🚨 Assessing a patient in shock requires immediate action. 👉 Radial pulse ≈ SBP ≥ 80 mmHg. 👉 Femoral pulse ≈ SBP ≥ 70 mmHg. 👉 Carotid pulse ≈ SBP ≥ 60 mmHg. ⚠️ Hypotension is a late finding — don’t wait for it.

⚡ Initial Shock Management (Oxygen 15 L/min unless COPD, NS = Normal Saline)
💉 Insert 2 large-bore IV lines → start crystalloids (unless pulmonary oedema). 🧪 Send FBC, U&E, LFTs, Group & Hold, Lactate. Extra tests: Troponin, D-dimer, ABG, ECG, CXR, AXR, Amylase (if abdominal pain). 🚽 Insert urinary catheter to monitor output. 🔴 >50y + abdo pain → urgent AAA rule-out. ❤️ Chest pain → ECG/CXR/CT for STEMI, PE, or aortic dissection. ⚡ Arrhythmias: Tachycardia → Amiodarone or DC shock. Bradycardia → Atropine or pacing. 🫁 Breathlessness → tension PTX? Needle decompression + chest drain. 🫀 PE + hypotension + high JVP → bedside Echo, consider thrombolysis. 💔 Tamponade → urgent echo + pericardiocentesis. 🦠 Sepsis → IV fluids, lactate, cultures, antibiotics, ± inotropes. 🟤 Pigmented skin → Addisonian crisis → IV NS + hydrocortisone 100–200 mg IV. 🤧 Anaphylaxis → IM adrenaline + IV fluids. 🩸 GI bleed → resuscitate, IV access, OGD ± variceal management, TXA. ♀️ Pregnancy: First trimester + abdo pain → ectopic until proven otherwise → urgent surgery. 3rd trimester → consider concealed placental abruption, uterine rupture, amniotic fluid embolism. Always tilt mother 15–30° to left (relieves aortocaval compression). ♀️ Retained tampon + rash → toxic shock syndrome → IV fluids + antibiotics. 🟣 Non-blanching rash → meningococcal sepsis → IV cefotaxime immediately. 👶 Children: Hypotension is very late — tachycardia, prolonged CRT, poor feeding, drowsiness are early signs. Bolus 10–20 mL/kg crystalloids (not 500 mL as in adults). Causes: sepsis, trauma, congenital heart disease, DKA.

⚡ Initial Shock Management (Oxygen 15 L/min unless COPD, NS = Normal Saline)

💉 Insert 2 large-bore IV lines → start crystalloids (unless pulmonary oedema).
🧪 Send FBC, U&E, LFTs, Group & Hold, Lactate.
Extra tests: Troponin, D-dimer, ABG, ECG, CXR, AXR, Amylase (if abdominal pain).
🚽 Insert urinary catheter to monitor output.
🔴 >50y + abdo pain → urgent AAA rule-out.
❤️ Chest pain → ECG/CXR/CT for STEMI, PE, or aortic dissection.
⚡ Arrhythmias:
- Tachycardia → Amiodarone or DC shock.
- Bradycardia → Atropine or pacing.
🫁 Breathlessness → tension PTX? Needle decompression + chest drain.
🫀 PE + hypotension + high JVP → bedside Echo, consider thrombolysis.
💔 Tamponade → urgent echo + pericardiocentesis.
🦠 Sepsis → IV fluids, lactate, cultures, antibiotics, ± inotropes.
🟤 Pigmented skin → Addisonian crisis → IV NS + hydrocortisone 100–200 mg IV.
🤧 Anaphylaxis → IM adrenaline + IV fluids.
🩸 GI bleed → resuscitate, IV access, OGD ± variceal management, TXA.
♀️ Pregnancy:
- First trimester + abdo pain → ectopic until proven otherwise → urgent surgery.
- 3rd trimester → consider concealed placental abruption, uterine rupture, amniotic fluid embolism.
- Always tilt mother 15–30° to left (relieves aortocaval compression).
♀️ Retained tampon + rash → toxic shock syndrome → IV fluids + antibiotics.
🟣 Non-blanching rash → meningococcal sepsis → IV cefotaxime immediately.
👶 Children:
- Hypotension is very late — tachycardia, prolonged CRT, poor feeding, drowsiness are early signs.
- Bolus 10–20 mL/kg crystalloids (not 500 mL as in adults).
- Causes: sepsis, trauma, congenital heart disease, DKA.

🫀 Shock = inadequate tissue perfusion. 💡 Remember: Shock can exist without hypotension → look for tachycardia, tachypnoea, confusion, oliguria.

🔎 Introduction

Defined as acute circulatory collapse with poor organ perfusion.
Caused by ↓ cardiac output, ↓ systemic vascular resistance, or both.
Rapid recognition + intervention = survival.

⚠️ Clinical Features of Shock

🫁 Tachypnoea
❤️ Tachycardia >100 bpm (children: may be >160 bpm)
⬇️ SBP <100 mmHg (late; <70 + 2×age in children = hypotension)
🧠 Altered mental state
🚽 Oliguria <0.5 mL/kg/hr
Multi-organ failure if severe
Vasodilatory: Warm peripheries, low diastolic BP
Hypovolaemic: Cold, clammy, poor refill

📊 Classification of Shock

🫀 Cardiogenic: MI, myocarditis, endocarditis
🫁 Obstructive: PE, tamponade, tension PTX
🦠 Septic: Infections (urine, chest, abdo, meningitis in children)
🤧 Anaphylactic: Allergic reactions
🩸 Hypovolaemic: Trauma, GI bleed, obstetric haemorrhage
🧠 Neurogenic: Spinal cord injury

🔍 Clinical Indicators of Aetiology

❤️ Chest pain → MI, dissection, PE
🫁 Breathlessness + cyanosis → LVF, PTX, tamponade
🩸 Haematemesis/melaena → GI bleed
🦴 Pelvic/femur fracture → haemorrhage or fat embolism
🦠 Fever/cough → Sepsis
🫀 Severe SOB + ketotic breath → DKA
♀️ Pregnancy + abdo pain → ectopic, abruption
👶 Child with non-blanching rash → meningococcal sepsis
🟤 Pigmentation + hypotension → Addisonian crisis

🧪 Investigations

FBC → WCC (infection), Hb (bleed)
U&E → AKI
Glucose → DKA/HHS
Lactate → tissue hypoxia
Troponin → MI
D-dimer → PE/DIC
CXR → consolidation, widened mediastinum, LVF
Cortisol → Addison’s
hCG → rule out pregnancy-related causes

🛠️ Management

ABC → airway, O₂, IV access, circulation
Identify and treat underlying cause
Early escalation to senior/critical care
Special considerations:
- Pregnancy → left lateral tilt, rapid obstetric involvement
- Children → weight-based fluids & drugs, beware rapid deterioration

💡 Pearls

Radial pulse = SBP ~80, femoral = 70, carotid = 60.
Shock without hypotension is common early (look for tachycardia + confusion).
Never delay treating sepsis — antibiotics within 1 hour save lives.
In trauma, assume hypovolaemia from bleeding until proven otherwise.
Persistent hypotension after 2L NS → consider blood, sepsis, or cardiogenic/obstructive cause.
Pregnancy and children mask shock until late — act early.

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Assessing a Patient who is Shocked