General Approach to All Patients

Shock

Shock is defined as a state of inadequate organ perfusion and tissue oxygenation. It is evidenced by the presence of any of the following signs and symptoms:

  • Hypotension
  • Narrow pulse pressure
  • Tachypnea
  • Tachycardia
  • Delayed capillary refill
  • Mottled skin appearance
  • Diaphoresis
  • Cool clammy skin
  • Pallor
  • Altered mental status

Signs and symptoms vary depending upon the stage of shock, which may be compensated (normal perfusion maintained) or decompensated (unable to maintain normal perfusion).

Categories of shock

  • Obstructive shock: Caused by an obstruction that interferes with return of blood to the heart. Examples include tension pneumothorax, cardiac tamponade, and massive pulmonary embolus.
  • Hypovolemic shock: Caused by decreased blood or water volume. Hypovolemic shock may be hemorrhagic or non-hemorrhagic.
  • Distributive shock: Caused by abnormal distribution of blood resulting from vasodilation, vasopermeability or both. Distributive shock may result from anaphylactic reactions (anaphylactic shock), sepsis (septic shock), or spinal cord injury (neurogenic shock).
  • Cardiogenic shock: Cardiogenic shock is a result of cardiac pump failure, usually caused by severe Left Ventricular failure. May result due to massive MI.

Perform the following in conjunction with protocols that apply to the specific etiology of the shock state (e.g. allergic reaction, sepsis, STEMI, trauma, etc.):

Advanced Life Support

  • Full ALS Assessment and Treatment
    • Record & monitor continuous 02 saturation and microstream capnography
  • Do not delay transport for IV insertion
  • IV 0.9% NaCl en route
    • Administer 250 ml boluses until systolic BP > 90 mmHg
    • Total amount of IVF should not exceed 2000 ml (1000 ml for chest trauma)
    • Boluses may be given in rapid succession if systolic remains < 90 mmHg
  • If systolic BP remains < 90 mmHg after 4th fluid bolus (1000 ml):
    • Dopamine infusion at 5-20 mcg/kg/min titrated to maintain systolic BP > 90 mm Hg