What are the steps in managing shock?

Management of Shock: Step-by-Step Approach

Shock management requires immediate recognition and time-sensitive, goal-directed resuscitation within the first hour, focusing on restoring tissue perfusion through sequential fluid resuscitation, vasopressor/inotrope support, and treatment of the underlying cause. 1

Initial Recognition and Assessment (0-5 minutes)

Recognize shock by identifying hypotension (SBP <90 mmHg for >30 minutes) combined with end-organ hypoperfusion signs: altered mental status, cold/clammy extremities, urine output <30 mL/h (or <1 mL/kg/h in children), or lactate >2.0 mmol/L. 2, 1

• Immediately secure airway and establish vascular access (IV/IO) 2
• Support oxygenation and ventilation as needed—many cardiogenic shock patients require invasive mechanical ventilation 3
• Obtain blood cultures before antibiotics if sepsis suspected, but do not delay antibiotic administration 2
• Begin continuous cardiac monitoring and pulse oximetry 2

Immediate Resuscitation (5-15 minutes)

Administer rapid fluid boluses of 20 mL/kg isotonic crystalloid (normal saline or lactated Ringer's) in adults, repeating up to and exceeding 60 mL/kg until perfusion improves or signs of fluid overload develop (rales, hepatomegaly). 1, 2

• In neonates, use 10 mL/kg boluses up to 60 mL/kg 2, 1
• Correct hypoglycemia and hypocalcemia immediately 2
• Administer empiric broad-spectrum antibiotics within 1 hour if septic shock suspected 2, 1
• For suspected toxic shock syndrome with erythroderma, add clindamycin to reduce toxin production 2

First Hour Goals:

• Capillary refill ≤2 seconds 2, 1
• Normal heart rate for age 2, 1
• SBP ≥90 mmHg in adults 1

Fluid-Refractory Shock (15-60 minutes)

If shock persists after adequate fluid resuscitation, immediately initiate vasopressor or inotrope therapy based on shock phenotype while obtaining central venous access. 1, 2

For Distributive/Septic Shock (Warm Shock):

• Start norepinephrine as first-line vasopressor, titrating to MAP ≥65 mmHg 1
• Consider higher MAP targets (>65 mmHg) in patients with baseline hypertension 1

For Cardiogenic Shock (Cold Shock with Low Blood Pressure):

• Start dobutamine or dopamine (5-10 mcg/kg/min) as first-line inotrope 1
• If dopamine-resistant, escalate to epinephrine (0.05-0.3 mcg/kg/min) 2
• Titrate fluid and epinephrine together 2

For Cold Shock with Normal Blood Pressure:

• Titrate fluid and epinephrine 2
• If ScvO2 remains <70% despite adequate hemoglobin (>10 g/dL), add vasodilator therapy (nitroglycerin, nitroprusside, or milrinone) with volume loading 2

Advanced Hemodynamic Assessment (60 minutes)

Monitor central venous pressure and target normal perfusion pressure (MAP-CVP) for age, ScvO2 >70%, and cardiac index 3.3-6.0 L/min/m². 1, 2

• Perform transthoracic echocardiography to identify etiology, assess biventricular function, and measure filling pressures 2, 3
• For cardiogenic shock, obtain invasive hemodynamic measurements: cardiac index ≤2.2 L/min/m² and PCWP >15 mmHg confirm diagnosis 2
• Cardiac power output <0.6 W indicates severe cardiogenic shock 2

Catecholamine-Resistant Shock

If shock persists despite fluid resuscitation and vasopressor/inotrope therapy, administer hydrocortisone for suspected absolute adrenal insufficiency. 2, 1

• Rule out and correct mechanical causes: pericardial effusion, tension pneumothorax, intra-abdominal hypertension (>12 mmHg) 2, 1
• Consider pulmonary artery catheter, transpulmonary thermodilution (PiCCO), or serial echocardiography to guide targeted therapy 1, 2
• Add vasopressin, terlipressin, or angiotensin for refractory warm shock with persistent hypotension 2

Etiology-Specific Interventions

Cardiogenic Shock from Acute Myocardial Infarction:

Perform emergent coronary revascularization (PCI or CABG)—this is the only therapy proven to reduce mortality in AMI-related cardiogenic shock. 2

• Early revascularization within hours of presentation improves outcomes 2
• For multivessel disease, perform culprit-lesion-only PCI with option for staged revascularization 2

Septic Shock:

• Perform aggressive source control: debride necrotizing infections, drain abscesses, repair perforated viscus, remove infected devices 2
• Delay in source control synergistically increases mortality with inadequate antibiotics 2

Valvular Disease:

• Emergency cardiac surgery remains gold standard for shock from acute valvular dysfunction 2

Arrhythmia-Induced Shock:

• Restore sinus rhythm emergently in hemodynamically unstable patients 2
• Use amiodarone for atrial fibrillation (present in ~20% of cardiogenic shock patients) 2

Mechanical Circulatory Support

Consider mechanical circulatory support devices for refractory cardiogenic shock unresponsive to medical therapy: intra-aortic balloon pump, Impella, TandemHeart, or VA-ECMO based on phenotype and institutional expertise. 2

• Right ventricular support: Impella RP or TandemHeart RVAD 2
• Left ventricular support: IABP, Impella, or TandemHeart LVAD 2
• Biventricular support: VA-ECMO 2
• For refractory pediatric or neonatal shock, consider ECMO as rescue therapy 2, 1

Critical Pitfalls to Avoid

• Never delay antibiotics waiting for cultures in suspected septic shock—mortality increases with each hour of delay 2
• Do not continue aggressive fluid resuscitation once rales or hepatomegaly develop—this indicates fluid overload 2
• Avoid excessive ventilation during resuscitation—use 8-10 breaths/minute with advanced airway 2
• Do not use dopamine as first-line vasopressor in distributive shock—norepinephrine is superior 1
• Rotate compressors every 2 minutes during CPR to prevent fatigue and maintain quality 2
• Initiate continuous renal replacement therapy if fluid overload exceeds 10% despite diuretics 1

Ongoing Management

• Reassess hemodynamics and perfusion continuously—shock states can transition from one type to another 4
• Repeat echocardiography daily in cardiogenic shock to monitor biventricular function and filling pressures 2
• Maintain hemoglobin >10 g/dL in cardiogenic shock to optimize oxygen delivery 2
• Implement multidisciplinary team approach with intensivists and cardiologists for cardiogenic shock 2