Management and Treatment of Shock
Shock requires immediate identification and management through a standardized approach that prioritizes rapid assessment, hemodynamic stabilization, and addressing the underlying cause to reduce mortality and improve outcomes. 1
Types of Shock
Shock can be classified into four major categories based on underlying pathophysiology:
- Hypovolemic shock: Due to intravascular volume loss
- Distributive shock: Results from pathological redistribution of intravascular volume (includes septic, anaphylactic, neurogenic)
- Cardiogenic shock: Due to inadequate cardiac function
- Obstructive shock: Caused by blockage of circulation (e.g., pulmonary embolism, cardiac tamponade)
Initial Management Approach
Immediate Assessment and Stabilization
- Secure airway, breathing, and circulation
- Establish vascular access (consider intraosseous access if IV access is difficult) 2
- Obtain ECG and echocardiography immediately in suspected cardiogenic shock 2
- Initiate invasive monitoring with arterial line 2
- Identify signs of hypoperfusion: oliguria (<0.5 ml/kg/h), altered mental status, cool extremities, lactate >2 mmol/L, metabolic acidosis, SvO2 <65% 2
Fluid Resuscitation
- For hypovolemic and distributive shock:
Vasopressor Support
- Initiate if hypotension persists despite adequate fluid resuscitation
- Norepinephrine is the vasopressor of choice (start at 8-12 μg/min and titrate) 1
- Vasopressors should only be used when strictly needed to maintain systolic BP in persistent hypoperfusion 2
Inotropic Support
- For cardiogenic shock or evidence of cardiac dysfunction:
Specific Management by Shock Type
Cardiogenic Shock
- Transfer rapidly to a tertiary care center with 24/7 cardiac catheterization and ICU capabilities 2
- Consider mechanical circulatory support in refractory cases 2
- Device selection should be guided by:
- Acuity of illness
- Shock phenotype
- Degree of circulatory support required
- Vascular access/anatomy
- Center expertise 2
- Mechanical support options:
- Left ventricular failure: Impella devices or TandemHeart
- Right ventricular failure: Impella RP or TandemHeart Protek-Duo
- Biventricular failure: Bilateral Impella pumps or VA-ECMO 1
- Intra-aortic balloon pump (IABP) is not routinely recommended 2, 1
Septic Shock
- Administer broad-spectrum antimicrobials within one hour of recognition 2
- Identify and control source of infection
- Empiric antimicrobial therapy should be broad enough to cover all likely pathogens 2
- Narrow antimicrobial coverage once pathogen is identified or clinical improvement occurs 2
Monitoring and Management Targets
- Cardiac index ≥2.2 L/min/m²
- Mixed venous oxygen saturation ≥70%
- Mean arterial pressure ≥70 mmHg
- Urine output >30 mL/h
- Lactate clearance 1
Advanced Considerations
Mechanical Ventilation
- Consider early endotracheal intubation to reduce work of breathing and improve oxygenation
- Use low tidal volumes (<30 cmH2O peak pressure)
- Limit PEEP to <10 cmH2O when possible 1
Multidisciplinary Approach
- Implement a multidisciplinary shock team approach, which has been associated with improved 30-day mortality 1
- For cardiogenic shock, consultation with interventional cardiologist, cardiothoracic surgeon, cardiac intensivist, and advanced heart failure specialist is recommended 2
Regionalized Systems of Care
- Comprehensive shock care should be provided at a level 1 center 2
- Implement efficient "one-call" communication systems for expedited transfer 2
Common Pitfalls to Avoid
- Delaying antimicrobial therapy in septic shock
- Excessive afterload reduction in cardiogenic shock
- Using beta-blockers or calcium channel antagonists in low-output states
- Routine use of IABP in cardiogenic shock
- Delaying transfer to appropriate level of care
Early recognition and aggressive management of shock with appropriate fluid resuscitation, vasopressors, inotropes, and mechanical support when indicated are essential to improve outcomes and reduce mortality.