Summary
Definition
History and exam
Key diagnostic factors
- altered cognition/agitation
- hypotension
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
- 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 tests
1st tests to order
- lactate (arterial blood gas)
- blood gases
- CBC
- BUN and creatinine
- serum electrolytes
- coagulation studies (INR, activated PTT)
- blood glucose
- anion gap
- CRP
- ECG
Tests to consider
- chest x-ray
- focused assessment with sonography for trauma scan
- echocardiography
- procalcitonin
- end tidal carbon-dioxide (capnography)
- ultrasound of thorax
- ultrasound of abdomen
- CT thorax, abdomen, and pelvis
- computed tomographic pulmonary angiography
- urinalysis and urine pregnancy test
- pelvic ultrasound
- x-ray long bones
- x-ray spine
Treatment algorithm
all patients
Contributors
Expert advisers
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 reviewers
Patrick Nee, FRCP, FRCS, FCEM
Consultant in Accident & Emergency Medicine
St Helens & Knowsley Hospitals NHS Trust
Whiston Hospital
Prescot
UK
Disclosures
PN declares that he has no competing interests.
James Brown, MD, MMM
Vice-Chair and Program Director
Wright State University Department of Emergency Medicine
Dayton
OH
Disclosures
JB declares that he has no competing interests.
References
Key articles
Cecconi M, De Backer D, Antonelli M, et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2014 Dec;40(12):1795-815.Full text Abstract
Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47(11):1181-247.Full text Abstract
McDonagh TA, Metra M, Adamo M, et al. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726.Full text Abstract
Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2022 May 3;79(17):e263-421.Full text Abstract
van Diepen S, Katz JN, Albert NM, et al. Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association. Circulation. 2017 Oct 17;136(16):e232-68.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
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