Summary
Definition
History and exam
Other diagnostic factors
- tachypnea
- tachycardia
- prolonged capillary refill time
- oliguria
- muscle weakness
- cyanosis
- cool extremities
- evidence of trauma
- petechial rash
- chest pain
- fever
- abdominal pain
- jugular venous distention (JVD)
- peripheral edema
- absent breath sounds on one side of chest
- tracheal deviation
- quiet heart sounds
- flaccid paralysis of lower limbs
- cardiac murmur
- distended bladder
- facial and tongue swelling
- urticarial rash
- pelvic pain/vaginal bleeding in woman of childbearing age
Risk factors
- increasing age
- comorbidities
- myocardial infarction
- cardiomyopathy
- heart valve disease
- arrhythmias
- trauma
- gastrointestinal bleeding
- ruptured abdominal aortic aneurysm
- burns/heat stroke
- gastrointestinal losses: diarrhea and vomiting
- pancreatitis
- sepsis
- anaphylaxis/poisoning
- spinal or brainstem injury
- endocrine disease
- pulmonary embolism
- cardiac tamponade
- new medication (anaphylactic shock)
Diagnostic investigations
1st investigations to order
- lactate (arterial blood gas)
- arterial blood gas
- CBC
- BUN and creatinine
- serum electrolytes
- coagulation studies (INR, activated PTT)
- blood glucose
- anion gap
- CRP
- procalcitonin (PCT)
- ECG
- hiss of air test: decompression of a tension pneumothorax with a cannula
Investigations to consider
- chest x-ray
- focused assessment with sonography for trauma (FAST) scan
- echocardiography
- ultrasound of thorax
- ultrasound of abdomen
- CT thorax, abdomen, and pelvis
- urine pregnancy test
- pelvic ultrasound
Treatment algorithm
Contributors
Authors

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.
Dr Samuel J. Stratton wishes to gratefully acknowledge Dr Christoph Pechlaner and Dr Christian Wiedermann, previous contributors to this topic. CP and CW declare that they have no competing interests.
Peer reviewers
Consultant in Accident & Emergency Medicine
St Helens & Knowsley Hospitals NHS Trust
Whiston Hospital
Prescot
UK
Disclosures
PN declares that he has no competing interests.
Vice-Chair and Program Director
Wright State University Department of Emergency Medicine
Dayton
OH
Disclosures
JB declares that he has no competing interests.
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