At the Bedside

Start with the ABCs and a shock index mindset: hypotension may be late. Look for altered mentation, cool/clammy skin, delayed cap refill, oliguria, narrow pulse pressure, tachycardia, and rising lactate.
  • Immediate actions
  • Place on monitor, pulse ox, cardiac monitor, capnography if ill, and get 2 large-bore IVs or IO.
  • Give oxygen if hypoxemic; avoid delaying resuscitation for perfect diagnostics.
  • If peri-arrest, activate resuscitation team early.
  • Check bedside glucose immediately.
  • Consider empiric airway support if worsening mental status, inability to protect airway, or refractory hypoxemia/hypercapnia.
  • Rapid bedside categorization
  • Distributive: warm extremities early, bounding pulses, wide pulse pressure, fever or clear source, anaphylaxis, neurogenic features.
  • Hypovolemic: flat neck veins, dry mucosa, hemorrhage, GI losses, trauma.
  • Cardiogenic: JVD, rales, S3, edema, ischemic ECG changes, pulmonary edema.
  • Obstructive: JVD with clear lungs and shock — think tamponade, PE, tension pneumothorax.
  • Mixed shock is common.
  • Diagnostics
  • VBG/ABG, lactate, CBC, CMP, troponin, BNP if indicated, coags, type and screen/crossmatch, blood cultures if septic, pregnancy test if relevant.
  • ECG and chest x-ray early.
  • POCUS is high yield:
  • Cardiac: gross LV function, RV strain, pericardial effusion, volume status
  • Lung: B-lines, pneumothorax, pleural effusion
  • IVC: helpful but not definitive
  • FAST if trauma/bleeding
  • Consider CT only after stabilization.
  • Initial resuscitation
  • Fluids: Balanced crystalloids in most undifferentiated shock. Use smaller boluses in cardiogenic or obstructive shock, reassess frequently.
  • Blood: If hemorrhage suspected, activate massive transfusion protocol early rather than giving endless crystalloid.
  • Antibiotics: In septic shock, give broad-spectrum antibiotics rapidly after cultures if this won’t delay treatment.
  • Source control: Drain abscess, remove infected line, decompress pneumothorax, etc.
  • Vasopressors: If hypotension persists despite appropriate preload or when fluid overload is likely, start norepinephrine early.
  • Procedural intervention: Needle decompression/chest tube for tension PTX, pericardiocentesis for tamponade in extremis, thrombolysis/thrombectomy in selected massive PE, endoscopy/surgery for bleeding.
  • Disposition
  • Most shock patients need ICU or step-down with close hemodynamic monitoring.
  • Discharge is appropriate only for a clearly reversible, fully treated, and stable cause with reliable follow-up — uncommon.
A Classic Presentation
A 68-year-old man with diabetes and CAD arrives confused, pale, and diaphoretic after a day of vomiting and fever. He is tachycardic, hypotensive, with cool extremities and delayed cap refill; lung exam is clear and there is mild lower abdominal tenderness. Point-of-care ultrasound shows a small, hyperdynamic LV with collapsible IVC, lactate is elevated, creatinine is rising, and ECG shows sinus tachycardia without STEMI. He gets fluids, blood cultures, broad-spectrum antibiotics, norepinephrine when BP remains low, and admission to the ICU for presumed septic shock from an abdominal source.
Patient Presentation to Attending
How you’d present this patient on the floor
This is a 68-year-old man with diabetes and CAD presenting with hypotension, tachycardia, and confusion after a day of fever and vomiting. My main concern is shock with a potentially distributive source, because he’s cool, poorly perfused, and persistently hypotensive rather than just dehydrated. He’s got delayed cap refill, elevated lactate, and rising creatinine; his lungs are clear, ECG doesn’t show an acute occlusion pattern, and bedside ultrasound suggests low preload without an obvious cardiogenic picture. I’m less worried about tension pneumothorax or tamponade because he doesn’t have unilateral breath sounds, severe JVD, or a pericardial effusion on POCUS. Overall this looks most consistent with septic shock, and I’m starting broad-spectrum antibiotics, continuing cautious fluid resuscitation, and preparing norepinephrine with ICU admission.

Study Directive

  • Draw a 4-box shock algorithm from memory: distributive, hypovolemic, cardiogenic, obstructive.
  • Practice a 30-second POCUS differential for shock using heart, lungs, IVC, and FAST.
  • Memorize first-line pressor choices and starting doses, then say them out loud without notes.
  • Review one septic shock case and one massive hemorrhage case, and write the first 5 ED actions for each.

Recent Literature