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Core definition: inadequate tissue perfusion, leading to anaerobic metabolism, rising acid, cellular hypoxia, and eventual organ failure.

All shock types follow the same three-stage progression:

Stage 1: Compensated – tachycardia, tachypnea, cool pale skin, anxiety, decreased urine output; BP may still look normal.

Stage 2: Decompensated – severe tachycardia, severe tachypnea, drop in BP, narrowed pulse pressure, mental status changes, oliguria/anuria, metabolic acidosis.

Stage 3: Irreversible – refractory hypotension, multiorgan failure, disseminated intravascular coagulation, poor response to pressors or fluids.

Causes: bleeding, trauma, burns, dehydration, massive fluid shifts (DKA, vomiting, diarrhea).

Key assessment:

Pale, cool, clammy

Flat neck veins

Thready pulses

Low urine output

Lab clues:

Low hemoglobin/hematocrit (bleeding)

High hemoglobin/hematocrit (hemoconcentration from dehydration)

BUN-to-creatinine ratio over 20:1 → prerenal dehydration

Priority actions:

Two large-bore IVs, rapid fluid resuscitation

Blood products if bleeding

Keep patient warm; control source of fluid loss

Causes: massive heart attack, myocarditis, pulmonary embolism, cardiac tamponade.

Key assessment:

Cold + wet

Jugular vein distention

Crackles, pulmonary edema, pink frothy sputum

New S3 heart sound

Advanced hemodynamics:

High wedge pressure

Low cardiac index

Priority actions:

Avoid aggressive fluids

Reduce afterload

Start inotropes (dobutamine, milrinone)

Pressors if needed (norepinephrine is first-line)

Immediate cardiology intervention (cath lab, mechanical support)

Includes:

Septic

Anaphylactic

Neurogenic

Adrenal crisis

Early septic shock often looks warm:

Warm, flushed skin

Bounding pulses

Wide pulse pressure

High cardiac output, low vascular resistance

Neurogenic shock exception:

Warm, dry

Bradycardic

Caused by spinal cord injury above T6

SIRS (old criteria): too sensitive, not specific; triggered by many non-infectious conditions.

Sepsis-3 definition:
Life-threatening organ dysfunction caused by a dysregulated response to infection.

ICU tool measuring organ failure across six systems.

Suspected infection + 2 of 3:

Respiratory rate 22 or higher

Altered mentation

Systolic pressure 100 or less
→ Activate sepsis pathway immediately.

Sepsis PLUS:

Vasopressors needed to maintain a MAP of 65

Lactate level over 2 despite adequate fluid resuscitation
→ Mortality increases dramatically.

Airway, breathing, circulation first

High-flow oxygen

Two large-bore IVs immediately

Goal-directed fluids

Urine output target: 0.5–1 per hour → early marker of organ perfusion

Serial lactates

For sepsis:

Blood cultures before antibiotics if no delay

Broad-spectrum antibiotics within 60 minutes

Pressors through central line when possible

Maintain warmth; initiate stress-ulcer and DVT prevention

Hypovolemic: Cold + flat veins

Cardiogenic: Cold + wet lungs

Distributive (early septic): Hot + flushed

Neurogenic: Warm + bradycardic

Master these patterns → fast, accurate recognition.

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