2.16A Shock - Adult
Any patient with signs, symptoms, and history suggesting inadequate tissue perfusion should be considered to be in shock. Make every effort to determine and treat the underlying cause. Regardless of etiology, shock patients should be transported immediately to the nearest appropriate facility for definitive care.
BASIC STANDING ORDERS
1.0 Routine Patient Care
Keep the patient supine.
Prevent heat loss by covering with warm blankets if available and if the patient is not febrile.
Physiological signs:
Altered mental status.
Radial pulse cannot be palpated.
Systolic blood pressure less than 100 mmHg.
Cardiogenic Shock:
Assess and treat for pulmonary edema and/or congestive heart failure (CHF), per 3.6 Congestive Heart Failure.
Distributive Shock:
If patient has history of adrenal insufficiency, manage according to 2.1 Adrenal Insufficiency.
Hypovolemic Shock:
Control active bleeding using direct pressure, pressure bandages, tourniquets (commercial tourniquets preferred), or hemostatic bandage.
Obstructive Shock:
ADVANCED EMT STANDING ORDERS
Cardiogenic Shock:
No fluid bolus
Distributive Shock:
Total volume administered is to be based on hemodynamic stability.
Consider Normal Saline fluid bolus.
Hypovolemic Shock:
Total volume administered is determined by hemodynamic stability.
Consider Normal Saline fluid bolus.
Obstructive Shock:
Total volume administered is to be based on hemodynamic stability.
Consider Normal Saline fluid bolus.
PARAMEDIC STANDING ORDERS
Consider fluid administration.
If signs and symptoms of hypoperfusion persist or symptoms worsen, regardless of etiology, consider norepinephrine, epinephrine or dopamine administration in the absence of hemorrhagic shock, with medical control approval.
MEDICAL CONTROL MAY ORDER
Cardiogenic Shock:
Norepinephrine infusion by pump 0.1-0.5 mcg/kg/min IV/IO, titrate to goal Systolic Blood Pressure of 90mmHg, OR
Epinephrine Infusion – 2-10 mcg/min IV/IO, OR
Dopamine 2-20 mcg/kg/min IV/IO
Distributive Shock:
Norepinephrine infusion by pump 0.1-0.5 mcg/kg/min IV/IO, titrate to goal Systolic Blood Pressure of 90mmHg, OR
Epinephrine infusion – 2-10 mcg/min IV/IO, OR
Dopamine 2-20 mcg/kg/min IV/IO
For patients with confirmed or suspected Adrenal Insufficiency, treat per 2.1 Adrenal Insufficiency.
Hypovolemic Shock:
Norepinephrine infusion by pump 0.1-0.5 mcg/kg/min IV/IO, titrate to goal Systolic Blood Pressure of 90mmHg, OR
Epinephrine infusion – 2-10 mcg/min IV/IO, OR
Dopamine 2-20mcg/kg/min IV/IO
Obstructive Shock:
Norepinephrine infusion by pump 0.1-0.5 mcg/kg/min IV/IO, titrate to goal Systolic Blood Pressure of 90mmHg, OR
Epinephrine infusion – 2-10 mcg/min IV/IO, OR
Dopamine 2-20 mcg/kg/min IV/IO
Needle Decompression, if tension pneumothorax suspected
NOTES:
Etiology of Shock
Cardiogenic Shock: History of cardiac surgery, rhythm disturbances, or post cardiac arrest. Assess for acute MI and pulmonary edema.
Signs & Symptoms of cardiogenic shock: chest pain, shortness of breath, crackles, JVD, hypotension, tachycardia, diaphoresis.
Distributive Shock: Anaphylaxis (see 2.2 Allergic Reaction/Anaphylaxis), neurogenic shock, sepsis. Assess for fever and signs of infection.
Signs & Symptoms of neurogenic shock: sensory and/or motor loss, hypotension, bradycardia versus normal heart-rate, warm, dry skin.
Hypovolemic Shock: Dehydration, volume loss, or hemorrhagic shock.
Signs & Symptoms of hypovolemic shock: tachycardia, tachypnea, hypotension, diaphoresis, cool skin, pallor, flat neck veins.
Obstructive Shock: Consider tension pneumothorax, pulmonary embolism, and cardiac tamponade.
Signs and symptoms of tension pneumothorax: asymmetric or absent unilateral breath sounds, respiratory distress or hypoxia, signs of shock including tachycardia and hypotension, JVD, possible tracheal deviation above the sternal notch (late sign).
For patients with uncontrolled hemorrhagic or penetrating torso injuries:
Restrict IV fluids. Delaying aggressive fluid resuscitation until operative intervention may improve the outcome.
Patients should be reassessed frequently, with special attention given to the lung examination to ensure volume overload does not occur.
Several mechanisms for worse outcomes associated with IV fluid administration have been suggested, including dislodgement of clot formation, dilution of clotting factors, and acceleration of hemorrhage caused by elevated blood pressure.