Lying → Standing Protocol RCP 2023
Use manual sphygmomanometer where possible — automated devices often miss the transient drop. Support the standing arm at heart level; letting it hang at the side can mask a postural drop in up to 2/3 of cases. Document symptoms: dizziness, light-headedness, vagueness, pallor, visual disturbance, palpitations.
Positive for Orthostatic Hypotension
- ≥20 mmHg fall in systolic (± symptoms)
- Fall to <90 mmHg systolic on standing, even if drop <20
- ≥10 mmHg fall in diastolic with symptoms
- If supine systolic >150: use ≥30 mmHg fall as the criterion
Prevalence & Causes
Leading contributors: antihypertensives, diuretics (esp. loop), nitrates, alpha-blockers; Parkinson's medications (levodopa, dopamine agonists) for neurogenic OH; antidepressants/antipsychotics. Always consider a post-fall medication review.
Inter-Arm Difference NICE NG136
Measure both arms on first assessment. If difference >15 mmHg, repeat — if still >15, use the arm with the higher reading for all future measurements.
| Difference | Significance |
|---|---|
| ≥10 mmHg | PAD association, ↑CV risk |
| >15 mmHg | NICE action threshold — repeat & switch arm |
| >20 mmHg | Suspect aortic dissection / subclavian stenosis |
Age-Specific Ranges
Adult — NICE NG136 staging
| Stage | Clinic BP |
|---|---|
| Normotensive | <140/90 |
| Stage 1 | ≥140/90 |
| Stage 2 | ≥160/100 |
| Severe / Stage 3 | ≥180/120 |
Paediatric hypotension — APLS/PALS
| Age | Systolic < |
|---|---|
| Neonate 0–28d | 60 |
| 1–12 months | 70 |
| 1–10 years | 70 + (2×age) |
| ≥10 years | 90 |
Elderly
Isolated systolic hypertension (raised systolic, normal/low diastolic) is the commonest pattern from arterial stiffening. Higher OH prevalence, frailty and polypharmacy — always pair with a postural check and med review in fallers.
Technique Errors & Magnitude
| Error | Effect |
|---|---|
| Cuff too small | +19.5 mmHg avg (XL arm, regular cuff) |
| Cuff too large | −3.6 mmHg |
| Arm unsupported at side | +6.5 (up to +9) mmHg |
| Arm in lap | +3.9 mmHg |
| Legs crossed | up to +15 mmHg |
| Talking during reading | up to +19 mmHg |
| Cuff below heart level | ~+8–10 mmHg per 10cm |
Cuff sizing: bladder length 75–100% and width 37–50% of arm circumference. Undercuffing is the more common error and overestimates BP.
Manual vs Automated (NIBP)
Oscillometric devices are less reliable in AF, at extremes of BP, and in shock/hypotension with movement or tremor. In AF, triplicate manual auscultatory measurement is preferred where practical. Use manual/palpated systolic if NIBP fails or looks implausible in a shocked or peri-arrest patient.
Action / Escalation
| NEWS2 Systolic | Score |
|---|---|
| ≤90 or ≥220 | 3 |
| 91–100 | 2 |
| 101–110 | 1 |
| 111–219 | 0 |
Escalate at aggregate NEWS2 ≥5 or any single parameter = 3. Only systolic scores — diastolic is not part of NEWS2.
Always correlate BP with HR response, symptoms, skin signs, cap refill and trend — a single normal reading does not exclude significant pathology, especially in children.
NICE falls guideline is CG161 (2013), superseded by NG249 (2025) — NG161 is unrelated (AKI). JRCALC paediatric BP columns not independently verified — check JRCALC Plus / Greenroom.