Hypotension and Shock
Not yet clinically reviewed
This protocol was migrated from the earlier Pharmapedia and Ward Guide apps for educational use. Follow your hospital's own policies and consult seniors when in doubt.
Common Causes 1. Hypovolemic
Acute diarrhea/Vomiting
: Severe blood loss
: Blood or fluid loss into concealed areas (Retroperitoneal hematoma, bleeding into pleural or peritoneal cavity, paralytic ileus, peritonitis, acute gastric dilatation)
: Renal loss
Diabetic ketoacidosis
Diuretics
Diabetes insipidus
2. Cardiogenic
Acute MI
: Myocarditis - Leptospirosis - Viral - Rheumatic fever
: Pulmonary thromboembolism
: Pericardial tamponade
3. Septicemia
Multiple factors are responsible
4. Peripheral circulatory failure
: Acute anaphylaxis, septicemia
: Autonomic disturbances
: Vasodilatory drugs/Poisons
5. Addisonian crisis
(Actually due to renal loss of fluid)
Clinical Approach to Hypotension and Shock • Fever
- Pneumonia with circulatory failure
- Septicemia
- Addisonian crisis precipitated by infection
• Diarrhea
- Is the fluid loss severe enough to cause
Vomiting
Hypotension and shock? If not think of Addisonian crisis or associated cardiac problems
• Polyuria/Polydipsia
- Diabetic ketoacidosis
- Diabetes insipidus
- Diuretic induced
• Chest pain
- Acute myocardial infarction (features of Pulmonary edema)
- Pulmonary thromboembolism (chest clear)
- Tension pneumothorax
- Intercostal bulging on the affected side + Tympanic note + Absent breath sound
- Pericardial tamponade
: Raised JVP
: Faint heart sounds
• Dyspnea
- Acute MI with pulmonary edema
- Pulmonary thromboembolism
- Pneumonia
- Tension pneumothorax
- Pericardial tamponade
- Tachypnoea due to metabolic Acidosis
• DKA
Pre-renal azotemia
HCO3— loss in diarrhea
• Abdominal pain
Look for
- Peritonitis
- Pancreatitis
- Intestinal obstruction
- Paralytic ileus
- Acute MI
- Mesenteric occlusion
- Acute gastric dilatation
- Diabetic ketoacidosis
- Addisonian crisis
• History of drug intake/injections/overdosage or poisonings
- Aluminum phosphide
- Anti-hypertensive overdose
- Penicillin anaphylaxis or anaphylaxis to other drugs
• Bradycardia
- IHD/Myocarditis
- Vasovagal syncope
- Beta blocker overdose
Blood
- <90 mm indicates hypotension. In pre pressure venously hypertensive patients shock can exist with apparently normal BP.
Management of shock
- Depends on the cause
- Start an IV line
- Correct dehydration if present with appropriate fluids
- Do not start on dopamine before correcting dehydration, if present. If the cause of hypotension is uncertain after a proper evaluation or if the patient is critically ill, give Inj. Hydrocortisone 200 to 400 mg or even more (unless there is a definite contraindication). This will save many cases of Addisonian crisis.
- Investigations are done depending on the clinical possibilities
- Treatment for the primary disorder
- Dopamine is useful in states of normal/hypervolemia with Hypotension— irrespective of the cause