Shock resident survival guide

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Resident Survival Guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Zaghw, MBChB. [2]


Shock is the syndrome of circulatory failure that results in inadequate cellular oxygen utilization. The diagnosis of shock is based on clinical signs (eg, altered mental status, oliguria, cold and clammy skin) and biochemical abnormalities (eg, hyperlactatemia, base deficit) indicative of tissue hypoperfusion.[1] Management of shock consists of stabilization of the hemodynamic status and correction of the underlying cause.


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.[2]

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

Abbreviations: CBC, complete blood count; CI, cardiac index; CK-MB, creatine kinase MB isoform; CVP, central venous pressure; DC, differential count; ICU, intensive care unit; INR, international normalized ratio; LFT, liver function test; MAP, mean arterial pressure; MVO2, mixed venous oxygen saturation; PCWP, pulmonary capillary wedge pressure; PT, prothrombin time; PTT, partial prothrombin time; SaO2, arterial oxygen saturation; SBP, systolic blood pressure; SCVO2, central venous oxygen saturation; SMA-7, sequential multiple analysis-7.

Does the patient have cardinal findings that increase the pretest probability of shock?

❑  Evidence of hypoperfusion

❑  Altered mental status
❑  Cool extremities
❑  Cyanosis
❑  Oliguria
❑  Sustained hypotension
❑  SBP <90 mm Hg or
❑  MAP ↓ >30 mm Hg below baseline for ≥30 min

Ventilate—Infuse—Pump (VIP)

❑  Oxygen ± intubation with mechanical ventilation

❑  Normal saline 300–500 mL over 20–30 min

❑  ± Norepinephrine 0.1–2.0 μg/kg/min
Consider alternative conditions
(eg, chronic hypotension, syncope)
Identify the cause
History of significant bleeding
or direct trauma to the
thoracic cavity?
NO, then proceed to the next question
Evidence of gastrointestinal hemorrhage,
vomiting, diarrhea?
YES, then consider and manage as
hypovolemic shock
NO, then proceed to the next question
Presence of fever
or hypothermia?
YES, then consider and manage as
septic shock
NO, then proceed to the next question
Presence of chest pain and/or
ischemic findings on ECG
with coronary risk factors?
YES, then consider and manage as
cardiogenic shock
NO, then proceed to the next question
Presence of
NO, then proceed to the next question
Presence of
YES, then consider and manage as
acute pulmonary embolism
NO, then proceed to the next question
Presence of abdominal pain or
low back pain?
YES, then consider intra-abdominal etiologies
and surgical consultation
NO, then proceed to the next question
Presence of wheezing with hives
or skin flushing?
YES, then consider and manage as
anaphylactic shock
NO, then proceed to
complete diagnostic approach below

Complete Diagnostic Approach

  • Review all medications
  • Findings suggestive of hypovolemic shock
  • Findings suggestive of cardiogenic shock
  • Findings suggestive of distributive shock
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
Type of Shock Etiology 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


Management of shock consists of stabilization of the hemodynamic status and correction of the underlying cause once it is identified.

Cardiogenic shock

Obstructive shock

Distributive shock

Hypovolemic shock


  • Initial Management
  • Resuscitation should be initiated while investigation is ongoing. Correct the cause of shock immediately once it is identified.
  • The VIP (Ventilate-Infuse-Pump) approach is useful for ensuring an orderly sequence of therapeutic-diagnostic maneuvers.[3]
  • Ventilate
  • Infuse
  • Pump



  1. 1.0 1.1 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. Rosen, Peter; Marx, John A. (2013). Rosen's emergency medicine : concepts and clinical practic. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1-4557-0605-1.
  3. 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)
  4. 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)