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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