Treatment of shock

Treatment of hemorrhagic shock includes volume resuscitation and control of bleeding,

in the OR or ED depending on the injury and available resources. Volume resuscitation

is initially with 2L of lactated Ringer’s solution unless blood products are immediately

available.

In the setting of trauma, transfusion of blood products should be in a 1:1:1 ratio between

packed RBCs, fresh frozen plasma, and platelets. Resuscitation should be continued

until BP and heart rate normalize and urine output reaches 0.5–1.0 ml/kg/hr. In the

setting of uncontrolled hemorrhage, permissive hypotension is recommended to prevent

further blood loss while awaiting definitive surgical repair, but a mean arterial pressure

>60 mm Hg should be maintained to ensure adequate cerebral perfusion.

The preferred route of fluid resuscitation in the trauma setting is 2 large bore peripheral

IV lines, 16-gauge or greater. If this cannot be obtained, percutaneous femoral vein

catheters should be inserted; saphenous vein cutdown and placement of ≥1 intraosseous

cannulas are acceptable alternatives. In children age <6, intraosseous cannulation of the

proximal tibia or femur is the alternate route.

Pericardial tamponade is generally a clinical diagnosis that can be confirmed with

U/S. Management requires evacuation of the pericardial space by pericardiocentesis,

subxiphoid pericardial window, or thoracotomy. Fluid and blood administration while

evacuation is being set up is helpful to maintain an adequate cardiac output.

Tension pneumothorax is a clinical diagnosis based on physical exam. Signs include

absent breath sounds, tracheal deviation, “hyperresonance,” and distended neck veins.

May also be hypotension and shock. Management requires immediate decompression of

the pleural space, initially with a large-bore needle (needle thoracostomy) which

converts the tension to a simple pneumothorax and followed by chest tube placement.

In the non-trauma setting, hypovolemic shock can also arise because of massive fluid

loss such as bleeding, burns, peritonitis, pancreatitis, or massive diarrhea. The clinical

picture is similar to trauma, with hypotension, tachycardia, and oliguria with a low

CVP. Stop the bleeding and replace the blood volume.

Non-traumatic (intrinsic) cardiogenic shock is caused by myocardial damage (e.g.

myocardial infarction or fulminant myocarditis). The clinical picture is hypotension,

tachycardia, and oliguria with a high CVP (presenting as distended neck veins). Treat

ment acutely consists of pharmacologic circulatory support, followed by attempts to

restore perfusion and/or cardiac function. Differential diagnosis is essential, because

additional fluid and blood administration in this setting could be lethal, as the failing

heart becomes easily overloaded.

Neurogenic/spinal shock is often associated with low BP and bradycardia. It can also

result in circulatory collapse. Patients are flushed, “pink and warm” with a low CVP.

Treatment with phenylephrine and fluids is aimed at filling dilated veins and restoring

peripheral resistance