History and exam
Key diagnostic factors
common
altered cognition/agitation
Agitation characterizes the early, milder shock stage, whereas clouded sensorium indicates more severe shock. Also an indication of possible secondary hypoxia or hypoglycemia.
hypotension
Most commonly defined as adult systolic blood pressure <90 mmHg.[2][3] Higher blood pressure does not rule out inadequate perfusion or early shock (e.g., systolic blood pressure <100 mmHg in early septic shock). Direct measurement via automatic cuff devices or an arterial line is preferred over routine sphygmomanometry, because direct blood pressure measurement is more precise and allows for continuous monitoring. If an arterial line is used, it also provides access for arterial blood sampling.[1]
Other diagnostic factors
common
tachypnea
May be part of the compensatory physiologic response to increase oxygen delivery or be a symptom of underlying etiology (e.g., tension pneumothorax or sepsis).
tachycardia
A physiologic response to hypotension to try and maintain cardiac output; may be limited by cardiac reserve or pharmacologic agents such as beta-blockers.
prolonged capillary refill time
Prolonged capillary refill time is usually defined as reversal of skin blanching more than 2 to 3 seconds after releasing pressure. It indicates low skin perfusion, but is not specific to shock (it may be prolonged with advancing age or at low temperature).
oliguria
A urine output <0.5 mL/kg/hour for >6 hours indicates renal hypoperfusion, and acute kidney injury may result if left untreated.[40]
muscle weakness
May be present in many shock states, and is suggestive of poor perfusion to vital organs and muscle.
cyanosis
Cyanotic or mottled skin indicates low skin perfusion. As with prolonged capillary refill, this is common in severe shock, except in distributive forms.
cool extremities
Cool hands and feet indicate low peripheral perfusion, but this is not specific to shock. Cool peripheries are common in severe shock, except in distributive forms.
evidence of trauma
If shock develops in the setting of trauma: hemorrhage, tension pneumothorax, or cardiac tamponade are to be considered.
petechial rash
Classic appearance in meningococcal septicemia.
chest pain
Classically present with myocardial infarction, but may also be a feature of tension pneumothorax or trauma, or secondary to cardiac ischemia as a result of shock.
uncommon
fever
May be present in septic shock.
abdominal pain
Nonspecific finding, but can be present with a ruptured abdominal aortic aneurysm (classically loin pain) or septic shock with abdominal/pelvic source. Also a sensitive symptom for ruptured ectopic pregnancy; typically unilateral lower abdominal pain, however the patient may present with generalized or upper abdominal pain.
jugular venous distention
Jugular venous distention helps differentiate between different causes of shock. Marked distention points at pericardial tamponade, tension pneumothorax, massive pulmonary embolism, or right heart failure.
peripheral edema
This is classically associated with heart failure but can also be seen in distributive shock (e.g., sepsis and anaphylaxis) when systemic vascular resistance is lowered.
absent breath sounds on one side of chest
Suggestive of pneumothorax (not necessarily a tension pneumothorax).
tracheal deviation
This is a late sign of tension pneumothorax.
quiet heart sounds
Quiet heart sounds in conjunction with jugular venous distention and hypotension is typical of cardiac tamponade.
flaccid paralysis of lower limbs
In the setting of shock, supports a neurogenic cause.
cardiac murmur
May indicate a heart valve abnormality.
distended bladder
May be found in neurogenic shock.
facial and tongue swelling
Angioedema is circumscribed swelling of any part of the body. Immediate treatment is warranted if this involves the airways.
Associated with anaphylaxis.
urticarial rash
Widespread, itchy, erythematous rash. Associated with anaphylaxis.
pelvic pain/vaginal bleeding in woman of childbearing age
May indicate ruptured ectopic pregnancy.
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