Internal Medicine

0521779407-19 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:21

Shock 1341

General Measures

■Prompt resuscitation to avoid end organ damage (renal failure,

hypoxic encephalopathy, ARDS, MI, ischemic colitis)

■Monitor in intensive care setting

■If hypotension fails to improve after two acute fluid challenges, hypo-

volemia is unlikely; consider inotropes

■Consider vasopressors when patient has a marked tachycardia

■No vasoactive agent is superior in shock. Choice should be guided

by side effect profile of agent

specific therapy

Indications

■Institute therapy upon diagnosis while etiology is sought

Treatment Options

■Fluids

➣Crystalloids(Lactated Ringers, 0.9% NaCl, 3% NaCl)

Most studies show no significant difference between colloid

and crystalloid resuscitation

➣Colloid(Albumin, Hetastarch, Fresh Frozen Plasma)

Certain outcome parameters support use of Hetastarch

FFP should only be used if coagulopathy is present

➣Packed RBC

Outcome is unaffected if Hgb >7 gm/dl

■Vasopressors: Phenylepherine, Vasopressin

➣Emerging literature support use of Vasopressin in ACLS proto-

cols

■Inotropes: (ephedrine, dopamine, epinephrine, norepinephrine,

dobutamine)

Other

■Cardiogenic:

➣Intraaortic Balloon Pump: Indicated for cardiogenic shock unre-

sponsive to pharmacologic therapy

■Neurogenic:

➣Naloxone; Steroids for acute spinal cord trauma as neuroprotec-

tive agents

■Septic:

➣Panculture

➣Cytokine inhibitors have not proven effective

➣Initiate broad spectrum antibiotic therapy