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Approach to shock & hypotension

The same eight steps, every presentation: threats first, then the history and exam that discriminate, one honest sentence, a mechanism-grouped differential, and the tests read in order.

  1. Immediate threats

    • All of it: shock is the threat; the question is which engine failure
    • Obstructive causes that die without a procedure: tension pneumothorax, tamponade, massive PE
    • Hemorrhage hiding in the belly, the GI tract, or the retroperitoneum

  2. History that discriminates

    • The setting does most of the diagnosis: post-procedure, febrile, chest pain, melena, anaphylaxis exposure
    • Thirst, urine output, and mentation as perfusion witnesses
    • Medications: beta blockade masks tachycardia; anticoagulants change the bleeding weight

  3. Examination

    • The pump-tank-pipes exam: JVP, heart sounds, lungs, skin temperature
    • Cold and clamped (cardiogenic, hemorrhagic) versus warm and dilated (septic, anaphylactic)
    • JVP up with clear lungs: think obstructive: tamponade, PE, tension
    • The belly, the rectum, and the skin survey for the hidden bleed

  4. Problem representation

    Warm extremities, fever and a wide pulse pressure after urinary symptoms (septic, distributive) versus cold extremities with raised JVP after an anterior infarct (cardiogenic): same blood pressure, opposite fluids decision.

  5. Differential, by mechanism

    Distributive

    • Sepsis
    • Anaphylaxis
    • Adrenal crisis
    • Neurogenic

    Hypovolemic

    • Hemorrhage
    • GI losses
    • Third-spacing

    Cardiogenic

    • MI
    • Arrhythmia
    • Acute valve failure
    • Myocarditis

    Obstructive

    • Massive PE
    • Tamponade
    • Tension pneumothorax

  6. Investigations

    • Lactate and its clearance: the shock severity gauge
    • ECG and bedside ultrasound: the fastest sort into the four categories
    • Hemoglobin, cultures, lipase, cortisol when the story fits
    • The gas: acidosis pattern and respiratory compensation

  7. Interpretation

    • Categorize before you treat: fluids help three categories and can kill the fourth
    • A rising lactate on treatment is a demand to re-examine the category, not to repeat the bolus

  8. Next steps

    • Source control for sepsis, the lab for coronaries, the needle or drain for obstruction, blood for blood
    • Reassess at a stated time with stated markers: pressure, lactate, urine, mentation

Connected

CaseSeptic shock, played outLabsLactate on the wardScriptPE illness script

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