Shock

Table of Contents

(Adapted from an evidence-based guideline created using the National Prehospital Evidence-Based Guideline Model Process)

Aliases

None noted

Patient Care Goals

1. Initiate early fluid resuscitation and vasopressors to maintain/restore adequate perfusion to vital organs
2. Differentiate between possible underlying causes of shock in order to promptly initiate additional therapy

Patient Presentation

Inclusion Criteria

1. Signs of poor perfusion (due to a medical cause) such as one or more of the following:
   1. Altered mental status
   2. Delayed/flash capillary refill
   3. Hypoxia (pulse oximetry 94%)
   4. Decreased urine output
   5. Respiratory rate greater than 20 in adults or elevated in children (see normal vital signs table)
   6. Hypotension for age (lowest acceptable systolic blood pressure in mm Hg):
      1. Less than 1 yo: 60
      2. 1-10 yo: (age in years) x (2)+70
      3. Greater than 10 yo: 90
   7. Tachycardia for age, out of proportion to temperature [see Appendix VIII – Abnormal Vital Signs]
   8. Weak, decreased or bounding pulses
   9. Cool/mottled or flushed/ruddy skin
2. Potential etiologies of shock:
   1. Hypovolemia (poor fluid intake, excessive fluid loss (e.g. bleeding, SIADH, hyperglycemia excessive diuretics, vomiting, diarrhea)
   2. Sepsis
      1. Temperature instability:
         1. Less than 36°C or 96.8°F or greater than 38.5°C or 101.3°F
            and/or
         2. Tachycardia, warm skin, tachypnea
      2. Anaphylaxis (urticaria, nausea/vomiting, facial edema, wheezing)
      3. Signs of heart failure (hepatomegaly, rales on pulmonary exam, extremity edema, JVD)

Exclusion Criteria

Shock due to suspected trauma [see Trauma section guidelines]

Patient Management

Assessment

1. History
   1. History of GI bleeding
   2. Cardiac problems
   3. Stroke
   4. Fever
   5. Nausea/vomiting, diarrhea
   6. Frequent or no urination
   7. Syncopal episode
   8. Allergic reaction
   9. Immunocompromised (malignancy, transplant, asplenia)
   10. Adrenal insufficiency
   11. Presence of a central line or port
   12. Other risk of infection (spina bifida or other genitourinary anatomic abnormality)
2.  Exam
   1. Airway/breathing (airway edema, rales, wheezing, pulse oximetry, respiratory rate)
   2. Circulation (heart rate, blood pressure, capillary refill)
   3. Abdomen (hepatomegaly)
   4. Mucous membrane hydration
   5. Skin (turgor, rash)
   6. Neurologic (GCS, sensorimotor deficits)
3. Determination of type of shock
   1. Cardiogenic
   2. Distributive (neurogenic, septic, anaphylactic)
   3. Hypovolemic
   4. Obstructive (e.g. pulmonary embolism, cardiac tamponade, tension pneumothorax)

Treatment and Interventions

1. Check vital signs
2. Administer oxygen as appropriate with a target of achieving 94-98% saturation
3. Cardiac monitor
4. Pulse oximetry and ETCO₂ (reading of less than 25 mmHg may be sign of poor perfusion)
5. Check blood sugar, and correct if less than 60 mg/dl
6. EKG
7. Establish IV access – if unable to obtain within 2 attempts or less than 90 seconds, place an IO needle
8. IV fluids (20 mL/kg Normal Saline; maximum of 1 liter) over less than 15 minutes, using a push-pull method of drawing up the fluid in a syringe and pushing it through the IV (preferred for pediatric patients) – may repeat up to 3 times based on patient’s condition and clinical impression
   1. Best Method: Push-pull method of drawing up the fluid in a 60-cc syringe and pushing it through the IV
   2. Better Method: Commercial pressure-bag
   3. Minimum Method: Hand squeezing or blood pressure cuff
9. If there is a history of adrenal insufficiency or long-term steroid dependence, give:
   1. Use patient’s emergency steroid kit if available. Otherwise:
   2. Dexamethasone 0.6 mg/kg oral, IV, or IM to max dose of 10 mg
10. Vasopressors (shock unresponsive to IV fluids)
    1. Epinephrine by push dose (dilute boluses)
       1. Prepare 10 mcg/mL by adding 1 mL of Epinephrine (0.1 mg/mL) to 9 mL normal saline, then administer 10 mcg boluses (1 mL) every 1 minute titrated MAP greater than 65 mmHg
11. Provide advanced notification to the hospital

Notes – Shock