Initial Management of Shock

Immediate Assessment and Recognition

The Society of Critical Care Medicine recommends rapidly evaluating vital signs including heart rate, blood pressure, respiratory rate, temperature, oxygen saturation, and mental status to confirm shock state 1, 4
Measure serum lactate immediately at time of shock recognition, as elevated lactate indicates tissue hypoperfusion and guides resuscitation intensity 3, 4
Identify shock type through focused clinical examination: assess jugular venous pressure, heart sounds, lung sounds, skin perfusion, and urine output 1, 4

The European Society of Intensive Care Medicine recommends administering a minimum of 30 mL/kg of IV crystalloid within the first 3 hours as the cornerstone of initial shock management 1, 2, 3
Use crystalloids as the first-line fluid choice; avoid hydroxyethyl starches completely as they increase acute kidney injury and mortality 5, 2, 3
Give fluid in rapid boluses of 500-1000 mL over 15-30 minutes, reassessing hemodynamic response after each bolus 1, 2

Target mean arterial pressure (MAP) ≥65 mmHg as the primary hemodynamic goal 1, 2, 3
Use dynamic measures of fluid responsiveness rather than static measures like central venous pressure (CVP) alone to guide ongoing fluid administration 1, 2

If hypotension persists despite adequate fluid resuscitation, initiate norepinephrine as the first-choice vasopressor to maintain MAP ≥65 mmHg 1, 2, 3, 4
Start norepinephrine at 0.05 mcg/kg/min and titrate upward every 10-15 minutes to achieve MAP target 2

Administer IV broad-spectrum antimicrobials within 1 hour of recognizing septic shock, even before obtaining cultures if this would cause delay 2, 3, 4
Obtain at least two sets of blood cultures before starting antimicrobials if this does not significantly delay therapy 3, 4

Control the source of bleeding as the absolute priority—arrange immediate surgical consultation for uncontrolled hemorrhage 6
In trauma with uncontrolled bleeding, use permissive hypotension with restrictive fluid strategy until surgical hemostasis is achieved 6, 5

Continuously monitor clinical markers of perfusion: mental status, capillary refill time, skin mottling, peripheral pulses, urine output 1, 2, 4
Reassess hemodynamic response after each fluid bolus and adjust therapy accordingly 1, 4

Do not delay antimicrobials in septic shock while waiting for cultures or imaging—administer within 1 hour 2, 3, 4
Do not rely solely on CVP to guide fluid resuscitation; it poorly predicts fluid responsiveness 1, 2
Do not use hydroxyethyl starches for volume replacement as they increase acute kidney injury and mortality 5, 2, 3
Do not use aggressive fluid resuscitation in trauma patients with uncontrolled hemorrhage; this worsens coagulopathy and mortality 6, 5
Do not use hypotonic fluids in patients with traumatic brain injury 6, 5