawal
  • Salicylate Intoxication (see Acetylsalicylic Acid, [[Acetylsalicylic Acid]])
    • Clinical : pseudosepsis with fever, tachypnea, metabolic acidosis, and hypotension
  • Scombroid (see Scombroid, [[Scombroid]])
  • Scorpion Sting (see Scorpion Sting, [[Scorpion Sting]])
  • Serotonin Syndrome (see Serotonin Syndrome, [[Serotonin Syndrome]])
  • Sevelamer (Renagel, Renvela) (see Sevelamer, [[Sevelamer]])
  • Staphylococcal Toxic Shock Syndrome (see Staphylococcal Toxic Shock Syndrome, [[Staphylococcal Toxic Shock Syndrome]])
  • Streptococcal Toxic Shock Syndrome (see Streptococcal Toxic Shock Syndrome, [[Streptococcal Toxic Shock Syndrome]])
  • Tetrodotoxin
    • Epidemiology: associated with ingestion of tetrodotoxin-contaminated pufferfish
    • Physiology: tetrodotoxin inhibits sodium channels on vascular smooth muscle
  • Thrombolytics (see Thrombolytics, [[Thrombolytics]])
  • Tocolytic-Induced Pulmonary Edema (see Tocolytic-Induced Pulmonary Edema, [[Tocolytic-Induced Pulmonary Edema]])
  • Transfusion-Associated Acute Lung Injury (TRALI) (see Transfusion-Associated Acute Lung Injury, [[Transfusion-Associated Acute Lung Injury]])
  • Tricyclic Antidepressant Intoxication (see Tricyclic Antidepressants, [[Tricyclic Antidepressants]])
  • Vancomycin-Associated Red Man Syndrome (see Vancomycin, [[Vancomycin]])
  • Widow Spider Bite (see Widow Spider Bite, [[Widow Spider Bite]])
    • Epidemiology: hypertension is more characteristically seen in widow spider bites, hypotension occurs rarely

Other

Hemorrhagic Shock (see Hemorrhagic Shock, [[Hemorrhagic Shock]])

Gastrointestinal Hemorrhage (see Gastrointestinal Hemorrhage, [[Gastrointestinal Hemorrhage]])

Hemoperitoneum (see Hemoperitoneum, [[Hemoperitoneum]])

  • Various Etiologies

Intramuscular Hemorrhage (Into Thigh)

  • Various Etiologies

Intra-Operative/Post-Operative Hemorrhage

  • Various Etiologies

Retroperitoneal Hemorrhage (see Retroperitoneal Hemorrhage, [[Retroperitoneal Hemorrhage]])

Severe Hemolysis (see Hemolytic Anemia, [[Hemolytic Anemia]])

Trauma with External Hemorrhage

  • Motor Vehicle Accident (MVA)
  • Traumatic Fall/Assault

Uterine/Vaginal Hemorrhage

  • Post-Partum Hemorrhage
  • Uterine Tumor
  • Vaginal Laceration

Other

Hypovolemic Shock (see Hypovolemic Shock, [[Hypovolemic Shock]])

Dermal Fluid Loss

  • Altered Mental Status with Inadequate Fluid Intake
    • Intoxication
  • Burns (see Burns, [[Burns]])
  • Diaphoresis (see Diaphoresis, [[Diaphoresis]])
  • Environmental Exposure
  • Heat Stroke (see Heat Stroke, [[Heat Stroke]])

Gastrointestinal Fluid Loss

  • Diarrhea (see Diarrhea, [[Diarrhea]])
  • Early Dumping Syndrome (After Gastric Bypass) (see Dumping Syndrome, [[Dumping Syndrome]] and Gastric Bypass, [[Gastric Bypass]])
    • Physiology: hyperosmolality of food causes rapid fluid shift from the plasma into the bowel
  • External Drainage
  • Vomiting (see Nausea and Vomiting, [[Nausea and Vomiting]])

Renal Fluid Loss

  • Excessive Diuresis
  • Hypoaldosteronism (see Hypoaldosteronism, [[Hypoaldosteronism]])
    • Epidemiology: although aldosterone normally acts to increase sodium retention, hypoaldosteronism is not usually associated with significant sodium wasting (except in young children)
      • This is due to the compensatory action of other sodium-retaining stimuli (such as angiotensin II and norepinephrine)
  • Pheochromocytoma (see Pheochromocytoma, [[Pheochromocytoma]])
    • Epidemiology: occurs in some cases
    • Clinical Patterns
      • Episodic Hypotension: in rare cases where the tumor secretes only epinephrine
      • Pattern of Rapid Cyclic Fluctuation Between Hypertension and Hypotension (Cycling Every 7-15 min): unclear mechanism
      • Orthostatic Hypotension: due predominantly to decreased plasma volume
  • Salt-Wasting Nephropathy

Third-Space Fluid Loss

  • Acute Pancreatitis (see Acute Pancreatitis, [[Acute Pancreatitis]])
  • Cirhosis (see Cirrhosis, [[Cirrhosis]])
  • Crush Injury
  • Intestinal Obstruction
  • Post-Operative Intraabdominal Fluid Loss
  • Trauma

Obstructive Shock

Mechanical

  • Abdominal Compartment Syndrome (see Abdominal Compartment Syndrome, [[Abdominal Compartment Syndrome]])
    • Physiology: xxxx
  • Aortocaval Compression (Due to Positioning or Surgical Retraction)
    • Physiology: xxxx
  • Constrictive Pericarditis (see Constrictive Pericarditis, [[Constrictive Pericarditis]])
    • Physiology: xxxx
  • Dynamic Hyperinflation (Severe)
    • Positive End-Expiratory Pressure (PEEP)/Auto-PEEP (see PEEP + Auto-PEEP, [[PEEP + Auto-PEEP]])
      • Physiology: impairs venous return to right side of the heart
  • Restrictive Cardiomyopathy (see Congestive Heart Failure, [[Congestive Heart Failure]])
  • Hemothorax (see Pleural Effusion-Hemothorax, [[Pleural Effusion-Hemothorax]])
  • Tamponade (see Tamponade, [[Tamponade]])
  • Tension Pneumothorax (see Pneumothorax, [[Pneumothorax]])

Pulmonary Vascular


Clinical Manifestations

Cardiovascular Manifestations

Neurologic Manifestations

  • Altered Mental Status
  • Fatigue (see Fatigue, [[Fatigue]])
  • Increased Intracranial Pressure (see Increased Intracranial Pressure, [[Increased Intracranial Pressure]])
    • Physiology: hypotension causes cerebral vasodilation
    • Clinical: potentiation of neurologic injury in traumatic brain injury (TBI), etc

Renal Manifestations

  • Acute Kidney Injury (AKI) (see Acute Kidney Injury, [[Acute Kidney Injury]])
    • Physiology
      • Acute Tubular Necrosis (ATN)
      • Impaired Renal Perfusion

Treatment

Vasopressors

  • xxxx

References

  • xxxx