What is the initial treatment of shock?

Initial Treatment of Shock

The initial treatment of shock involves rapid recognition of decreased perfusion, establishing IV/IO access, administering high-flow oxygen, and providing fluid resuscitation with 20-30 mL/kg of isotonic crystalloid solution while simultaneously addressing the underlying cause. 1, 2

Initial Assessment and Stabilization

• Recognize signs of shock including decreased mental status, poor perfusion, tachycardia, and hypotension 1, 3
• Begin high-flow oxygen therapy immediately to improve tissue oxygenation 1
• Establish vascular access rapidly (IV or IO) according to resuscitation guidelines 1
• Monitor vital signs continuously including temperature, pulse oximetry, blood pressure, ECG, and urine output 1, 2

Fluid Resuscitation

• Administer isotonic crystalloid fluid boluses (20 mL/kg in adults, 10-20 mL/kg in children) and reassess after each bolus 1, 4
• Up to 60 mL/kg may be required in the first hour of resuscitation, observing for signs of fluid overload such as hepatomegaly or increased work of breathing 1
• Target restoration of normal perfusion parameters including capillary refill ≤2 seconds, normal pulses, warm extremities, and adequate urine output 1
• Use dynamic measures to assess fluid responsiveness when available rather than static measures 4

Hemodynamic Support

• If shock persists despite initial fluid resuscitation (fluid-refractory shock), begin vasopressor therapy 1
• Norepinephrine is the first-choice vasopressor for most shock states, particularly distributive shock 1, 5
• Initial norepinephrine dosing should be titrated to maintain a mean arterial pressure (MAP) of at least 65 mmHg 2, 5
• For cardiogenic shock, consider adding inotropic support with dobutamine 1, 6

Monitoring and Therapeutic Endpoints

• Target the following therapeutic endpoints: 1

  • Capillary refill ≤2 seconds
  • Normal pulses with no differential between peripheral and central pulses
  • Warm extremities
  • Urine output >1 mL/kg/hr
  • Normal mental status
  • Normal blood pressure for age
  • Arterial oxygen saturation >95%

• Measure serum lactate levels at presentation and repeat within 6 hours if initially elevated 2, 4

• Guide additional resuscitation to normalize lactate levels as a marker of improved tissue perfusion 4, 6

Type-Specific Considerations

• Identify the underlying shock category (hypovolemic, cardiogenic, distributive, or obstructive) to guide specific interventions 1, 7
• For hypovolemic shock: focus on aggressive fluid resuscitation and control of ongoing losses 1, 6
• For cardiogenic shock: optimize preload, consider inotropes, and address the underlying cardiac dysfunction 1, 8
• For distributive shock: administer early antibiotics (within 1 hour) if sepsis is suspected, in addition to fluids and vasopressors 2, 4
• For obstructive shock: rapidly identify and address the mechanical obstruction (tension pneumothorax, cardiac tamponade, pulmonary embolism) 1, 3

Common Pitfalls to Avoid

• Delaying fluid resuscitation while waiting for laboratory results or imaging studies 1, 2
• Failing to reassess frequently after interventions to guide ongoing management 4, 6
• Overlooking the need for source control in infectious causes of shock 2, 4
• Administering excessive fluid volumes without appropriate monitoring for signs of fluid overload 1, 6
• Delaying vasopressor initiation in persistent hypotension despite adequate fluid resuscitation 1, 5