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, aids to determine the type and initial 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 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 signifies 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 correlates with increased left ventricular end diastolic pressure and decreased left ventricular ejection fraction and suggests heart failure, tricuspid stenosis, pulmonary hypertension, superior vena cava obstruction, constrictive pericarditis, or cardiac tamponade.
- Kussmaul's sign may occur with constrictive pericarditis, restrictive cardiomyopathy, tricuspid stenosis, superior vena cava obstruction, or right ventricular infarction.
- Abdominojugular reflux
- A positive abdominojugular reflux correlates with a PCWP of 15 mmHg or greater and suggests constrictive pericarditis, cardiac tamponade, tricuspid insufficiency, inferior vena cava obstruction, or heart failure (except pure backward left-sided heart failure).
- Blunted y descent suggests cardiac tamponade or tricuspid stenosis.
- Steep y descent suggests constrictive pericarditis or severe tricuspid insufficiency.
- Cardiovascular
- Pulmonary
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- Chest percussion may aid in the diagnosis of tension pneumothorax, pleural effusions, and pneumonia
- Abdominal
- Extremities
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- Erythema at the site of vascular access
- Genitals
- Perform a pelvic examination in women of childbearing age to rule out ectopic pregnancy or pelvic inflammatory disease.