postural hypotension:

causes
administration of drugs
prolonged recumbency
inadequate posttural reflex
late stage pregnancy
advanced age
venous defects in leg
addison s disease
exhauustion
chronic postural hypotension or shy drager syndrome
In
general, drugs produce postural hypotension by diminishing the body s ability to m
aintain blood pressure
(and in turn adequate cerebral perfusion) in response
to the increased influence of gravity that occurs when
the patient rises suddenly. An exaggerated blood pressure
response is observed
during pregnancy"
In the first, the woman experiences postural
hypotension during the first trimester; this usually
occurs when she rises from bed in the morning but does
not recur during the day. The precise cause of this
phenomenon is not known.
The second form, known as the supine hypotensive
syndrome of pregnancy,occurs late in the third trimester
if the woman remains in the supine position for more
than 3 to 7 minutes.
In the first, the woman experiences postural
hypotension during the first trimester; this usually
occurs when she rises from bed in the morning but does
not recur during the day. The precise cause of this
phenomenon is not known.
The second form, known as the supine hypotensive
syndrome of pregnancy,occurs late in the third trimester
if the woman remains in the supine position for more
than 3 to 7 minutes.
Postural
hypotension may be detectable if the patient s blood
pressure and heart rate are recorded in both the supine
and standing positions, something that is rarely done
in most medical or dental practices. The doctor should
record the first blood pressure reading after the patient
has been in a supine position for 2 to 3 minutes and the
second after the patient has been standing for 1 minute.

PATHOPHYSIOLOGY
Normal regulatory mechanisms
When the patient changes from a supine to an upright
position, the influence of gravity on the cardiovascular
system intensifies. Blood pumped from the heart must
now move upward, against gravity, to reach the cerebral

circulation to supply the brain with the O

2
and glucose
it needs to maintain consciousness. On the other hand,
with the patient in the supine position the force of
gravity is distributed equally over the entire body and
blood flows more readily from the heart to the brain.
With other positions (e.g., semisupine, Trendelenburg),
gravity s effect is usually such that systolic blood pressure
decreases by 2 mm Hg for each 25 mm (1 inch) that
the patient s head is situated above the level of the heart;
for each 25 mm (1 inch) that the head is situated below
the level of the heart, blood pressure increases by 2 mm
Hg (Figure 7-1).
A number of intricate mechanisms have evolved to
protect the brain and ensure that it receives an adequate
supply of O
2
and glucose.
24
These include the following:
A reflex arteriolar constriction mediated through
baroreceptors (pressure receptors) located in the
carotid sinus and aortic arch
A reflex increase in heart rate, which occurs
simultaneously with the increase in arteriolar tone
and is mediated through the same mechanisms
A reflex venous constriction that increases the
return of venous blood to the heart, mediated both
intrinsically and sympathetically
An increase in muscle tone and contraction in the
legs and abdomen the so-called venous pump
facilitating the return of venous blood (of vital
importance because at least 60% of circulating
blood volume at any given moment is in venous
circulation)
A reflex increase in respiration, which also aids in
the return of blood to the right side of the heart
via changes in intraabdominal and intrathoracic
pressures
The release into the blood of various neurohumoral
substances, such as norepinephrine, antidiuretic
hormone, renin, and angiotensin
management:
Step 1:assessment of consciousness
Step 2:activation of the office emergency
system.
Step 3:P (position)
tep 4: A?B?C (airway-breathing-circulation
Step
Step
Step
Step
Step
Step

5:D (definitive care).

5a:administration of O2
5b:monitoring of vital signs
6:subsequent management
6a:delayed recovery'
7:discharge