Ask: What was it before? Manual or machine — please repeat it manually on the other arm. Is he awake and making sense? Heart rate? Is he warm or cold and clammy? Urine output? Any new drug or infusion in the last two hours?
Tell the nurse now: lie him flat if he tolerates it — a passive leg raise is a free, reversible test of fluid responsiveness, and if pulmonary oedema is the problem he needs sitting up instead · repeat cycle every 5 minutes · large-bore IV access · stop any antihypertensive infusion or sedation running · ECG · get a glucose · and a balanced crystalloid at the bedside, drawn up. The point of asking the questions first is to know whether fluid is the treatment or the injury — not to make a shocked patient wait for it.
- Distributive (sepsis, anaphylaxis, adrenal crisis) — warm periphery, wide pulse pressure, fever or recent antibiotic/contrast
- Hypovolaemic (bleeding, GI losses, over-diuresis) — cold, tachycardic, look under the sheets and do a rectal if there is any suspicion
- Cardiogenic (infarct, arrhythmia, tamponade, massive PE) — raised JVP, crackles, cold. Fluid harms this bucket
- Obstructive (tension pneumothorax, tamponade, PE) — raised JVP with clear lungs is the classic pairing
- Iatrogenic — the commonest cause on a ward at night. Read the drug chart before you read the patient
Name the dominant mechanism, not the only one. Real shock is usually mixed — sepsis on top of a poor ventricle, haemorrhage in a beta-blocked patient, PE with an empty tank — and the man at 80/50 does not wait politely while you finish assigning him to a single box.
FIRST MOVES Confirm manually with the right cuff — but if he is obviously shocked, treat him while you confirm. A cold, mottled, oliguric, confused patient at 80/50 is a different emergency from a chronically low 80/50 who is chatting. JVP and lung fields tell you about congestion; they do not tell you about fluid responsiveness, whatever you were taught, and they lie in the obese, the ventilated and the chronically breathless. Use a passive leg raise, POCUS if you are trained, and above all the response to a small bolus. If hypovolaemic or distributive shock is likely and there is no pulmonary oedema: 250–500 mL of balanced crystalloid, promptly, reassessed after each bolus — pressure, rate, capillary refill, mental state, urine, chest, oxygen requirement, lactate. Small, fast, reassessed; never a litre hung and forgotten. Lactate and cultures — cultures before antibiotics only where that costs no time, because in septic shock the antibiotic goes in inside the hour and an empty culture bottle is poor consolation. ECG. And if adrenal crisis is plausible or he is genuinely steroid-dependent, stress-dose hydrocortisone is not a “consider”: it is an order you write now, per the local protocol, without waiting for a cortisol.
Ward call: [AGE]-year-old [SEX], day [X] of admission for [REASON]. BP [BP] (manual, confirmed), previously running [BASELINE]. HR [HR], RR [RR], temp [T], sats [SAT]%, GCS [GCS]. Periphery [WARM/COLD]. JVP [FINDING]. Chest [FINDING]. Urine output last 6h [mL]. Drug chart: [ANTIHYPERTENSIVES/SEDATION/DIURETICS/NEW ANTIBIOTIC]. Fluid balance since admission [+/-]. Lactate [IF KNOWN]. Sort this into distributive / hypovolaemic / cardiogenic / obstructive / iatrogenic and tell me which bedside finding would move me between them. Tell me explicitly whether fluid is safe here. Then next five minutes, orders, escalation threshold.