Hypotension and Shock

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