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Surgical sieve
📉 Hypotension
First: is it real, and what is their normal? Then: which shock — hypovolaemic, distributive, cardiogenic or obstructive? That decides whether fluid helps.
| Sepsis (any source) Must exclude | Warm peripheries early, then cold. Fever may be absent, and hypothermia is worse. Distributive: fluid helps, but only to a point.Sepsis Six within the hour. Lactate guides how worried to be. |
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| GI bleed Must exclude | Melaena or haematemesis — but a big bleed can present as hypotension and nothing else, especially in the elderly and the anticoagulated.Two large cannulae, group and save, Blatchford. PR examination is part of the assessment. |
| Post-operative or occult haemorrhage Must exclude | Tachycardia and a falling pressure after surgery or a procedure, with no visible blood. Retroperitoneal and intra-abdominal bleeds are invisible on the outside.Call the operating team. Serial haemoglobins are too slow to rely on alone — the observations are the test. |
| Cardiogenic shock Must exclude | Cold, clammy, oliguric, with a raised JVP and crackles. Fluid makes this one worse, which is what makes it the important one to spot.ECG and echo. Critical care early — this needs inotropes, not a bag of saline. |
| Massive PE Must exclude | Sudden hypotension with hypoxia and a clear chest. Raised JVP, right heart strain on the ECG.Obstructive shock. Urgent CTPA, or bedside echo if too unstable to move. Consider thrombolysis. |
| Cardiac tamponade Must exclude | Beck's triad and pulsus paradoxus. Think of it after cardiac surgery, in malignancy, and after any central line.Obstructive shock. Urgent echo — the diagnosis is made at the bedside. |
| Tension pneumothorax Must exclude | Absent breath sounds, hyper-resonance, tracheal deviation. Obstructive shock that kills in minutes.Clinical diagnosis — decompress before imaging. |
| Anaphylaxis Must exclude | Sudden hypotension after a drug, blood product or contrast. Skin signs may be absent, particularly in the profoundly shocked.IM adrenaline 500 micrograms, now. |
| Ruptured AAA Must exclude | Back or abdominal pain with hypotension in an older patient. A pulsatile mass is unreliable, and a normal blood pressure does not exclude it.Vascular surgery and CT if stable enough. Do not over-resuscitate — permissive hypotension. |
| Addisonian crisis Must exclude | Hypotension resistant to fluid, with hyponatraemia, hyperkalaemia and hypoglycaemia. Ask about long-term steroids that were stopped, missed or not doubled during illness.Hydrocortisone 100mg IV immediately — do not wait for a cortisol result. |
| Arrhythmia Time-sensitive | Too fast or too slow to fill. A rate above 150 or below 40 will drop a pressure on its own.ECG before anything else. Adverse features mean synchronised cardioversion or pacing, not drugs. |
| Hypovolaemia / pre-renal Time-sensitive | Dry, thirsty, oliguric, with a rising urea out of proportion to creatinine. Poor intake, diuretics, vomiting, diarrhoea, bleeding.Fluid challenge and reassess. This is the one where fluid is the treatment. |
| Drug-induced (opioids, beta-blockers) Time-sensitive | Check the drug chart and the timing. Antihypertensives, opioids, sedation, epidural top-ups, diuretics, and anything given in the last hour.Withhold the culprit. Specific antidotes exist for some — naloxone, glucagon for beta-blockers. |
| Neurogenic shock Time-sensitive | Hypotension WITHOUT a compensatory tachycardia — often bradycardic — with warm peripheries, after spinal cord injury or a high spinal or epidural block.The absent tachycardia is the clue. Vasopressors rather than endless fluid; involve anaesthetics and the spinal team. |
| Measurement or monitoring artefact Common | Cuff too large, arm above the heart, a damped arterial line, or a patient whose baseline systolic is 95. Check the other arm and the observation chart before treating.Repeat it manually. Treating a measurement artefact with fluid is common and occasionally harmful. |
15 differentials · 11 open a full pathway in the app.