Management of Hypotensive Emergency

Initial Rapid Assessment

The American College of Cardiology recommends rapid assessment of the patient's volume status through clinical examination, looking for signs of dehydration, blood loss, or distributive shock 1, 2
The patient should undergo a passive leg raise test to assess fluid responsiveness before starting vasopressors, as recommended by the American Heart Association 3, 2
Positioning the patient in a supine position has been shown to improve mean arterial pressure compared to a semi-sitting position, according to the American College of Cardiology 3
Continuous monitoring of ECG, blood pressure, oxygen saturation, and urine output is essential, as stated by the American College of Cardiology 1, 2
Obtaining arterial blood gas and serum lactate levels can help assess tissue perfusion, as recommended by the American College of Cardiology 1, 2

If the passive leg raise test is positive, administer crystalloids immediately, preferably lactated Ringer's solution, as recommended by the American College of Cardiology 1, 2
An initial bolus of 30 mL/kg of crystalloids should be administered in patients with shock, which may require 1-2 L in adults in the first 5 minutes, according to the Society of Critical Care Medicine 4
Continue volume replacement as long as there is improvement in hemodynamic parameters, such as blood pressure, heart rate, and peripheral perfusion, as stated by the Society of Critical Care Medicine 4

Norepinephrine should be started as the first-line vasopressor to maintain a mean arterial pressure ≥65 mmHg, as recommended by the Society of Critical Care Medicine 4, 1, 2
Avoid using dopamine due to the risk of tachyarrhythmias, except in highly selected patients with relative bradycardia, as stated by the Society of Critical Care Medicine 4, 2

Consider adding vasopressin (up to 0.03 U/min) if norepinephrine alone is insufficient to maintain target blood pressure, as recommended by the Society of Critical Care Medicine 4, 2
In refractory shock, consider epinephrine as an additional agent or substitute for norepinephrine, according to the Society of Critical Care Medicine 4, 1

For cardiogenic shock, consider dobutamine (2.5-10 mcg/kg/min) if there is evidence of low cardiac output after stabilization of blood pressure with norepinephrine, as recommended by the American College of Cardiology 1, 2
For obstructive shock (massive pulmonary embolism), consider thrombolytic therapy or mechanical intervention after diagnostic confirmation, according to the American College of Cardiology 1
For anaphylaxis, administer intramuscular epinephrine 1:1000 (0.2-0.5 mL or 0.01 mg/kg in children) in the deltoid or lateral thigh every 5 minutes as needed, as recommended by the American Academy of Allergy, Asthma, and Immunology 5

Administer supplemental oxygen to maintain saturation >94%, as recommended by the American College of Cardiology 1
Consider endotracheal intubation if there is significant respiratory compromise, according to the American College of Cardiology 1
Monitor the response to treatment through clinical parameters (blood pressure, heart rate, peripheral perfusion, urine output) and laboratory tests (lactate, SvO2), as stated by the American College of Cardiology 1