Scenario: Patient might be having a history of Diabetes or Parkinson’s Disease for several years. Patients usually have this upon standing from sitting especially standing up from commode. This develops slowly and keeps getting worse in some. Finally one day they pass out and are brought to the hospital.
EMS:
They may place iv line and give IV fluid bolus.
EKG if cardiac etiology suspected
ER:
In the ER they get IV fluid bolus like NS 1Liter.
Routine blood work
Urinalysis to rule out UTI
CT head is usually done
EKG and Tele monitoring.
Hospitalist:
Telemetry monitoring
IV fluids-most important. Give NS at 75-100ml/hr depending on how dehydrated they look. Be careful with fluids in heart failure patients and in very elderly. Always order for 12hrs and re-evaluate so patients do not go into fluid overload.
Order Orthostatic vitals with each shift. The staff will check BP lying down, sitting and standing and document.
Usually monitored under observation status.
Hold Diuretics, antihypertensive medications, alpha blockers, anti-depressants and nitrates if patient is on them. Keep Blood Pressure slightly higher than normal in this population.
Physical Therapy and Occupational therapy consults.
Fall precautions-This order will prompt nurses to keep bed low, soft pads on floor around bed, assist when going to bathroom or put bedside commode etc.
Explain the patient how to get up slowly from supine to sitting to standing position.
Avoid straining on the commode by taking stool softeners.
Avoid hot climates. Keep well hydrated if unable to avoid.
Sleep with head of bed elevated 30 degrees to stimulate Renin-angiotensin-aldosterone system which expands extracellular fluid volume.
Drink plenty of water first thing in the morning before getting out of bed unless contraindicated.
Remove Salt restriction.
Avoid large meals especially avoid large carbohydrate meals.
Compression stockings up to knee or even up to thigh.
Abdominal binder if stockings do not help.
If non pharmacological measures do not help, patients can be started on medications.
Start with Midodrine [alpha-1 agonist] with low dose and increase gradually if not having enough response with lower dose. We can give 2.5-10mg TID.
Droxidopa [approved by the FDA] is a medication for the treatment of symptomatic neurogenic orthostatic hypotension.
Fludrocortisone [not approved by FDA] is an other medication that can be started later if Midodrine alone is not helping.
All these measures increase blood pressure while lying down.
Patients might need rehab placement if severe symptoms.
