Specific Plans

1. Hypovolemic shock. Resuscitate with isotonic crystalloids (normal saline or lactated Ringer). Blood products may be given if hemoglobin is < 8 g/dL or coagulopathy exists. Ensure adequate fluid resuscitation before instituting therapy with inotropes or vasopressors. Place a Foley catheter to monitor urine output. If a central venous catheter is required, measure CVP and provide fluid resuscitation until CVP is at least 10 cm H2O. If BP, perfusion, or urine output remains inadequate, consider vasopressors or inotropes.

2. Cardiogenic shock. A central venous catheter will be required. Consider a pulmonary artery catheter. If pericardial tamponade is present, drainage of pericardial fluid is required. If there is evidence of myocarditis, cardiology colleagues should be consulted. Generally, medications that are both inotropes and afterload reducers are best in these situations. Consider dobutamine, milrinone, or amrinone. Dopamine may also be helpful. If patient is still poorly responsive, then norepi-nephrine or epinephrine may be useful. Neurogenic shock. Initial therapy includes aggressive volume resuscitation. If hypotension persists, therapy with vasopres-sors or inotropes is indicated.

Vasogenic shock (includes septic shock and anaphylactic shock). Initial therapy consists of aggressive volume resuscitation; be prepared to give very large volumes of fluid. Therapy with vasopressors or inotropes may be required, but should not be started until adequate fluid resuscitation has occurred (CVP > 10 cm H2O). If patient is poorly responsive to resuscitation with crystalloids, blood products should be considered, especially if anemia, thrombocytopenia, or coagulopathy is present. Treatment of underlying infection with appropriate antibiotics is essential. If patient is in anaphylactic shock, treat immediately with isotonic fluids and epinephrine (0.01 mL/kg of 1:1000 SQ to a maximum dose of 0.3 mL). Diphenhydramine and ranitidine may be useful adjuncts to therapy. Vasogenic shock can also be seen with an addisonian crisis, which should be treated with hydrocortisone.

VI. Problem Case Diagnosis. The 2-year-old patient was diagnosed with hypovolemic shock secondary to gastroenteritis. Despite initial resuscitation, he continued to have ongoing fluid losses and the need for further aggressive fluid resuscitation. He was given an additional 20 mL/kg of normal saline, which was repeated twice until the systolic BP remained adequate (> 75 mm Hg).

VII. Teaching Pearl: Question. Is presence of hypotension necessary to make the diagnosis of shock?

VIII. Teaching Pearl: Answer. No; shock is an acute syndrome characterized by inadequate circulatory perfusion of tissue to meet the metabolic demands of vital organs. It is a misconception that shock occurs only with low BP (hypotension). Through various compensatory mechanisms, hypotension may be a late finding in shock.

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