Priorities for Shock Treatment in an EMS Setting
The top priorities for shock treatment in an EMS setting are early recognition, rapid transport to an appropriate facility, and immediate interventions targeting the specific type of shock, with emphasis on maintaining tissue perfusion and oxygen delivery. 1, 2
Initial Assessment and Recognition
- Use validated assessment tools to quickly identify shock, focusing on vital signs (hypotension, tachycardia), mental status changes, and signs of poor perfusion 1, 3
- Determine the type of shock present (hypovolemic, cardiogenic, distributive, or obstructive) through rapid assessment of clinical presentation 2, 3
- Recognize that early shock is primarily hemodynamic and potentially reversible, while prolonged shock develops an inflammatory component leading to multiple organ failure 4
Immediate Interventions
- Secure airway and provide supplemental oxygen to hypoxemic patients (oxygen saturation <94%) or those with unknown oxygen saturation 1
- Establish vascular access (IV or IO) as quickly as possible for medication and fluid administration 1
- Position the patient appropriately based on shock type (supine with legs elevated for hypovolemic/distributive shock; semi-recumbent for cardiogenic shock with pulmonary edema) 3, 5
Type-Specific Management
Hypovolemic Shock
- Administer balanced crystalloid solutions for volume replacement 2, 3
- Control any visible external bleeding through direct pressure, tourniquets, or hemostatic agents as appropriate 5
- Avoid excessive fluid administration in traumatic shock with uncontrolled hemorrhage 3, 5
Cardiogenic Shock
- Identify patients with acute coronary syndromes (ACS) using 12-lead ECG; transmit to receiving facility when possible 1
- Prioritize rapid transport to PCI-capable centers for patients with STEMI or cardiogenic shock 1
- Administer aspirin (160-325 mg chewed) unless contraindicated by allergy or recent gastrointestinal bleeding 1
- Consider nitroglycerin for patients with ACS if systolic BP >90 mmHg and no contraindications (right ventricular infarction, PDE-5 inhibitor use) 1
Distributive Shock (including Anaphylactic)
- For anaphylactic shock, administer epinephrine immediately - intramuscular route preferred (0.3-0.5 mg of 1:1000 concentration in lateral thigh) 1, 6, 7
- For IV epinephrine in anaphylactic shock (when IV already established), use 0.05-0.1 mg (5-10% of cardiac arrest dose) administered slowly 1, 6
- Consider epinephrine infusion (5-15 μg/min) for persistent anaphylactic shock 1, 6
- Avoid injecting epinephrine into digits, hands, feet, or buttocks due to risk of tissue necrosis 7
Obstructive Shock
- Identify and treat tension pneumothorax immediately if suspected (especially in asthma patients receiving positive pressure ventilation) 1
- Consider cardiac tamponade, massive pulmonary embolism, or tension pneumothorax as reversible causes requiring immediate intervention 3, 5
Transport Considerations
- Minimize on-scene time - the goal is to "recognize and mobilize" quickly 1, 4
- Provide pre-notification to receiving facilities for all shock patients 1
- Transport to appropriate facilities based on shock type: PCI-capable centers for cardiogenic shock, trauma centers for hemorrhagic shock, and facilities with advanced capabilities for complex cases 1
Monitoring During Transport
- Continuously monitor vital signs, oxygen saturation, and cardiac rhythm 1, 5
- Reassess frequently to identify deterioration or response to interventions 3, 4
- Document timing of interventions and patient response to guide hospital management 5
Common Pitfalls to Avoid
- Delaying epinephrine administration in anaphylactic shock while focusing on second-line treatments 6
- Using incorrect epinephrine concentration or route for the clinical situation 6, 7
- Failing to recognize cardiogenic shock in patients with ACS, which requires rapid revascularization 1
- Excessive fluid administration in cardiogenic shock, which may worsen pulmonary edema 3, 5
- Delaying transport for interventions that can be performed en route 1, 4