Last reviewed: 26 Oct 2020
Last updated: 05 Mar 2020

Summary

Definition

History and exam

Key diagnostic factors

  • hypotension
  • tachycardia
  • skin changes
  • oliguria
  • mental state changes
  • risk factors
  • fever
  • chest pain
  • dyspnoea
  • hypoxaemia
  • hypothermia

Other diagnostic factors

  • abdominal pain
  • peripheral oedema
  • raised jugular venous pressure (JVP) 
  • muffled or quiet heart sounds 
  • arrhythmia
  • petechial rash 
  • urticarial rash 
  • angio-oedema
  • reduced breath sounds on one side of the chest 
  • tracheal deviation 
  • distended bladder 
  • flaccid paralysis of the limbs 

Risk factors

  • increasing age
  • comorbidities
  • myocardial infarction
  • cardiomyopathy
  • heart valve disease
  • arrhythmias
  • trauma
  • gastrointestinal bleeding
  • ruptured abdominal aortic aneurysm
  • burns/heat stroke
  • gastrointestinal losses: diarrhoea and vomiting
  • pancreatitis
  • sepsis
  • anaphylaxis/poisoning
  • spinal or brainstem injury
  • endocrine disease
  • pulmonary embolism
  • cardiac tamponade
  • new medicine (anaphylactic shock)

Diagnostic investigations

1st investigations to order

  • lactate (from arterial blood gas)
  • arterial blood gas (ABG) or venous blood gas (VBG) 
  • glucose
  • full blood count 
  • urea and electrolytes
  • coagulation studies
  • C-reactive protein
  • ECG
Full details

Investigations to consider

  • CXR
  • urinalysis and urine pregnancy test 
  • infection screen
  • point-of-care ultrasound 
  • CT chest, abdomen, and pelvis 
  • x-ray long bones
  • x-ray spine
Full details

Treatment algorithm

Contributors

Expert advisersVIEW ALL

Flight Doctor 

Greater Sydney Area Helicopter Emergency Medical Service

Sydney

New South Wales

Australia

Disclosures

AA declares that he has no competing interests.

ST4 Emergency Medicine

Emergency Department

University College Hospital

University College London Hospitals NHS Foundation Trust

UK

Disclosures

CR declares that he has no competing interests. 

BMJ Best Practice would like to gratefully acknowledge the previous expert contributor, whose work has been retained in parts of the content: 

Samuel J. Stratton MD, MPH

Professor

Fielding School of Public Health

David Geffen School of Medicine at UCLA

Los Angeles

Deputy Health Officer

Orange County Health Care Agency

Health Disaster Management/Emergency Medical Services

Santa Ana

CA

Disclosures

SJS declares that he has no competing interests. 

Peer reviewersVIEW ALL

Reader (clinical)

Centre for Medical Education

School of Medicine

Cardiff University

Honorary Consultant in Intensive Care Medicine

University Hospital of Wales

Cardiff

UK

Disclosures

PF declares that he has no competing interests.

Section Editor, BMJ Best Practice

Disclosures

AS declares that she has no competing interests.

Lead Section Editor, BMJ Best Practice

Disclosures

TAO declares that she has no competing interests.

Head of Research and Development, BMJ

Disclosures

Comorbidities Editor, BMJ Best Practice

Disclosures

JC declares that she has no competing interests.

Drug Editor, BMJ Best Practice

Disclosures

AM declares that he has no competing interests.

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