What is the initial management for a patient in shock?

Initial Management of Shock

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

Immediate Assessment and Recognition (First 15 Minutes)

• Rapidly evaluate vital signs including heart rate, blood pressure, respiratory rate, temperature, oxygen saturation, and mental status to confirm shock state 1, 4
• Measure serum lactate immediately at time of shock recognition, as elevated lactate (>2 mmol/L) indicates tissue hypoperfusion and guides resuscitation intensity 3, 4
• Identify shock type through focused clinical examination: assess jugular venous pressure, heart sounds, lung sounds, skin perfusion (temperature, mottling, capillary refill), and urine output 1, 4

Fluid Resuscitation (First 3 Hours)

Administer a minimum of 30 mL/kg of IV crystalloid (either normal saline or balanced crystalloids like Ringer's lactate) within the first 3 hours as the cornerstone of initial shock management. 1, 2, 3

• Use crystalloids as the first-line fluid choice; avoid hydroxyethyl starches completely as they increase acute kidney injury and mortality 1, 2, 3
• Give fluid in rapid boluses of 500-1000 mL over 15-30 minutes, reassessing hemodynamic response after each bolus 1, 2
• Continue additional fluid challenges beyond the initial 30 mL/kg if hemodynamic parameters continue to improve with each bolus 1, 2

Special Considerations for Fluid Choice

• Use isotonic crystalloids (normal saline or balanced solutions) for most shock patients 1, 3
• Avoid hypotonic solutions like Ringer's lactate in patients with severe traumatic brain injury to prevent fluid shift into damaged cerebral tissue and worsening cerebral edema 1
• In trauma patients with hemorrhagic shock, use restrictive fluid strategy targeting systolic blood pressure of 80-90 mmHg (permissive hypotension) until bleeding is surgically controlled, except in patients with traumatic brain injury or spinal cord injury who require normal blood pressure to maintain adequate perfusion 1

Hemodynamic Monitoring and Targets

• Target mean arterial pressure (MAP) ≥65 mmHg as the primary hemodynamic goal 1, 2, 3, 5
• Use dynamic measures of fluid responsiveness (passive leg raise, pulse pressure variation, stroke volume variation) rather than static measures like central venous pressure (CVP) alone to guide ongoing fluid administration 1, 2
• Place arterial catheter for continuous blood pressure monitoring as soon as practical in patients requiring vasopressors 2
• Repeat lactate measurement within 6 hours after initial resuscitation if initially elevated, targeting lactate normalization 3, 4

Vasopressor Therapy

If hypotension persists despite adequate fluid resuscitation (after initial 30 mL/kg), initiate norepinephrine as the first-choice vasopressor to maintain MAP ≥65 mmHg. 1, 2, 3, 4

• Start norepinephrine at 0.05 mcg/kg/min and titrate upward every 10-15 minutes to achieve MAP target 2, 5
• Add epinephrine (starting at 0.05 mcg/kg/min, titrating to 2 mcg/kg/min) or vasopressin (0.01-0.04 units/minute for septic shock) when additional agent is needed beyond norepinephrine alone 2, 5, 6, 7
• Avoid low-dose dopamine for renal protection as it is ineffective 2

Septic Shock-Specific Management

Administer IV broad-spectrum antimicrobials within 1 hour of recognizing septic shock, even before obtaining cultures if this would cause delay. 2, 3, 4

• Obtain at least two sets of blood cultures (aerobic and anaerobic) before starting antimicrobials if this does not significantly delay therapy (>45 minutes) 3, 4
• Identify and control source of infection as rapidly as possible; implement drainage or debridement procedures as soon as medically and logistically practical 3, 4
• Remove any potentially infected foreign body or device 4

Hemorrhagic Shock-Specific Management

• Control the source of bleeding as the absolute priority—arrange immediate surgical consultation for uncontrolled hemorrhage 1, 8
• In trauma with uncontrolled bleeding, use permissive hypotension (target systolic BP 80-90 mmHg) with restrictive fluid strategy until surgical hemostasis is achieved 1
• Transfuse packed red blood cells when hemoglobin falls below 70 g/L (target 70-90 g/L) in most patients 1
• Avoid excessive crystalloid administration (>2-3 liters pre-hospital) in trauma patients as this increases coagulopathy and mortality 1

Ongoing Reassessment (Every 15-30 Minutes)

• Continuously monitor clinical markers of perfusion: mental status, capillary refill time, skin mottling, peripheral pulses, urine output (target ≥0.5 mL/kg/hour) 1, 2, 4
• Reassess hemodynamic response after each fluid bolus and adjust therapy accordingly 1, 4
• Perform bedside echocardiography when available to assess cardiac function, volume status, and identify obstructive causes (tamponade, massive pulmonary embolism) 1

Critical Pitfalls to Avoid

• Do not delay antimicrobials in septic shock while waiting for cultures or imaging—administer within 1 hour 2, 3, 4
• Do not rely solely on CVP to guide fluid resuscitation; it poorly predicts fluid responsiveness 1, 2
• Do not use hydroxyethyl starches for volume replacement as they increase acute kidney injury and mortality 1, 2, 3
• Do not use aggressive fluid resuscitation in trauma patients with uncontrolled hemorrhage; this worsens coagulopathy and mortality 1
• Do not use hypotonic fluids in patients with traumatic brain injury 1
• In dialysis-dependent patients, monitor closely for fluid overload and arrange urgent dialysis or continuous renal replacement therapy if signs of volume overload develop during resuscitation 2