Option 1: Impending cardiovascular collapse

The patient shows signs of severe hypotension. He is diaphoretic, lethargic, and barely responsive when you call his name. The nurse tells you the patient looks worse now than 10 minutes ago when the page was sent.

Question: What are you going to do next?

Make your choice, then click on the explanation bubble to reveal the answer.

• Let the patient tell the tale of how they got to this point.
• Call for help!

Patients in shock are at risk of cardiopulmonary arrest; be prepared to start CPR if the patient loses their pulse.

Question: Backup is on the way! Now what?

While you’re waiting for the rapid response team to arrive, do the following steps (concurrently, not sequentially):

• Perform an ABCDE survey and identify the need for immediate airway or breathing intervention (e.g., supplemental O₂, basic airway maneuvers).
• Establish vascular access immediately.
  • For adults, use ≥ 2 large-bore peripheral IVs.
  • Consider IO insertion if there is difficulty obtaining peripheral IV access or a central venous line if vasoactive medication may be needed.
• Initiate hemodynamic monitoring (e.g., pulse oximetry and telemetry; consider invasive monitoring for severe shock).
• Quickly classify the type of shock using a focused physical examination and rapid diagnostic studies (e.g., POCUS, portable CXR, ECG, serum lactate, ABG/VBG).
• Provide immediate hemodynamic support.
  • Initiate fluid resuscitation; administer fluids judiciously if cardiogenic shock is suspected.
  • Determine the need for vasopressors, inotropes, and/or blood transfusions.
• Determine the need for other life-saving procedures (e.g., needle thoracostomy for tension pneumothorax, epinephrine administration for anaphylaxis).

Further management

Once you’ve identified the likely cause of shock, start targeted management.

• Hypovolemic shock
• Cardiogenic shock
• Obstructive shock
• Distributive shock (e.g., septic shock, neurogenic shock, anaphylactic shock)

Swiftly provide hemodynamic support while simultaneously identifying the underlying type of shock for targeted treatment.

Now it’s time to polish your bedside POCUS skills!

POCUS for undifferentiated shock

As part of your focused shock assessment, POCUS examinations can help you quickly identify the shock subtype and guide treatment decisions. Because interpreting POCUS findings may be challenging under pressure, practicing this skill can significantly improve your diagnostic accuracy. Here are illustrations showing probe placement, along with images with overlays to guide you in identifying key structures on the ultrasound screen.

With timely intervention, you can hopefully prevent this patient’s condition from deteriorating further. However, if severe hypotension leads to a need for advanced support, “Shock” has you covered. You'll find recommendations for escalation (including when to consider vasopressors), fluid resuscitation protocols, and instructions for further intervention.

Related resources

• Intravenous fluid therapy
• FAST and eFAST

Want to explore the other scenario? Jump over to “Option 2: Hypotension responsive to IV fluids.” You can also return to the main module to wrap up “Under pressure.”