Hypotension is one of the most common reason for a ‘rapid response’ or emergencies in a hospital setting. Time is of the essence and it helps to have a handy method to quickly recall all the differential diagnoses for hypotension and see what might apply in the context of your patient to take quick diagnostic and therapeutic actions.
Since hypotension can imply shock, we shall use the mnemonic “SHOCKED” to our advantage to mentally go over differential diagnoses of hypotension:
Mnemonic for causes of acute hypotension: “SHOCKED“
S – Sepsis: Is there Fever? Patient Warm & toasty to touch instead of cold & clammy?
H – Hemorrhage: Does patient look pale? A bleed can be internal or external. That effusion on CXR might be a hemothorax, and that ascites could be hemoperitoneum. A GI bleed may be occurring but might only be visible or cause anemia later.
O – Obstructive: As in obstruction of blood flow , which can be Internal such as Pulmonary embolism or External due to a compression & compromise of venous return (e.g. tension pneumothorax, abdominal compartment syndrome).
C – Cardiac: For anything related to the heart, think in terms of layers to quickly think of causes!! [Pericardium : Pericardial tamponade, Myocardium : ACS/MI ! Valves : Stenosis/Rupture, Conduction pathways = Arrythmias! ]
K – Kuff too tight? : A tongue-in-cheek play on K for Cuff or remember “Korotkoff’s sounds” used to measure BP. A tight cuff adds its own constricting pressure and falsely reduces the blood pressure reading during measurement. Say a cuff too tight exerts it’s own 20 mm Hg pressure, a BP of 100 systolic will be read falsely as 80 !
E – Epinephrine deficiency (in other words – Adrenal insufficiency – including Adrenal hemorrhage esp if they are anticoagulated) . Also IgE Antibody-mediated Hypotension a.k.a Anaphylaxis!
D – Dehydration? Drugs (Meds – including Spinal Anesthesia)? , Dysautonomia?
💡 Wasn’t that a piece of cake! Now Let’s Summarize :
S – Septic Shock
H – Hemorrhagic Shock (Internal or External)
O – Obstruction of blood vessel (Internal or External)
C – Cardiogenic (think of each layer of heart to recall causes)
K – Kuff error (or Korotkoff’s sounds error ) = BP cuff too tight
E – Epinephrine deficiency (i.e. Adrenaline Insuffiency) & IgE-Ab mediated Anaphylaxis
D – Dehydration, Drugs (meds), Dysautonomia
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