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Managing Adult Medical Emergencies in the Dental Office
Postural (Orthostatic) Hypotension

Course Author(s): Palma A. Freydinger, DDS;Fady F. Faddoul, DDS, MSD

Postural (Orthostatic) Hypotension

Postural hypotension (Table 2) is defined as a decline of ≥20 mm Hg in the systolic BP, and/or a decline of ≥10 mm Hg in the diastolic BP, or an increase of ≥20 beats/minute in pulse rate, and abrupt symptoms of cerebral ischemia (syncope) following postural change from a supine to an upright position. It may be secondary to impaired homeostatic mechanisms of blood pressure regulation; age and/or cardiovascular-disease-related physiological changes; anti-hypertensive medications; and/or recent intake of food.

Table 2. Postural Hypotension.

Prevention:
  • Identify at-risk patient
    • Schedule dental appointments 30 to 60 minutes after the ingestion of meals and medications
    • Ensure profound local anesthesia
      • Use local anesthetic agents containing a vasoconstrictor congruent with the patient’s functional capacity
    • Upon completion of procedures, allow at-risk patients to assume an upright position gradually over 2 minutes
Signs and symptoms:
  • No prodromal signs and symptoms
  • Abrupt syncope when patient assumes an upright position
    • A decline (from baseline) of 20 mm Hg or more in the systolic blood pressure AND/OR
    • A decline (from baseline) of 10 mm Hg or more in the diastolic blood pressure AND/OR
    • An increase (from baseline) in pulse rate of 20 beats per minute or more
Emergency response:
  • Immediately return patient to supine position for 5-10 minutes
    • Administer oxygen
      • 4 to 6 L/min by nasal cannula
    • Reevaluate vital signs
  • Allow patient to assume a sitting position for at least 2 minutes
    • Reevaluate vital signs
  • Allow patient to stand for 2 minutes
    • Reevaluate vital signs
  • If patient’s condition is deteriorating
    • Activate EMS
      • Monitor vital signs
        • If at any time the patient becomes unresponsive, no normal breathing, and no palpable pulse consider the diagnosis of cardiac arrest
          • Immediate CPR and defibrillation congruent with current recommendations
Nota bene:
  • Signs of recovery: vital signs return to baseline values, patient is alert
  • Signs of deterioration: vital signs unstable, mental status labile
  • Postural hypotension, often observed in older patients, may result in significant morbidity from associated falls
    • The lack of prodromal signs and symptoms should prompt oral healthcare providers to take preemptive action.
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