Shock physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Physical examination, along with medical history and clinical investigations, may aid in establishing diagnosis and directing mamngement of shock.

Physical Examination

• Vital signs

• Temperature

• Fever may suggest sepsis or anaphylactic reaction related to transfusion.
• Hypothermia may be associated with sepsis, adrenal crisis, or myxedema.

• Pulse

• Bradycardia or tachycardia can either be a primary or secondary process.
• Pulsus paradoxus may be seen in cardiac tamponade, pulmonary embolism, hemorrhagic shock, or tension pneumothorax.
• Pulsus alternans may be seen in heart failure, severe aortic insufficiency, or hypovolemic shock.

• Respiration

• Tachypnea commonly occurs in pneumothorax, sepsis, and cardiogenic shock.
• Hypopnea may be seen in narcotic or sedative overdose.

• Blood pressure

• Confirm arterial hypotension by checking blood pressure in both arms manually. Arterial line may be considered.
• Postural hypotension suggests volume depletion or autonomic dysfunction. Do not test orthostatic hypotension in hypotensive patients.

• Mental status

• Altered mental status may indicate inadequate perfusion to vital organs or use of sedatives or narcotics.

• Cutaneous

• Decreased skin turgor and dry mucous membrane signify dehydration.
• Cool extremities, clammy and mottled skin, peripheral cyanosis, and delayed capillary refill are commonly noted in cardiogenic shock and hypovolemic shock, whereas warm and moist skin may represent hyperdynamic phase of septic shock.
• Extensive burns and severe trauma may be evident on inspection and are associated with significant fluid loss.
• Hyperpigmentation may be an indicator of adrenal crisis.

• Neck

• Elevated jugular venous pressure (JVP) correlates with increased left ventricular end diastolic pressure (LVEDP) and decreased left ventricular ejection fraction (LVEF). Jugular venous distention or elevated JVP typically occurs in:

• Heart failure
• Tricuspid stenosis
• Pulmonary hypertension
• Superior vena cava obstruction
• Constrictive pericarditis
• Cardiac tamponade

• Kussmaul's sign

• Constrictive pericarditis
• Restrictive cardiomyopathy
• Tricuspid stenosis
• Superior vena cava obstruction
• Right ventricular infarction

• Abdominojugular reflux

• A positive abdominojugular reflux correlates with a PCWP of 15 mmHg or greater and may be seen in:
• Cardiac tamponade
• Constrictive pericarditis
• Tricuspid insufficiency
• Inferior vena cava obstruction
• Heart failure (except for pure backward left-sided heart failure)

• Jugular venous pressure waveform

• Blunted y descent suggests cardiac tamponade or tricuspid stenosis.
• Steep y descent suggests constrictive pericarditis or severe tricuspid insufficiency.

• Cardiovascular

• Decrescendo early systolic murmur

• Acute severe mitral regurgitation

• Third heart sound (S₃)

• Heart failure

• Pansystolic murmur along lower left sternal border with palpable thrill

• Ventricular septal defect

• Pericardial friction rubs

• Pericarditis

• Distant, muffled heart sounds

• Cardiac tamponade

• Pulmonary

• Tracheal deviation

• Tension pneumothorax

• Stridor and wheezing

• Anaphylaxis
• Acute exacerbation of chronic obstructive pulmonary disease

• Rales

• Anaphylaxis
• Pneumonia
• Heart failure

• Chest percussion may aid in the diagnosis of tension pneumothorax, pleural effusions, and pneumonia

• Abdominal

• Ecchymoses

• Retroperitoneal hemorrhage

• Hepatomegaly

• Inferior vena cava obstruction
• Heart failure

• Rebound tenderness with absent bowel sounds

• Sepsis due to Intraabdominal infection
• Ischemic colitis
• Gastrointestinal hemorrhage

• Pulsatile mass

• Abdominal aortic aneurysm

• Rectal

• Bright red blood or melena

• Gastrointestinal hemorrhage

• Diminished sphincter tone

• Spinal cord injury

• Extremities

• Digital clubbing

• Heart failure

• Edema

• Heart failure

• Erythema at the site of venous access

• Catheter-associated infection

• Pelvic girdle pain or instability

• Pelvic fracture

• Genitals

• Perform a pelvic examination in women of childbearing age to rule out ectopic pregnancy or pelvic inflammatory disease.

• Neurologic

• Agitation or delirium

• Poor cerebral perfusion

• Meningeal signs

• Meningitis