Patient Presentation
A 65-year-old male is brought in with severe hypotension, tachycardia, and altered mental status after a prolonged episode of vomiting and diarrhea. On exam he has cool, clammy skin and weak peripheral pulses. His past medical history includes hypertension and type 2 diabetes.
The clinical picture suggests circulatory failure with inadequate delivery of blood, oxygen, and nutrients to vital organs. The combination of large-volume GI fluid losses, cool/clammy skin, and weak pulses points toward hypovolemic shock, but the broad differential of distributive, obstructive, and cardiogenic shock must be considered—particularly given his age and cardiac risk factors.
You are the surgeon evaluating him in the emergency department. You must stabilize, classify the shock, and direct etiology-specific therapy.
What You'll Be Asked — and What a Strong Resident Discusses
-
What is your immediate priority on first contact with this patient?
Expected answer
ABCs first. Assess and secure the airway—he is altered, so I evaluate his ability to protect his airway and intubate if needed. Confirm breathing/oxygenation, then address circulation: establish two large-bore IVs, place him on monitors, and begin an initial isotonic crystalloid bolus while simultaneously considering the etiology of shock. I draw labs during resuscitation rather than delaying treatment for results.
-
How do you classify shock, and which category does this patient most likely fall into?
Expected answer
Shock is divided into hypovolemic, distributive, obstructive, and cardiogenic. Given prolonged vomiting and diarrhea with cool, clammy skin and weak pulses, this is most consistent with hypovolemic shock from GI volume losses. Cool/clammy peripheries reflect high systemic vascular resistance and compensatory vasoconstriction, which distinguishes it from the warm extremities of early distributive (e.g., neurogenic or septic) shock.
-
What labs and studies do you order, and what are you looking for?
Expected answer
BMP (to assess electrolytes, renal function, and a metabolic derangement from GI losses), CBC, coagulation studies, serum lactate as a marker of hypoperfusion, liver and renal function tests, ABG, ECG given his cardiac risk factors, CXR, and blood cultures if infection is suspected. Lactate helps gauge severity and trend resuscitation; the ECG screens for ischemia/arrhythmia as an alternative or contributing cause.
-
You give 2 liters of crystalloid and he remains hypotensive. What now?
Expected answer
I reassess for adequacy of resuscitation and reconsider the etiology. Hypovolemic shock from GI losses often needs larger volumes, so I continue fluid resuscitation guided by endpoints—MAP, urine output, lactate clearance, and central venous parameters. If he remains hypotensive despite adequate volume, I start a vasopressor, place an arterial line and central venous access for monitoring, and aggressively rule out missed causes (occult bleeding, sepsis, cardiogenic, obstructive). Persistent shock unresponsive to fluids and pressors should also raise suspicion for adrenal crisis.
-
How would your fluid strategy differ if this were cardiogenic or obstructive shock instead?
Expected answer
Cardiogenic shock from LV infarction and obstructive shock from PE may require only small fluid volumes, because excess volume worsens cardiac function or fails to address the obstruction. By contrast, hemorrhagic shock, sepsis, and right ventricular infarction often require large volumes. This is why etiology must guide the total volume of resuscitation rather than reflexively giving large boluses to everyone.
-
He has a known infection history and now you suspect sepsis is contributing. How does management change?
Expected answer
Sepsis is treated with a multifaceted approach centered on volume resuscitation, early broad-spectrum IV antibiotics, and source control. I'd resuscitate to MAP and CVP goals using urine output, lactate clearance, and venous saturations to guide therapy, obtain cultures before antibiotics if feasible without delay, and add vasopressors (norepinephrine first-line) for persistent hypotension. Source control means identifying and addressing the focus—abscess drainage, perforation repair, etc.
-
If this patient instead had refractory hypotension unresponsive to fluids AND vasopressors, what diagnosis must you not miss, and how do you treat it?
Expected answer
Adrenal insufficiency/crisis, which presents as acute cardiovascular collapse unresponsive to fluids and vasopressors. I would give empiric IV corticosteroids—dexamethasone is first-line because it can be given empirically and does not interfere with the ACTH (cosyntropin) stimulation test used for diagnosis. I'd send a cortisol level and proceed with the stimulation test while treating.
-
Walk me through the emergent interventions for each type of obstructive shock.
Expected answer
Cardiac tamponade is relieved with pericardiocentesis or a pericardial window plus volume to support preload; tension pneumothorax requires immediate needle decompression followed by a chest tube; and massive pulmonary embolism causing shock is treated with thrombolysis (in the absence of contraindications). Each is a true emergency where intervention precedes extensive imaging once the diagnosis is clinically apparent.
-
How do you confirm your resuscitation is working?
Expected answer
I trend objective endpoints rather than blood pressure alone: improving mental status, warming extremities, restoration of MAP/CVP goals, urine output of roughly 0.5 mL/kg/hr or greater, clearing lactate, and adequate central/mixed venous oxygen saturation. Failure to improve despite appropriate therapy prompts me to re-examine the diagnosis and escalate monitoring and support.
What Residents Often Miss
- Delaying resuscitation to obtain imaging or wait for lab results in an unstable patient instead of starting ABCs and fluids immediately.
- Giving large fluid boluses indiscriminately—overresuscitating a cardiogenic (LV infarct) or PE patient who needs only small volumes.
- Anchoring on hypovolemia and failing to broaden the differential when the patient does not respond to fluids (missing sepsis, cardiogenic shock, or obstructive causes).
- Forgetting adrenal crisis in shock refractory to both fluids and vasopressors, or giving hydrocortisone in a way that confounds the ACTH stimulation test rather than empiric dexamethasone.
- Failing to address source control in sepsis—relying on antibiotics and fluids alone while ignoring a surgical focus.
- Using blood pressure as the sole resuscitation endpoint instead of lactate clearance, urine output, MAP/CVP, and venous oxygen saturation.
- Not securing the airway in an altered patient who cannot protect it, risking aspiration during resuscitation.
Want More Practice?
Run this case live with an AI examiner that pushes back, asks for operative detail, and grades you on the ABS competencies — then gives instant feedback.
Start practicing freeNo credit card required · 5 free practice cases
Keep Studying
This page is educational content for general-surgery board-exam practice. It is not medical advice and is not a substitute for clinical judgment, institutional protocols, or current primary literature.