Peri-arrest HypotensionAPPROACH

RESUSCITATION AND UNIVERSAL APPROACHES · 19 SECTIONS

⚲

626 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Unresponsive Patient Airway Obstruction And Stridor Acute Respiratory Distress With Impending Failure Peri-arrest Hypotension Post Resuscitation Care After Rosc Cardiac Arrest Rhythms, Pea, Asystole Cardiac Arrest Rhythms, Vf, Pulseless Vt Severe Agitation With Safety Risk Procedural Sedation

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx44

Presentation context

›Context

›Triggered by

›Sepsis concern

›Bleeding concern

›Chest pain concern

›Dyspnea concern

›Trauma concern

›Prehospital course

›Syncope

›Near syncope

›CPR initiated

›Vasopressors given

Symptom inventory

›Associated symptoms

›Cardiorespiratory

›Chest pain

›Dyspnea

›Palpitations

›Infectious

›Fever

›Rigors

›Productive cough

›Bleeding

›Hematemesis

›Melena

›Hematochezia

›Neurologic

›Altered mental status

›Focal deficit

Timeline and trajectory

›Course

›Onset pattern

›Sudden

›Progressive

›Preceding losses

›Vomiting

›Diarrhea

›Poor intake

Baseline and prior episodes

›Baseline status

›Baseline blood pressure

›Known low baseline

›Known hypertension

›Prior shock episodes

›Sepsis

›GI bleed

›Heart failure

02Alarm Features/alarm35

Immediate peri-arrest triggers

›Escalation triggers

›Perfusion failure

›Altered mental status

›Cool mottled skin

›Oliguria

›Respiratory failure

›SpO2 persistently low despite oxygen

›Exhaustion with rising CO2

›Hemodynamic collapse

›SBP < 80 mmHg despite initial resuscitation

›MAP < 60 mmHg despite initial resuscitation

›Rising lactate with worsening mentation

High risk vitals and patterns

›Vital sign danger thresholds

›Hypotension

›SBP < 90 mmHg

›MAP < 65 mmHg

›Shock index

›HR divided by SBP > 1

›Trend worsening over serial vitals

›Bradycardia with hypotension

›HR < 50 with poor perfusion

›High grade AV block pattern

High risk causes to rule out now

›Cannot miss etiologies

›Obstructive

›Tension pneumothorax

›Massive pulmonary embolism

›Pericardial tamponade

›Hemorrhagic

›GI bleed

›Ruptured ectopic pregnancy

›Ruptured abdominal aortic aneurysm

›Cardiogenic

›STEMI

›Mechanical complication of MI

›Malignant arrhythmia

03Medications/meds33

Current and recent medications

›Medication exposures

›Antihypertensives

›Beta blockers

›Calcium channel blockers

›ACE inhibitor

›ARB

›Diuretics

›Vasodilators

›Nitrates

›PDE5 inhibitors

›Anticoagulants and antiplatelets

›DOAC

›Warfarin

›Heparin

›Aspirin

›P2Y12 inhibitor

High risk tox and iatrogenic contributors

›Contributors

›Sedatives and opioids

›Recent procedural sedation

›Overuse concern

›Endocrine agents

›Insulin

›SGLT2 inhibitor

›Recent antibiotics

›Anaphylaxis concern

›C difficile risk

Medication contraindications to likely therapies

›Contraindication flags

›Beta blocker or CCB overdose concern

›Blunted tachycardia

›Hyperglycemia with CCB

›Anticoagulated state

›Hemorrhage risk with thrombolysis

›Need reversal planning

04Diet/diet15

Intake and hydration

›Intake pattern

›Dehydration risk

›Poor oral intake

›Vomiting

›Diarrhea

›Salt and fluid restriction

›Heart failure diet

›Dialysis fluid restriction

Exposures that worsen hypotension

›Exposures

›Alcohol

›Recent binge

›Withdrawal concern

›Caffeine and energy drinks

›High intake

›Abrupt cessation

05Review of Systems/ros27

Cardiopulmonary

›Cardiopulmonary

›Cardiac

›Chest pressure

›Orthopnea

›PND

›Respiratory

›Pleuritic pain

›Hemoptysis

›Wheeze

Infectious and inflammatory

›Infectious

›Systemic

›Fever

›Rigors

›Myalgias

›Source symptoms

›Dysuria

›Flank pain

›Abdominal pain

›Skin pain or redness

Neurologic and endocrine

›Neuro endocrine

›Neuro

›Confusion

›Seizure

›Endocrine

›Polyuria

›Polydipsia

›Heat intolerance

06Collateral History and Family History/chafh18

Collateral source and reliability

›Collateral

›Source

›EMS report

›Family

›Facility staff

›Reliability factors

›Baseline cognition known

›Medication list verified

Family history

›Family history

›Early cardiovascular disease

›MI < 55 male first degree

›MI < 65 female first degree

›Inherited arrhythmia syndromes

›Long QT syndrome

›Brugada syndrome

›Thrombophilia history

›VTE at young age

›Recurrent VTE

07Risk Factors/rf22

Infection and sepsis risk

›Sepsis risks

›Host factors

›Immunosuppression

›Diabetes mellitus (E11.9)

›Chronic kidney disease (N18.9)

›Exposure factors

›Indwelling catheter

›Recent surgery

Hemorrhage and volume loss risk

›Bleeding risks

›Medication related

›Anticoagulant use

›Antiplatelet use

›Disease related

›Cirrhosis (K74.60)

›Peptic ulcer disease (K27.9)

Cardiovascular and obstructive risk

›Shock phenotype risks

›Cardiogenic

›Coronary artery disease (I25.10)

›Heart failure (I50.9)

›Obstructive

›Prior VTE (I82.90)

›Malignancy (C80.1)

08Differential Diagnosis/ddx66

Life threatening

›Life threatening

›Obstructive shock

›Tension pneumothorax (J93.0)

›Unilateral absent breath sounds

›Tracheal deviation late

›Massive pulmonary embolism (I26.99)

›Sudden dyspnea

›RV strain on POCUS

›Pericardial tamponade (I31.4)

›JVP elevation

›Diastolic RV collapse on POCUS

›Cardiogenic shock

›Acute coronary syndrome (I21.9)

›Ischemic ECG changes

›Regional wall motion abnormality

›Malignant arrhythmia (I49.9)

›Wide complex tachycardia

›High grade AV block

›Hypovolemic shock

›GI hemorrhage (K92.2)

›Melena

›Hematemesis

›Ruptured ectopic pregnancy (O00.9)

›Reproductive age

›Positive pregnancy test

›Ruptured AAA (I71.4)

›Back or abdominal pain

›Pulsatile mass

Common

›Common

›Distributive

›Sepsis and septic shock (R65.21)

›Warm early shock possible

›Lactate elevation

›Anaphylaxis (T78.2)

›Urticaria

›Bronchospasm

›Hypovolemia

›Dehydration (E86.0)

›Poor intake

›GI losses

›Medication effect

›Overdiuresis

›Recent dose increase

›AKI pattern

›Vasodilator effect

›Nitrate use

›PDE5 inhibitor use

Less common

›Less common

›Endocrine

›Adrenal crisis (E27.2)

›Chronic steroid use

›Hyponatremia pattern

›Myxedema coma (E03.5)

›Hypothermia

›Bradycardia

›Tox

›Beta blocker toxicity (T44.7)

›Bradycardia

›Hypoglycemia

›Calcium channel blocker toxicity (T46.1)

›Bradycardia

›Hyperglycemia

›Neurogenic shock

›Spinal cord injury (S14.0)

›Bradycardia with hypotension

›Warm dry skin

09Past Medical History/pmh27

Relevant chronic disease

›Comorbidities

›Cardiovascular

›Heart failure (I50.9)

›Atrial fibrillation (I48.91)

›Valvular disease (I38)

›Pulmonary

›COPD (J44.9)

›Pulmonary hypertension (I27.20)

›Renal and hepatic

›CKD (N18.9)

›Cirrhosis (K74.60)

Prior procedures and devices

›Procedures devices

›Cardiac

›PCI history

›CABG history

›Pacemaker

›ICD

›Vascular access

›Dialysis access

›Central line history

Baseline function and frailty

›Baseline

›Functional status

›Independent

›Needs assistance

›Long term care resident

›Baseline vitals available

›Goals of care available

10Physical Exam/exam40

General and perfusion

›General perfusion

›Appearance

›Toxic appearance

›Diaphoresis

›Perfusion markers

›Capillary refill prolonged

›Skin cool clammy

›Mottling

Hemodynamics and volume status

›Hemodynamics

›Pulse quality

›Weak thready

›Bounding

›Jugular venous pressure

›Flat

›Elevated

›Lung fluid signs

›Crackles

›Pink frothy sputum

Focused system exam for causes

›System focused

›Cardiac

›New murmur

›S3 gallop

›Respiratory

›Unilateral breath sounds decreased

›Wheeze

›Abdomen

›Tenderness

›Distension

›Peritonitis

›Skin

›Rash

›Cellulitis

›Track marks

Special populations cues

›Population modifiers

›Pregnancy

›Uterine size estimate

›Vaginal bleeding

›Elderly

›Atypical infection signs

›Medication sensitivity

11Lab Studies/labs43

Core shock labs

›Baseline panel

›CBC

›Hemoglobin trend

›Leukocytosis or leukopenia

›Electrolytes and renal function

›Creatinine trend

›Potassium

›Lactate

›Serial trend every 2 to 4 hours if shock

›Rising value as failure of resuscitation marker

Metabolic and endocrine threats

›Metabolic endocrine

›Glucose

›Hypoglycemia as reversible cause

›Hyperglycemia as CCB toxicity clue

›Venous blood gas

›pH

›PCO2 mmHg

›Cortisol

›Refractory shock with steroid exposure

›Interpretation local protocol dependent

Cardiac and bleeding evaluation

›Cardiac bleeding

›Troponin

›Serial testing if ACS concern

›Type 2 myocardial injury in shock possible

›BNP or NT proBNP

›Supportive for heart failure phenotype

›Limited specificity in renal failure

›Coagulation studies

›INR

›aPTT

›Type and screen

›If hemorrhage possible

›Massive transfusion protocol trigger planning

Infection workup

›Infection testing

›Blood cultures

›Before antibiotics when feasible

›Do not delay antibiotics in shock

›Urinalysis

›Pyuria

›Nitrites

›Respiratory testing

›Viral panel local protocol dependent

›Sputum culture in severe pneumonia

12Imaging/img40

Scoring Systems

›Risk and response tools

›Shock index

›HR divided by SBP > 1

›Trend for deterioration

›qSOFA

›RR >= 22

›Altered mentation

›SBP <= 100

›Dynamic fluid responsiveness

›Passive leg raise with stroke volume change

›POCUS IVC and LV filling pattern integration

MRI

›MRI considerations

›Neurogenic shock concern

›Spinal cord compression evaluation

›MRI timing after stabilization

›Contraindications

›Non MRI compatible devices

›Unstable patient unable to tolerate scanner

›CT pathways

›Pulmonary embolism

›CT pulmonary angiography if stable enough

›Contrast nephropathy risk balancing

›Aortic catastrophe

›CT angiography chest abdomen pelvis if dissection concern

›Blood pressure target planning during transport

›Hemorrhage source

›CT abdomen pelvis for intraabdominal bleeding if stable enough

›CT head for intracranial hemorrhage if anticoagulated with collapse

Ultrasound

›POCUS in undifferentiated hypotension

›RUSH protocol components

›Heart

›IVC and volume status

›Lungs

›Abdomen free fluid

›Aorta

›DVT evaluation

›Key obstructive findings

›Pericardial effusion with tamponade physiology

›RV dilation with strain pattern

›Absent lung sliding with lung point

13Special Tests/spec21

Bedside perfusion and hemodynamics

›Bedside markers

›Capillary refill time

›Serial response to resuscitation

›Prolonged as hypoperfusion marker

›End tidal CO2 if ventilated

›Low value as low flow marker

›Sudden rise with ROSC indicator

Procedures for diagnosis and monitoring

›Advanced monitoring

›Arterial line

›Refractory shock needing accurate MAP

›Frequent blood gas sampling

›Central venous access

›Multiple infusions

›Vasopressor requirement

Targeted bedside tests

›Targeted tests

›Pregnancy test

›All patients with pregnancy potential

›Ectopic pregnancy risk gating

›Rectal exam

›Melena confirmation when unclear

›Gross blood detection

14ECG/ecg17

Immediate ECG evaluation

›ECG indications

›Any peri-arrest hypotension

›Chest pain present

›Dyspnea present

›Bradycardia or tachycardia on monitor

›Rhythm diagnosis

›Conduction block detection

High risk ECG patterns

›ECG red flags

›Ischemia

›STEMI criteria

›New LBBB with ischemic concern

›Conduction disease

›High grade AV block

›Wide QRS with bradycardia

›Electrical instability

›VT

›Torsades risk QT prolongation

15Assessment/ax31

Shock phenotype and severity

›Shock classification

›Distributive

›Warm extremities early

›Wide pulse pressure possible

›Cardiogenic

›Pulmonary edema signs

›Depressed LV function on POCUS

›Hypovolemic

›Flat IVC pattern

›History of losses or bleeding

›Obstructive

›Tamponade pattern

›Tension pneumothorax pattern

›RV strain pattern

Complications to rule out

›Immediate threats

›Hypoxemia

›Severe VQ mismatch

›Need for ventilatory support

›Severe metabolic acidosis

›pH low with high lactate

›Refractory hypotension risk

›Dysrhythmia driven collapse

›VT or VF risk

›Bradyarrhythmia needing pacing

Diagnostic uncertainty handling

›Uncertainty approach

›Mixed shock

›Sepsis with cardiomyopathy

›Hemorrhage with sympathetic failure

›Response guided reclassification

›Fluid nonresponse suggests cardiogenic or obstructive

›Pressor resistance suggests ongoing hemorrhage or profound vasoplegia

16Plan/plan79

First 5 minutes

›Immediate workflow

›Monitoring

›Cardiac monitor

›Continuous SpO2

›NIBP cycling every 1 to 2 minutes

›Access

›Two large bore IVs

›IO access if IV failure

›Airway and breathing

›Oxygen to target SpO2 >= 94

›BVM support if inadequate ventilation

›Rapid diagnostics

›ECG within 10 minutes

›POCUS RUSH during parallel resuscitation

›Immediate reversible causes

›Glucose correction if low

›Naloxone if opioid toxidrome with respiratory depression

Hemodynamic targets and fluids

›Hemodynamic goals

›MAP target

›MAP >= 65 mmHg initial default

›Higher target if chronic hypertension local protocol dependent

›Fluid strategy

›Balanced crystalloid bolus 250 to 500 mL with reassessment

›Smaller boluses if pulmonary edema phenotype

›Blood products

›RBC transfusion if hemorrhagic shock suspected

›Massive transfusion protocol activation local protocol dependent

Vasopressors and inotropes

›Vasoactive support

›Norepinephrine first line for septic shock and many shock states

›Start peripheral if central delayed with frequent site checks

›Transition to central access when feasible

›Epinephrine

›Anaphylaxis with shock

›Refractory shock as add on agent

›Push dose vasopressor local protocol dependent

›Temporary bridge to infusion

›Avoid in uncontrolled tachyarrhythmia

›Dobutamine

›Low cardiac output with adequate MAP

›Avoid in profound hypotension without pressor support

Cause specific emergency actions

›Etiology directed actions

›Tension pneumothorax

›Immediate decompression if clinical diagnosis

›Chest tube definitive management

›Tamponade

›Emergent cardiology or CT surgery activation

›Pericardiocentesis if crashing and expertise available

›Massive PE

›Thrombolysis consideration local protocol dependent

›Contraindication screening for bleeding risk

›Sepsis

›Broad spectrum antibiotics within 1 hour in shock local protocol dependent

›Source control planning

›Bradycardia with shock

›Atropine trial if vagal pattern

›Transcutaneous pacing if unstable high grade block

Monitoring and reassessment loop

›Reassessment loop

›Timing

›Every 5 to 10 minutes during active titration

›After each fluid bolus

›What to repeat

›Mental status

›Perfusion exam

›Lung exam

›POCUS response

›Response markers

›MAP trend

›Lactate downtrend

›Urine output improvement

Special populations

›Population modifications

›Pregnancy

›Left lateral uterine displacement if late pregnancy

›Early OB consult for suspected ectopic

›Pediatrics

›Weight based fluid bolus local protocol dependent

›Early sepsis pathway activation local protocol dependent

›Elderly and frail

›Lower physiologic reserve

›Earlier ICU threshold

17Disposition/dispo32

ICU and higher level of care

›ICU criteria

›Ongoing vasoactive infusion requirement

›Norepinephrine infusion running

›Multiple pressors needed

›Persistent hypoperfusion

›Lactate persistently elevated despite resuscitation

›Altered mental status persists

›Respiratory support

›Mechanical ventilation

›High flow oxygen with instability

Admission and observation pathways

›Inpatient or observation

›Inpatient

›Suspected sepsis needing ongoing IV therapy

›Cardiogenic shock or ACS workup

›Observation

›Transient hypotension resolved with clear benign cause

›Stable vitals for several hours with normal lactate

Transfer and definitive therapy access

›Transfer triggers

›Time critical procedures unavailable

›Cath lab needed

›Cardiothoracic surgery needed

›Critical imaging unavailable

›CT angiography unavailable

›ICU bed unavailable

Discharge criteria

›Discharge rare and high bar

›Objective stability

›Normal mentation baseline

›SBP stable without fluids or pressors

›Lactate normal or clearly improving with low risk context

›Reliability

›Clear diagnosis with low risk course

›Follow up within 24 to 72 hours

18Discharge Instructions/di20

Copy discharge instructions

›Patient instructions

›Summary

›You were treated for low blood pressure and poor circulation

›Your vital signs improved and tests did not show an immediate life threatening cause

›Medications

›Take medications exactly as prescribed

›Do not take extra blood pressure medications unless instructed

›Hydration and activity

›Drink fluids as tolerated unless you were told to restrict fluids

›Avoid driving or risky activity until fully back to normal

›Follow up

›See your primary clinician within 1 to 3 days

›Return for repeat blood pressure check if instructed

›Return to ED now for

›Fainting

›Chest pain

›Shortness of breath

›Black or bloody stool

›Fever with worsening weakness

›New confusion

19References/r16

Guideline and evidence sources

›Core references

›Surviving Sepsis Campaign international guidelines for management of sepsis and septic shock 2021

›Hemodynamic recommendations include balanced crystalloids and vasopressor use in shock

›Early recognition and treatment emphasis

›American Heart Association Guidelines for CPR and ECC 2025

›Peri-arrest and resuscitation systems approach

›Post arrest care integration with shock management

›CAEP vasopressor and inotrope use in Canadian Emergency Departments 2015

›Norepinephrine recommended first line for septic shock and cardiogenic shock in ED settings

›Practical ED focused vasopressor guidance

›ACEP Sonoguide RUSH protocol 2021

›POCUS role in undifferentiated hypotension

›Serial ultrasound response assessment

›Systematic review meta analysis of POCUS protocols for shock etiology 2019

›Diagnostic accuracy evidence base for RUSH like protocols

›Limitations and heterogeneity considerations

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Peri-arrest HypotensionAPPROACH

RESUSCITATION AND UNIVERSAL APPROACHES · 19 SECTIONS

⚲

626 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx44

Presentation context

›Context

›Triggered by

›Sepsis concern

›Bleeding concern

›Chest pain concern

›Dyspnea concern

›Trauma concern

›Prehospital course

›Syncope

›Near syncope

›CPR initiated

›Vasopressors given

Symptom inventory

›Associated symptoms

›Cardiorespiratory

›Chest pain

›Dyspnea

›Palpitations

›Infectious

›Fever

›Rigors

›Productive cough

›Bleeding

›Hematemesis

›Melena

›Hematochezia

›Neurologic

›Altered mental status

›Focal deficit

Timeline and trajectory

›Course

›Onset pattern

›Sudden

›Progressive

›Preceding losses

›Vomiting

›Diarrhea

›Poor intake

Baseline and prior episodes

›Baseline status

›Baseline blood pressure

›Known low baseline

›Known hypertension

›Prior shock episodes

›Sepsis

›GI bleed

›Heart failure

02Alarm Features/alarm35

Immediate peri-arrest triggers

›Escalation triggers

›Perfusion failure

›Altered mental status

›Cool mottled skin

›Oliguria

›Respiratory failure

›SpO2 persistently low despite oxygen

›Exhaustion with rising CO2

›Hemodynamic collapse

›SBP < 80 mmHg despite initial resuscitation

›MAP < 60 mmHg despite initial resuscitation

›Rising lactate with worsening mentation

High risk vitals and patterns

›Vital sign danger thresholds

›Hypotension

›SBP < 90 mmHg

›MAP < 65 mmHg

›Shock index

›HR divided by SBP > 1

›Trend worsening over serial vitals

›Bradycardia with hypotension

›HR < 50 with poor perfusion

›High grade AV block pattern

High risk causes to rule out now

›Cannot miss etiologies

›Obstructive

›Tension pneumothorax

›Massive pulmonary embolism

›Pericardial tamponade

›Hemorrhagic

›GI bleed

›Ruptured ectopic pregnancy

›Ruptured abdominal aortic aneurysm

›Cardiogenic

›STEMI

›Mechanical complication of MI

›Malignant arrhythmia

03Medications/meds33

Current and recent medications

›Medication exposures

›Antihypertensives

›Beta blockers

›Calcium channel blockers

›ACE inhibitor

›ARB

›Diuretics

›Vasodilators

›Nitrates

›PDE5 inhibitors

›Anticoagulants and antiplatelets

›DOAC

›Warfarin

›Heparin

›Aspirin

›P2Y12 inhibitor

High risk tox and iatrogenic contributors

›Contributors

›Sedatives and opioids

›Recent procedural sedation

›Overuse concern

›Endocrine agents

›Insulin

›SGLT2 inhibitor

›Recent antibiotics

›Anaphylaxis concern

›C difficile risk

Medication contraindications to likely therapies

›Contraindication flags

›Beta blocker or CCB overdose concern

›Blunted tachycardia

›Hyperglycemia with CCB

›Anticoagulated state

›Hemorrhage risk with thrombolysis

›Need reversal planning

04Diet/diet15

Intake and hydration

›Intake pattern

›Dehydration risk

›Poor oral intake

›Vomiting

›Diarrhea

›Salt and fluid restriction

›Heart failure diet

›Dialysis fluid restriction

Exposures that worsen hypotension

›Exposures

›Alcohol

›Recent binge

›Withdrawal concern

›Caffeine and energy drinks

›High intake

›Abrupt cessation

05Review of Systems/ros27

Cardiopulmonary

›Cardiopulmonary

›Cardiac

›Chest pressure

›Orthopnea

›PND

›Respiratory

›Pleuritic pain

›Hemoptysis

›Wheeze

Infectious and inflammatory

›Infectious

›Systemic

›Fever

›Rigors

›Myalgias

›Source symptoms

›Dysuria

›Flank pain

›Abdominal pain

›Skin pain or redness

Neurologic and endocrine

›Neuro endocrine

›Neuro

›Confusion

›Seizure

›Endocrine

›Polyuria

›Polydipsia

›Heat intolerance

06Collateral History and Family History/chafh18

Collateral source and reliability

›Collateral

›Source

›EMS report

›Family

›Facility staff

›Reliability factors

›Baseline cognition known

›Medication list verified

Family history

›Family history

›Early cardiovascular disease

›MI < 55 male first degree

›MI < 65 female first degree

›Inherited arrhythmia syndromes

›Long QT syndrome

›Brugada syndrome

›Thrombophilia history

›VTE at young age

›Recurrent VTE

07Risk Factors/rf22

Infection and sepsis risk

›Sepsis risks

›Host factors

›Immunosuppression

›Diabetes mellitus (E11.9)

›Chronic kidney disease (N18.9)

›Exposure factors

›Indwelling catheter

›Recent surgery

Hemorrhage and volume loss risk

›Bleeding risks

›Medication related

›Anticoagulant use

›Antiplatelet use

›Disease related

›Cirrhosis (K74.60)

›Peptic ulcer disease (K27.9)

Cardiovascular and obstructive risk

›Shock phenotype risks

›Cardiogenic

›Coronary artery disease (I25.10)

›Heart failure (I50.9)

›Obstructive

›Prior VTE (I82.90)

›Malignancy (C80.1)

08Differential Diagnosis/ddx66

Life threatening

›Life threatening

›Obstructive shock

›Tension pneumothorax (J93.0)

›Unilateral absent breath sounds

›Tracheal deviation late

›Massive pulmonary embolism (I26.99)

›Sudden dyspnea

›RV strain on POCUS

›Pericardial tamponade (I31.4)

›JVP elevation

›Diastolic RV collapse on POCUS

›Cardiogenic shock

›Acute coronary syndrome (I21.9)

›Ischemic ECG changes

›Regional wall motion abnormality

›Malignant arrhythmia (I49.9)

›Wide complex tachycardia

›High grade AV block

›Hypovolemic shock

›GI hemorrhage (K92.2)

›Melena

›Hematemesis

›Ruptured ectopic pregnancy (O00.9)

›Reproductive age

›Positive pregnancy test

›Ruptured AAA (I71.4)

›Back or abdominal pain

›Pulsatile mass

Common

›Common

›Distributive

›Sepsis and septic shock (R65.21)

›Warm early shock possible

›Lactate elevation

›Anaphylaxis (T78.2)

›Urticaria

›Bronchospasm

›Hypovolemia

›Dehydration (E86.0)

›Poor intake

›GI losses

›Medication effect

›Overdiuresis

›Recent dose increase

›AKI pattern

›Vasodilator effect

›Nitrate use

›PDE5 inhibitor use

Less common

›Less common

›Endocrine

›Adrenal crisis (E27.2)

›Chronic steroid use

›Hyponatremia pattern

›Myxedema coma (E03.5)

›Hypothermia

›Bradycardia

›Tox

›Beta blocker toxicity (T44.7)

›Bradycardia

›Hypoglycemia

›Calcium channel blocker toxicity (T46.1)

›Bradycardia

›Hyperglycemia

›Neurogenic shock

›Spinal cord injury (S14.0)

›Bradycardia with hypotension

›Warm dry skin

09Past Medical History/pmh27

Relevant chronic disease

›Comorbidities

›Cardiovascular

›Heart failure (I50.9)

›Atrial fibrillation (I48.91)

›Valvular disease (I38)

›Pulmonary

›COPD (J44.9)

›Pulmonary hypertension (I27.20)

›Renal and hepatic

›CKD (N18.9)

›Cirrhosis (K74.60)

Prior procedures and devices

›Procedures devices

›Cardiac

›PCI history

›CABG history

›Pacemaker

›ICD

›Vascular access

›Dialysis access

›Central line history

Baseline function and frailty

›Baseline

›Functional status

›Independent

›Needs assistance

›Long term care resident

›Baseline vitals available

›Goals of care available

10Physical Exam/exam40

General and perfusion

›General perfusion

›Appearance

›Toxic appearance

›Diaphoresis

›Perfusion markers

›Capillary refill prolonged

›Skin cool clammy

›Mottling

Hemodynamics and volume status

›Hemodynamics

›Pulse quality

›Weak thready

›Bounding

›Jugular venous pressure

›Flat

›Elevated

›Lung fluid signs

›Crackles

›Pink frothy sputum

Focused system exam for causes

›System focused

›Cardiac

›New murmur

›S3 gallop

›Respiratory

›Unilateral breath sounds decreased

›Wheeze

›Abdomen

›Tenderness

›Distension

›Peritonitis

›Skin

›Rash

›Cellulitis

›Track marks

Special populations cues

›Population modifiers

›Pregnancy

›Uterine size estimate

›Vaginal bleeding

›Elderly

›Atypical infection signs

›Medication sensitivity

11Lab Studies/labs43

Core shock labs

›Baseline panel

›CBC

›Hemoglobin trend

›Leukocytosis or leukopenia

›Electrolytes and renal function

›Creatinine trend

›Potassium

›Lactate

›Serial trend every 2 to 4 hours if shock

›Rising value as failure of resuscitation marker

Metabolic and endocrine threats

›Metabolic endocrine

›Glucose

›Hypoglycemia as reversible cause

›Hyperglycemia as CCB toxicity clue

›Venous blood gas

›pH

›PCO2 mmHg

›Cortisol

›Refractory shock with steroid exposure

›Interpretation local protocol dependent

Cardiac and bleeding evaluation

›Cardiac bleeding

›Troponin

›Serial testing if ACS concern

›Type 2 myocardial injury in shock possible

›BNP or NT proBNP

›Supportive for heart failure phenotype

›Limited specificity in renal failure

›Coagulation studies

›INR

›aPTT

›Type and screen

›If hemorrhage possible

›Massive transfusion protocol trigger planning

Infection workup

›Infection testing

›Blood cultures

›Before antibiotics when feasible

›Do not delay antibiotics in shock

›Urinalysis

›Pyuria

›Nitrites

›Respiratory testing

›Viral panel local protocol dependent

›Sputum culture in severe pneumonia

12Imaging/img40

Scoring Systems

›Risk and response tools

›Shock index

›HR divided by SBP > 1

›Trend for deterioration

›qSOFA

›RR >= 22

›Altered mentation

›SBP <= 100

›Dynamic fluid responsiveness

›Passive leg raise with stroke volume change

›POCUS IVC and LV filling pattern integration

MRI

›MRI considerations

›Neurogenic shock concern

›Spinal cord compression evaluation

›MRI timing after stabilization

›Contraindications

›Non MRI compatible devices

›Unstable patient unable to tolerate scanner

›CT pathways

›Pulmonary embolism

›CT pulmonary angiography if stable enough

›Contrast nephropathy risk balancing

›Aortic catastrophe

›CT angiography chest abdomen pelvis if dissection concern

›Blood pressure target planning during transport

›Hemorrhage source

›CT abdomen pelvis for intraabdominal bleeding if stable enough

›CT head for intracranial hemorrhage if anticoagulated with collapse

Ultrasound

›POCUS in undifferentiated hypotension

›RUSH protocol components

›Heart

›IVC and volume status

›Lungs

›Abdomen free fluid

›Aorta

›DVT evaluation

›Key obstructive findings

›Pericardial effusion with tamponade physiology

›RV dilation with strain pattern

›Absent lung sliding with lung point

13Special Tests/spec21

Bedside perfusion and hemodynamics

›Bedside markers

›Capillary refill time

›Serial response to resuscitation

›Prolonged as hypoperfusion marker

›End tidal CO2 if ventilated

›Low value as low flow marker

›Sudden rise with ROSC indicator

Procedures for diagnosis and monitoring

›Advanced monitoring

›Arterial line

›Refractory shock needing accurate MAP

›Frequent blood gas sampling

›Central venous access

›Multiple infusions

›Vasopressor requirement

Targeted bedside tests

›Targeted tests

›Pregnancy test

›All patients with pregnancy potential

›Ectopic pregnancy risk gating

›Rectal exam

›Melena confirmation when unclear

›Gross blood detection

14ECG/ecg17

Immediate ECG evaluation

›ECG indications

›Any peri-arrest hypotension

›Chest pain present

›Dyspnea present

›Bradycardia or tachycardia on monitor

›Rhythm diagnosis

›Conduction block detection

High risk ECG patterns

›ECG red flags

›Ischemia

›STEMI criteria

›New LBBB with ischemic concern

›Conduction disease

›High grade AV block

›Wide QRS with bradycardia

›Electrical instability

›VT

›Torsades risk QT prolongation

15Assessment/ax31

Shock phenotype and severity

›Shock classification

›Distributive

›Warm extremities early

›Wide pulse pressure possible

›Cardiogenic

›Pulmonary edema signs

›Depressed LV function on POCUS

›Hypovolemic

›Flat IVC pattern

›History of losses or bleeding

›Obstructive

›Tamponade pattern

›Tension pneumothorax pattern

›RV strain pattern

Complications to rule out

›Immediate threats

›Hypoxemia

›Severe VQ mismatch

›Need for ventilatory support

›Severe metabolic acidosis

›pH low with high lactate

›Refractory hypotension risk

›Dysrhythmia driven collapse

›VT or VF risk

›Bradyarrhythmia needing pacing

Diagnostic uncertainty handling

›Uncertainty approach

›Mixed shock

›Sepsis with cardiomyopathy

›Hemorrhage with sympathetic failure

›Response guided reclassification

›Fluid nonresponse suggests cardiogenic or obstructive

›Pressor resistance suggests ongoing hemorrhage or profound vasoplegia

16Plan/plan79

First 5 minutes

›Immediate workflow

›Monitoring

›Cardiac monitor

›Continuous SpO2

›NIBP cycling every 1 to 2 minutes

›Access

›Two large bore IVs

›IO access if IV failure

›Airway and breathing

›Oxygen to target SpO2 >= 94

›BVM support if inadequate ventilation

›Rapid diagnostics

›ECG within 10 minutes

›POCUS RUSH during parallel resuscitation

›Immediate reversible causes

›Glucose correction if low

›Naloxone if opioid toxidrome with respiratory depression

Hemodynamic targets and fluids

›Hemodynamic goals

›MAP target

›MAP >= 65 mmHg initial default

›Higher target if chronic hypertension local protocol dependent

›Fluid strategy

›Balanced crystalloid bolus 250 to 500 mL with reassessment

›Smaller boluses if pulmonary edema phenotype

›Blood products

›RBC transfusion if hemorrhagic shock suspected

›Massive transfusion protocol activation local protocol dependent

Vasopressors and inotropes

›Vasoactive support

›Norepinephrine first line for septic shock and many shock states

›Start peripheral if central delayed with frequent site checks

›Transition to central access when feasible

›Epinephrine

›Anaphylaxis with shock

›Refractory shock as add on agent

›Push dose vasopressor local protocol dependent

›Temporary bridge to infusion

›Avoid in uncontrolled tachyarrhythmia

›Dobutamine

›Low cardiac output with adequate MAP

›Avoid in profound hypotension without pressor support

Cause specific emergency actions

›Etiology directed actions

›Tension pneumothorax

›Immediate decompression if clinical diagnosis

›Chest tube definitive management

›Tamponade

›Emergent cardiology or CT surgery activation

›Pericardiocentesis if crashing and expertise available

›Massive PE

›Thrombolysis consideration local protocol dependent

›Contraindication screening for bleeding risk

›Sepsis

›Broad spectrum antibiotics within 1 hour in shock local protocol dependent

›Source control planning

›Bradycardia with shock

›Atropine trial if vagal pattern

›Transcutaneous pacing if unstable high grade block

Monitoring and reassessment loop

›Reassessment loop

›Timing

›Every 5 to 10 minutes during active titration

›After each fluid bolus

›What to repeat

›Mental status

›Perfusion exam

›Lung exam

›POCUS response

›Response markers

›MAP trend

›Lactate downtrend

›Urine output improvement

Special populations

›Population modifications

›Pregnancy

›Left lateral uterine displacement if late pregnancy

›Early OB consult for suspected ectopic

›Pediatrics

›Weight based fluid bolus local protocol dependent

›Early sepsis pathway activation local protocol dependent

›Elderly and frail

›Lower physiologic reserve

›Earlier ICU threshold

17Disposition/dispo32

ICU and higher level of care

›ICU criteria

›Ongoing vasoactive infusion requirement

›Norepinephrine infusion running

›Multiple pressors needed

›Persistent hypoperfusion

›Lactate persistently elevated despite resuscitation

›Altered mental status persists

›Respiratory support

›Mechanical ventilation

›High flow oxygen with instability

Admission and observation pathways

›Inpatient or observation

›Inpatient

›Suspected sepsis needing ongoing IV therapy

›Cardiogenic shock or ACS workup

›Observation

›Transient hypotension resolved with clear benign cause

›Stable vitals for several hours with normal lactate

Transfer and definitive therapy access

›Transfer triggers

›Time critical procedures unavailable

›Cath lab needed

›Cardiothoracic surgery needed

›Critical imaging unavailable

›CT angiography unavailable

›ICU bed unavailable

Discharge criteria

›Discharge rare and high bar

›Objective stability

›Normal mentation baseline

›SBP stable without fluids or pressors

›Lactate normal or clearly improving with low risk context

›Reliability

›Clear diagnosis with low risk course

›Follow up within 24 to 72 hours

18Discharge Instructions/di20

Copy discharge instructions

›Patient instructions

›Summary

›You were treated for low blood pressure and poor circulation

›Your vital signs improved and tests did not show an immediate life threatening cause

›Medications

›Take medications exactly as prescribed

›Do not take extra blood pressure medications unless instructed

›Hydration and activity

›Drink fluids as tolerated unless you were told to restrict fluids

›Avoid driving or risky activity until fully back to normal

›Follow up

›See your primary clinician within 1 to 3 days

›Return for repeat blood pressure check if instructed

›Return to ED now for

›Fainting

›Chest pain

›Shortness of breath

›Black or bloody stool

›Fever with worsening weakness

›New confusion

19References/r16

Guideline and evidence sources

›Core references

›Surviving Sepsis Campaign international guidelines for management of sepsis and septic shock 2021

›Hemodynamic recommendations include balanced crystalloids and vasopressor use in shock

›Early recognition and treatment emphasis

›American Heart Association Guidelines for CPR and ECC 2025

›Peri-arrest and resuscitation systems approach

›Post arrest care integration with shock management

›CAEP vasopressor and inotrope use in Canadian Emergency Departments 2015

›Norepinephrine recommended first line for septic shock and cardiogenic shock in ED settings

›Practical ED focused vasopressor guidance

›ACEP Sonoguide RUSH protocol 2021

›POCUS role in undifferentiated hypotension

›Serial ultrasound response assessment

›Systematic review meta analysis of POCUS protocols for shock etiology 2019

›Diagnostic accuracy evidence base for RUSH like protocols

›Limitations and heterogeneity considerations

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.