Stethopedia | Approach

Approach to

Shock

Recognize hypoperfusion even when blood pressure looks normal. Give fluid (blood if bleeding), then norepinephrine to a MAP of 65 outside trauma bleeding; sort the mechanism: distributive, hypovolemic, cardiogenic, obstructive.

  1. Hypotension or signs of poor tissue perfusion
  2. Access, monitor; mentation, UOP, skin, lactate; ECG, CXR, labs, cultures, POCUS1,10
  3. Hypoperfusion or MAP <65?

Shock: resuscitate while you find the cause

  • Failing airway: intubate, pressors ready10
  • Hypovolemia: fluid bolus; bleeding: blood2,9
  • MAP <65: peripheral norepinephrine2
  • Possible septic shock: antibiotics ≤1 h2
  • Anaphylaxis: IM epi (1 mg/mL), thigh8
  • High lactate: repeat to guide resuscitation2

→ Anaphylaxis: epi 0.5 mg IM; rising NE: add vasopressin, then epi2,8

Then: which type (skin, JVP, POCUS)?

CausesCluesWorkupManagement

Distributive

  • Septic shock
  • Anaphylaxis
  • Adrenal crisis, neurogenic, drugs
  • Warm skin, wide pulse pressure1,10
  • Sepsis + pressors + lactate >2 mmol/L3
  • Exposure; urticaria, wheeze, stridor8
  • Blood cultures before antibiotics2
  • Image for a source needing control2
  • Cortisol, ACTH if adrenal crisis possible11
  • Sepsis: crystalloid ≥30 mL/kg in 3 h2
  • Hydrocortisone 50 mg q6h (sepsis)2,10
  • Adrenal crisis: IV hydrocortisone 100 mg11

Hypovolemic

  • Hemorrhage: GI, trauma, AAA, ectopic
  • GI losses: vomiting, diarrhea
  • Renal losses, burns, pancreatitis
  • Cold, pale; flat neck veins1,10
  • Small, collapsing IVC on POCUS
  • Melena, trauma, anticoagulants
  • CBC, INR, fibrinogen, iCa; crossmatch10
  • FAST, rectal exam; CTA if stable10
  • β-hCG if pregnancy possible
  • Bleed: blood not crystalloid; GI/IR/OR9,10
  • Trauma: SBP 80–90 (no TBI), TXA ≤3 h9
  • Reverse anticoag; losses: LR > NS10

Cardiogenic

  • Acute MI
  • Decompensated HF, myocarditis
  • Acute MR/AR; arrhythmia
  • Cold, wet: high JVP, crackles, S31
  • Chest pain; new murmur
  • Inferior MI: right-sided ECG for RV infarct
  • Any MI + shock → emergent cath10,12
  • Echo: LV, RV, valves6
  • Troponin, lactate
  • Revascularize MI; cardiovert or pace6,10
  • NE ± dobutamine; avoid dopamine5,6
  • Shock team; mechanical support6

Obstructive

  • High-risk PE
  • Tension pneumothorax
  • Cardiac tamponade
  • High JVP, clear lungs (or RV infarct)1
  • No breath sounds; pulsus paradoxus
  • POCUS: effusion, big RV, no sliding1
  • CTPA only if stable enough7
  • Tension PTX: needle, then chest tube10
  • Tamponade: pericardiocentesis10
  • PE with shock: systemic thrombolysis7

Can't-miss cause Superscripts link to the references below.

References

  1. Vincent JL, De Backer D. Circulatory shock. N Engl J Med. 2013;369:1726–1734. PubMed 24171518
  2. Prescott HC, Antonelli M, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2026. Crit Care Med. 2026;54:725–812. PubMed 41869847
  3. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315:801–810. PubMed 26903338
  4. Bentzer P, Griesdale DE, Boyd J, et al. Will this hemodynamically unstable patient respond to a bolus of intravenous fluids? JAMA. 2016;316:1298–1309. PubMed 27673307
  5. De Backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010;362:779–789. PubMed 20200382
  6. Sinha SS, Morrow DA, Kapur NK, et al. 2025 Concise clinical guidance: an ACC expert consensus statement on the evaluation and management of cardiogenic shock. J Am Coll Cardiol. 2025;85:1618–1641. PubMed 40100174
  7. Writing Committee Members; Creager MA, Barnes GD, Giri J, et al. 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN guideline for the evaluation and management of acute pulmonary embolism in adults. Circulation. 2026;153:e977–e1051. PubMed 41712677
  8. Cardona V, Ansotegui IJ, Ebisawa M, et al. World Allergy Organization anaphylaxis guidance 2020. World Allergy Organ J. 2020;13:100472. PubMed 33204386
  9. Rossaint R, Afshari A, Bouillon B, et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care. 2023;27:80. PubMed 36859355
  10. Gay E, Levy N, eds. Shock; Sepsis; Vasopressors. In: Department of Medicine Housestaff Manual, 30th ed. 2024:61–64.
  11. Beuschlein F, Else T, Bancos I, et al. European Society of Endocrinology and Endocrine Society joint clinical guideline: diagnosis and therapy of glucocorticoid-induced adrenal insufficiency. J Clin Endocrinol Metab. 2024;109:1657–1683. PubMed 38724043
  12. Thiele H, Akin I, Sandri M, et al. PCI strategies in patients with acute myocardial infarction and cardiogenic shock. N Engl J Med. 2017;377:2419–2432. PubMed 29083953

For education only; not a substitute for clinical judgment or local protocols. Where sources differ, the flowchart follows the current guideline.

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