Management depends on accurate diagnosis. Once the team understands the underlying condition(s), they can begin management in the appropriate order by:

1. Addressing rate irregularities (arrhythmias) – Symptomatic arrhythmias should be treated first when they cause hypotension:
   • The duration of the arrhythmia can provide a useful clue as to the type. 
   • Atrial fibrillation rarely causes hypotension; instead, hypovolemia is often the underlying cause.
2. Managing volume irregularities (fluid loss or overload) – Symptomatic hypovolemia is treated first when it causes hypotension. If there is a concern for concurrent volume loss with contractility issues, the patient should be challenged with a small fluid bolus (250–500 mL of normal saline).
3. Managing contractility irregularities (cardiac and vascular) – Primary contractility issues (myocardial infarction, pulmonary edema secondary to cardiomyopathy, heart failure) should be treated with inotropic medicines rather than fluid. Vasopressor medicines should not be the initial therapy. However, if hypotension is severe (SBP < 60 mm Hg), both therapies may be administered concurrently. Providers should be cautious when using vasodilators to manage primary cardiac failure causing reduced cardiac output. They should ensure volume and blood pressure are adequate and be prepared to provide fluid as needed.