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Shock

Name the pump, the tank, the pipes, or the obstruction.

LearnQuick referenceClinical practice

Your objective: explain the approach, recognize important warning signs, then test your recall.

Abbreviations explained
ACS
Acute coronary syndrome
OMI
Occlusion myocardial infarction
ECG
Electrocardiogram
PE
Pulmonary embolism
POCUS
Point-of-care ultrasound
QTc
QT interval corrected for heart rate
LBBB
Left bundle branch block
RBBB
Right bundle branch block
hs-cTn
High-sensitivity cardiac troponin
CTA
Computed tomography angiography
ICU
Intensive care unit
Filter

The jobName the pump, the tank, the pipes, or the obstruction.

  1. Shock is hypoperfusion, not a blood-pressure number.
  2. Assign the box with RUSH/POCUS: empty tank, broken pump, leaky pipes, obstruction.
  3. Fluids help hypovolemic and distributive shock; they harm wet cardiogenic and the obstructed RV. In septic shock, use balanced crystalloid then dynamic reassessment; start norepinephrine if MAP remains low during resuscitation.
  4. The drug follows the box: blood, epinephrine, norepinephrine, needle, or OR.

Shock is tissue hypoperfusion, not a blood-pressure number.

Classify early with history, exam, and a RUSH/POCUS exam: hypovolemic, distributive, cardiogenic, obstructive — mixed pictures are the rule in the ED. Lactate and serial exams beat a single MAP. Fluids help hypovolemic and distributive shock; they harm the wet cardiogenic and the obstructed RV.

Obstructive shock (tamponade, tension PTX, massive PE) Critical

Key: POCUS first: effusion with RA/RV collapse, absent lung sliding, RV strain. Needle/finger thoracostomy, pericardiocentesis, or reperfusion — not a 30 mL/kg bolus.

Cardiogenic shock Critical

Key: Wet, cool, JVP up, B-lines, poor LV — cautious fluids, vasopressors (norepinephrine), urgent revascularization if ACS (2025 ACC/AHA ACS).

Septic / distributive shock Critical

Key: Antibiotics within 1 h. Use balanced crystalloid for initial resuscitation, then dynamic reassessment to guide further fluid. Start norepinephrine if MAP remains low (SSC 2026).

Neurogenic shock Critical

Key: Hypotension with warm dry skin after spinal injury — fluids then norepinephrine; do not treat as hypovolemia alone.

Hemorrhagic / hypovolemic shock Critical

Key: Blood, source control, TXA in trauma/PPH per pathway; do not dilute with litres of crystalloid in exsanguination.

Anaphylactic shock Critical

Key: IM epinephrine anterolateral thigh immediately, then fluids and aerosolized epinephrine if airway edema — do not wait for a rash.

Adrenal crisis / occult bleeding / mixed Emergent

Key: Steroid-dependent, meningococcemia, GI bleed without hematemesis, ruptured AAA — treat while you look.

Compensated / occult shock Common

Key: Normal BP with lactate, delayed cap refill, or unexplained tachypnea — especially in the young and pregnant.

Tick what your patient has — the banner updates as you go.

Tempo

sudden (PE, tamponade, anaphylaxis, arrhythmia) vs hours (sepsis, bleed)

Chest pain, dyspnea, fever, allergen, trauma, GI bleeding, pregnancy

Heart failure, anticoagulation, adrenal replacement, immunocompromise

Drugs

beta-blockers, calcium-channel blockers, antihypertensives

Skin

warm vs cool; mottling; urticaria

JVP, heart sounds (muffled, new murmur), lung sliding and B-lines

Pulse pressure, cap refill, mental status, urine output

Abdomen and pelvis

AAA, pregnancy, peritonism, occult blood

Anaphylaxis

stridor, wheeze, swelling — or none of these

Bedside

  • RUSH/POCUS: pump, tank, pipes, sliding, DVT
  • ECG, SpO₂, glucose, lactate
  • Finger thoracostomy / pericardiocentesis when the ultrasound diagnosis is made in extremis

Labs

  • Lactate, VBG, CBC, coagulation, troponin, cultures before antibiotics when they will not delay them
  • Type & crossmatch; cortisol/TSH if endocrine shock is possible
  • Pregnancy test in patients of childbearing potential

Imaging

  • CXR; CT only in the stabilized patient
  • CTPA, CTA aorta, or FAST as the leading diagnosis dictates
Medication safety reminder

Use this as a first-pass prompt; verify all medications, doses, concentrations, contraindications, weight, pregnancy status, and local protocols before administration.

Check indication, allergy, route, renal/hepatic risk, interactions, monitoring, and local formulary.

Discharge

  • Almost never from undifferentiated shock. Occasional fully reversed anaphylaxis after a full observation window with a prescription for epinephrine autoinjectors and allergy follow-up.

Admit (HDU)

  • Resolved occult hypoperfusion under monitoring, treated infection with improving lactate, compensated cardiogenic states pending further testing.

ICU / theatre / cath lab / IR

  • Any shock needing vasopressors, airway, massive transfusion, reperfusion, or source-control surgery.

Use objective reassessment and the local pathway.

Before the next decision · reassess and hand over

Use these learning prompts with the presentation’s pathway. They are not discharge criteria.

  1. Reassess: compare symptoms, observations and examination with the initial assessment and response to treatment.
  2. Warning signs for Shock:
    • Hypotension with cool skin or rising lactate
    • Muffled heart sounds or absent lung sliding
    • Anaphylaxis features after an exposure
    • GI bleeding, AAA, or positive hCG with shock
    • Chest pain with shock (ACS, dissection, PE, tamponade)
    • Fever with neutropenia or asplenia
  3. Reconsider: check unresolved findings and alternative explanations, including the pitfalls below.
  4. Escalate: communicate deterioration, uncertainty or needs beyond the current setting.
  5. Plan the transition: identify outstanding results, responsibility for follow-up, patient understanding and specific return advice.
Review this presentation’s disposition pathway →Practice a handover →

Clinical Pearls

  • Four boxes: empty tank, broken pump, leaky pipes, obstruction. POCUS assigns the box in minutes.
  • Norepinephrine is the first-line vasopressor for septic shock (SSC).
  • Blood for blood loss; epinephrine for anaphylaxis; needle for tension; OR for the ruptured AAA — the drug follows the box.
  • Serial lactate and cap refill outperform a single MAP target.

Pitfalls

  • A “normal” blood pressure does not exclude shock — use lactate, mentation, and skin.
  • Fluids are not interchangeable across shock phenotypes: cardiogenic and obstructive shock need immediate cause-directed care.
  • Epinephrine in anaphylaxis is IM first, not an IV drip you wait to mix.
  • Pressors without a diagnosis: look at the RV and the pericardium before the third litre.
  • Beta-blocked and the elderly decompensate without tachycardia.
PRACTICE REFRESHER

Rapid recall

Test your first action and the dangerous diagnoses before revealing the answer.

01 · First move

Before you scroll, what needs to happen first?

02 · Immediate threats

Name at least two diagnoses that cannot wait.

PRIVATE TO THIS DEVICE

Your learning note

Capture a weak point, a teaching pearl, or a question to take to your next shift.

Review schedule starts when marked reviewed
Chest PainShortness of BreathGI BleedingFever & SepsisPoisoning & OverdoseAcute Limb IschemiaDKA, HHS & Adrenal CrisisECG Guide

Selected guidance · source check 2026-09-07. These 2 source links support selected teaching points, not a complete review of this topic. Check population, setting and local protocol before applying a recommendation.

  • Rosen’s Emergency Medicine, 10th ed. (2023) — shock
  • Surviving Sepsis Campaign 2021 and 2026 update
  • 2025 ACC/AHA ACS Guideline (cardiogenic shock); RUSH protocol literature
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