Approach to Shock (Shock management)

Definition

Shock is an acute, life-threatening state of circulatory failure resulting in inadequate tissue perfusion and insufficient oxygen delivery to organs. If not recognized and treated promptly, shock progresses to multiple organ dysfunction and death.

Early identification of the underlying cause and prompt evidence-based management significantly improve survival.

Clinical Presentation

Common features of shock include:

• Systolic blood pressure <80 mmHg (or severe hypotension)

• Weak, rapid pulse

• Rapid, shallow breathing (tachypnea)

• Cold extremities (except neurogenic shock)

• Altered mental status, confusion, or restlessness

• Generalized weakness

• Reduced urine output (oliguria)

• Delayed capillary refill

• Signs of poor peripheral perfusion

Table Types of Shock

Investigations

Investigations should be guided by the suspected cause of shock.

Recommended investigations include:

• Complete blood count (including hemoglobin)

• Serum electrolytes

• Renal function tests

• Liver function tests

• Blood glucose

• Serum lactate

• Arterial or venous blood gas analysis

• Blood cultures (before antibiotics where feasible)

• Cardiac troponins

• Point-of-care ultrasound (lung, inferior vena cava, and cardiac assessment)

• Echocardiography

• Cerebrospinal fluid analysis (if meningitis is suspected)

Non-Pharmacological Management

Early recognition and treatment of the underlying cause are essential.

Perform the following immediately:

• Apply the ABCD approach and intervene as required.

• Maintain a patent airway.

• Administer supplemental oxygen.

• Perform endotracheal intubation and mechanical ventilation if indicated.

• Establish two large-bore intravenous lines.

• Monitor vital signs frequently.

• Assess mental status.

• Monitor urine output.

• Correct hypoglycemia if present.

• Identify and treat the underlying cause.

Pharmacological Management

Management depends on the type of shock.

Fluid Resuscitation

Hypovolemic, septic, and neurogenic shock

Adults

• 0.9% Sodium chloride IV, 2 L rapid bolus.

• Repeat boluses according to clinical response.

Children

• 0.9% Sodium chloride IV, 20 mL/kg over an appropriate period.

• Reassess after each bolus.

In hemorrhagic shock, administer blood products as soon as possible.

Vasopressors and Inotropes

If hypotension persists after:

• Adults: 4 L of crystalloid (two 2-L boluses), or

• Children: 40 mL/kg,

initiate vasopressor or inotropic therapy according to the underlying cause (refer to the Sepsis and Septic Shock section).

Antibiotics

All children with shock that is not clearly caused by trauma or simple watery diarrhea should receive empirical antibiotic therapy for suspected septicemia.

Patients with septic shock should receive empirical broad-spectrum antibiotics within 1 hour of recognition.

Important Precautions

• Do not administer calcium-containing IV fluids (e.g., Ringer's Lactate) within 48 hours of ceftriaxone administration.

• Avoid routine IV fluid resuscitation in cardiogenic shock; maintain IV access and administer only small fluid challenges if clinically indicated.

• If respiratory distress or pulmonary edema develops during fluid administration, stop IV fluids immediately while maintaining IV access.

• Ceftriaxone is contraindicated in neonates with jaundice.

Referral

Refer urgently to a higher-level facility when:

• The patient remains hypotensive despite initial resuscitation.

• Advanced monitoring or intensive care is required.

• Blood products or vasopressor support are unavailable.

• The underlying cause cannot be managed at the current facility.

During referral:

• Continue resuscitation and monitoring.

• Ensure the patient is accompanied by a trained healthcare provider (preferably a nurse).

• Document the patient's clinical status, investigations, treatments administered, and response to therapy in the referral note.