What is the initial management of shock?

Initial Management of Shock

Begin immediate resuscitation with at least 30 mL/kg of IV crystalloid fluid within the first 3 hours while simultaneously identifying and treating the underlying cause of shock. 1, 2

Immediate Assessment and Recognition

Recognize shock as a medical emergency requiring immediate treatment. 1 Look for early signs including:

• Decreased pulse pressure, tachycardia, tachypnea 3
• Altered mental status or decreased alertness 3
• Decreased urine output (target >0.5 mL/kg/hr) 4
• Elevated lactate levels (≥4 mmol/L indicates severe tissue hypoperfusion) 4, 1
• Cold, clammy skin and oliguria are late findings 3

Perform thorough clinical examination evaluating heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, and urine output to determine shock type. 1, 2

Fluid Resuscitation

Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours as the initial resuscitation strategy. 4, 1, 2, 5 This is a strong recommendation with moderate quality evidence from the Surviving Sepsis Campaign. 4

Use crystalloids (normal saline or balanced crystalloids) as the fluid of choice for initial resuscitation. 4, 2 Either balanced crystalloids or saline are acceptable options. 4

Continue fluid administration using a fluid challenge technique as long as hemodynamic parameters continue to improve. 4, 1, 2 Reassess frequently using dynamic variables (pulse pressure variation, stroke volume variation) over static variables when available. 4

Consider albumin in addition to crystalloids when patients require substantial amounts of crystalloids. 4 This is a weak recommendation with low quality evidence. 4

Avoid hydroxyethyl starches for intravascular volume replacement due to increased risk of acute kidney injury and mortality. 4, 2, 5 This is a strong recommendation with high quality evidence. 4

Hemodynamic Support

Target a mean arterial pressure (MAP) of 65 mmHg in patients requiring vasopressors. 4, 1, 2, 5 This is a strong recommendation with moderate quality evidence. 4

Use norepinephrine as the first-choice vasopressor for persistent hypotension despite adequate fluid resuscitation. 4, 1, 2, 5 This is a strong recommendation with moderate quality evidence from the Surviving Sepsis Campaign. 4

Add vasopressin (0.01-0.03 units/minute for septic shock; 0.03 units/minute for post-cardiotomy shock) or epinephrine when additional agents are needed to maintain adequate blood pressure. 4, 6 For septic shock, start vasopressin at 0.01 units/minute and titrate up by 0.005 units/minute at 10-15 minute intervals. 6

Source Control and Antimicrobials (for Septic Shock)

Obtain blood cultures and appropriate microbiologic samples before starting antimicrobials if this causes no substantial delay (>45 minutes). 4, 1, 2 Collect at least two sets of blood cultures (aerobic and anaerobic). 4, 1

Administer IV broad-spectrum antimicrobials within one hour of recognition for sepsis or septic shock. 1, 2, 5 This should cover all likely pathogens based on clinical syndrome and local epidemiology. 1, 5

Identify or exclude anatomic sources of infection requiring emergent source control as rapidly as possible. 4, 1, 2, 5 Implement required interventions (drainage, debridement, device removal) as soon as medically and logistically practical. 4, 1

Oxygenation and Monitoring

Apply oxygen to achieve oxygen saturation >90%. 1, 5 Consider non-invasive ventilation for patients with dyspnea or persistent hypoxemia despite oxygen therapy. 1, 5

Measure lactate levels at initial presentation and repeat within 6 hours if initially elevated. 1, 2 Guide resuscitation to normalize lactate as a marker of tissue hypoperfusion. 4, 1, 2

Monitor for signs of adequate tissue perfusion including capillary refill time, skin mottling, temperature of extremities, peripheral pulses, mental status, and urine output. 1

Critical Pitfalls to Avoid

Do not delay treatment while waiting for definitive diagnosis—shock is a medical emergency requiring immediate intervention. 1, 2 The most common errors include late diagnosis, inadequate fluid loading, and excessive reliance on vasopressors before adequate volume resuscitation. 3

Avoid fluid overresuscitation after initial stabilization, which can delay organ recovery and increase mortality. 5 Reassess hemodynamic status frequently and adjust fluid administration based on response. 4, 1, 2

Do not use systolic hypotension as the sole indicator of shock—look for earlier signs including decreased pulse pressure, tachycardia, and elevated lactate. 3