What is the initial treatment for shock?

Initial Treatment for Shock

The initial treatment for shock is rapid administration of at least 30 mL/kg of intravenous crystalloid fluid within the first 3 hours, followed by vasopressor therapy targeting a mean arterial pressure of 65 mmHg if hypotension persists despite adequate fluid resuscitation. 1, 2, 3

Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for patients with shock-induced hypoperfusion 1, 2
• Use crystalloids (balanced crystalloids or normal saline) as the fluid of choice for initial resuscitation 1, 3
• Continue fluid administration using a fluid challenge technique as long as hemodynamic parameters continue to improve 1
• For pediatric patients with hypovolemic shock, administer a bolus of 20 mL/kg of isotonic crystalloid even if blood pressure is normal, and give additional boluses if systemic perfusion fails to improve 1

Type of Fluid

• Crystalloids are preferred over colloids for initial resuscitation due to better survival outcomes and lower cost 1, 4
• Consider using either balanced crystalloids (e.g., lactated Ringer's solution) or normal saline for fluid resuscitation 1
• Albumin may be considered in addition to crystalloids when patients require substantial amounts of crystalloids 1
• Avoid hydroxyethyl starches for intravascular volume replacement due to increased risk of acute kidney injury and mortality 1, 5

Vasopressor Therapy

• If hypotension persists despite adequate fluid resuscitation, initiate vasopressor therapy to target a mean arterial pressure (MAP) of 65 mmHg 1, 2
• Use norepinephrine as the first-choice vasopressor 1, 5
• Consider adding either vasopressin (up to 0.03 U/min) or epinephrine to norepinephrine when an additional agent is needed to maintain adequate blood pressure 1
• Place an arterial catheter as soon as practical in patients requiring vasopressors if resources are available 1

Monitoring and Assessment

• Measure lactate levels at the time of shock diagnosis and repeat within 6 hours if initially elevated 2, 3
• Guide additional fluid administration by frequent reassessment of hemodynamic status using dynamic variables (e.g., change in pulse pressure, stroke volume variation) when available 1, 3
• Monitor for signs of adequate tissue perfusion, including capillary refill time, skin mottling, temperature of extremities, peripheral pulses, mental status, and urine output 2

Type-Specific Considerations

Septic Shock

• Obtain appropriate microbiologic cultures before starting antimicrobial therapy (if no significant delay >45 minutes) 2
• Administer broad-spectrum antimicrobials as soon as possible and within one hour of recognition of septic shock 2, 5
• Identify and control the source of infection as rapidly as possible 2, 3

Hypovolemic Shock

• In trauma patients, use an isotonic crystalloid solution (e.g., lactated Ringer's solution or normal saline) as the initial fluid for treatment 1
• For pediatric patients with hypovolemic shock, give a bolus of 20 mL/kg of isotonic crystalloid even if blood pressure is normal 1

Common Pitfalls and Caveats

• Avoid fluid overresuscitation, which can delay organ recovery, prolong ICU stay, and increase mortality 5, 6
• Do not use etomidate in patients with septic shock due to its association with higher mortality rates 1
• Avoid hydroxyethyl starches for fluid resuscitation due to increased risk of acute kidney injury and mortality 1, 5
• Do not delay vasopressor initiation if the patient remains hypotensive despite initial fluid resuscitation 1

Phases of Fluid Management

• Consider the four phases of fluid therapy: resuscitation phase (initial aggressive fluid administration), optimization phase (titrated fluid administration), stabilization phase (maintenance fluids only), and evacuation phase (fluid removal) 6
• After initial resuscitation, transition to a more conservative fluid strategy to prevent fluid overload 6