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Management of Shock: 2024-2026 Guidelines

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Classification

• Sabiston Textbook of Surgery, p. 934

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Universal Initial Steps (All Shock Types)

1. Airway/Breathing: Supplemental O2; intubate if severe or ventilation is inadequate (O2 sat <94%)
2. IV Access: Two large-bore (14-16G) peripheral IVs; central line or intraosseous if peripheral access fails
3. Monitoring: Continuous pulse oximetry, ECG, urine output (Foley), arterial line if vasopressors required
4. Identify and treat underlying cause - this is the cornerstone of definitive management

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Hemodynamic Monitoring (ESICM 2025 Guidelines - PMID 41236566)

• Capillary refill time (CRT) should be monitored as a perfusion marker; complement with skin temperature and mottling assessment
• Echocardiography is the first-line imaging modality to identify shock type (graded recommendation)
• Dynamic variables (e.g., stroke volume variation, pulse pressure variation) are preferred over static markers (CVP) for assessing fluid responsiveness
• Cardiac output/stroke volume monitoring in patients not responding to initial therapy
• Arterial catheter for BP monitoring in shock unresponsive to initial therapy or requiring vasopressors
• Serial ScvO2 and venoarterial CO2 difference in patients with central venous catheters
• Before giving further fluids after initial resuscitation, assess fluid responsiveness - do not continue fluids blindly

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1. Septic Shock

Definition (Sepsis-3)

Surviving Sepsis Campaign (SSC) 2026 Adult Framework

• 30 mL/kg balanced crystalloid (e.g., Lactated Ringer's or Plasmalyte) in first 3 hours
• Reassess after each bolus; continue only if fluid-responsive (use dynamic indices)
• Avoid normal saline (0.9% NaCl) as first choice - associated with hyperchloremic acidosis
• ESICM 2025 Part 1 recommends balanced crystalloids over saline for resuscitation

• Administer within 1 hour of recognition (draw cultures first)
• Broad-spectrum empirical coverage; narrow once sensitivities return
• Source control: surgical drainage/debridement as indicated

• Start norepinephrine as first-line (0.01-0.5 mcg/kg/min); target MAP ≥65 mmHg
• In vasodilatory shock, permissive hypotension targeting MAP 60-65 mmHg does not appear superior to standard MAP 65 mmHg targets in general patients
• Add vasopressin (0.03-0.04 U/min) as second-line when norepinephrine doses escalate (>0.25-0.5 mcg/kg/min)
• Dopamine is not preferred over norepinephrine (higher arrhythmia risk)

• Hydrocortisone 200 mg/day (IV infusion) in septic shock not responding adequately to fluids + vasopressors
• Do not use to diagnose relative adrenal insufficiency (ACTH stimulation test no longer recommended to guide steroid use)

• Transfuse pRBCs when Hb <7 g/dL (7-9 g/dL is equivalent)
• No routine role for platelets or FFP in septic shock resuscitation

• Target blood glucose 140-180 mg/dL; avoid both hypoglycemia and hyperglycemia
• Rosen's Emergency Medicine, p. 62; Goldman-Cecil Medicine, p. 3615; Sabiston Textbook of Surgery, p. 934

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2. Hemorrhagic (Hypovolemic) Shock

ATLS Classification (American College of Surgeons)

Management (AAST/ACS 2024 Damage Control Resuscitation Protocol)

1. Hemorrhage control first: direct pressure, tourniquets, REBOA (resuscitative endovascular balloon occlusion of the aorta), or surgical exploration
2. Judicious isotonic crystalloid: 10-20 mL/kg initially; avoid large-volume saline
3. Massive transfusion protocol (for suspected massive hemorrhage or Class III-IV):
   • Balanced blood product ratios: 1:1:1 (pRBC : FFP : platelets) - damage control resuscitation
   • Early PRBC (5-10 mL/kg) if >30 min delay to hemorrhage control and signs of poor organ perfusion
4. Permissive hypotension: target systolic 80-90 mmHg (MAP ~50 mmHg) until hemorrhage is surgically controlled - reduces ongoing blood loss and coagulopathy
5. Treat coagulopathy: tranexamic acid within 3 hours of injury (CRASH-2 evidence); calcium supplementation; avoid hypothermia and acidosis

• The European Guideline on Major Bleeding and Coagulopathy following Trauma (6th edition, 2023) is the landmark reference for trauma hemorrhage.
• Goldman-Cecil Medicine, hemorrhagic shock classification table, p. 2481

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3. Cardiogenic Shock

ACC 2025 Expert Consensus Statement (PMID 40100174)

• A (At risk) → B (Beginning shock) → C (Classic/florid) → D (Deteriorating) → E (Extremis)

1. Oxygenation: O2, non-invasive ventilation (CPAP/BiPAP) for pulmonary edema; intubate if needed
2. Vasopressors/Inotropes:
   • Norepinephrine (0.5+ mcg/min) for hypotension - preferred over dopamine
   • Dobutamine (5+ mcg/kg/min) as inotrope for low output with adequate pressure
3. Revascularization: Immediate PCI for STEMI-related cardiogenic shock (even if >12 hours)
4. Mechanical Circulatory Support (MCS):
   • IABP (intra-aortic balloon pump): still used; trial evidence (IABP-SHOCK II) showed no mortality benefit in unselected patients but may be considered for specific situations
   • Impella: increasing evidence for higher-risk patients; RECOVER II trial data informing selection
   • ECMO (VA-ECMO): for refractory shock (Extremis/Stage E); ECLS-SHOCK trial (2023) showed no 30-day mortality benefit in early routine use
5. Interdisciplinary Shock Team: Cardiology + cardiac surgery + critical care early involvement is recommended
6. Fluid management: Cautious; avoid aggressive fluid loading - risk of worsening pulmonary edema
7. Transfusion threshold: 8 g/dL safe vs. 10 g/dL in AMI patients

• Fuster and Hurst's The Heart, 15th Ed., p. 1823-1829; Goldman-Cecil Medicine, p. 2489

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4. Obstructive Shock

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5. Distributive Shock - Special Subtypes

Anaphylactic Shock

• Epinephrine IM (0.3-0.5 mg, 1:1000) into outer thigh - first-line, no contraindications
• IV fluids: aggressive resuscitation (1-2 L crystalloid)
• Adjuncts: diphenhydramine, corticosteroids, H2 blockers, bronchodilators
• Vasopressors (norepinephrine) if refractory

Neurogenic Shock

• IV fluids first
• Norepinephrine preferred over phenylephrine (especially for high cervical injuries with bradycardia)
• Atropine for symptomatic bradycardia
• Maintain MAP >85 mmHg for first 7 days in complete SCI (per ATLS)
• Sabiston Textbook of Surgery, p. 934

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Vasopressor Quick Reference

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Key Recent Guideline Sources (2023-2026)

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• Routine early goal-directed therapy (EGDT) with CVP/ScvO2 targets is no longer recommended; individualized dynamic assessment is preferred
• Fluid responsiveness testing before continuing resuscitation after the initial phase is now a key recommendation
• qSOFA should not replace SOFA or SIRS for sepsis screening per SSC
• VA-ECMO showed no routine mortality benefit in the ECLS-SHOCK RCT (2023) - selection criteria matter
• Balanced crystalloids (LR, Plasmalyte) are preferred over normal saline for nearly all shock resuscitation