Hypotension
ABCs
- manually recheck BP, compare with baseline
- MAP goal > 65 mmHg; SBP goal > 90 mmHg
- signs of end-organ hypoperfusion
- altered mental status
- dizziness
- cold or clammy extremities
- oliguria or decreased urine output
- volume status: JVP, skin turgor, lung exam (rales), peripheral edema
- identify shock type to guide workup
escalate early
- persistent hypotension despite resuscitation
- altered mental status
- rising lactate
- decreasing urine output
shock type differentials
| condition | clues | do |
|---|---|---|
| Septic | fever, chills, URTI, SOB, abdominal pain, diarrhea, dysuria, travel, sick contacts | broad-spectrum antibiotics, norepinephrine |
| Hypovolemic | vomiting, diarrhea, decreased PO intake, diuretics, new antihypertensives | IV fluids, identify source |
| Obstructive | pleuritic chest pain, hemoptysis, leg swelling, recent surgery or immobility (PE) | bedside echo, CTPA, thrombolysis if massive PE |
| Cardiogenic | chest pain, dyspnea, palpitations, diaphoresis, syncope | ECG, troponin, BNP, CXR, bedside echo, cardiology |
| Anaphylactic | hives, wheeze, oropharyngeal swelling, recent exposure | epinephrine 0.5 mg IM (1:1000), antihistamines, corticosteroids |
| Neurogenic | spinal injury, recent trauma | neuro assessment, CT/MRI brain & spine |
initial management
- if hypoglycemic → D50% 50 mL IV bolus
- start IV fluids: NS or RL 500 mL bolus; repeat as needed (monitor in elderly, CKD, HF)
- review or hold antihypertensives / sedatives
- if persistent hypotension → start vasopressors
- norepinephrine (Levophed) up to 0.4 mcg/kg/min
- vasopressin up to 0.04 unit/min
- reassess perfusion frequently
- escalate early for unstable patients
- check coagulation profile before central line insertion
calculator shock index · MDCalc ↗︎
shock-specific workup & management
septic
- CBC, CRP, PCT, LFT/RFT, lactic acid, cultures, VBG
- septic shock → 30 mL/kg crystalloid within first 3 h, then reassess for further boluses
- broad-spectrum antibiotics
- inotrope: norepinephrine
hemorrhagic
- CBC, coagulation profile, reserve blood products
- transfuse PRBCs as needed
cardiogenic
- ECG, hs-troponin, BNP, CXR, bedside echo
- cardiology referral
massive PE
- high suspicion → bedside echo, urgent CCU transfer
- consider thrombolysis
anaphylaxis
- oxygen + epinephrine 0.5 mg IM (1:1000)
- antihistamines, corticosteroids
neurogenic
- CT/MRI brain and spine
- neurology consult
studying for the IM exam? the IM Rapid Review covers shock and hemodynamic support in the same format. see the sample chapter.
Last reviewed · June 2026