What are the physical exam findings of inadequate tissue perfusion?

From the Guidelines

Physical examination findings of inadequate tissue perfusion include cool, pale, or mottled skin, delayed capillary refill time, weak or thready peripheral pulses, tachycardia, hypotension, mental status changes, and decreased urine output. These signs are indicative of poor microcirculation and decreased cardiac output, which can lead to organ dysfunction and failure if left untreated 1. The physical exam may reveal:

• Cool, pale, or mottled skin due to peripheral vasoconstriction and reduced blood flow
• Delayed capillary refill time (greater than 3 seconds in children and adults under 65, and greater than 4.5 seconds in elderly patients) 1
• Weak or thready peripheral pulses, suggesting decreased cardiac output
• Tachycardia, representing a compensatory mechanism to maintain tissue perfusion
• Hypotension, or normal blood pressure in early stages due to compensatory mechanisms
• Mental status changes, such as confusion, lethargy, or agitation, from cerebral hypoperfusion
• Decreased urine output (oliguria), reflecting renal hypoperfusion, with a urine output of less than 0.5 mL/kg/hour in adults or 1 mL/kg/hour in children 1 These signs vary depending on the cause of inadequate perfusion, which may include shock states, heart failure, severe dehydration, or sepsis, and the severity of findings correlates with the degree of perfusion deficit 1.

From the Research

Physical Exam of Inadequate Tissue Perfusion

The physical exam of inadequate tissue perfusion can manifest in various ways, depending on the underlying cause and severity of the condition. Some common signs and symptoms include:

• Altered mental status, such as confusion or decreased consciousness 2
• Decreased urine output, indicating inadequate renal perfusion 2
• Cool or cold extremities, indicating decreased peripheral perfusion 2
• Decreased capillary refill, indicating impaired microcirculation 3
• Tachycardia or bradycardia, indicating compensatory mechanisms or cardiac dysfunction 4
• Hypotension, indicating decreased cardiac output or peripheral resistance 4

Specific Causes of Inadequate Tissue Perfusion

Different causes of inadequate tissue perfusion may present with distinct physical exam findings, such as:

• Cardiogenic shock: signs of cardiac dysfunction, such as S3 gallop or jugular venous distension 5
• Hypovolemic shock: signs of dehydration, such as dry mucous membranes or decreased skin turgor 2
• Distributive shock: signs of vasodilation, such as warm extremities or bounding pulses 2
• Obstructive shock: signs of impaired cardiac filling, such as jugular venous distension or decreased cardiac output 2

Diagnostic Techniques

Various diagnostic techniques can be used to assess tissue perfusion, including:

• Transcutaneous oxygen measurements, which can estimate tissue oxygenation 3
• Laboratory testing, such as serum lactate levels, which can indicate tissue hypoperfusion 2
• Imaging studies, such as echocardiography or angiography, which can evaluate cardiac function or vascular perfusion 2