Clinical Management for Three Common Causes of Shock ...

Clinical Management for Three Common Causes of Shock 


 • Ensure adequate ventilation and oxygenation.

 • Provide immediate control of hemorrhage, when possible (eg, traction for long bone fractures, direct pressure), and obtain urgent consultation as indicated for uncontrollable hemorrhage.

 • Initiate judicious infusion of isotonic crystalloid solution (10-20 mL/kg).

 • With evidence of poor organ perfusion and 30-min anticipated delay to hemorrhage control, begin packed red blood cell (PRBC) infusion (5—10 mL/kg).

 • With suspected massive hemorrhage, immediate PRBC transfusion may be preferable as the initial resuscitation fluid.

 • Treat coincident dysrhythmias (eg, atrial fibrillation with synchronized cardioversion).


 • Ameliorate increased work of breathing; provide oxygen and positive end-expiratory pressure (PEEP) for pulmonary edema.

 • Begin vasopressor or inotropic support; norepinephrine (0.5 ug/min) and dobutamine (5 ug/kg/min) are common empirical agents.

 • Seek to reverse the insult (eg, thrombolysis, percutaneous transluminal angioplasty).

 • Consider intraaortic balloon pump counterpulsation for refractory shock.


 • Ensure adequate oxygenation; remove work of breathing.

 • Administer 20 mL of crystalloid/kg or 5 mL of colloid (albumin)/kg, and titrate infusion based on dynamic indices, volume responsiveness, and/or urine output.

 • Begin antimicrobial therapy; attempt surgical drainage or débridement.

 • Begin PRBC infusion for hemoglobin level <7 g/dL. If volume restoration fails to improve organ perfusion, begin vasopressor support with norepinephrine, infused at 0.5 ug/min.

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