Initial Management of Shock
Begin immediate resuscitation with 30 mL/kg IV crystalloid within the first 3 hours while simultaneously identifying the shock type through focused clinical assessment, then initiate norepinephrine if hypotension persists despite adequate fluid resuscitation to maintain mean arterial pressure ≥65 mmHg. 1, 2
Immediate Recognition and Assessment
Rapidly evaluate vital signs and measure serum lactate immediately at the time of shock recognition, as elevated lactate indicates tissue hypoperfusion and guides resuscitation intensity 1. The critical vital signs to assess include heart rate, blood pressure, respiratory rate, temperature, oxygen saturation, mental status, and urine output 1, 2.
Identify the shock type through focused clinical examination by assessing jugular venous pressure, heart sounds, lung sounds, skin perfusion (including capillary refill time and mottling), and urine output 1, 2. If the clinical examination does not lead to a clear diagnosis, perform further hemodynamic assessment such as echocardiography to determine the type of shock 2.
Fluid Resuscitation: The Cornerstone of Initial Management
Administer a minimum of 30 mL/kg of IV crystalloid within the first 3 hours as the cornerstone of initial shock management 1, 2. This fixed volume enables clinicians to initiate resuscitation while obtaining more specific information about the patient and awaiting more precise hemodynamic measurements 2.
Give fluid in rapid boluses of 500-1000 mL over 15-30 minutes, reassessing hemodynamic response after each bolus 1. Continue fluid administration using a fluid challenge technique as long as hemodynamic factors continue to improve, based on either dynamic measures (such as pulse pressure variation or stroke volume variation) or static measures (such as arterial pressure, heart rate, urine output) 2, 1.
Use crystalloids as the first-line fluid choice for initial resuscitation and subsequent intravascular volume replacement 2, 1. Either balanced crystalloids or saline may be used 2. Consider adding albumin when patients require substantial amounts of crystalloids 2, 1.
Avoid hydroxyethyl starches completely for intravascular volume replacement, as they increase acute kidney injury and mortality 2, 1.
Hemodynamic Targets and Monitoring
Target a mean arterial pressure (MAP) of 65 mmHg as the primary hemodynamic goal in patients requiring vasopressors 2, 1.
Use dynamic measures of fluid responsiveness rather than static measures like central venous pressure (CVP) alone to guide ongoing fluid administration 2, 1. The use of CVP alone to guide fluid resuscitation can no longer be justified because its ability to predict response to a fluid challenge is limited 2.
Guide resuscitation to normalize lactate levels in patients with elevated lactate as a marker of tissue hypoperfusion 2, 1.
Vasopressor Therapy
If hypotension persists despite adequate fluid resuscitation, initiate norepinephrine as the first-choice vasopressor to maintain MAP ≥65 mmHg 1, 3, 4. Start norepinephrine at 0.05 mcg/kg/min and titrate upward every 10-15 minutes to achieve the MAP target 1, 4. The dosage may be adjusted periodically in increments of 0.05 mcg/kg/min to 0.2 mcg/kg/min to achieve the desired blood pressure goal 4.
Septic Shock-Specific Interventions
Administer IV broad-spectrum antimicrobials within 1 hour of recognizing septic shock, even before obtaining cultures if this would cause delay 1, 3. Obtain at least two sets of blood cultures before starting antimicrobials if this does not significantly delay therapy 1, 3.
Identify and control the source of infection rapidly, with any required source control intervention implemented as soon as medically and logistically practical after diagnosis 2. Remove intravascular access devices promptly if they are a possible source of sepsis or septic shock, after other vascular access has been established 2.
Hemorrhagic Shock-Specific Interventions
Control the source of bleeding as the absolute priority—arrange immediate surgical consultation for uncontrolled hemorrhage 1. In trauma with uncontrolled bleeding, use permissive hypotension with restrictive fluid strategy until surgical hemostasis is achieved 1.
Ongoing Reassessment
Continuously monitor clinical markers of perfusion: mental status, capillary refill time, skin mottling, peripheral pulses, and urine output 1, 2. Reassess hemodynamic response after each fluid bolus and adjust therapy accordingly 1, 2.
Use echocardiography to assess cardiac function and guide further management when available 2, 1.
Critical Pitfalls to Avoid
- Do not delay antimicrobials in septic shock while waiting for cultures or imaging—administer within 1 hour 1, 3
- Do not rely solely on CVP to guide fluid resuscitation, as 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
- Do not use aggressive fluid resuscitation in trauma patients with uncontrolled hemorrhage, as this worsens coagulopathy and mortality 1
- Do not withhold fluids due to concerns about concurrent conditions like atrial fibrillation, as adequate volume resuscitation takes precedence 5
- Avoid fluid overresuscitation once hemodynamic parameters stabilize, as this can prolong ICU stay and worsen outcomes 5