Mt. Zion report: Hypotension in Clinic!

Thanks Lev for presenting a great case testing our triage skills in clinic! Our patient was a 68M severe alcohol use disorder, depression, and unintentional weight loss presenting to clinic with low blood pressures. We reviewed the triage tools available in clinic, and how to approach undifferentiated hypotension in the outpatient setting.

Steps to take for workup of low blood pressures in clinic:

  1. Vitals are vital!! Be sure to repeat the blood pressure AND  review blood pressure trends from patient’s outpatient visits, home monitoring, etc. Remember, patient’s don’t always have to reach an absolute blood pressure (i.e. SBPs < 90) for them to qualify as hypotensive. Relative drops in blood pressure or orthostasis counts too!
  2. See the patient! Do they look acutely ill? Are they conversing and ambulating in clinic? Are they breathing comfortably? Are they diaphoretic or cyanotic appearing? These are all good first pass signs that can help you quickly triage the patient.
  3. Talk to the patient! Ask about symptoms that could indicate the most common etiologies of the low blood pressure. Other less common causes – adrenal insufficiency, PE, tamponade, tension PTX
    • Hypovolemia
      • Dehydration – po intake? urine output? dizziness/orthostasis? recent illnesses? low blood sugars?
      • Bleeding – signs of GI bleeding? Menorrhagia? Recent trauma? Flank pain?
    • Cardiogenic
      • ACS – chest pain? dyspnea? syncope? exertional symptoms?
      • Arrhythmia – dyspnea? palpitations? lightheadedness/dizziness?
      • Heart failure / poor cardiac output – dyspnea? LE edema? PND? orthopnea?
    • Distributive
      • Sepsis – infectious ROS?
      • Anaphylaxis – new medications or exposures? rashes? stridor, throat tightness?
    • Medication review – new medication changes? antihypertensives at home? accidental overdose?
  4. Decide what should be done immediately in clinic
    • Most of our clinics can provide the following stat interventions/triage tools:
      • Orthostatic blood pressures
      • Putting patient in trendelenberg
      • EKG
      • POC blood sugar
  5. Transfer patient to the Emergency Department
    • Most patients with ABNORMAL vital signs like hypotension deserve an evaluation in the ED – the end point doesn’t have to be hospital admission! Sometimes patients just need expedited labs, IVFs, and antibiotics administered and can be safely discharged home.
    • Ambulance or car? If patient has been triaged to the ED from clinic AND has abnormal vital signs, they should go via EMS.
    • Call the emergency room to provide referral and sign out on patient scenario!
  6. Involve your attendings EARLY on – they can help you triage, put the plan in motion (i.e. notify staff to call EMS), and decompress your clinic schedule if you are running behind in clinic!




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