Patient appears to be in shock
Characteristic clinical markers:
 Hypotension
 Tachycardia or bradycardia
 Tachypnea
 Cutaneus hypoperfusion
 Mental abnormalities
Hypovolemic or Inflammatory shock
Control bleeding; obtain vascular access; infuse crystalloid
(e.g., normal saline) in initial boluses of 60 ml/kg body
weight; give RBCs to maintain [Hb] ≥ 9 g/dl; treat pain,
hypothermia, acidemia, and coagulopathy. Goals:resolution
of clinical abnormalities and generation of adequate pressure
to perfuse CNS and organs with obstructed arterial inflow.
If patient remains unstable, transfer to setting where MAP
and CVP can be transduced. Goal:resolution of shock
without excessive CVP. If necessary, give dobutamine (5-
15µg/kg/min) or milrinone (loading dose followed by infusion
of 0,375-0,750 µg/kg/min)
Insert Swan-Ganz catheter if patient (1) requires excessive
fluid, (2) requires inotropes for >30 min, (3) might need
vasoconstrictors, (4) may have nonviable myocardium, or (5)
requires excessively high FIO2.
Decide on priority for subsequent resuscitation:
To ensure tissue perfusion (even at the cost possible
edema formation and increrased ventricular o2
requirements), or
To minimize edema and ventricular O2 requirements (even
at the cost of possible slow or incomplete resuscitation
from shock).
Identify and treat any immediately life threatening
conditions:
Oligouria  Dysrhythmias
Myocardial ischemia  Airway compromise, inadequate ventilation or
Metabolic acidemia compression of heart and great vessels (or both)
Hypoxemia  Bleeding
 Medical emergencies
Shock persists Shock resolves
Initiate specific therapy based on type of shock persistent
Compressive shock Intravascular obstuctive shock Neurogenic shock Cardiogenic shock
Compression of heart or great Reduce RVESP and LVESP by Place in Trendelenburg position. If RVEDV and LVEDV seem too large, initiate
vessels, as immediately life- decreasing arterial stiffness with diuretics, Infuse fluids as necessary, and give diuresis.
threatening condition (see above), beta blockers, ACE inhibitors, and vasoconstrictors (dopamine if HR≤ 89 Initiate beta blockade to keep HR≤89 beats/min
should already have been treated.
nitroglycerin. beats/min; norepinephrine if HR≥ 90 unless patient is hypotensive or wheezing.
Nevertheless, reassess periodically
(specifically, for adverse effects of If pressures remain too high, insert Swan- beats/min). Control LVESP. Reduce arterial stiffness with
mechanical ventilation and for Ganz catheter. Treat as for hypovolemic Periodically reassess for possibility of more agressive diuresis, increased beta
abdominal compartment or inflammatory shock (see left). hypovolemia or other cause of blockade, ACE inhibition, and nitroglycerin.
syndrome). If pulmonary vasculature is obstructed, inadequate end-diastolic volume (e.g., Goals: adequate MAP, adequate peripheral
If compressive shock is a ventilator mode may have to be changed. cardiac compression). If such possibility perfusion, and HR≤89 beats/min, with no sign of
possibility, insert Swan-Ganz If systemic vasculature is obstructed, is significant, insert Swan-Ganz myocardial ischemia.
catheter. Treat as for hypovolemic
aortic counterpulsating ballonn pump may catheter. Treat As for hypovolemic or If effort are unsuccessful, insert Swan-Ganz
or inflammatory shock (see left).
be needed. inflammatory shock (see left). catheter. Adjust left ventricular afterload to equal
50% of contractility. Balloon pump, coronary
angioplasty, or cardiac surgery may be required.
If problem is with right ventricle, adjustment of
ventilator may help.
Priority is ensuring resuscitaion; edema is Priority is minimizing edema formation and protecting heart; less than full resuscitation is
not a major problem, and myocardium is acceptable
not at risk Give fluids or diuretics (e.g., furosemide, 10-40 mg) as needed. Goal: either RVEDV or LVEDV (whichever is
Infuse fluids. Goal:RVEDV and LVEDV ≥ normal (2,5 smaller) normal, with neither volume below normal.
ml/kg)
If contractility is subnormal on either side, increase with dobutamine or milrinone. If it is supranormal on both
Give inotropes. Goal:normal contractility in both right
ventricle (0,4 mm Hg/ml) and left (2 mmHg/ml). sides, give beta blocker, starting with esmolol (loading dose followed by infusion of 50 µg/kg/min increased as
If absolutely necessary, and only as last resort,give needed) and switching to metoprolol (5-15µg q. 6hr).
vasopressors, starting with vasopressin. Goal: normal contractility on both right and left.
If HR≤89 beats/min, add dopamine (2-20 µg/kg/min). Adjust left ventricular afterload to equal 50% of contractility. If afterload ≤49% of contractility, give dopamine or
If HR≥90 beats/min, use norepinephrine (2-12µg/kg). dobutamine. Rarely (as last resort), use vasopressin and norepinephrine, but reassess frequently.
Increase left ventricular afterload until it equals If afterload ≥51% of contractility, reduce arterial stiffness with diuretic, beta blocker, ACE inhibitor (e.g.,
contractility; do not let it exceed contractility except in
enalaprilat, 1,25-5,0 mg q. 6 hr), and nitroglycerin (5-200 µg/kg/min)
desperate cases.
If HR≥ 90 beats/min, increase beta blockade until limited by hypotension or wheezing. If HR is still too fast, add
calcium channel blocker (e.g., diltiazem, 5-15 mg/hr).