(http://www.ugm.ac.id.ezproxy.ugm.ac.

id)

FIRSTCONSULT

Evaluationofshockinadults
Revised:June24,2013
CopyrightElsevierBV.Allrightsreserved.

Keypoints
Shockisinadequatetissueperfusion,whichisoftenmanifestedbyhypotensionbutcanoccur
beforemajorchangesinvitalsigns
Determiningtheetiologyofshockiscrucialtodefiningtheoptimaltreatmentapproach
Themostcommonetiologiesofshockare:hypovolemicshock,septicshock,cardiogenicshock,
obstructiveshock,neurogenicshock,anaphylacticshock,andhypoadrenalshock
Initialmanagementofundifferentiatedshockinvolvesadministrationofvolumefollowedby
inotropesandvasopressorsonceintravascularvolumehasbeenrestored
Goaldirectedresuscitationhasbeenshowntobebeneficialinmanagementofsepticshock

Background
Description
Shockisdefinedasinadequatetissueperfusion
Inadequatetissueperfusionleadstoanaerobicmetabolismduetoinadequateoxygen
deliveryoroxygenutilizationbythetissues
Shockalsoleadstodevelopmentofasystemicinflammatoryresponse,whichcanleadto
organinjury

Causes
Hypovolemicshock:
Hypovolemicshockisduetoinadequateintravascularvolume
Themostcommoncausesarehemorrhageanddehydration
Massivebleedingcanoccurasaresultoftraumaticinjury,rupturedaneurysms,and
gastrointestinalbleeding

Hemorrhagicshockisclassifiedbasedontheseverityofbloodloss:
ClassIshockinvolveslossof10%to15%ofcirculatingbloodvolume(500700mL)
ClassIIshockinvolveslossof20%to30%ofcirculatingbloodvolume(7501,500mL)
ClassIIIshockinvolveslossof30%to40%ofcirculatingbloodvolume(1,5002,000
mL)
ClassIVshockinvolveslossofmorethan40%ofcirculatingbloodvolume(>2,000
mL)
Dehydrationcanoccurasaresultofacuteillnesswithfluidlossesfromdiarrheaoremesisor
urinarylossesascanoccurindiabeticketoacidosis
Patientswithsevereburnssufferdramaticfluidshiftsthatalsoleadtohypovolemia
Septicshock:
Septicshockisassociatedwithaninfectiousetiologyleadingtoasystemicinflammatory
responsesyndrome(SIRS)
TraditionaldiagnosisofSIRSincludestwoormoreofthefollowingoriginalSIRS
criteria:
Temperature>38C(100.4F)or<36C(96.8F)
Heartrate>90beats/min
Respiratoryrate>20breaths/minorPaCO2<32mmHg
Leukocytes>12,000cells/mm3or<4,000cells/mm3or>10%immatureforms
SeveresepsisisdefinedasclinicalinfectionmeetingSIRScriteriawithorgandysfunction,or
tissuehypoperfusionabnormalitiesduetotheinfection(hypotension,oliguria,elevated
lactate,oralteredmentalstatus).Theofficialdefinitionforsepticshockisseveresepsiswith
hypotensionrefractorytoadequatefluidresuscitation
Septicshockcanbeclassifiedasearlyshockorpostresuscitationshock
Inearlysepticshock,ventriclesareoftenpoorlyfilledandcardiacoutputislowdueto
hypovolemia
Followingrestorationofintravascularvolume,cardiacoutputistypicallyhighas
patientsarehyperdynamicbutmayremainhypotensiveduetoperipheral
vasodilatation
Cardiogenicshock:
Cardiogenicshockisduetoinadequatecardiacoutput,usuallyasaresultofprimarycardiac

dysfunctionsuchasacutemyocardialinfarction,acutevalvulardisruption,cardiomyopathy,
orbluntcardiacinjury
Obstructiveshock:
Obstructiveshockresultsfromphysicalobstructionofthegreatvesselsortheheartitself.
Thismaybecausedbymassivepulmonaryemboli,tensionpneumothorax,orpericardial
tamponade
Neurogenicshock:
Neurogenicshockresultsfromdisruptionofthespinalcord,usuallyinthehighcervical
region,leadingtolossofsympathetictoneand,thus,peripheralvasodilation
Anaphylacticshock:
Anaphylacticshockisduetoanacutesevereallergicreactionthatleadstomassive
inflammation,peripheralvasodilation,andsuppressionofcardiaccontractility
Hypoadrenalshock:
Hypoadrenalshockisduetoacuteadrenalinsufficiency,whichcanoccurwithadrenal
infarction,acutewithdrawalfromlongtermcorticosteroidtherapy,orcriticalillnessrelated
tocorticosteroidinsufficiency.Itsfeaturesarevirtuallyidenticaltosepticshock

Diagnosis
Summaryapproach
Summaryapproachbytypeofshock
Diagnosisofshockdependsontheclinicalcontextaspatientsmaypresentwith'coldshock'
duetoimpairedtissueperfusionandvasoconstriction,or'warmshock'withperipheral
vasodilation.Additionally,patientswithmetabolicacidosisbasedonelevatedserumlactate
(1422324)levelsorbasedeficitsshouldalsobeconsideredinearlyshock,evenifnotyet
hypotensive
Patientswithcoldshockwillbecoolandpaleandareusuallyhypovolemic.
Cardiogenicshockandlaterstagesofsepticshockmayalsocausecoldshock
Patientswithwarmshockmaybewarmandappearwellperfusedbutmaystillbe
hypotensive.Thispresentationoccurswithneurogenicshock,fluidresuscitatedseptic
shock,andanaphylacticshock
Forallpatientsinitialassessmentinvolvesevaluationofairway,breathing,andcirculation
(ABC)
Patientswhoareunabletoprotecttheirairwayorwhoneedventilatorassistance

shouldbeintubatedandprovidedwithsupplementaloxygen
Oncetheseissuesareaddressedthenassessmentandmanagementofcirculationis
initiatedbasedonthetypeofshockasoutlinedbelow
Hypovolemicshock:
Firstvitalsignchangeistachycardiafollowedbyhypotension.Othersignsandsymptoms
canincludecoolperiphery(skin),tachypnea,narrowpulsepressure,anddiminished
capillaryrefill
Evaluateforsourceofhemorrhageorfluidloss
Assessresponsetofluidchallenge
Monitorurineoutput
Identifyanysourceofhemorrhageand,ifpresent,intervenetostopthebleeding
Ifthereisconcernforongoinghemorrhage,serialhemoglobin(1422317)changesovertimeare
moreusefulthantheinitialhemoglobinmeasurement
Notethatpatientsonblockersmaynotbeabletomanifestatachycardiainthesettingof
hypovolemicshock
Septicshock:
EvaluateforSIRScriteria(temperature>38C[100.4F]or<36C[96.8F],heartrate>90
beats/min,respiratoryrate>20breaths/minorPaCO2<32mmHg,andleukocytes>12,000
cells/mm3or<4,000cells/mm3or>10%immatureforms)andknownorexpectedsiteof
infectiontoconfirmsepticshock
Assessresponsetofluidbolus
Sendblood(1422327)andotherculturesasappropriate
Considerimagingtoidentifysourceofinfection
Measureserumlactatelevel
Placecentrallinetomeasurecentralvenouspressure(CVP)andcentralvenousoxygen
saturation(ScvO2)toguideearlygoaldirectedresuscitation
Cardiogenicshock:
Signsandsymptomsincludehypotension,jugularvenousdistension,coolextremities,
peripheraledema

Obtainurgentelectrocardiogram(ECG)(1422331)toevaluateforacutemyocardialischemia
AssessvolumestatusandconsiderCVPmonitoringtoguidefluidresuscitation
Orderechocardiogram(1422332)toevaluatecardiacfunction
Ifacutemyocardialinfarction,evaluateforcardiaccatheterizationandpossibleintervention
Obstructiveshock:
Evaluatefortensionpneumothoraxandpericardialtamponade
Tensionpneumothoraxmaypresentwithdecreasedorabsentbreathsoundsonone
side,jugularvenousdistension,and/ortrachealdeviation
Pericardialtamponademaypresentwithmuffledhearttones,jugularvenous
distention,lowvoltageonECG.Itcanbeadifficultclinicaldiagnosisso,ifsuspected,
shouldbeassessedbyurgentbedsideechocardiogram
Forpatientswithsuspectedpulmonaryembolicausingobstructiveshock,computed
tomography(CT)pulmonaryangiogramcanbedonetoconfirmdiagnosisbasedonpatient
stability.Transesophagealechocardiogramcanalsobeusedtoassessforlargepulmonary
emboli.Unstablepatientsmaybebestassessedbyinterventionalradiologywhere
pulmonaryarterycatheterizationcanconfirmthediagnosisbyangiogramandinitiate
intervention
Neurogenicshock:
Signsandsymptomsincludehypotensioninthesettingofperipheralvasodilationand
neurologicdeficitsconsistentwithahighspinalcordinjury
Maintainspineprecautions
Evaluateforhighcervicalspineinjury
Performdetailedneurologicexamination
Anaphylacticshock:
Signsandsymptomsincludeskinrash,diffuseedema,tachypnea,wheezing,andstridor
Assessforairwayedema/bronchospasmasmayrequireearlyintubationandrespiratory
support
Hypoadrenalshock:
Mostcommonincriticallyillpatientswhomayhaveotherreasonsforshock,soitisa
diagnosisofexclusioninthissetting.Maypresentacutelyinpatientswithprimaryadrenal

insufficiency(Addisondisease)
Treatmentishighdosecorticosteroidsinconjunctionwithtreatmentoftheunderlying
disease
Thediagnosticassessmentforadrenalinsufficiencycanbecomplexdependinguponvarious
patientrelatedcircumstances,butoftentheevaluationstartswithaserumrandomcortisol
andcorticotropinstimulationtest(1422326)

Clinicalpresentation
Symptoms:
Symptomsmaybenonspecificandrelatedtohypotensionandoverwhelmingillness,suchas
lightheadedness,clamminess,nausea,palpitations
Specificorlocalizingsymptomsmayrelatetothecauseofshockandmayincludefever,pain,
bleeding,dyspnea
Otherhistoricalinformation:
Historyisimportantinhelpingdeterminethelikelyetiologyofshock
Forexample,ahistoryoftraumashouldraiseconcernforhypovolemic,obstructive,or
neurogenicshock
Ahistoryofcoronaryarterydiseaseandacutechestpainmaysuggestcardiogenic
shockismorelikely
Ahistoryofrecentinfectionmaysuggestsepticshock
Signs:
Patientspresentinginshockareoftenhypotensive,butinearlyshockmaybenormotensive
buttachycardic
Forintubatedpatients,alowendtidalCO2readingmayalsobeasignofearlyshock
Otherphysicalexaminationfactors:
Thephysicalexaminationisoftenunrevealingwithregardtoidentifyingthespecificetiology
oftheshock
Pallororobviousbleedingorbruisingmayindicatehemorrhage
Urticariaorangioedemaareusuallyevidentinanaphylacticshock
Jugularvenousdistensionandmuffledheartsoundssuggestcardiactamponadeor
cardiogenicshock

Wheezingmaysuggestheartfailureduetocardiogenicshock,pulmonaryembolus,or
anaphylaxis
Otherlocalizingsignsmaysuggestasourceofsepsis(eg,peritonealsigns)
Cyanosisandmottlingoftheextremitiesoccursinthelaterstagesofcoldshock

Diagnostictesting
Laboratorystudieswillnotleadtoadefinitivediagnosisofshockbutareimportantadjuncts
inassessingtheseverityofhypoperfusionandendorgandysfunction,helpingtodetermine
theetiologyofshockandjudgingsuccessoftherapeuticintervention
Metabolicacidosisduetotissuehypoperfusionmaybeassessedbyserumelectrolytes
(1422319)alongwithserumlactate(1422324)levelorbasedeficitbasedonarterialbloodgas
(1422323)results.Theseindicesserveasmarkersofimpairedtissueperfusion.Aserum

lactatelevel>4mmol/Lorbasedeficit<6mEq/Larevaluesthathavebeenassociatedwith
moreseveretissuehypoperfusion.Arenalfunctionpanel(1422321)shouldbeobtainedto
assessforendorgandysfunction
Serialhemoglobinorhematocrit(1422317)assessmentsmaybeimportantinfollowingpatients
fortheriskofongoinghemorrhage.However,significantbloodlosscanoccurwithoutan
initialchangeinhematocritifpatienthasnotyethadrestorationofintravascularvolume
Cultureresults(blood(1422327),urine(1422328))areimportantinguidingantibiotictherapy
insepticshock
Corticotropinstimulationtesting(1422326)maybeusedinsome,butnotall,circumstancesasan

aidforthediagnosisofhypoadrenalshock
Typeandcross(1422318)shouldbeobtainedtoestablishABObloodtypeandthepresenceof

antibodiesthatmayreacttotransfusedblood
Serumglucose(1422320)shouldbemeasuredtoexcludehypoglycemia
Cardiacenzymes(1422325)maybeassessedtoevaluateforevidenceofcardiacischemia,

whichmaycontributetocardiogenicshock.Btypenatriureticpeptide(BNP)(1422325)canhelp
toevaluateforcongestiveheartfailure
AsputumGramstain(1422329)mayhelpprovideinformationastotheclassofarespiratory
pathogen.Thesputumcultureshouldbeobtainedtoidentifytheprecisecausativeorganism
andtheantibioticsensitivities
Chestradiography(1422330)shouldbeobtainedtoassessforconsolidation,collapse,

pneumothorax,orpleuraleffusions

Electrocardiography(1422331)shouldbeobtainedtodetectischemiaand/orarrhythmias
Echocardiography(1422332)maybeusefultoevaluateforcardiomyopathy,cardiogenicshock,

andassessmentforpericardialeffusionsandcardiactamponade

Serumelectrolytes

Description
Venousbloodsample
Normalranges
Sodium:136to142mEq/L
Potassium:3.5to5mEq/L
Chloride:96to106mEq/L
Bicarbonate:22to28mEq/L
Comments
Measurementofelectrolytesishelpfultoassessformetabolicacidosis(tobeconfirmedby
measurementsfromarterialbloodgasresults)andtocalculateaniongap
Lowsodiumandhighpotassiuminconjunctionwithacidosiscouldsuggestprimary
adrenalinsufficiency

Lactate

Description
Venousbloodsampletomeasurelactate,ametabolicendproductofexcessmetabolism
andanaerobicrespiration
Normalresult
0.5to2.2mmol/L
Comments
Abnormalresultsmaybedueto:
Hypermetabolicstates
Severehypoxia,hypoperfusion,andshock
Metabolicdisorders

Druginducedmitochondrialinjury

Arterialbloodgas

Description
Anarterialsampleistakenusingaheparinizedsyringetomonitorlungfunctionand
developmentofacidosis
Normalranges
PaO2:80to100mmHg
PaCO2:35to45mmHg
pH:7.35to7.45
Calculatedbicarbonate(HCO3):21to28mEq/L
Comments
Avoidcontactbetweenthesampleandroomair
Theradialarteryisusuallyused,butthebrachialandfemoralarecommonalternatives
HypoxemiaiscausedbyPaO2<80mmHgfromventilation/perfusionmismatchingand
intrapulmonaryshuntinginthepresenceofacuterespiratorydistresssyndrome(ARDS)
orpulmonaryedema
RespiratoryalkalosisiscausedbyanelevatedpHwithareducedPaCO2secondaryto
hyperventilationinthefirststageofARDSorsepsis
RespiratoryacidosiswithanincreasedPaCO2andareducedpHmayoccurwith
respiratorydepressionduetodecreasedcerebralperfusionoroverdose(eg,ofnarcotics)
Metabolicacidosisiscausedbytissuehypoperfusionorhypoxemia.Abasedeficit6
mEq/Lisassociatedwithshockseverity.Calculationoftheaniongapisalsohelpfulin
evaluatingtheetiologyofametabolicacidosis.Theaniongapiscalculatedbasedonthe
serumsodiumandpotassiumminustheserumchlorideandbicarbonate.Anormalanion
gapis<11mEq/L
Preexistingrespiratoryormetabolicpathologycanaltertheresults.Thegaporratio
canhelpidentifythecoexistenceofbothmetabolicacidosisandalkalosis,orapresenceof
simultaneousnonaniongapacidosisandananiongapacidosis.Theratioequalsthe
changeinaniongapoverthechangeinserumbicarbonate.Itiscalculatedasfollows:
Measuredaniongapnormalaniongap/normal(HCO3)measured(HCO3)=

[(AG12)/24HCO3]
Aratiolessthan1to1suggestsamixedmetabolicacidosisaratiogreaterthan2
to1suggestsaconcurrentrespiratoryacidosiswithmetabolicalkalosis

Renalfunction

Description
Venousbloodsample
Normalranges
Bloodureanitrogen:8to23mg/dL
Creatinine:0.6to1mg/dL
Comments
Measurementofindicesofrenalfunctionareimportanttoassessforendorgan
dysfunction

Hemoglobinandhematocrit

Description
Venousbloodsample
Normalranges
Hemoglobin:12to15g/dL(femalepatients),14to17.5g/dL(malespatients)
Hematocrit:41%to50%
Comments
Serialmeasurementsofhemoglobinorhematocritmaybeimportantinfollowingpatients
fortheriskofongoinghemorrhage.However,significantbloodlosscanoccurwithoutan
initialchangeinhematocritifthepatienthasnotyethadrestorationofintravascular
volume

Bloodculture

Description
Between5and10mLofvenousorarterialbloodisdrawnandplacedinsterileculture
bottles,oneaerobicandoneanaerobic,preferablybeforeantibiotictherapy
Mayrequirespecialculturetechniquessuchasprolongedincubationtodetectgrowthof

mycobacteria
Obtaintwosetsofcultures,eachfromaseparatepuncturesite
Normalresult
Nogrowth
Comments
Antibioticscansuppressthegrowthofinfectingorganismsandcauseafalsenegative
result

Urineculture

Description
Cleancatchmidstreamurinesampleinasterilecontainer,orurinespecimenobtained
asepticallythroughurinarycatheterization
Normalresult
Nogrowth
Comments
Commonlycontaminatedwithskincommensals,particularlyinwomen
Antibioticsmayinhibitthegrowthofinfectingorganismsandsogiveafalsenegative
result

Corticotropinstimulationtest

Description
Dynamicendocrinetestingusingsyntheticadrenocorticotropichormone(ACTH)to
determinewhethercorticosteroidinsufficiencyispresent
Abaselinecortisollevelisobtained,followedbyintravenousadministrationof250gof
cosyntropinwithserialcortisolmeasurement30and60minutesafterinjection
Normalresults
NormalresponsetoACTHstimulationisariseinserumcortisolto18g/dLwithin60
minutes
Comments
Adrenalinsufficiencyincriticalillnessisbestdiagnosedbyacortisolafterstimulation

with250gofcosyntropinof<9g/dLorarandomtotalcortisolof<18g/dL
Indeterminateresultsmayrequirerepeattesting
Ifindeterminateresultsoccur,treatpatientwithcorticosteroidsuntiladefinitive
diagnosiscanbemade
Recentonsetsecondaryadrenalinsufficiencymaygivefalsenegativetestresults
TheACTHstimulationtestshouldnotbeusedtoidentifythosepatientswithsepticshock
orARDSwhoshouldreceiveglucocorticoidtherapy

Typeandcrossmatch

Description
VenousbloodsampletoestablishABObloodtypeandpresenceofantibodiesthatmay
reacttotransfusedblood
Normalresults
Variable
Comments
Guidesselectionofbloodproductsfortransfusion

Serumglucose

Description
Venousbloodsample
Normalrange
70to100mg/dL
Comments
Hypoglycemiacanindicateadvancedsepsisandapoorprognosis

CardiacenzymesandBtypenatriureticpeptide

Description
Venousbloodsample
Normalresults
TroponinI:0to0.1ng/mL

CreatininekinaseMB:0to3ng/mL
BNP:<100pg/mL
Comments
Cardiacenzymes(troponinandCKMB)maybeassessedtoevaluateforevidenceof
cardiacischemia,whichmaycontributetocardiogenicshock.Troponinisthemost
sensitivemarkerandgenerallypeaks4to6hoursafteranischemicevent
ElevatedBNPissuggestiveofcongestiveheartfailure
BNPlevelsbelow100pg/mLindicatenoheartfailure
BNPlevelsof100to300pg/mLsuggestheartfailureispresent
BNPlevelsabove300pg/mLindicatemildheartfailure
BNPlevelsabove600pg/mLindicatemoderateheartfailure
BNPlevelsabove900pg/mLindicatesevereheartfailure

SputumGramstainandculture

Description
Sputumisobtainedfollowingastrongcough,eitherspontaneouslyorinducedbya
nontoxicnoxiousinhalant
AsputumsamplemaybeconsideredadequateiftheGramstainshowsmorethan25
polymorphonuclearneutrophilicleukocytesandfewerthan10epithelialcellsperlow
powerfield
Inintubatedpatients,bestspecimensareobtainedfromadeepsuctionfroman
endotrachealtube
Normalresults
Nogrowth
Growthofordinaryrespiratorytractcommensals
Comments
ApositiveGramstaincanprovideimmediatecluestothelikelyclassofinfecting
organism
TheappearanceofoneormorepredominantorganismsonGram/potassiumhydroxide

stainusuallysuggestsinfectiousetiologymixedGramstainusuallyindicatesnormal
respiratoryflora(withsubsequentconfirmationbyculture)
Culturecanprovidemorepreciseinformationaboutthecausativeorganismandits
antibioticsensitivities
Antibioticscansuppressthegrowthofinfectingorganismsandcauseafalsenegative
result

Chestradiography

Description
Radiographicimageoforgansandbonystructureswithinthethorax,includingthelungs,
heart,andmediastinum
Normalresults
Clearlungfieldswithappropriateexpansion
Normalheartsize
Notrachealdeviation,masses,oreffusions
Comments
Large,irregularopacitiesmayresultfromconsolidation,collapse,abscess,empyema,
pleuraleffusions,orpleurallesions
Airinthepleuralspacemayindicatepneumothorax
Contralateraltrachealdeviationmayindicatetensionpneumothorax
DiffuseshadowingmayresultfrompneumonitisorARDS
Enlargedheartmaysupportcardiogenicshockduetocardiomyopathyorcardiac
tamponade

Electrocardiography

Description
Recordoftheelectricalactivityoftheheartovertime,usedtodetectischemia,irregular
rates,and/orarrhythmias
Normalresults
Normalcardiacrateandrhythm

NormalQRSpattern,normalPRinterval,noSTsegmentchanges,noTwaveinversions
Comments
Electrocardiographyisessentialfordiagnosisofcardiogenicshock
LowvoltageorflatteningoftheTwavesmaybeseeninthesettingofapericardial
effusion,whichmayleadtopericardialtamponade

Echocardiography

Description
Sonographicimagingstudyusedtovisualizetheheartandpericardium
Normalresults
Normalcardiacvalvesandchambers
Coordinatedcardiacchambercontractility
Noexcesspericardialfluid
Comments
Echocardiographymaybeusefulforevaluationofcardiomyopathy,cardiogenicshock,
andassessmentforpericardialeffusionsandcardiactamponade
Adilatedrightventriclemaysuggestpulmonaryembolism
Apoorlyfilledhyperdynamicventriclesupportshypovolemicshock
Focalwallmotionabnormalitiessupportacutemyocardialischemia
Preservedejectionfractiondoesnotensureadequatecardiacoutput

Consultation
Hemorrhagicshock:Aspecialistinsuchareasasgeneralsurgery,vascularsurgery,
gastroenterology,andinterventionalradiologymayberequiredtohelplocalizeandtreatthe
sourceofhemorrhage
Shockaftertraumaticinjury:General/traumasurgeonsshouldbeinvolvedintheimmediate
assessmentandmanagementofthesepatients
Septicshock:Complexcasesmayrequireaninfectiousdiseaseconsulttoassistwith
identifyingthesourceofinfection
Cardiogenicshock:Cardiologyconsultmayberequiredforassessmentofcardiacischemia

orcongestiveheartfailure
Neurogenicshock:Consultaneurosurgeonorspinesurgeonforassessmentoftheinjury
Hypoadrenalshock:Endocrinologyconsultationmaybeusefultoguidethetestingstrategy
andtheinterpretationofadrenalglandfunctionaltestingresults

Treatment
Summaryapproach
Hypovolemicshock:
Provideairwaymanagementandventilatorsupportasneededprovidesupplementaloxygen
Ensurelargeboreintravenousaccessandinitiatevolumeresuscitation(1422386)with
crystalloid
Searchforsourceofhemorrhageand,ifidentified,initiatemeasurestocontrolthe
hemorrhage
Ifnotimprovedafter2Lofnormalsalineandsignsofactivehemorrhageareevident,begin
bloodtransfusion(1422398)andconsideractivationofamassivetransfusionprotocolwhich

providespredefinedresuscitationwithbloodproducts,includingplasmaandplatelets,to
addressacutecoagulopathy
Inunstablepatientsinitialtransfusionmayrequireuseofuncrossmatcheduniversaldonor
products.Atypeandcrossmatchshouldbeobtainedassoonaspossibletoprovidetype
specificbloodwhenavailable
Somestudieshavesuggestedlimitinginitialvolumeresuscitationforpatientswithahigh
riskofongoinghemorrhage(suchaspatientswithpenetratingtorsotrauma)forconcern
thathighvolumesofcrystalloidwillraisethebloodpressureandexacerbatebleeding.These
authorsadvocatelimitingvolumeadministrationuntilhemorrhageiscontrolled.However,
theroleoffluidrestrictionforthepatientwithblunttraumaandpossibletraumaticbrain
injuryislessclear
Septicshock:
Ensureadequateintravenousaccessandinitiatevolumeresuscitationwithcrystalloid
Afterappropriateculturesareobtained,initiateempiricantibioticsforsepsis
PlacecentrallinetomeasureCVPandScvO2toguideearlygoaldirectedresuscitation
Theguidelines(http://link.springer.com.ezproxy.ugm.ac.id/content/pdf/10.1007%2Fs001340122769
8.pdf)fortheSurvivingSepsisCampaignrecommendresuscitationtothefollowingend

points:
CVP:8to12mmHg
Meanarterialpressure(MAP):65mmHg
Urineoutput:0.5mL/kg/h
Centralvenous(ie,superiorvenacava)(ScvO2)orpulmonaryarterymixedvenous
oxygensaturation(SvO2):70%or65%,respectively
Ifduringthefirst6hoursofresuscitationthegoalsforScvO2orSvO2arenotachieved
withfluidresuscitationtotheCVPtarget,thentransfusiontoahematocritof30%or
moreand/oradministrationofadobutamineinfusionarerecommendedtoachieve
thesegoals
Ifvasopressorsarerequired,norepinephrinewithorwithoutlowdosevasopressinare
thepreferredagents
Hydrocortisoneshouldbeconsideredinthemanagementofsepticshock,particularlyforthose

patientswhohaverespondedpoorlytofluidresuscitationandvasopressoragents
TheACTHstimulationtestcanbeusedtodistinguishthosemorelikelytobenefit,although
thereiscontroversyinthisareasosomeclinicianstreatwithoutACTHtesting
Cardiogenicshock:
ConsiderplacementofCVPmonitortoguidefluidresuscitation
Vasopressorsandinotropes(norepinephrine,vasopressin,epinephrine,dobutamine,milrinone,
phenylephrine)areindicatedinselectedcircumstancesforcardiogenicshock

Considerintraaorticballoonpumpforrefractorycardiogenicshockassociatedwithacute
myocardialischemiaoracutemitralregurgitationwithrefractorycardiogenicshock
Obstructiveshock:
Iftensionpneumothoraxissuspected,thepatientneedsimmediateneedledecompression
followedbychesttubeplacement
Pericardialtamponadewarrantsimmediateintervention
Fortraumapatients,thismeansimmediateoperativeinterventiontodecompressand
evaluateforsourceofhemorrhage
Formedicalpatients,pericardiocentesiswithorwithoutcatheterdrainageshouldbe
performed

Forpatientswithsuspectedpulmonaryembolicausingobstructiveshock,anticoagulationis
indicated.Considerthrombolytictherapy.Ifthrombolyticagentsarecontraindicated,
embolectomyviasurgeryorinterventionalradiologyshouldbeconsidered
Neurogenicshock:
Maintainspineprecautions
Initiatefluidresuscitationtoensureadequatepreload.Ifstillhypotensiveafterfluid
resuscitation,initiatevasopressors(phenylephrinefirstline)
Anaphylacticshock:
Mayrequireearlyintubationandrespiratorysupport
Administerepinephrine,giveintravenousfluidsforhypotension
Steroidsandhistaminereceptorantagonists(ranitidineorcimetidine)mayalsobeconsidered
Hypoadrenalshock:
Treatmentisstressdosesteroidsinconjunctionwithtreatmentoftheunderlyingdisease
TheAmericanCollegeofCriticalCareMedicinehascreatedaguideline
(http://www.learnicu.org/Docs/Guidelines/CoricosteroidInsufficiencyAdult.pdf)forthediagnosisand

managementofcorticosteroidinsufficiencyincriticallyilladultpatients.These
recommendationsinclude:
Adrenalinsufficiencyincriticalillnessisbestdiagnosedbyacortisolafter
stimulationwith250gofcosyntropinof<9g/dLorarandomtotalcortisolof<18
g/dL
TheACTHstimulationtestshouldnotbeusedtoidentifythosepatientswithseptic
shockorARDSwhoshouldreceiveglucocorticoidtherapy
Recentevidencereportsresultsconflictwithcurrentguidelinesshowingno
improvementinsurvivalassociatedwithsteroidtreatmentforpatientswithseptic
shock

Medications

Fluidresuscitation

Indication
Crystalloidsarefirstlinetherapytorestoreintravascularvolumeinthesettingof
hypovolemicordistributiveshock
Doseinformation

Initial:500to1,000mL/huntilhemodynamicstabilityisachieved
Aninitialrapidinfusionof20to30mL/kgistypicallyperformed
Fluidscansubsequentlybetitratedbasedonurinaryoutputandassessmentofpreload
viaultrasoundorCVP
Comments
Thepreferredcrystalloidintravenousfluidtypestouseforresuscitationinshockare
0.9%normalsalineorlactatedRinger'ssolution
Albumincanalsobegiventoexpandintravascularvolume.However,severalstudieshave

failedtodemonstrateanadvantagetocolloidsovercrystalloids
Hypertonicsalinesolutionshavebeenusedinavarietyofconcentrationsforthe
treatmentofshock,butstudieshavefailedtoshowanybenefitoverinitialstandard
crystalloidresuscitationforpatientswithhemorrhagicshock
Aftertheinitialfluidbolusduringresuscitation,carefulmonitoringisrequiredduringthe
continuedadministrationofintravenousfluidsinelderlypatientstopreventfluid
overload

Evidence
Asystematicreviewevaluatedtheliteratureforstudiescomparingcrystalloidsto
colloidsfortheresuscitationofcriticallyillorinjuredpatients.Twentyfourtrials
reporteddataonalbuminwithapooledrelativerisk(RR)formortalityof1.01(95%
confidenceinterval[CI],0.931.10).Twentyonetrialscomparedhydroxyethylstarch
tocrystalloidwithapooledRRof1.10(95%CI,0.911.32).Eleventrialscompared
modifiedgelatinwithapooledRRof0.91(95%CI,0.491.72).Finally,ninetrials
compareddextrantocrystalloidwithapooledRRof1.24(95%CI,0.941.65).The
authorsconcludethatthereisnoevidencethatresuscitationwithcolloidsreducesthe
riskofdeathcomparedtocrystalloids,andgiventhatcolloidsaremoreexpensive,
theiruseinnotjustified.[1]Levelofevidence:1
Asystematicreviewevaluatedthesafetyofcolloiduseincriticallyillpatientsand
concludedthatsignificantsafetydifferencesexistamongcolloidswithconcernfor
anaphylactoidreactionsandconcernregardingexacerbationofcoagulopathy.[2]Level
ofevidence:2
Arandom,controlledtrial(RCT)comparedaninitialbolusof250mL7.5%salinewith
andwithout6%dextran70tonormalsalinefortheinitialprehospitalresuscitationof
patientswithtraumatichypovolemicshock(n=853).Therewasnodifferencein28day
mortalitybetweenthetreatmentgroups.[3]Levelofevidence:1

AnRCTof598patientsevaluatedimmediateversusdelayedfluidresuscitationfor
hypotensivepatientswithpenetratingtorsotrauma.Patientswererandomlyassigned
tonofluidbeginningintheprehospitalsettingandextendinguntiloperativecontrolof
hemorrhagewasachievedversusstandardresuscitation.Survivalinthedelayed
resuscitationgroupwas70%versus62%fortheimmediateresuscitationgroup.RRfor
deathwithearlyfluidadministrationwas1.26(95%CI,11.58).Thereweresome
concernswithprotocoladherencebyemergencymedicalservices,andallpatientswere
inanurbansystemwithashorttransporttimetodefinitivecare.[4]Levelofevidence:
2
AnRCTof1,309traumapatientscomparedimmediateversusdelayedfluid
resuscitationbeginningintheprehospitalsetting.Protocolcompliancewaspoor.
Mortalitywas10.4%intheearlyresuscitationgroupversus9.8%inthedelayedgroup.
TheRRwithearlyfluidadministrationwas1.06(95%CI,0.771.47).[5]Levelof
evidence:2
AnRCTcomparedresuscitationof110traumapatientswithhemorrhagicshocktoa
targetbloodpressureof70mmHgversus100mmHg.Mortalitywas7.3%inboth
groups,andRRfordeathwas1(95%CI,0.263.81).[6]Levelofevidence:2
Asystematicreviewofsixstudiesinvolving2,128patientscomparedearlyversus
delayedfluidresuscitationorlargeversussmallvolumeresuscitationforbleeding
traumapatients.ThestudyconcludedthattherewasnoevidencefromRCTsthatwas
clearlyfororagainstearlyorlargervolumeofintravenousfluidadministrationin
bleedingtraumapatients.[7]Levelofevidence:1
AnRCTof263patientswithseveresepsisandsepticshockcomparedearlygoal
directedtherapyofseveresepsisandsepticshocktostandardcare.Patientswere
randomlyassignedtoreceiveaprotocolforearlygoaldirectedtherapybeginningin
theemergencydepartmentandcontinuingforthefirst6hoursafterpresentation,orto
standardcare(thecontrolgroup).Theprimaryefficacyoutcomewasinhospital
mortality,whichwas30.5%fortheearlygoaldirectedgroupascomparedto46.5%for
thestandardcaregroup(P=.009).ThisprotocolwasadoptedbytheSurvivingSepsis
Campaignguidelines
(http://link.springer.com.ezproxy.ugm.ac.id/content/pdf/10.1007%2Fs0013401227698.pdf).[8]

Levelofevidence:1

References

Corticosteroids

Indications
Classicadrenalinsufficiencyincriticallyilladultpatients

Patientswithsepticshockwhorespondpoorlytofluidresuscitationandvasopressor
agents
Doseinformation
Hydrocortisone

Forsepticshockpoorlyresponsivetofluidandvasopressors:
Initial:50mgintravenouslyevery6hours,or50mgbolusfollowedbyintravenous
infusionat10mg/h
Forclassicadrenalinsufficiency:
100mgintravenouslyevery8hours
Majorcontraindications
Fungalinfection(hydrocortisone)
Comments
TheAmericanCollegeofCriticalCareMedicineguidelines
(http://www.learnicu.org/Docs/Guidelines/CoricosteroidInsufficiencyAdult.pdf)forthemanagement

ofcorticosteroidinsufficiencyincriticallyilladultpatientsrecommendthat
hydrocortisonebeconsideredinthemanagementofsepticshock,particularlyforthose
patientswhorespondpoorlytofluidresuscitationandvasopressoragents
Thereisconflictingevidenceregardingthebenefitsofcorticosteroidtreatmentfor
patientswithsepticshock
Hydrocortisonedoseshouldbetaperedoverseveraldays,oncehemodynamicparameters
improve
Corticosteroidsmaycauseimmunosuppression.Thismaymasksignsofinfectionand
increasepatientsusceptibilitytoinfection

Evidence
Amulticenter,doubleblindRCTwasconductedthatassigned499patientswithseptic
shocktohydrocortisone(n=251,initially50mgevery6hours)orplacebo(n=248).
Theprimaryoutcomewasdeathamongthesepatientswhodidnothavearesponseto
corticotropinstimulationtestingat28days.Anincreaseinthecortisollevelofnomore
than9g/dLafter250gcosyntropinwasdefinedasanabsenceoforinappropriate
response.Ofthe499patients,233(46.7%)didnotrespondappropriatelyto
corticotropin.At28days,therewasnosignificantdifferenceinmortalitybetween
patientsassignedhydrocortisoneversusplacebofornonresponderstocorticotropin

(39.2%inthehydrocortisonegroupvs36.1%intheplacebogroup,P=.69),nor
betweenthoseassignedhydrocortisoneversusplaceboamongthosewhodidrespond
tocorticotropin(28.8%inthehydrocortisonegroupvs28.7%intheplacebogroup,P=
1).Thus,therewasnosignificantdifferenceinsurvivalbetweenthosewhoreceived
hydrocortisoneandthosewhodidnot,regardlessofresponsetocorticotropin.The
groupreceivinghydrocortisoneresolvedtheshockstatemorequicklybutdeveloped
moreepisodesofsubsequentinfection.[9]Levelofevidence:1

References

Vasopressors/inotropes

Indications
Theclassofmedicationsreferredtoasvasopressorsorinotropesareindicatedfor
patientsinrefractoryshockwhorequirebloodpressuresupport
Norepinephrineandlowdose(typicallyupto0.03units/min)vasopressinarecommonly
usedinthetreatmentofsepticshock
Epinephrineisindicatedasfirstlinetreatmentofanaphylacticshock
Epinephrine,dobutamine,andmilrinoneareindicatedinselectedcircumstancesfor
cardiogenicshock
Phenylephrineisindicatedasafirstlineagentinneurogenicshock(inadditiontofluid
resuscitation)
Doseinformation
Norepinephrine

2to12g/minintravenously,titratedtoeffect,typicallyupto30g/min
Vasopressin

0.01to0.04units/minintravenouslymaximumdose0.04units/min
Epinephrine

Foranaphylaxis:
0.3mgintramuscularly(0.3mLof1:1000solution)mayberepeatedifsevere
anaphylaxispersists:
Repeattheabovedoseevery10to15minutes
Orgive0.1to0.25mgintravenouslyof1:10,000solutionover5to10minutes,
repeatevery5to10minutesasneeded

Orstartcontinuousinfusionof1:10,000solutionat1to4g/min
Forrefractoryhypotensionfromothercauses:
1to10g/minintravenously,titratedtoeffect
Dobutamine

2.5to20g/kg/minintravenously,titratedtoeffectmaximumdose40g/kg/min
Milrinone

Initialloadingdose50g/kgintravenouslyover10minutesthen0.3750.75g/kg/min
titratedtoeffect
Phenylephrine

40to180g/minintravenously,titratedtoeffectmaximumdose9g/kg/min
Majorcontraindications
Closedangleglaucoma(epinephrine,phenylephrine)
Cyclopropaneanesthesia(norepinephrine)
Halothaneanesthesia(norepinephrine)
Hypertension(phenylephrine)
Hypovolemia(norepinephrine)
Idiopathichypertrophicsubaorticstenosis(dobutamine)
Labor(epinephrine)
Mesentericthrombosis(norepinephrine)
Organicbrainsyndrome(epinephrine)
Shock(epinephrine)
Thyrotoxicosis(phenylephrine)
Ventriculartachycardia(phenylephrine)
Comments
Dopamineisnolongerrecommendedasfirstlinetreatmentofshock

Norepinephrineisacombinedinotropevasopressor,whichisprimarilyanadrenergic
agonistbutwithsomeadrenergiceffectsaswell
VasopressinisanendogenoushormonethatbindstotheV1receptorsinvascularsmooth
muscle,leadingtovasoconstriction.Italsoincreasestheresponsetocatecholamines.
Manypatientsmayhavearelativedeficiencyofvasopressin,especiallyinthesettingof
septicshock,soitisoftenusedinthesepatientsincombinationwithotheradrenergic
agents.Itdoesnothaveinotropiceffects
Epinephrinehasbothadrenergicandadrenergiceffects.adrenergiceffectsusually
predominate,leadingtoincreasedcardiaccontractility,tachycardia,andperipheral
vasodilation.Atveryhighdosesadrenergiceffectswillpredominate,leadingto
vasoconstriction.Itisusedprimarytoaddressissueswithcardiaccontractility,usuallyin
combinationwithotheragents.Itisthefirstlinetherapyforbronchospasminthe
treatmentofanaphylacticshock
Dopamineisacatecholamine,whichisaprecursortoepinephrine.Atlowdosesithas
beenreportedtoincreaserenalbloodflow,butseveralstudieshavesuggestedthatthis
doesnotreducetherateofacuterenalfailureinpatientswithshock.Atmoderatedoses,
adrenergiceffectspredominatewithincreasedcardiaccontractility,butpatientsmay
becomeverytachycardicandhaveincreasedcardiacarrhythmias.Athighdoses
adrenergiceffectspredominate,leadingtovasoconstriction.Recentrandomizedtrials
supportitsuseonlyasasecondlinetherapy
Dobutamineisacatecholaminewithprimaryagonisteffectsand,thus,improves
cardiaccontractilitybutmayalsocauseperipheralvasodilation,whichcanbeaconcern
inpatientswhoarealreadyhypotensive.Thus,itmayneedtobeusedincombination
withavasopressor
Milrinoneisaphosphodiesteraseinhibitorthathasprimaryinotropiceffectswithlesser
effectsonheartrate.Likedobutamine,itcanbeassociatedwithsignificantperipheral
vasodilation,whichmaybevaluableforpatientswithprimarycardiogenicshockanda
highafterload,butmaybeharmfulinpatientswithhypotension
Phenylephrineisapureadrenergicagonistand,thus,causesprimarilyperipheral
vasoconstriction.Itcanbethefirstlineagentforpatientswithneurogenicshock

Evidence
Asystematicreviewwasoriginallypublishedin2004andupdatedin2011toevaluate
theliteratureregardingvasopressoruseinshock.Twentythreestudieswerereviewed
involving3,212patients.Sixdifferentvasopressors,aloneorincombination,were
studied.Therewasnodifferenceinmortalityforanyofthecomparisonsbetween
differentvasopressors.Morearrhythmiaswerenotedinpatientsreceivingdopamine

versusnorepinephrine.Theauthorsconcludedthatthereisnotsufficientevidencethat
anyoneofthevasopressorsisclearlysuperiorovertheothers.[10]Levelofevidence:1
AnRCTcomparedepinephrineversusnorepinephrinewithdobutamineforthe
managementofpatientswithsepticshock(n=330).Therewerenosignificant
differencesinefficacyorsafetybetweenthetwogroups.[11]Levelofevidence:1
AnRCTassignedpatientswithsepticshocktoreceiveeitherlowdosevasopressinor
norepinephrineinadditiontoopenlabelvasopressors(n=778).Therewasno
significantdifferenceinmortalityorratesofseriousadverseeventsbetweenthe
groups.[12]Levelofevidence:1
AnRCTcompareddopaminetonorepinephrineasfirstlinetherapyforpatientswith
shock(n=1679).Therewasnosignificantdifferenceinmortalitybetweenthegroups,
butmorearrhythmiceventsoccurredinthedopaminegroup(24.1%vs12.4%,P<
.001).[13]Levelofevidence:1

References

Histadine2(H2)blockers

Indications
Usedtotreatanaphylacticshockthisisanofflabelindication
Doseinformation
Ranitidine:

50mgintravenouslyover5minutes
Cimetidine:

4mg/kgintravenouslyover5minutes
Comments
Ranitidinehasbeenassociatedwithprecipitationofacuteporphyriaattacks
Doseadjustmentisrequiredinrenalimpairment
Thesedrugsshouldbeusedcautiouslyinpatientswithhepaticimpairment

Nondrugtreatments

Erythrocytetransfusion

Description

Administrationofbloodproductsviaintravenousaccess
Indication
Patientsinshockexperiencingongoinghemorrhage
Complications
Intravascularhemolytictransfusionreaction(ie,redplasmaandredurine)
Comments
Effortsshouldbemadetoidentifypatientsatneedformassivetransfusionasearlyas
possibletoinitiateappropriatetherapy,includingamassivetransfusionprotocol
Forpatientsrequiringlargevolumesofbloodproducts,thereisadvantagetousinga
standardizedmassivetransfusionprotocoltoguidebloodcomponentadministration
ratherthanrelyingonlaboratoryassaysofcoagulationtoguidetherapy
Thereiscurrentdebateregardingtheidealratiosofbloodproductstoincludeinthese
protocols,andalargemulticenterclinicaltrialisnowrecruitingpatientstoaddressthis
issue

Evidence
Asystematicreviewoftheliteratureevaluatedtheimpactofahighversuslow
erythrocytetoplasmaratioonmortalityforpatientsrequiringmassivetransfusion.
ElevenobservationalstudieswereidentifiedwithnoRCTs.Theauthorsconcludedthat
thereisinsufficientevidencetosupportasurvivaladvantagewitha1to1plasmato
packederythrocytetransfusionstrategy.[14]Levelofevidence:2

References
Consultation
Hemorrhagicshock:Aspecialistinsuchareasasgeneralsurgery,vascularsurgery,
gastroenterology,orinterventionalradiologymayberequiredtohelpcontrolthesourceof
hemorrhage
Shockaftertraumaticinjury:General/traumasurgeonsshouldbeinvolvedintheimmediate
assessmentandmanagementofthesepatients
Septicshock:Complexcasesmayrequireaninfectiousdiseaseconsulttoassistwith
antibioticcoverage
Cardiogenicshock:Cardiologyconsultmayberequiredformanagementofcardiacischemia
orcongestiveheartfailure

Neurogenicshock:Consultaspinesurgeonforstabilizationoftheinjury

Followup
Endpointsforresuscitation
Endpointstodeterminetheadequacyofshockresuscitation:
Itispreferablenottofocusonasingleendpointinisolationbutrathertouseacombinationof
factors
Bloodlactatehasbeenshowntobeamarkeroftissuehypoperfusion,leadingtoanaerobic
metabolism.Lactateclearancehasbeenassociatedwithimprovedoutcomeaftershock
however,clearancemaybedelayedinpatientswithimpairedrenalorhepaticfunction
Basedeficitisalsoamarkerofmetabolicacidosisandshouldimprovewithresuscitation.Thus,
trendingthebasedeficitovertimecanhelpgaugetheadequacyofresuscitation
Urineoutputisamarkerofadequatepreloadalongwithadequaterenalfunction
Thisisnotareliablemarkerofadequateresuscitationinpatientswithacutekidney
injury,butforpatientswithnormalrenalfunction,urineoutputgreaterthan0.05
mL/kg/hfortheaveragesizeadultsuggestsreasonablerenalperfusion
CVPmonitoringcanbeusedtoassessthepreloadbutislimitedinthesettingofcardiac
dysfunctionorincreasedintrathoracicpressure
ScvO2canbeintermittentlymonitoredthroughaCVPline(ScvO2)orcontinuouslymonitored
withapulmonaryarterycatheter(SvO2)
ScvO2andSvO2areglobalindicatorsofthebalancebetweenoxygensupplyanddemand
AlowSvO2(<65%)orScvO2(<70%)suggestinadequateoxygendeliveryrelativetothe
demandandcanbeatargetforshockresuscitation
InsomeshockstatespatientshaveahighSvO2duetoimpairedutilizationofoxygenin
thetissuebeds,thusmakingthisapproachlessuseful
Invasivehemodynamicmonitoring:
Forpatientswhodonotappeartoberespondingadequatelytovolumeresuscitationor
forwhomcardiacdysfunctionissuspected,variousapproachescanbeusedtodirectly
measurecardiacoutput,suchasapulmonaryarterycatheterordevicesthatrelyon
continuousarterialwaveformanalysis.Thesedevicesalsoallowbetterestimatesof
preload,suchasthepulmonarycapillarywedgepressureandtheassessmentofafterload
viacalculationofthesystemicvascularresistance

Hemodynamicmonitoringcandirectlyassesscardiacoutputandtheadequacyofoxygen
delivery
Vascularresistanceisacalculatedvaluethatshouldnotbeusedsolelytodriveclinical
decisionmaking
Thistypeofmonitoringcanbeimportanttoguidetherapy,especiallywhenmultiple
inotropicandvasoactivemedicationsarerequired
Ultrasound/echocardiography:
Anotherlessinvasiveapproachtoassessingpreloadandcardiacfunctionistheuseof
bedsideultrasound,whichcanassessinferiorvenacavadiameterandleftventricular
filling
Echocardiographycanassesscardiacfillingandejectionfraction
Thesetoolsareusefulformonitoringbutareoperatordependent,andcontinuous
monitoringisnotyetavailable

Evidence
AnRCTcomparedtwodifferentprotocolsforgoaldirectedresuscitationof300patients
withsepticshock.OnegrouptargetednormalizationoftheScvO2withgoalsofanormalCVP
andMAP,andanScvO2ofatleast70%.Theotherarmtargetedlactateclearancewithend
pointsofnormalCVPandMAP,andalactateclearanceofatleast10%.Therewereno
differencesinthetreatmentsdeliveredinthefirst72hoursandnosignificantdifferencein
mortalityrates.[15]Levelofevidence:1
AnRCTof263patientswithseveresepsisandsepticshockcomparedearlygoaldirected
therapyofseveresepsisandsepticshocktostandardcare.Patientswererandomlyassigned
toreceiveaprotocolforearlygoaldirectedtherapybeginningintheemergencydepartment
andcontinuingforthefirst6hoursafterpresentation,ortostandardcare(thecontrol
group).Theprimaryefficacyoutcomewasinhospitalmortality,whichwas30.5%forthe
earlygoaldirectedgroupascomparedto46.5%forthestandardcaregroup(P=.009).This
protocolwasadoptedbytheSurvivingSepsisCampaignguidelines
(http://link.springer.com.ezproxy.ugm.ac.id/content/pdf/10.1007%2Fs0013401227698.pdf).[8]Level

ofevidence:1
AnRCTcomparedtwodifferentresuscitationprotocolsforseverelyinjuredpatients(n=75)
withhemorrhagicshock.Thestandardprotocolwasbasedonresuscitationtonormalvalues
ofsystolicbloodpressure,urineoutput,basedeficit,hemoglobin,andcardiacindexwhile
the'supranormalgroup'wasresuscitatedtocardiacindexabove4.5L/min/m2,ratioof
transcutaneousoxygentensiontofractionalinspiredoxygenabove200,oxygendelivery
indexabove600mL/min/m2,andoxygenconsumptionindexabove170mL/min/m2.There

werenodifferencesinratesofdeath,organfailure,orsepsisbetweenthegroups.[16]Level
ofevidence:2

References

Resources
Summaryofevidence
Treatment
Fluidresuscitation:
Asystematicreviewevaluatedtheliteratureforstudiescomparingcrystalloidstocolloidsfor
theresuscitationofcriticallyillorinjuredpatients.Twentyfourtrialsreporteddataon
albuminwithapooledRRformortalityof1.01(95%CI,0.931.10).Twentyonetrials
comparedhydroxyethylstarchtocrystalloidwithapooledRRof1.10(95%CI,0.911.32).
EleventrialscomparedmodifiedgelatinwithapooledRRof0.91(95%CI,0.491.72).
Finally,ninetrialscompareddextrantocrystalloidwithapooledRRof1.24(95%CI,0.94
1.65).Theauthorsconcludethatthereisnoevidencethatresuscitationwithcolloidsreduces
theriskofdeathcomparedtocrystalloids,andgiventhatcolloidsaremoreexpensive,their
useinnotjustified.[1]Levelofevidence:1
Asystematicreviewevaluatedthesafetyofcolloiduseincriticallyillpatientsandconcluded
thatsignificantsafetydifferencesexistamongcolloidswithconcernforanaphylactoid
reactionsandconcernregardingexacerbationofcoagulopathy.[2]Levelofevidence:2
AnRCTcomparedaninitialbolusof250mL7.5%salinewithandwithout6%dextran70to
normalsalinefortheinitialprehospitalresuscitationofpatientswithtraumatichypovolemic
shock(n=853).Therewasnodifferencein28daymortalitybetweenthetreatmentgroups.
[3]Levelofevidence:1

AnRCTof598patientsevaluatedimmediateversusdelayedfluidresuscitationfor
hypotensivepatientswithpenetratingtorsotrauma.Patientswererandomlyassignedtono
fluidbeginningintheprehospitalsettingandextendinguntiloperativecontrolof
hemorrhagewasachievedversusstandardresuscitation.Survivalinthedelayed
resuscitationgroupwas70%versus62%fortheimmediateresuscitationgroup.RRfor
deathwithearlyfluidadministrationwas1.26(95%CI,11.58).Thereweresomeconcerns
withprotocoladherencebyemergencymedicalservices,andallpatientswereinanurban
systemwithashorttransporttimetodefinitivecare.[4]Levelofevidence:2
AnRCTof1,309traumapatientscomparedimmediateversusdelayedfluidresuscitation
beginningintheprehospitalsetting.Protocolcompliancewaspoor.Mortalitywas10.4%in
theearlyresuscitationgroupversus9.8%inthedelayedgroup.TheRRwithearlyfluid
administrationwas1.06(95%CI,0.771.47).[5]Levelofevidence:2

AnRCTcomparedresuscitationof110traumapatientswithhemorrhagicshocktoatarget
bloodpressureof70mmHgversus100mmHg.Mortalitywas7.3%inbothgroups,andRR
fordeathwas1(95%CI,0.263.81).[6]Levelofevidence:2
Asystematicreviewofsixstudiesinvolving2,128patientscomparedearlyversusdelayed
fluidresuscitationorlargeversussmallvolumeresuscitationforbleedingtraumapatients.
ThestudyconcludedthattherewasnoevidencefromRCTsthatwasclearlyfororagainst
earlyorlargervolumeofintravenousfluidadministrationinbleedingtraumapatients.[7]
Levelofevidence:1
AnRCTof263patientswithseveresepsisandsepticshockcomparedearlygoaldirected
therapyofseveresepsisandsepticshocktostandardcare.Patientswererandomlyassigned
toreceiveaprotocolforearlygoaldirectedtherapybeginningintheemergencydepartment
andcontinuingforthefirst6hoursafterpresentation,ortostandardcare(thecontrol
group).Theprimaryefficacyoutcomewasinhospitalmortality,whichwas30.5%forthe
earlygoaldirectedgroupascomparedto46.5%forthestandardcaregroup(P=.009).This
protocolwasadoptedbytheSurvivingSepsisCampaignguidelines
(http://link.springer.com.ezproxy.ugm.ac.id/content/pdf/10.1007%2Fs0013401227698.pdf).[8]Level

ofevidence:1
Corticosteroids:
Amulticenter,doubleblindRCTwasconductedthatassigned499patientswithsepticshock
tohydrocortisone(n=251,initially50mgevery6hours)orplacebo(n=248).Theprimary
outcomewasdeathamongthesepatientswhodidnothavearesponsetocorticotropin
stimulationtestingat28days.Anincreaseinthecortisollevelofnomorethan9g/dLafter
250gcosyntropinwasdefinedasanabsenceoforinappropriateresponse.Ofthe499
patients,233(46.7%)didnotrespondappropriatelytocorticotropin.At28days,therewas
nosignificantdifferenceinmortalitybetweenpatientsassignedhydrocortisoneversus
placebofornonresponderstocorticotropin(39.2%inthehydrocortisonegroupvs36.1%in
theplacebogroup,P=.69),norbetweenthoseassignedhydrocortisoneversusplacebo
amongthosewhodidrespondtocorticotropin(28.8%inthehydrocortisonegroupvs28.7%
intheplacebogroup,P=1).Thus,therewasnosignificantdifferenceinsurvivalbetween
thosewhoreceivedhydrocortisoneandthosewhodidnot,regardlessofresponseto
corticotropin.Thegroupreceivinghydrocortisoneresolvedtheshockstatemorequicklybut
developedmoreepisodesofsubsequentinfection.[9]Levelofevidence:1
Vasopressors/inotropes:
Asystematicreviewwasoriginallypublishedin2004andupdatedin2011toevaluatethe
literatureregardingvasopressoruseinshock.Twentythreestudieswerereviewedinvolving
3,212patients.Sixdifferentvasopressors,aloneorincombination,werestudied.Therewas
nodifferenceinmortalityforanyofthecomparisonsbetweendifferentvasopressors.More

arrhythmiaswerenotedinpatientsreceivingdopamineversusnorepinephrine.Theauthors
concludedthatthereisnotsufficientevidencethatanyoneofthevasopressorsisclearly
superiorovertheothers.[10]Levelofevidence:1
AnRCTcomparedepinephrineversusnorepinephrinewithdobutamineforthemanagement
ofpatientswithsepticshock(n=330).Therewerenosignificantdifferencesinefficacyor
safetybetweenthetwogroups.[11]Levelofevidence:1
AnRCTassignedpatientswithsepticshocktoreceiveeitherlowdosevasopressinor
norepinephrineinadditiontoopenlabelvasopressors(n=778).Therewasnosignificant
differenceinmortalityorratesofseriousadverseeventsbetweenthegroups.[12]Levelof
evidence:1
AnRCTcompareddopaminetonorepinephrineasfirstlinetherapyforpatientswithshock
(n=1679).Therewasnosignificantdifferenceinmortalitybetweenthegroups,butmore
arrhythmiceventsoccurredinthedopaminegroup(24.1%vs12.4%,P<.001).[13]Levelof
evidence:1
Erythrocytetransfusion:
Asystematicreviewoftheliteratureevaluatedtheimpactofahighversuslowerythrocyte
toplasmaratioonmortalityforpatientsrequiringmassivetransfusion.Eleven
observationalstudieswereidentifiedwithnoRCTs.Theauthorsconcludedthatthereis
insufficientevidencetosupportasurvivaladvantagewitha1to1plasmatopacked
erythrocytetransfusionstrategy.[14]Levelofevidence:2
Followup
AnRCTcomparedtwodifferentprotocolsforgoaldirectedresuscitationof300patients
withsepticshock.OnegrouptargetednormalizationoftheScvO2withgoalsofanormalCVP
andMAP,andanScvO2ofatleast70%.Theotherarmtargetedlactateclearancewithend
pointsofnormalCVPandMAP,andalactateclearanceofatleast10%.Therewereno
differencesinthetreatmentsdeliveredinthefirst72hoursandnosignificantdifferencein
mortalityrates.[15]Levelofevidence:1
AnRCTof263patientswithseveresepsisandsepticshockcomparedearlygoaldirected
therapyofseveresepsisandsepticshocktostandardcare.Patientswererandomlyassigned
toreceiveaprotocolforearlygoaldirectedtherapybeginningintheemergencydepartment
andcontinuingforthefirst6hoursafterpresentation,ortostandardcare(thecontrol
group).Theprimaryefficacyoutcomewasinhospitalmortality,whichwas30.5%forthe
earlygoaldirectedgroupascomparedto46.5%forthestandardcaregroup(P=.009).This
protocolwasadoptedbytheSurvivingSepsisCampaignguidelines
(http://link.springer.com.ezproxy.ugm.ac.id/content/pdf/10.1007%2Fs0013401227698.pdf).[8]Level

ofevidence:1

AnRCTcomparedtwodifferentresuscitationprotocolsforseverelyinjuredpatients(n=75)
withhemorrhagicshock.Thestandardprotocolwasbasedonresuscitationtonormalvalues
ofsystolicbloodpressure,urineoutput,basedeficit,hemoglobin,andcardiacindexwhile
the'supranormalgroup'wasresuscitatedtocardiacindexabove4.5L/min/m2,ratioof
transcutaneousoxygentensiontofractionalinspiredoxygenabove200,oxygendelivery
indexabove600mL/min/m2,andoxygenconsumptionindexabove170mL/min/m2.There
werenodifferencesinratesofdeath,organfailure,orsepsisbetweenthegroups.[16]Level
ofevidence:2

References
[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[8],[16]

Evidencereferences
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2.BarronME,WilkesMM,NavickisRJ.Asystematicreviewofthecomparativesafetyof
colloids.ArchSurg.2004139:55263
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3.BulgerEM,MayS,KerbyJD,etal.Outofhospitalhypertonicresuscitationaftertraumatic
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4.BickellWH,WallMJJr,PepePE,etal.Immediateversusdelayedfluidresuscitationfor
hypotensivepatientswithpenetratingtorsoinjuries.NEnglJMed.1994331:11059
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5.TurnerJ,NichollJ,WebberL,CoxH,DixonS,YatesD.Arandomizedcontrolledtrialof
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6.DuttonRP,MackenzieCF,ScaleaTM.Hypotensiveresuscitationduringactivehemorrhage:
impactoninhospitalmortality.JTrauma.200252:11416
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7.KwanI,BunnF,RobertsI,WHOPreHospitalTraumaCareSteeringCommittee.Timing
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2003:CD002245
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8.RiversE,NguyenB,HavstadS,etal.Earlygoaldirectedtherapyinthetreatmentofsevere
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9.SprungCL,AnnaneD,KehD,etal.Hydrocortisonetherapyforpatientswithsepticshock.
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10.HavelC,ArrichJ,LosertH,GamperG,MllnerM,HerknerH.Vasopressorsfor
hypotensiveshock.CochraneDatabaseSystRev.2011:CD003709
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11.AnnaneD,VignonP,RenaultA,etal,andCATSStudyGroup.Norepinephrineplus
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Lancet.2007370:67684
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12.RussellJS,WalleyKR,SingerJ,etal,andVASSTInvestigators.Vasopressinversus
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13.DeBackerD,BistonP,DevriendtJ,etal.Comparisonofdopamineandnorepinephrinein
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14.RajasekharA,GowingR,ZarychanskiR,etal.Survivaloftraumapatientsaftermassive
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15.JonesAE,ShapiroNI,TrzeciakS,etal,andEmergencyMedicineShockResearchNetwork
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Guidelines
TheSurvivingSepsisCampaignhasproducedthefollowing:
DellingerRP,LevyMM,RhodesA,etal.SurvivingSepsisCampaign:internationalguidelines

forthemanagementofseveresepsisandsepticshock,2012
(http://link.springer.com.ezproxy.ugm.ac.id/content/pdf/10.1007%2Fs0013401227698.pdf).

IntensiveCareMed.201339:165228
TheAmericanCollegeofCriticalCareMedicinehasproducedthefollowing:
MarikPE,PastoresSM,AnnaneD,etal.Recommendationsforthediagnosisandmanagement
ofcorticosteroidinsufficiencyincriticallyilladultpatients:consensusstatementfromaninternational
taskforcebytheAmericanCollegeofCriticalCareMedicine
(http://www.learnicu.org/Docs/Guidelines/CoricosteroidInsufficiencyAdult.pdf).CritCareMed.

200836:193749

Furtherreading
GroeneveldAB,NavickisRJ,WilkesMM.Updateonthecomparativesafetyofcolloids:a
systematicreviewofclinicalstudies.AnnSurg.2011253:47083
AlamHB.Advancesinresuscitationstrategies.IntJSurg.20119:512
YoungPP,CottonBA,GoodnoughLT.Massivetransfusionprotocolsforpatientswith
substantialhemorrhage.TransfusMedRev.201125:293303
BrachtH,CalziaE,GeorgieffM,SingerJ,RadermacherP,RussellJA.Inotropesand
vasopressors:morethanhaemodynamics!BrJPharmacol.2012165:200911
BulgerEM,HoytDB.Hypertonicresuscitationaftersevereinjury:isitofbenefit?Adv
Surg.201246:7385

Codes
ICD9code
785.5Shockwithoutmentionoftrauma
785.50Shock,unspecified,failureofperipheralcirculation
785.51Cardiogenicshock
785.52Septicshock
995.0Anaphylacticshock
998.0Postoperativeshock

FAQ
Whatisshockandwhatarethemostcommoncausesforshock?Shockis
inadequatetissueperfusion,whichisoftenmanifestedbyhypotensionbutcanoccurbefore

majorchangesinvitalsigns.Determiningtheetiologyofshockiscrucialtodefiningthe
optimaltreatmentapproach.Themostcommonetiologiesofshockare:hypovolemicshock,
septicshock,cardiogenicshock,obstructiveshock,neurogenicshock,anaphylacticshock,
andhypoadrenalshock
HowdoIrecognizeapatientinshock?Patientspresentinginshockareoften
hypotensive,butinearlyshockpatientsmaybenormotensivebuttachycardic.Forintubated
patientsalowendtidalCO2readingmayalsobeasignofearlyshock.Diagnosisofshock
dependsontheclinicalcontextaspatientsmaypresentwith'coldshock'duetoimpaired
tissueperfusionandvasoconstriction,or'warmshock'withperipheralvasodilation.Patients
withcoldshockwillbecoolandpaleandareusuallyhypovolemicresponsetofluidbolus
shouldbeassessedandlaboratorystudiessenttoevaluateforanemiaandmetabolic
acidosis.Ifthereisconcernforongoinghemorrhage,serialhemoglobinchangesovertime
aremoreusefulthantheinitialhemoglobinmeasurement.Patientswithmetabolicacidosis
basedonelevatedlactateorbasedeficitshouldalsobeconsideredinearlyshockevenifnot
yethypotensive.Patientswithwarmshockmaybewarmandappearwellperfusedbutmay
stillbehypotensive.Thisisseenwithneurogenicshock,earlysepticshock,andanaphylactic
shock.Patientswithsuspectedneurogenicshockneedearlyimagingtoevaluateforspinal
cordinjury.Patientswithanaphylacticshockmayhavearash(classicallyurticaria)and
significantedema(angioedema)duetothesevereallergicreaction.Patientswithsuspected
septicshockshouldhavebloodandotherculturesbasedonthesuspectedsiteofinfection
Whatistheinitialtherapyforpatientswithundifferentiatedshock?Initial
therapyformosttypesofshockinvolvesfluidboluswithcrystalloidwhiletheetiologyof
shockisdetermined,andthentherapyistailoredbasedontheunderlyingcause.Patients
whoremainhypotensivedespiteadequatefluidresuscitationrequirevasopressortherapy
Whatarethestepsforearlygoaldirectedtherapyforpatientswithseptic
shock?Ensureadequateintravenousaccessandinitiatevolumeresuscitationwith
crystalloid,sendbloodandotherculturesasappropriateandconsiderimagingtoidentify
thesourceofinfection,checkserumlactatelevel,andplacecentrallinetomeasureCVPand
ScvO2toguideresuscitation.Theguidelines
(http://link.springer.com.ezproxy.ugm.ac.id/content/pdf/10.1007%2Fs0013401227698.pdf)forthe

SurvivingSepsisCampaignrecommendresuscitationtothefollowingendpoints:CVP8to
12mmHgMAPatleast65mmHgurineoutputatleast0.5mL/kg/hScvO2orSvO2atleast
70%or65%,respectively.Ifduringthefirst6hoursofresuscitationthegoalsforScvO2or
SvO2arenotachievedwithfluidresuscitationtotheCVPtarget,thentransfusiontoa
hematocritofatleast30%and/oradministrationofadobutamineinfusionare
recommendedtoachievethesegoals
Whatarethemostimportantinterventionsforpatientsinhemorrhagicshock?
Identifyandcontrolthesourceofhemorrhageandinitiateresuscitationwithcrystalloid.If

signsofactivebleedingbecomeevident,initiatebloodtransfusionspromptly.Patients
needingamassivetransfusionshouldbemanagedbasedonaprotocol,whichprovidesearly
accesstofreshfrozenplasmaandplatelets

Currentcontributors
EileenM.Bulger,MD,ProfessorofSurgery,UniversityofWashington,Seattle,Washington

Copyright2016Elsevier,Inc.Allrightsreserved.