Notes – Shock

Shock

Patient Safety Considerations

  1. Recognition of cardiogenic shock – if patient condition deteriorates after fluid administration, rales or hepatomegaly develop, then consider cardiogenic shock and holding further fluid administration

Notes/Educational Pearls

Key Considerations

  1. Early, aggressive IV fluid administration is essential in the treatment of suspected shock
  2. Patients predisposed to shock:
    1. Immunocompromised (patients undergoing chemotherapy or with a primary or acquired immunodeficiency)
    2. Adrenal insufficiency (Addison’s disease, congenital adrenal hyperplasia, chronic or recent steroid use)
    3. History of a solid organ or bone marrow transplant
    4. Infants
    5. Elderly
  3. In most adults, tachycardia is the first sign of compensated shock, and may persist for hours. Tachycardia can be a late sign of shock in children and a tachycardic child may be close to cardiovascular collapse
  4. Hypotension indicates uncompensated shock, which may progress to cardiopulmonary failure within minutes
  5. Hydrocortisone succinate, if available, is preferred over methylprednisolone and dexamethasone for the patient with adrenal insufficiency, because of its dual glucocorticoid and mineralocorticoid effects
    1. Patients with no reported history of adrenal axis dysfunction may have adrenal suppression due to their acute illness, and hydrocortisone should be considered for any patient showing signs of treatment-resistant shock
    2. Patients with adrenal insufficiency may have an emergency dose of hydrocortisone available that can be administered IV or IM

Pertinent Assessment Findings

  1. Decreased perfusion manifested by altered mental status, or abnormalities in capillary refill or pulses, decreased urine output (1 mL/kg/hr):
    1. Cardiogenic, hypovolemic, obstructive shock: capillary refill greater than 2 seconds, diminished peripheral pulses, mottled cool extremities
    2. Distributive shock: flash capillary refill, bounding peripheral pulses

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914127 – Medical-Hypotension/Shock (Non-Trauma)

Key Documentation Elements

  • Medications administered
  • Full vital signs with reassessment every 15 minutes or as appropriate
  • Lactate level (if available)
  • Neurologic status assessment [see Appendix VII]
  • Amount of fluids given

Performance Measures

  • Percentage of patients who have full vital signs (HR, RR, BP, T, O2) documented
  • Presence of a decision support tool (laminated card, a protocol, or electronic alert) to identify patients in shock
  • Percentage of patients with suspected shock for whom advanced notification to the hospital was provided
  • Mean time from abnormal vitals to initiation of a fluid bolus
  • Percentage of patients who receive pressors for ongoing hypotension after receiving 30 mL/kg isotonic fluid in the setting of shock

References

  1. Annane D, Bellissant E, Bollaert P, Briegel J, Keh, D, Kupfer Y. Corticosteroids for treating severe sepsis and septic shock. 2004. Cochrane Database Syst Rev. 2004;(1):CD002243.
  2. Band, RA, Gaieski DF, Hylton JH, Shofer FS, Goyal M, Meisel ZF. Arriving by emergency medical services improves time to treatment endpoints for patients with severe sepsis or septic shock. Acad Emerg Med. 2011;18(9):934-40.
  3. Bernardin G, Pradier C, Tiger F, Deloffre P, Mattei M. Blood pressure and arterial lactate level are early indicators of short-term survival in human septic shock. Intensive Care Med. 1996;22(1):17-25.
  4. Boluyt N, Bollen C, Bos A, Kok J, Offringa M. Fluid resuscitation in neonatal and pediatric hypovolemic shock: A Dutch Pediatric Society evidence-based clinical practice guideline. Intensive Care Med. 2006;32(7):995-1003.
  5. Brierley J, Carcillo JA, Choong K, et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med. 2009;37(2):666-8.
  6. Carcillo JA, Davis AL, Zaritsky A. Role of early fluid resuscitation in pediatric septic shock. JAMA. 1991;266(9):1242-5.
  7. Choong K, Bohn D, Fraser DD, et al. Vasopressin in pediatric vasodilatory shock: a multicenter randomized controlled trial. Am J Respir Crit Care Med. 2009;180(7):632-9.
  8. Chopra A, Kumar V, Dutta A. Hypertonic versus normal saline as initial fluid bolus in pediatric septic shock. Indian J Pediatr. 2011;78(7):833-7.
  9. Cronin L, Cook DJ, Carlet J, et al. Corticosteroid treatment for sepsis: a critical appraisal and meta-analysis of the literature. Crit Care Med. 1995;23(8):1430-9.
  10. Cruz AT, Perry AM, Williams EA, Graf JM, Wuestner ER, Patel B. Implementation of goal-directed therapy for children with suspected sepsis in the emergency department. Pediatrics. 2011;127(3):e758-66.
  11. De Backer D, Aldecoa C, Njimi H, Vincent J. Dopamine versus norepinephrine in the treatment of septic shock: a meta-analysis. Crit Care Med. 2011;13(6):1-6.
  12. De Backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010;362(9):779-89.
  13. Guyette F, Suffoletto B, Castillo JL, Quintero J, Callaway C, Puyana, JC. Prehospital serum lactate as a predictor of outcomes in trauma patients: a retrospective observational study. J Trauma. 2011;70(4):782-6.
  14. Guyette FX, Gomez H, Suffoletto B, et al. Prehospital dynamic tissue oxygen saturation response predicts in-hospital lifesaving interventions in trauma patients. J Trauma Acute Care Surg. 2012;72(4):930-5.
  15. Han YY, Carcillo JA, Dragotta MA, et al. Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. Pediatrics. 2013;112(4):793-9.
  16. Hartholt KA, van Lieshout EM, Thies WC, Patka P, Schipper IB. Intraosseous devices: a randomized controlled trial comparing three intraosseous devices. Prehosp Emerg Care. 2010;14(1):6-13.
  17. Howell MD, David AM. Management of sepsis and septic shock. JAMA. 2017;317(8):847-8.
  18. Hunter CL, Silvestri S, Dean M, Falk JL, Papa L. End-tidal carbon dioxide is associated with mortality and lactate in patients with suspected sepsis. Am J Emerg Med (2013) 31, 64–71
  19. Jansen TC, van Bommel J, Mulder PG, Rommes JH, Schieveld SJ, Bakker, J. The prognostic value of blood lactate levels relative to that of vital signs in the pre-hospital setting: a pilot study. Crit Care. 2008;12(6):R160.
  20. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589-96.
  21. Lampard JG, Lang E. Vasopressors for hypotensive shock. Ann Emerg Med. 2013;31(3):351-2.
  22. Larsen GY, Mecham N, Greenberg R. An emergency department septic shock protocol and care guideline for children initiated at triage. Pediatrics. 2011;127(6):e1585-92.
  23. Levy B, Bastien O, Karim B, et al. Experts’ recommendations for the management of adult patients with cardiogenic shock. Ann Intensive Care. 2015;5(1):17.
  24. Lillis KA, Jaffe DM. Prehospital intravenous access in children. Ann Emerg Med. 1992;21(12):1430-4.
  25. Martin C, Papazian L, Perrin G, Saux P, Gouin F. Norepinephrine or dopamine for the treatment of hyperdynamic septic shock? Chest. 1993;103(6):1826-31.
  26. Martin C, Viviand X, Leone M, Thirion X. Effect of norepinephrine on the outcome of septic shock. Crit Care Med. 2000;28(8):2758-65.
  27. Mikkelsen ME, Miltiades AN, Gaieski DF, et al. Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock. Crit Care Med. 2009;37(5):1670-7.
  28. Morimatsu H, Singh K, Uchino S, Bellomo R, Hart G. Early and exclusive use of norepinephrine in septic shock. Resuscitation. 2004;62(2):249-54.
  29. Oliveira CF, Nogueira de Sá FR, Oliveira DS, et al. Time- and fluid-sensitive resuscitation for hemodynamic support of children in septic shock: barriers to the implementation of the American College of Critical Care Medicine/Pediatric Advanced Life Support Guidelines in a pediatric intensive care unit in a developing world. Pediatr Emerg Care. 2008;24(12):810-5.
  30. Patel GP, Grahe JS, Sperry M, et al. Efficacy and safety of dopamine versus norepinephrine in the management of septic shock. Shock. 2010;33(4):375-80.
  31. Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. Epub 2017 Jan 18.
  32. Santhanam I, Sangareddi S, Venkataraman S, Kissoon N, Thiruvengadamudayan V, Kasthuri RK. A prospective randomized controlled study of two fluid regimens in the initial management of septic shock in the emergency department. Pediatr Emerg Care. 2008;24(10):647-55.
  33. Sebat F, Johnson D, Musthafa AA, et al. A multidisciplinary community hospital program for early and rapid resuscitation of shock in nontrauma patients. Chest. 2005;127(5):1729-43.
  34. Seymour CW, Band RA, Cooke CR, et al. Out-of-hospital characteristics and care of patients with severe sepsis: a cohort study. J Crit Care. 2010;25(4):553-62.
  35. Shapiro NI, Howell MD, Talmor D, et al. Implementation and outcomes of the multiple urgent sepsis therapies (MUST) protocol. Crit Care Med. 2006;34(4):1025-32.
  36. Sholl JM, Chung S, Prentiss S, Smith JM, Shah MI. An evidence-based guideline for pediatric prehospital shock management using GRADE methodology. Manuscript in preparation.
  37. Studnek JR, Artho MR, Garner CL Jr., Jones AE. The impact of emergency medical services on the ED care of severe sepsis. Am J Emerg Med. 2012;30(1):51-6.
  38. Trzeciak S, Dellinger RP, Chansky ME, et al. Serum lactate as a predictor of mortality in patients with infection. Intensive Care Med. 2007;33(6):970-7.
  39. Van Beest PA, Mulder PJ, Oetomo SB, van den Broek B, Kuiper MA, Spronk PE. Measurement of lactate in a prehospital setting is related to outcome. Eur J Emerg Med. 2009;16(6):318-22.