Cannot miss / life threats
Cannot miss / life threats
Diagnostic flow β check first
Diagnostic flow β check first
- Vital signs + ECG + glucose + pregnancy test.
- POCUS RUSH to categorize: tank (volume), pump (heart), pipes (vessels).
- Empty IVC + flat heart β fluids/blood.
- Distended IVC + poor squeeze β cardiogenic, pressors + inotrope, NO bolus.
- Distended IVC + RV strain β obstructive (PE, tamponade, tension PTX).
- Warm + bounding + history β distributive (sepsis, anaphylaxis, neurogenic).
Differential diagnosis β checklist
0/18
Check off each diagnosis as you consider it. Tap the name for unique exam, lab/imaging clues, first-line confirmatory test, and management.
Hypovolemic / hemorrhagic0/5
Distributive0/4
Cardiogenic0/4
Obstructive0/3
Other0/2
Initial ED workup
Bedside0/5
- ABCs, 2 large-bore IVs, monitor, O2
- POCUS RUSH protocol (heart, IVC, lungs, aorta, FAST)
- ECG
- Lactate, glucose, hemoglobin (POC)
- Pregnancy test in females of reproductive age
Labs0/8
- CBC
- BMP, lactate
- Type & screen / cross
- Troponin
- VBG
- Coags
- Cortisol if adrenal crisis suspected
- Cultures if sepsis
Imaging0/4
- CXR
- Bedside echo + IVC
- FAST in trauma / suspected hemorrhage
- CTA chest if PE; CT abd/pelvis (with IV contrast) if hemorrhage source unclear
Initial management0/6
- Identify shock type with POCUS (RUSH): empty tank, fluid-overloaded, RV strain, effusion, hemorrhage.
- Crystalloid bolus 500β1000 mL while assessing response (avoid in cardiogenic).
- Blood products if hemorrhagic; activate MTP for class III/IV shock.
- Norepinephrine first-line vasopressor for septic / undifferentiated shock; titrate to MAP β₯ 65.
- Source-specific therapy: abx (sepsis), epi (anaphylaxis), needle decomp (tension PTX), pericardiocentesis (tamponade), tPA (massive PE), hydrocortisone (adrenal crisis).
- Treat reversible causes: 'H's & T's' from ACLS.
Pearls / pitfalls
Pearls
- MAP < 65 = inadequate organ perfusion regardless of SBP.
- Norepinephrine is the default pressor; epinephrine for anaphylaxis and arrest.
- In trauma: permissive hypotension (SBP ~90) until hemorrhage controlled.
- Cold extremities + narrow pulse pressure = cardiogenic/hypovolemic; warm + wide = distributive.