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KEY CONCEPTS

KEY CONCEPTS

  • image The presence of shock is indicated by inadequate global tissue perfusion. Low blood pressures represent states of poor tissue perfusion but are not required to define shock.

  • image Shock is typically classified into one of four etiologic mechanisms: (1) hypovolemic, (2) cardiogenic, (3) obstructive, or (4) vasodilatory/distributive.

  • image Shock syndromes can be differentiated based on evaluation of preload, cardiac output, and afterload or assessment of surrogate markers.

  • image Inadequate oxygen delivery leads to organ damage in critical illness.

  • image Blood lactate should be measured in all patients in whom shock is suspected.

  • image Treatment of the patient with circulatory shock can be divided into four phases: salvage, optimization, stabilization, and de-escalation. Each phase has different but sometimes overlapping goals and therapeutic strategies.

  • image Crystalloid solutions are the first-line fluid of choice for forms of circulatory insufficiency that are associated with hemodynamic instability.

  • image Vasopressors and inotropes are required in patients with shock when volume resuscitation fails to maintain adequate blood pressure and tissues remain hypoperfused.

  • image The choice of a particular vasopressor or inotrope agent depends on the underlying shock pathophysiology, goals of therapy, and clinical pharmacology.

  • image Norepinephrine is the preferred initial vasopressor for shock.

PATIENT CARE PROCESS

Patient Care Process for Shock Syndromes

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Collect

  • Reason(s) for hospitalization

  • History of present illness

  • Patient characteristics (eg, age, sex, pregnant)

  • Past medical history

  • Social history (eg, tobacco/ethanol use)

  • Medication history, including intravenous fluids that have been administered

  • Review of systems and physical examination findings

  • Objective data

    • Blood pressure (BP), heart rate (HR), respiratory rate (RR), height, weight, O2-saturation

    • Labs including lactate, hemoglobin, platelets, serum creatinine, activated partial thromboplastin time, prothrombin time

    • Urine production if catheterized

    • Presence of visually evident bleeding

    • Other hemodynamic or advanced monitoring data (echocardiography) if available

Assess

  • Hemodynamic stability/instability (eg, systolic BP <90 mm Hg, HR >110 bpm, O2-sat <90% [0.90])

  • Noninvasive measures of circulatory insufficiency (eg, skin color, capillary refill, and temperature; level of consciousness; urine production if catheterized)

  • Dynamic markers of fluid responsiveness and advanced monitoring parameters if available

  • Change in baseline organ function as evidenced by laboratory or other measures of circulatory insufficiency

  • Risk for bleeding or ongoing bleeding based on objective data

  • Need for vasopressors

  • Goals and wishes of patient or healthcare surrogate decision maker's goals and wishes for the patient if the patient cannot express their goals and wishes

Plan

  • Surgery or procedure if needed (eg, noncompressible bleeding, coronary revascularization, debridement of infected tissue)

  • Initial focus on fluid resuscitation with type and amount of fluid based on patient-specific data

  • Initiation of vasoactive medications when patient is not responding to fluid resuscitation as is commonly seen in patients with vasodilatory/distributive forms of shock

  • Administer blood products as needed for hemorrhagic forms of shock

  • Intra-aortic balloon pump or extracorporeal life support for cardiac output augmentation

  • Referrals or consults to specialist providers (eg, infectious diseases providers, hematology providers) when appropriate

Implement*

  • Ensure that all members of the interprofessional care team and patient's ...

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