Hypotension
at the bedside
- confirm → manual recheck, correct cuff, compare with baseline; do not treat one artefactual reading
- check glucose early; treat hypoglycemia (first steps below)
- perfusion → mental status, cap refill, skin temperature, urine output, lactate trend
- MAP ≥ 65 mmHg is an initial septic-shock target, not universal; interpret against baseline
- volume status: JVP, skin turgor, lung exam, peripheral edema
- identify shock type to guide treatment
escalate now if
- persistent hypotension despite initial resuscitation
- altered mental status
- rising lactate or escalating vasopressor requirement
- decreasing urine output
focused check
| condition | clues | do |
|---|---|---|
| Septic / distributive | fever or hypothermia, suspected source, warm periphery early | cultures, early antibiotics, balanced crystalloid, norepinephrine (see below) |
| Hypovolemic, non-hemorrhagic | vomiting, diarrhea, poor intake, diuretics, new antihypertensives | IV fluids, stop losses |
| Hemorrhagic | overt bleeding, melena, post-procedure, falling Hb, tachycardia | activate massive-hemorrhage protocol, blood products, source control |
| Cardiogenic | chest pain, dyspnea, ischemic ECG, cool periphery, pulmonary edema | ECG, troponin, bedside echo, urgent cardiology |
| Obstructive | high-risk PE (pleuritic pain, hemoptysis, leg swelling, immobility) · tension pneumothorax (unilateral silent chest, tracheal shift) · tamponade (muffled sounds, distended neck veins) | bedside echo first if unstable; treat cause (below) |
| Anaphylactic | hives, wheeze, oropharyngeal swelling, recent exposure | epinephrine IM immediately (first steps below) |
| Neurogenic | spinal injury, recent trauma, bradycardia with hypotension | neuro assessment, imaging, vasopressors per senior advice |
unstable patient: no CTPA transfer; bedside echo with urgent senior / ICU / PERT input. Reperfusion for high-risk PE weighs clinical context and contraindications.
send now
- if cardiogenic shock is suspected → ECG, hs-troponin, CXR, bedside echo
calculator shock index · MDCalc ↗︎
treat
- fluids are not the answer for every phenotype: identify the shock type first
- if hypovolemia or fluid responsiveness likely → balanced crystalloid 250–500 mL bolus, reassess BP, perfusion, lungs and JVP before repeating
- review and hold antihypertensives, diuretics, sedatives
septic shock
- cultures before antibiotics if no delay
- empiric antibiotics within 1 h of recognition → choose by source →
- identify and control the source
- prefer balanced crystalloids unless a specific reason favours saline
- 30 mL/kg within 3 h is conditional and individualized; reassess frequently, not an automatic order
- in unstable shock, fluids and vasopressors may begin concurrently
vasopressors
- norepinephrine first-line, titrated to MAP and perfusion; no fixed ward maximum: escalating requirement → early ICU
- may start via a monitored peripheral IV while central access is arranged; do not delay for a central line
- vasopressin is an ICU add-on to escalating norepinephrine, not interchangeable first-line
- do not delay resuscitation for a coagulation profile
hypoglycemia, first steps
- glucose already checked at the bedside; recheck if altered
- glucose < 4 mmol/L with unsafe swallow or reduced consciousness → IV dextrose per local / MOH protocol
- no IV access → glucagon 1 mg IM
- full hypoglycemia pathway →
anaphylaxis, first actions
- stop trigger, call for help
- position flat, legs raised; sit up if breathing requires it
- epinephrine 0.5 mg IM (1 mg/mL) into anterolateral thigh
- IV crystalloid for hypotension → 500–1,000 mL rapid bolus, reassess and repeat per response (smaller boluses if overload risk); fluids never delay repeat IM adrenaline or airway support
- antihistamines: adjuncts for persistent skin symptoms after stabilization; corticosteroids are not first-line
- full anaphylaxis protocol →
hemorrhage & transfusion
- active major bleeding with shock → massive-hemorrhage protocol now, do not wait for Hb; blood products are the resuscitation fluid, minimize crystalloid → massive hemorrhage guide
- stable, not actively bleeding, thresholds
- most stable inpatients → transfuse around Hb 7 g/dL
- pre-existing cardiovascular disease → consider 8 g/dL
- acute MI → target around 10 g/dL after individualized senior / cardiology assessment
- TACO precautions
- assess: cardiac/renal dysfunction, fluid overload, low body weight, severe chronic anemia
- use minimum volume at a slower rate
- consider diuretic when appropriate, not routinely
- transfusion reactions and complications →
cardiogenic
- urgent cardiology; avoid reflex fluid boluses in pulmonary edema
recheck
- reassess perfusion after every intervention
- septic shock → serial lactate and perfusion reassessment
- hypoglycemia → recheck glucose at 10–15 min, repeat if still low
- anaphylaxis → repeat IM adrenaline at 5 min if airway, breathing, or circulation problems persist
- transfusion → give one unit then reassess; monitor vitals and SpO₂ during and after
if not improving / further escalation
- persistent vasopressor requirement despite adequate resuscitation and source control → ICU
- consider hydrocortisone when norepinephrine requirement persists → see empiric antibiotics for sourced dose
before leaving
- document: shock type, interventions (fluids, vasopressors, specific treatment), response
- pending: cultures, troponin, echo sent
- hand over: vasopressor requirement and trend, escalation trigger, who to call
evidence
| source | type |
|---|---|
| Surviving Sepsis Campaign 2026 | international guideline |
| ERC anaphylaxis guidance 2025 | international guideline |
| UK NatPSA TACO alert 2024 | international guideline |
Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.
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Last clinically reviewed · 17 August 2026 · Last updated · September 2026