Low blood pressure on the ward
Go now. Lie the patient flat, give a fluid challenge, and work out whether it's sepsis, bleeding, the heart or drugs.
The nurse phones: a 72-year-old man admitted with pneumonia has a BP of 82/50, pulse 118, temperature 38.6 °C and RR 26. His BP was 128/76 this morning. He is drowsier than earlier.
Two beds away, a 64-year-old woman on amlodipine, ramipril and furosemide has a BP of 88/54 but is chatting, warm and has a pulse of 76.
Which patient needs you first, and what do you do in the first 15 minutes?
- Go and see nowLow BP with a high heart rate, drowsiness, cold peripheries or low urine output is shock.
- Lie flat, raise the legs, oxygen if sats lowRaising the legs is a quick test of fluid response.
- Two large cannulas, bloodsFBC, U&E, lactate, glucose, cultures, group and save, venous or arterial gas.
- Fluid challenge500 mL crystalloid over 15 minutes. Reassess. Repeat up to about 2 L if responding and no signs of overload.
- Find the causeSepsis, bleeding, heart (MI, arrhythmia, tamponade), PE, anaphylaxis, drugs, adrenal crisis.
- Not responding to 2 L or lactate above 4Senior and critical care for vasopressors.
- Well, warm, slow pulse, on BP drugsHold the BP medicines, recheck.
- Systolic under 90 with any sign of shock
- Lactate above 4
- No response to 2 L of fluid
- Chest pain or ECG changes
- Active bleeding
- Drowsiness or confusion
- Hidden bleeding (GI, retroperitoneal, after surgery)
- Tension pneumothorax
- Cardiac tamponade
- PE
- Adrenal crisis in long-term steroid users
- Epidural or spinal anaesthesia effect
| Hypotension | Systolic below 90 mmHg or MAP below 65 mmHg, or a drop of 40 mmHg from baseline |
| Fluid challenge | 500 mL crystalloid over 15 minutes (250 mL in heart failure or frail elderly) |
| Target MAP | 65 mmHg or more |
| Urine output target | 0.5 mL/kg/hour or more |
| Lactate | Above 2 is raised, above 4 is severe |
| Shock index | Heart rate ÷ systolic BP above 1 suggests shock |
| Anaphylaxis | Adrenaline 0.5 mg IM (0.5 mL of 1 mg/mL) |
Check every dose against a current drug reference and your hospital protocol.
On this page
On the phone
- What is the BP, heart rate, RR, sats, temperature and GCS? What is the baseline?
- Is the patient talking? Warm or cold?
- Any chest pain, bleeding or a new rash?
- Recent medicines: antihypertensives, opioids, sedatives, new antibiotic (anaphylaxis)?
- Ask the nurse to lie the patient flat, raise the legs, put on oxygen if sats are low, and get the observations repeated while you come.
Assessment
- A and BAirway, RR, sats, chest sounds. Tracheal deviation or absent breath sounds: tension pneumothorax.
- CPulse, BP, capillary refill (over 3 seconds is slow), skin temperature, JVP, heart sounds, urine output. Look for bleeding.
- DGCS or AVPU, glucose, pupils.
- ETemperature, rash, wounds, drains, calves, abdomen, PR if GI bleed suspected.
- ReviewNotes, drug chart, fluid balance, recent results.
What kind of shock?
Septic: cultures, antibiotics within 1 hour, fluids
Hypovolaemic: fluids, blood, stop the bleeding
Cardiogenic: cautious fluids, ECG, echo, cardiology
Obstructive: PE, tension pneumothorax, tamponade
Anaphylaxis: adrenaline IM
Adrenal crisis: hydrocortisone
Drug effect or dehydration: hold drugs, oral or IV fluid
The fluid challenge
- Give 500 mL of crystalloid (Ringer's lactate or 0.9% saline) over 15 minutes.
- Reassess: heart rate, BP, capillary refill, mental state, urine output.
- Repeat if improving and no signs of overload (crackles, rising JVP, falling sats).
- Use 250 mL in heart failure, kidney failure or frail elderly.
- After about 2 litres without response, involve your senior and critical care.
Raising both legs to 45° for a minute gives an "auto-transfusion" of about 300 mL. If BP and pulse improve, the patient is likely to respond to fluid.
Investigations
| Test | Why |
|---|---|
| Lactate (blood gas) | Tissue perfusion, severity |
| FBC, group and save, clotting | Bleeding |
| U&E, glucose | Kidney injury, sodium, potassium |
| Blood cultures, CRP | Sepsis |
| ECG, troponin | MI, arrhythmia |
| Chest X-ray | Pneumonia, pneumothorax, heart failure |
| Bedside echo (if available) | Tamponade, poor heart function, empty heart |
| Cortisol (before hydrocortisone) | Suspected adrenal crisis |
Treatment
See sepsis, shock, anaphylaxis and upper GI bleed.
Special situations
- After surgery: bleeding until proven otherwise. Check drains, wounds, abdomen and Hb.
- Epidural: a sympathetic block can lower BP; fluids, check the block level, anaesthetics.
- Long-term steroids: stress dose steroids if unwell.
- Beta-blockers: heart rate may stay normal even in shock.
- Pregnancy: tilt to the left side (from 20 weeks) to relieve pressure on the vena cava.
Common mistakes
- Treating a number down the phone instead of seeing the patient.
- Reassured by a normal heart rate in someone on beta-blockers.
- Giving litres of fluid to a patient with cardiogenic shock.
- Forgetting a hidden bleed after surgery.
- Delaying antibiotics in septic shock for tests.
- Restarting BP tablets the next morning without review.
Frequently asked questions
What is the first step for low blood pressure on the ward?
Go and see the patient, lie them flat and raise the legs, assess A to E, put in two cannulas and give a 500 mL fluid challenge if there are signs of shock.
How much fluid is a fluid challenge?
500 mL of crystalloid over 15 minutes, or 250 mL in heart failure or frail patients, then reassess.
What are the main causes of shock?
Sepsis, bleeding or fluid loss, heart failure (cardiogenic), obstruction (PE, tension pneumothorax, tamponade) and anaphylaxis.
When should vasopressors be considered?
When BP does not respond to about 2 litres of fluid, or lactate stays above 4. Involve critical care.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A 67-year-old man on day 2 after bowel surgery has BP 82/50, pulse 112 and a temperature of 38.1 °C. His chest is clear and neck veins are not raised. What is the first step after lying him flat?
Answer: 500 mL fluid challenge. A fluid challenge of 500 mL crystalloid over 15 minutes (250 mL if frail or heart failure) with reassessment is the first step when there are no signs of overload.
- Wait for the morning bloods: Hypotension needs action now.
- IV furosemide 40 mg: He is not overloaded.
- Give his evening ramipril: Antihypertensives should be held.
- Start noradrenaline peripherally now: Fluid first if no overload.
2. A hypotensive ward patient is cold and clammy, has raised neck veins and crackles at both bases. What is the most likely type of shock?
Answer: Cardiogenic. Cold peripheries with high venous pressure and pulmonary oedema suggest cardiogenic shock. Avoid large fluid boluses; ECG and senior review.
- Neurogenic: No spinal injury.
- Anaphylactic: No trigger or rash.
- Hypovolaemic: Neck veins would be flat.
- Septic: Usually warm early on.
3. A patient who has taken prednisolone for 5 years is vomiting and has BP 78/46 that does not respond to fluid. What should be given?
Answer: IV hydrocortisone 100 mg. Long-term steroid use suppresses the adrenal glands. Adrenal crisis needs IV hydrocortisone and fluids.
- IV furosemide: Harmful.
- IV ondansetron only: Doesn't treat the cause.
- IV noradrenaline alone: Steroid replacement is the key.
- Oral prednisolone 5 mg: Inadequate and may not be absorbed.
4. After an extensive anterior MI, a patient has BP 75/45, cold peripheries, confusion, oliguria and pulmonary crackles. What is the key definitive management?
Answer: Urgent PCI. Cardiogenic shock (commonly from large MI): hypotension with hypoperfusion (cold, oliguria, confusion, raised lactate) and congestion. Early revascularisation (PCI of the culprit lesion) improves survival. Support with inotropes (dobutamine) and vasopressors (noradrenaline), oxygen/ventilation, mechanical circulatory support in selected cases. Exclude mechanical complications (VSD, papillary rupture) with echo.
- 2 L crystalloid bolus: Fluids worsen pulmonary oedema.
- IV metoprolol: Metoprolol is negatively inotropic.
- Oral isosorbide: Isosorbide causes hypotension.
5. A 60-year-old woman with pyelonephritis has BP 82/50 mmHg after 30 mL/kg of crystalloid, lactate 4.6 mmol/L and confusion. What should be started next to reach a MAP of 65 mmHg?
Answer: Noradrenaline infusion. Septic shock is sepsis with vasopressor need to keep MAP ≥ 65 mmHg and lactate > 2 mmol/L despite adequate fluid. Surviving Sepsis Campaign: 30 mL/kg crystalloid in the first 3 hours, cultures before antibiotics (without delaying them), broad-spectrum antibiotics within 1 hour, and noradrenaline as the first-line vasopressor (can start peripherally while central access is arranged). Vasopressin is added if MAP stays low; hydrocortisone 200 mg/day if vasopressor needs keep rising. Source control (e.g. relieving an obstructed kidney) is part of resuscitation.
- Dopamine infusion: Dopamine causes more arrhythmias and is second-line.
- IV hydrocortisone alone: Hydrocortisone is added for refractory shock, not given alone.
- Further 3 L fluid bolus: More fluid causes overload once the patient is unresponsive to fluid.
6. Ventricular preload is best represented by which measurement?
Answer: LV end-diastolic volume. Preload is the stretch on ventricular muscle before it contracts, best measured as end-diastolic volume (or pressure). It depends mainly on venous return. By the Frank–Starling law, greater preload increases stroke volume up to a point.
- Mean arterial blood pressure: An index of afterload.
- Systemic vascular resistance: Determines afterload.
- Stroke volume per beat: The result of contraction, not preload.
- Aortic diastolic pressure: Related to afterload.
7. Which of the following directly stimulates renin release from juxtaglomerular cells?
Answer: Sympathetic stimulation through β1 receptors. Renin release rises with three signals: sympathetic β1 stimulation of JG cells, low perfusion pressure in the afferent arteriole, and low sodium chloride delivery to the macula densa. Angiotensin II and ANP inhibit renin. Beta-blockers lower renin.
- High sodium chloride at the macula densa: Low NaCl, not high, stimulates renin.
- Angiotensin II: Gives negative feedback.
- Atrial natriuretic peptide: Inhibits renin.
- Raised pressure in the afferent arteriole: High pressure inhibits renin.
References and dose sources
- NICE CG174: Intravenous fluid therapy in adults in hospital
- Resuscitation Council UK: the ABCDE approach
- Ringer's lactate (Hartmann's solution) dosing: Drugs.com: Lactated Ringer's dosage (see also our ringer's lactate (hartmann's solution) dose page)
- Sodium chloride (normal saline, 3% saline) dosing: Drugs.com: Sodium chloride dosage (see also our sodium chloride (normal saline, 3% saline) dose page)
- Adrenaline (epinephrine) dosing: Drugs.com: Epinephrine dosage (see also our adrenaline (epinephrine) dose page)
- Hydrocortisone dosing: Drugs.com: Hydrocortisone dosage (see also our hydrocortisone dose page)
- Noradrenaline (norepinephrine) dosing: Drugs.com: Norepinephrine dosage (see also our noradrenaline (norepinephrine) dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.