ABCs
- Manually recheck BP and compare with baseline
- MAP goal > 65 mmHg SBP goal > 90 mmHg
- Look for signs of end-organ hypoperfusion
- Altered mental status
- Dizziness
- Cold/clammy extremities
- Oliguria/decreased urine output
- Volume status: JVP, skin turgor, lung exam (rales) and peripheral edema
- Look for signs of shock type and tailor workup accordingly
causes
| Type | Key Clues |
|---|---|
| Septic | Fever/chills, URTI, SOB, abdominal pain, diarrhea, dysuria, travel, sick contacts |
| Hypovolemic | Vomiting, diarrhea, ↓ PO intake, diuretics or new antihypertensives |
| Obstructive | Pleuritic CP, hemoptysis, leg swelling, recent surgery or immobility (PE) |
| Cardiogenic | Chest pain, dyspnea, palpitations, diaphoresis, syncope |
| Other | Anaphylaxis, neurogenic shock (e.g., spinal injury) |
initial management
- If hypoglycemic → D50% 50 mL IV bolus
- Start IV fluids
- Normal Saline or Ringer’s Lactate 500 mL bolus
- Repeat as needed, but monitor for fluid overload (esp. 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 (mental status, UOP, skin)
- Escalate early: Call senior/ICU for unstable patients
- Central line tip: Check coagulation profile before insertion
| Type of Shock | Key Clues & Steps |
|---|---|
| Septic | CBC, CRP, PCT, LFT/RFT, lactic acid, cultures, VBG. Start broad-spectrum antibiotics. Inotrope: norepinephrine. |
| Hemorrhagic | CBC, coag profile, reserve blood products. Transfuse PRBCs as needed. |
| Cardiogenic | ECG, hs-Trop, BNP, CXR, bedside echo. Refer to cardiology. |
| Neurogenic | CT/MRI brain & spine. Neurology consult. |
| Massive PE | High suspicion → bedside echo, urgent CCU transfer, consider thrombolysis. |
| Anaphylaxis | Oxygen + epinephrine 0.3–0.5 mg IM, antihistamines, corticosteroids. |
Studying for R1? The IM Rapid Review covers this in the same format — see the sample chapter.
Last reviewed · May 2026