Initial Treatment Algorithm in Shock States - Flowchart
Initial Treatment Algorithm in Shock States - Flowchart
«Flowchart»

General Considerations


ICU setting preferred
IV access (16G or 18G)
Consider central venous or pulmonary artery catheter (for diagnostic uncertainty or persistent shock)
Arterial line: for continuous BP, and arterial O2 tension and acid-base assessment
Urinary catheter: measure urine output
Airway management: maintain SpO2 92-95%; if needed, intubate and mechanically ventilate

General Considerations


ICU setting preferred
IV access (16G or 18G)
Consider central venous or pulmonary artery catheter (for diagnostic uncertainty or persistent shock)
Arterial line: for continuous BP, and arterial O2 tension and acid-base assessment
Urinary catheter: measure urine output
Airway management: maintain SpO2 92-95%; if needed, intubate and mechanically ventilate

General Considerations

General Considerations


ICU setting preferred
IV access (16G or 18G)
Consider central venous or pulmonary artery catheter (for diagnostic uncertainty or persistent shock)
Arterial line: for continuous BP, and arterial O2 tension and acid-base assessment
Urinary catheter: measure urine output
Airway management: maintain SpO2 92-95%; if needed, intubate and mechanically ventilate


ICU setting preferred
IV access (16G or 18G)
Consider central venous or pulmonary artery catheter (for diagnostic uncertainty or persistent shock)
Arterial line: for continuous BP, and arterial O2 tension and acid-base assessment 2
Urinary catheter: measure urine output
Airway management: maintain SpO2 92-95%; if needed, intubate and mechanically ventilate 2

Hypotension

Hypotension

Hypotension

Hypotension

End

End

End

BP, blood pressure; Echo, echocardiogram; IABP, intraaortic balloon pump; ICU, intensive care unit; PCI, percutaneous coronary intervention; PCWP, pulmonary capillary wedge pressure; RBC, red blood cell; RV, right ventricular.

BP, blood pressure; Echo, echocardiogram; IABP, intraaortic balloon pump; ICU, intensive care unit; PCI, percutaneous coronary intervention; PCWP, pulmonary capillary wedge pressure; RBC, red blood cell; RV, right ventricular.

BP, blood pressure; Echo, echocardiogram; IABP, intraaortic balloon pump; ICU, intensive care unit; PCI, percutaneous coronary intervention; PCWP, pulmonary capillary wedge pressure; RBC, red blood cell; RV, right ventricular.

Volume Resuscitation
(Frequently recheck volume status by exam, CVP, PCWP, or IVC diameter by echo)


Consider Trendelenburg position temporarily
Crystalloid bolus (e.g., 500 mL); repeat as needed
RBC transfusion for ongoing hemorrhage, or if hemoglobin <7 g/dL

Volume Resuscitation
(Frequently recheck volume status by exam, CVP, PCWP, or IVC diameter by echo)


Consider Trendelenburg position temporarily
Crystalloid bolus (e.g., 500 mL); repeat as needed
RBC transfusion for ongoing hemorrhage, or if hemoglobin <7 g/dL

Volume Resuscitation
(Frequently recheck volume status by exam, CVP, PCWP, or IVC diameter by echo)

Volume Resuscitation


Consider Trendelenburg position temporarily
Crystalloid bolus (e.g., 500 mL); repeat as needed
RBC transfusion for ongoing hemorrhage, or if hemoglobin <7 g/dL


Consider Trendelenburg position temporarily
Crystalloid bolus (e.g., 500 mL); repeat as needed
RBC transfusion for ongoing hemorrhage, or if hemoglobin <7 g/dL

Hypotension

Hypotension

Hypotension

Hypotension

Vasopressor and/or Inotropic Agents (Table 12-3)


Norepinephrine is first-line agent in distributive shock
Consider vasopressin as second choice in distributive/septic shock
Consider dobutamine in cardiogenic shock (can combine with norepinephrine, if needed for BP support)

Vasopressor and/or Inotropic Agents (Table 12-3)


Norepinephrine is first-line agent in distributive shock
Consider vasopressin as second choice in distributive/septic shock
Consider dobutamine in cardiogenic shock (can combine with norepinephrine, if needed for BP support)

Vasopressor and/or Inotropic Agents (Table 12-3)

Vasopressor and/or Inotropic Agents (Table 12-3)


Norepinephrine is first-line agent in distributive shock
Consider vasopressin as second choice in distributive/septic shock
Consider dobutamine in cardiogenic shock (can combine with norepinephrine, if needed for BP support)


Norepinephrine is first-line agent in distributive shock
Consider vasopressin as second choice in distributive/septic shock
Consider dobutamine in cardiogenic shock (can combine with norepinephrine, if needed for BP support)

Specific Therapies

Specific Therapies

Specific Therapies

Specific Therapies

Distributive shock


Suspected sepsis: Broad spectrum antibiotics after cultures obtained
Anaphylaxis: Remove allergen, epinephrine
Adrenal insufficiency: Stress dose steroids

Distributive shock

Distributive shock


Suspected sepsis: Broad spectrum antibiotics after cultures obtained
Anaphylaxis: Remove allergen, epinephrine
Adrenal insufficiency: Stress dose steroids


Suspected sepsis: Broad spectrum antibiotics after cultures obtained Suspected sepsis:
Anaphylaxis: Remove allergen, epinephrine Anaphylaxis:
Adrenal insufficiency: Stress dose steroids Adrenal insufficiency: Distributive shock

Cardiogenic shock


Acute coronary syndrome: Rapid reperfusion (PCI)
Acute MR, VSD, or free wall rupture: IABP, cardiac surgical repair
RV infarction: volume infusion to achieve RAP 10-15 mmHg

Cardiogenic shock

Cardiogenic shock


Acute coronary syndrome: Rapid reperfusion (PCI)
Acute MR, VSD, or free wall rupture: IABP, cardiac surgical repair
RV infarction: volume infusion to achieve RAP 10-15 mmHg


Acute coronary syndrome: Rapid reperfusion (PCI) Acute coronary syndrome:
Acute MR, VSD, or free wall rupture: IABP, cardiac surgical repair Acute MR, VSD, or free wall rupture:
RV infarction: volume infusion to achieve RAP 10-15 mmHg RV infarction: Cardiogenic shock

Obstructive shock


Tension pneumothorax: Mechanical decompression
Proximal pulmonary embolism: Thrombolysis, surgical/catheter clot removal
Cardiac tamponade: pericardiocentesis

Obstructive shock

Obstructive shock


Tension pneumothorax: Mechanical decompression
Proximal pulmonary embolism: Thrombolysis, surgical/catheter clot removal
Cardiac tamponade: pericardiocentesis


Tension pneumothorax: Mechanical decompression Tension pneumothorax:
Proximal pulmonary embolism: Thrombolysis, surgical/catheter clot removal Proximal pulmonary embolism:
Cardiac tamponade: pericardiocentesis Cardiac tamponade: Obstructive shock

Hypovolemic shock


Hemorrhage: Surgical, endoscopic, or interventional radiology approaches to eliminate source of bleeding

Hypovolemic shock

Hypovolemic shock


Hemorrhage: Surgical, endoscopic, or interventional radiology approaches to eliminate source of bleeding


Hemorrhage: Surgical, endoscopic, or interventional radiology approaches to eliminate source of bleeding Hemorrhage: Hypovolemic shock