Evaluation of and initial approach to the adult patient with undifferentiated hypotension and shock
- David F Gaieski, MD
David F Gaieski, MD
- Associate Professor
- Sidney Kimmel Medical College at Thomas Jefferson University
- Mark E Mikkelsen, MD, MSCE
Mark E Mikkelsen, MD, MSCE
- Assistant Professor of Medicine
- Perelman School of Medicine, University of Pennsylvania
- Section Editors
- Polly E Parsons, MD
Polly E Parsons, MD
- Editor-in-Chief — Pulmonary and Critical Care Medicine
- Section Editor — Critical Care
- Professor of Medicine
- University of Vermont College of Medicine
- Robert S Hockberger, MD, FACEP
Robert S Hockberger, MD, FACEP
- Section Editor — Adult Signs and Symptoms
- Emeritus Professor of Medicine
- David Geffen School of Medicine at UCLA
Shock is a life-threatening condition of circulatory failure that most commonly presents with hypotension. It can also be heralded by other vital sign changes or the presence of elevated serum lactate levels. The effects of shock are initially reversible but can rapidly become irreversible, resulting in multi-organ failure (MOF) and death. Thus, when a patient presents with undifferentiated hypotension and/or is suspected of having shock, it is important that the clinician rapidly identify the etiology so that appropriate therapy can be administered to prevent MOF and death [1,2].
This topic reviews the clinical presentation as well as the initial diagnostic and therapeutic approaches to the adult patient with hypotension and suspected shock of unknown etiology (ie, undifferentiated shock). The definition, classification, etiology, and pathophysiology of shock are discussed separately. (See "Definition, classification, etiology, and pathophysiology of shock in adults".)
DEFINITION AND CLASSIFICATION
Shock is defined as a state of cellular and tissue hypoxia due to reduced oxygen delivery and/or increased oxygen consumption or inadequate oxygen utilization. This most commonly occurs when there is circulatory failure manifest as hypotension (ie, reduced tissue perfusion). “Undifferentiated shock” refers to the situation where shock is recognized, but the cause is unclear.
While patients often have a combination of more than one form of shock (multifactorial shock), four classes of shock are recognized (table 1):
●Distributive (eg, septic shock, systemic inflammatory response syndrome, neurogenic shock, anaphylactic shock, toxic shock, end-stage liver disease, endocrine shock)
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- DEFINITION AND CLASSIFICATION
- WHEN TO SUSPECT SHOCK
- Clinical manifestations
- - Features of shock
- - Features due to the underlying cause
- INITIAL APPROACH
- Assess airway, breathing, circulation
- Risk stratification
- - Common conditions needing lifesaving interventions
- Anaphylactic shock
- Tension pneumothorax
- Pericardial tamponade
- Hemodynamically significant hemorrhage
- Life-threatening arrhythmias
- Septic shock
- Cardiogenic shock from myocardial infarction
- Cardiogenic shock from acute aortic or mitral valve insufficiency
- Dissection of the ascending aorta
- Hemodynamically significant pulmonary embolism
- Adrenal crisis
- Insect or animal bites
- Initial diagnostic evaluation
- - Clinical bedside evaluation
- - Laboratory evaluation
- - Imaging
- Point-of-care ultrasonography
- - Pulmonary artery catheterization
- Hemodynamic support
- - Intravenous fluids
- - Vasopressors
- DIFFERENTIAL DIAGNOSIS
- Distributive shock
- Cardiogenic shock
- Hypovolemic shock
- Obstructive shock
- REVERSE THE ETIOLOGY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS