The presentation of<unk> is variable, with some people having only minimal symptoms such as confusion and weakness. While the general signs for all types of<unk> are low blood pressure, decreased urine output, and confusion, these may not always be present. While a fast heart rate is common, those on β-blockers, those who are athletic, and in 30% of cases of those with<unk> due to intra abdominal bleeding may have a normal or slow heart rate. Specific subtypes of<unk> may have additional symptoms. Dry mucous membrane, reduced skin turgor, prolonged capillary refill time, weak peripheral pulses and cold extremities can be early signs of<unk>  Low volume Hypovolemic<unk> is the most common type of<unk> and is caused by insufficient circulating volume. The most common cause of hypovolemic<unk> is hemorrhage (internal or external); however, vomiting and diarrhea are more common causes in children. Other causes include burns, as well as excess urine loss due to diabetic ketoacidosis and diabetes insipidus. +Hemorrhage classes Class Blood loss (liters) Response Treatment I 40% (>2 l) critical blood pressure and heart rate aggressive interventions Signs and symptoms of hypovolemic<unk> include: *A rapid, weak, thready pulse due to decreased blood flow combined with tachycardia *Cool skin due to vasoconstriction and stimulation of vasoconstriction *Rapid and shallow breathing due to sympathetic nervous system stimulation and acidosis *Hypothermia due to decreased perfusion and evaporation of sweat *Thirst and dry mouth, due to fluid depletion *Cold and mottled skin (livedo reticularis), especially extremities, due to insufficient perfusion of the skin The severity of hemorrhagic<unk> can be graded on a 1–4 scale on the physical signs. The<unk> index (heart rate divided by systolic blood pressure) is a stronger predictor of the impact of blood loss than heart rate and blood pressure alone. This relationship has not been well established in pregnancy-related bleeding. Cardiogenic Cardiogenic<unk> is caused by the failure of the heart to pump effectively. This can be due to damage to the heart muscle, most often from a large myocardial infarction. Other causes of cardiogenic<unk> include dysrhythmias, cardiomyopathy/myocarditis, congestive heart failure (CHF), myocardial contusion, or valvular heart disease problems. Symptoms of cardiogenic<unk> include: *Distended jugular veins due to increased jugular venous pressure *Weak or absent pulse *Abnormal heart rhythms, often a fast heart rate *Pulsus paradoxus in case of tamponade *Reduced blood pressure *Shortness of breath, due to pulmonary congestion Obstructive Obstructive<unk> is a form of<unk> associated with physical obstruction of the great vessels of the systemic or pulmonary circulation. Several conditions can result in this form of<unk>  *Cardiac tamponade in which fluid in the pericardium prevents inflow of blood into the heart (venous return). Constrictive pericarditis, in which the pericardium shrinks and hardens, is similar in presentation. *Tension pneumothorax Through increased intrathoracic pressure, bloodflow to the heart is prevented (venous return). *Pulmonary embolism is the result of a thromboembolic incident in the blood vessels of the lungs and hinders the return of blood to the heart. *Aortic stenosis hinders circulation by obstructing the ventricular outflow tract *Hypertrophic sub-aortic stenosis is overly thick ventricular muscle that dynamically occludes the ventricular outflow tract. *Abdominal compartment syndrome defined as an increase in intra-abdominal pressure to > 20 mmHg with organ dysfunction. Increased intraabdominal pressure can be due to sepsis and severe abdominal trauma. This increased pressure reduced blood flow back to the heart, thereby reducing blood flow to the body and resulting in signs and symptoms of<unk>  Many of the signs of obstructive<unk> are similar to cardiogenic<unk>  however treatments differ. Symptoms of obstructive<unk> include: * Abnormal heart rhythms, often a fast heart rate. * Reduced blood pressure. * Cool, clammy, mottled skin, often due to low blood pressure and vasoconstriction. * Decreased urine output. Distributive Distributive<unk> is low blood pressure due to a dilation of blood vessels within the body. This can be caused by systemic infection (septic<unk> , a severe allergic reaction (anaphylaxis), or spinal cord injury (neurogenic<unk> . *Septic<unk> is the most common cause of distributive<unk>  It is caused by an overwhelming systemic infection resulting in vasodilation leading to hypotension. Septic<unk> can be caused by Gram negative bacteria such as (among others) Escherichia coli, Proteus species, Klebsiella pneumoniae which have an endotoxin on their surface which produces adverse biochemical, immunological and occasionally neurological effects which are harmful to the body, and other Gram-positive cocci, such as pneumococci and streptococci, and certain fungi as well as Gram-positive bacterial toxins. Septic<unk> also includes some elements of cardiogenic<unk>  In 1992, the ACCP/SCCM Consensus Conference Committee defined septic<unk>  " … sepsis-induced hypotension (systolic blood pressure < 90 mmHg or a reduction of 40 mmHg from baseline) despite adequate fluid resuscitation along with the presence of perfusion abnormalities that may include, but are not limited to, lactic acidosis, oliguria, or an acute alteration in mental status. Patients who are receiving inotropic or vasopressor agents may have a normalized blood pressure at the time that perfusion abnormalities are identified. The pathophysiology behind septic<unk> is as follows: 1) Systemic leukocyte adhesion to endothelial cells 2) Reduced contractility of the heart 3) Activation of the coagulation pathways, resulting in disseminated intravascular coagulation 4). Increased levels of neutrophils *The main manifestations of septic<unk> are due to the massive release of histamine which causes intense dilation of the blood vessels. People with septic<unk> will also likely be positive for SIRS criteria. The most generally accepted treatment for these patients is early recognition of symptoms, and early administration of broad spectrum and organism specific antibiotics. *Signs of septic<unk> include: *Abnormal heart rhythms, often a fast heart rate * Reduced blood pressure *Decreased urine output *Altered mental status *Anaphylactic<unk> is caused by a severe anaphylactic reaction to an allergen, antigen, drug or foreign protein causing the release of histamine which causes widespread vasodilation, leading to hypotension and increased capillary permeability. Signs of anaphylaxisSigns typically occur after exposure to an allergen and may include: * Skin changes, such as hives, itching, flushing and swelling. * Wheezing and shortness of breath. *Abdominal pain, diarrhea, and vomiting. * Lightheadedness, confusion, headaches, loss of consciousness. *High spinal injuries may cause neurogenic<unk>  which is commonly classified as a subset of distributive<unk>  The classic symptoms include a slow heart rate due to loss of cardiac sympathetic tone and warm skin due to dilation of the peripheral blood vessels. (This term can be confused with spinal<unk> which is a recoverable loss of function of the spinal cord after injury and does not refer to the hemodynamic instability.) Endocrine Although not officially classified as a subcategory of<unk>  many endocrinology disturbances in their severe form can result in<unk>  *Hypothyroidism (can be considered a form of cardiogenic<unk>  in people who are critically ill patients, reduces cardiac output and can lead to hypotension and respiratory insufficiency. *Thyrotoxicosis (cardiogenic<unk>  may induce a reversible cardiomyopathy. *Acute adrenal insufficiency (distributive<unk>  is frequently the result of discontinuing corticosteroid treatment without tapering the dosage. However, surgery and intercurrent disease in patients on corticosteroid therapy without adjusting the dosage to accommodate for increased requirements may also result in this condition. *Relative adrenal insufficiency (distributive<unk>  in critically ill patients where present hormone levels are insufficient to meet the higher demands
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