Hypotension should be treated initially with isotonic crystalloid fluids in increments of 10 mL/kg. In the setting of impaired cardiac contractility, pulmonary edema can develop if excessive fluids are administered. Hypotension that does improve with appropriate fluid challenges should be treated with NaHCO 3 (regardless of QRS width). Vasopressors should be used when hypotension is unresponsive to fluids and sodium bicarbonate therapy. The most effective vasopressor is norepinephrine, because it directly competes with TCAs at a-adrenergic receptors. Dopamine is less effective than norepinephrine in reversing TCA-induced hypotension. 15 In many cases, dopamine administration actually will cause a lowering in systolic blood pressure due to its b-adrenergic and dopaminergic actions that promote vasodilation. If used, it should be adjusted at the upper range of the dose (12 to 20 pg/kg/min). A pulmonary artery catheter should be placed in patients whose hypotension is refractory to fluid, NaHCO3, and vasopressor therapy. Mechanical irritation of the heart during pulmonary artery catheter placement may precipitate life-threatening conduction abnormalities and ventricular dysrhythmias. Hypotension induced by TCAs represents a potentially reversible cause of cardiovascular collapse. Mechanical support of the circulation with cardiopulmonary bypass, overdrive pacing, or aortic balloon pump assistance may be warranted in patients with refractory hypotension, although no studies document their effectiveness.

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