Undifferentiated Shock & Vasopressor GuideICU / resuscitation

MAP 58 with cold mottled legs and a lactate of 5 — cold & wet, warm & dry, or obstructed? Pick the right pressor for the physiology.

• Lactate ≥4
• Cool mottled extremities
• SBP <90 with oliguria
• Syncope with chest pain (think PE/dissection/ACS)

• Sepsis
• Acute MI / decompensated heart failure
• Massive PE, tamponade, tension pneumothorax
• Adrenal crisis, anaphylaxis, spinal shock

• Noradrenaline: First-line: sepsis, most shock — 0.05–1 mcg/kg/min
• Vasopressin: Add-on ≤0.03 U/min in refractory septic shock
• Adrenaline: Anaphylaxis; cold septic shock alternative
• Dobutamine: Inotrope for cardiogenic with low output — 2.5–10 mcg/kg/min

• MAP target is 65 — higher targets add arrhythmia, not survival
• Stage cardiogenic shock with SCAI SHOCK 2022 staging (A–E); angiotensin II (Giapreza) is a third-line catecholamine-sparing option (ATHOS-3)
• Bedside echo changes management in ~1/3 of undifferentiated shock
• The pressor buys time; only treating the cause saves the patient

• Give dopamine first-line (arrhythmias, worse outcomes)
• Withhold pressors until central access — peripheral noradrenaline through a good IV is safe short-term
• Bolus fluids into cardiogenic or obstructive shock

• Assuming sepsis in every warm patient
• Chasing a MAP number while lactate climbs
• Starting dobutamine in hypotension without a pressor (it vasodilates)
• Missing obstruction — POCUS early

ICU for all vasopressor-dependent patients; review pressor dose and volume status every hour; identify and document the shock type within the first hour.