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Shock
Resident Survival Guide
Overview
Causes
FIRE
Approach
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: Circulatory shock

Overview

Shock is the syndrome of circulatory failure that results in inadequate cellular oxygen utilization. The diagnosis of shock is based on clinical signs and biochemical abnormalities indicative of tissue hypoperfusion.[1]

Causes

Life Threatening Causes

Shock is a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Causes

  • Cardiogenic shock
  • Arrhythmic
  • Mechanical
  • Myopathic
  • Pharmacologic
  • Obstructive shock
  • Decreased cardiac compliance
  • Decreased ventricular preload
  • Increased ventricular afterload
  • Hypovolemic shock
  • Fluid depletion
  • Hemorrhage
  • Distributive shock

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Boxes in the salmon color signify that an urgent management is needed.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Identify cardinal findings
that increase the pretest
probability of shock

Altered mental status
Cold and clammy skin
Hypotension
Oliguria
Tachycardia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
 
 
 
 
 
 
 
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initial Management[1][2]

Ventilate—Infuse—Pump (VIP)
❑ Ventilatory support
❑ Normal saline 0.5–1.0 L q10–15 min
❑ ± Transfusion as needed
❑ ± Norepinephrine 0.1–2.0 μg/kg/min


❑ Arterial blood gas
❑ Pulse oximetry
❑ ECG monitor
❑ Central venous catheter

❑ ICU admission
 
 
 
 
 
 
 
 
 
Consider other causes
(eg, chronic hypotension, syncope)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Workups

❑ CBC/DC/SMA-7/LFT/PT/PTT/INR
❑ Troponin ± CK-MB
❑ Lactate
❑ CXR
❑ ± Cultures of blood, urine, etc.
❑ ± Echocardiography

❑ ± Pulmonary artery catheter
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Immediate Goals[3]

❑ SaO2 >90%–92%
❑ CVP 8–12 mmHg
❑ MAP >65–70 mmHg
❑ PCWP 12–15 mmHg
❑ CI >2.1 L/min/m2
❑ MVO2 >60%
❑ SCVO2 >70%
❑ Hemoglobin >7–9 g/dL
❑ Lactate <2.2 mM/L

❑ Urine output >0.5 mL/kg/h
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Complete Diagnostic Approach
Classify and Treat Accordingly
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Complete Diagnostic Approach

History

  • Review all medications
  • Accompanying symptoms that could pinpoint the underlying disease include:

Physical Examination

  • Vital signs
  • Temperature
  • Pulse
  • Respiration
  • Blood pressure
  • Mental status
  • Cutaneous
  • Neck
  • Cardiovascular
  • Pulmonary
  • Abdominal
  • Rectal
  • Extremities
  • Genitals
  • Neurologic

Laboratory Findings

  • Complete blood count
  • Electrolytes
  • Coagulation panel (PT, PTT, INR, etc.)
  • Cardiac markers
  • Liver function
  • Renal function
  • Lactate
  • Hyperlactatemia generally reflects the development of anaerobic metabolism in hypoperfused tissue and/or imparied hepatic clearance.
  • Lactate level could decrease within hours with effective therapy.[1]
  • Arterial blood gas
  • Cultures
  • Nasogastric aspirate
  • Pregnancy test

ECG Findings

Radiographic Findings

  • CT scan may aid in directing management in the following conditions:

Hemodynamic Profiles and Echocardiography Findings

Classification of shock based on hemodynamic profiles and echocardiographic findings.[4][5][1]
Type of Shock CO SVR PCWP CVP SVO2 Echocardiographic Findings
Cardiogenic Acute Ventricular Septal Defect ↓↓ N — ↑ ↑↑ ↑ — ↑↑ Large ventricles with poor contractility
Acute Mitral Regurgitation ↓↓ ↑↑ ↑ — ↑↑
Myocardial Dysfunction ↓↓ ↑↑ ↑↑
RV Infarction ↓↓ N — ↓ ↑↑ Dilated RV, small LV, abnormal wall motions
Obstructive Pulmonary Embolism ↓↓ N — ↓ ↑↑ Dilated RV, small LV
Cardiac Tamponade ↓ — ↓↓ ↑↑ ↑↑ Pericardial effusion, small ventricles, dilated inferior vena cava
Distributive Septic Shock N — ↑↑ ↓ — ↓↓ N — ↓ N — ↓ ↑ — ↑↑ Normal cardiac chambers with preserved contractility
Anaphylactic Shock N — ↑↑ ↓ — ↓↓ N — ↓ N — ↓ ↑ — ↑↑
Hypovolemic Volume Depletion ↓↓ ↓↓ ↓↓ Small cardiac chambers with normal or high contractility

Do's

  • Resuscitation should be initiated while investigation of the cause is ongoing. Correct the cause of shock immediately once it is identified.

Don'ts

References

  1. 1.0 1.1 1.2 1.3 Vincent, JL.; De Backer, D. (2013). "Circulatory shock". N Engl J Med. 369 (18): 1726–34. doi:10.1056/NEJMra1208943. PMID 24171518. Unknown parameter |month= ignored (help)
  2. Weil, MH.; Shubin, H. (1969). "The VIP approach to the bedside management of shock". JAMA. 207 (2): 337–40. PMID 5818156. Unknown parameter |month= ignored (help)
  3. Dellinger, RP.; Levy, MM.; Rhodes, A.; Annane, D.; Gerlach, H.; Opal, SM.; Sevransky, JE.; Sprung, CL.; Douglas, IS. (2013). "Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012". Crit Care Med. 41 (2): 580–637. doi:10.1097/CCM.0b013e31827e83af. PMID 23353941. Unknown parameter |month= ignored (help)
  4. Parrillo, Joseph E.; Ayres, Stephen M. (1984). Major issues in critical care medicine. Baltimore: William Wilkins. ISBN 0-683-06754-0.
  5. Weil, Max Harry; Shubin, Herbert (1967). Diagnosis and Treatment of Shock. Williams & Wilkins. ISBN 1125885874.


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