Aimed at rapid improvement of tissue hypoperfusion and respiratory impairment while underlying cause of shock is investigated (Fig. 12-1. Initial Treatment Algorithm in Shock States):

• Serial measurements of bp (intraarterial line preferred), heart rate, continuous ECG monitor, urine output, pulse oximetry, blood studies: Hct, electrolytes, creatinine, BUN, ABGs, pH, calcium, phosphate, lactate, urine Na concentration (<20 mmol/L suggests volume depletion). Consider monitoring of CVP and/or pulmonary artery pressure/PCW pressures in pts with ongoing blood loss, marked fluid shifts, or suspected cardiac dysfunction (majority of pts do not require pulmonary artery catheter monitoring).
• Insert urinary catheter to monitor urine output.
• Assess mental status frequently.
• Augment systolic bp to >100 mmHg: (1) Temporarily place in reverse Trendelenburg position; (2) IV volume infusion (500- to 1000-mL bolus), unless cardiogenic shock suspected (begin with crystalloid [normal saline or Ringer's lactate]; consider transfusion as part of fluid resuscitation, especially if Hgb <7 g/dL); continue volume replacement as needed to restore vascular volume.
• Add vasoactive drugs after intravascular volume is optimized; administer vasopressors (Table 12-3 Vasopressors Used in Shock Statesa ) if systemic vascular resistance (SVR) is decreased (norepinephrine preferred; for persistent hypotension, add vasopressin or phenylephrine).
• For cardiogenic shock, add inotropic agent (usually dobutamine) (Table 12-3 Vasopressors Used in Shock Statesa ); aim to maintain cardiac index >2.2 (L/m² )/min [>4.0 (L/m² )/min in septic shock].
• Administer supplemental O₂ to maintain SpO₂ 92-95%; intubate with mechanical ventilation if necessary.
• If severe metabolic acidosis is present (pH <7.15), administer NaHCO₃.
• Identify and treat underlying cause of shock. Cardiogenic shock in acute MI is discussed in Chap. 121 ST-Segment Elevation Myocardial Infarction. Emergent coronary revascularization may be lifesaving if persistent ischemia is present.