2. • (SBP) to ≤90 mmHg, a decrease in SBP of ≥
20% from a baseline, a decrease
in mean arterial pressure (MAB) to ≤65
mmHg,
3.
4.
5. Initial approach undifferentiated hypotension
1 stabilize airway and secure iv access
Intubation
2 Risk stratification
Based on brief history ,PE ,ecg
7. Anaphylaxis
• Extremely rare for ketamine and etomidate
• Neuromuscular blocking agents are divalent
molecules that make it easier for anaphylaxis
to occur, even in the setting of no previous
exposure
• More common with rocuronium and
succinylcholine.
9. Tension Pneumothorax
• Consider in patient with obstructive lung
disease that has increased airway pressures.
• Use ultrasound to confirm whether a
pneumothorax is present.
11. Cardiac Tamponade
• Elderly patients ,Pt on anticoagulants , ESRD
patients may have occult / borderline
tamponade that only declares itself after a
change to positive pressure ventilation.
pericardiocentesis
12.
13. Cardiogenic shock from myocardial infarction
•Anterior crushing chest pain, respiratory
distress, and the ECG changes with MI
•Request troponin
• Antiplatelet agents, heparin consult for
reperfusion, or balloon pump
14. Cardiogenic shock from acute aortic or mitral
valve insufficiency
• Patients with chest pain, hypotension, and
new low-pitched early diastolic murmur
consistent with aortic insufficiency should
undergo POC ultrasonography or
echocardiography
15. Acute arrhythmias can cause hypotension
• 12-lead electrocardiography.
cardioversion
16. Hypovolemia
• Hypovolemia from profound shock states such
as hemorrhage, sepsis, and anaphylaxis
• Occult hypovolemia can be unmasked by the
physiologic insult that occurs when patients
are switched from spontaneous ventilation to
positive pressure ventilation.
17. • With the increase in intrathoracic pressure
that accompanies positive pressure ventilation
any patient with low venous pressures / low
pre-load may develop hypotension.
Adjusting PEEP settings, and giving a
bolus of an appropriate resuscitative fluid
18. Dissection of the ascending aorta
• Retrograde dissection that results in acute
aortic insufficiency, pericardial tamponade, or
myocardial infarction
• Transthoracic echocardiography or POCUS
•Aortic root dilatation
•Intimal flap
19. Pulmonary Hypertension
• Patients with known severe pulmonary
hypertension are a nightmare to intubate.
• Hypervolemia, hypoxia, and hypercarbia are
known to worsen their right heart function.
• Fluid boluses , and may worsen LV
impingement.
20. Acidosis
• Patients with profound metabolic acidosis
typically have a high minute ventilation, until
they become fatigued and then their pH can
drop.
provide minute ventilation that
approximates pre-intubation levels.
8cc/kg tidal volume
high RR
21. Stacked breaths / Autopeep
• Patients with obstructive lung pathology who
are not completely exhaling before breath
• Decrease venous return overtime, an cause
hypotension, and eventual arrest.
22. Induction /sedation Agent
• Propofol
• Any sedative agent can result in post
intubation collapse
• Decreasing the dose of sedative,
• Pressors / push dose pressors ready could
help to mitigate this
23. Electrolytes
• Succinylcholine has a well known set of
contraindications due to the risk of
succinylcholine associated hyperkalemia. Major
burns, crush injuries, and end stage renal disease
patients are typically rather obvious.
• Occult contraindications include those patients
with histories of malignant hyperthermia,
previous stroke / spinal cord injuries, or those
with prolonged ICU stays.
24. • Several case reports exist of patients who
have had profound hyperkalemia without
obvious risk factors. In the absence of an
alternative explanation for hypotension, and
especially in the setting of any rhythm change
consider checking a potassium level, or
empirically treating with Calcium
36. • Rupture of the pipes’’: aortic aneurysm and
dissection
• The sensitivity of EP-performed ultrasound for
the detection of AAA ranges from 93% to
100%, with specificities approaching 100%
• Epigastrium down to the iliac bifurcation
37. Short-axis view: large
abdominal aortic aneurysm
A measurement of
greater than 3 cm is
abnormal and defines an
abdominal aortic
aneurysm
