SHOCK
GENERAL CONSIDERATIONS
A. Hypoperfusion (shock) is the inadequate perfusion of body tissues, resulting inadequate
supply of oxygen and nutrients to the body tissues.
B. Shock is almost always a result of inadequate cardiac output. A number of factors can
decrease effective cardiac output. These include:
1. Inadequate pump function caused by:
• Inadequate preload;
• Inadequate contractile strength;
• Inadequate heart rate; and/or
• Excessive afterload
2. Inadequate fluid caused by hypovolemia
3. Inadequate container (vascular system)
• Dilated container without change in fluid volume (inadequate systemic
vascular resistance)
• Leak in container
C. Occasionally shock may develop even when cardiac output is adequate. This can happen
when cell metabolism is so excessive that the body cannot increase perfusion enough to
meet the demands. (e.g., fever, infections, pain, respiratory distress, etc.)
D. The Shock Syndromes:
1. Low-Volume Shock (absolute hypovolemia) is caused by hemorrhage or other major
body fluid loss (diarrhea, vomiting, and “third spacing” due to burns, peritonitis, and
other causes).
2. High-Space Shock (relative hypovolemia) is caused by spinal injury, vasovagal
syncope, sepsis, and certain drug overdoses.
3. Mechanical Shock is caused by pericardial tamponade, tension pneumothorax,
massive pulmonary embolism, or conditions weakening the heart muscle, such as
myocardial contusion or infarction (cardiogenic shock).
E. Generally the signs and symptoms of hypovolemic shock occur in the following order.
1. Compensated Shock
• Weakness & lightheadedness – caused by decreased blood volume
• Thirst – caused by hypovolemia
• Pallor – caused by catecholamine-induced vasoconstriction and/or loss of
circulating red blood cells
• Tachycardia – caused by the effects of catecholamines on the heart as the
brain increases the activity of the sympathetic nervous system
• Diaphoresis – caused by the effects of catecholamines on sweat glands
• Tachypnea – caused by brain elevating the respiratory rate under the
influence of stress, catecholamines, acidosis, and hypoxia
• Decreased urinary output – caused by hypovolemia, hypoxia, and
circulating catecholamines
• Weakened peripheral pulse – the “thready” pulse (meaning “threadlike”, the
arteries actually shrink in width as intravascular volume is lost); caused by
vasoconstriction, tachycardia, and loss of blood volume
• NOTE- the symptoms and signs listed above are in the order of
progressive “compensation” as the body attempts to deal with the cause of
shock. Beginning with the next sign, hypotension, the body is no longer
able to maintain perfusion, and the shock condition is now
“decompensated.”
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Shock
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2. Decompensated Shock
• Hypotension – caused by hypovolemia, either relative or absolute, and/or
by diminished cardiac output seen in mechanical shock
• Altered Mental Status (confusion, restlessness, combativeness,
unconsciousness) – caused by decreased cerebral perfusion, acidosis,
hypoxia, and catecholamine stimulation
• Cardiac Arrest – caused by critical organ failure secondary to blood / fluid
loss, hypoxia, and occasionally dysrhythmias caused by catecholamines
and/or low perfusion
Basic EMT
A. Assess and manage airway
1. Apply pulse oximeter and treat per Pulse Oximeter Procedure
2. Be prepared to ventilate and/or assist ventilations with an oral / nasal airway and
BVM or positive-pressure ventilations
B. Evaluate patient’s general appearance, relevant history of condition and determine OPQRSTI
and SAMPLE.
C. Control bleeding as indicated – direct pressure, application of tourniquets, ITClamp, or
hemostatic agents. See Trauma Emergencies Protocol
D. If shock syndrome is due to anaphylaxis, See Allergic Reaction / Anaphylactic Shock
Protocol.
E. Transport patient in horizontal or slightly head-down position. Exceptions to this transport
position: if suspected severe head injury or if patient does not tolerate this position due to
respiratory distress, transport with head (head of backboard) elevated.
F. Maintain normal body temperature.
G. Establish communications with Medical Control and advise of patient condition. Transport
IMMEDIATELY to the most appropriate facility unless an ALS unit is en route and has an
ETA of less than 5 minutes.
Advanced EMT / Paramedic
A. If shock is due to a tension pneumothorax, perform needle decompression. See Needle
Decompression Procedure.
B. Obtain IV access with large-bore catheters. Consider IO access if patient is critical and you
are unable to establish an IV line.
1. If symptoms are due to High-Space Shock (i.e., spinal injury, sepsis) administer 20
ml/kg normal saline IV/IO boluses. Repeat as needed to a systolic BP above 110
mmHg in adolescents and adults.
2. If symptoms due to mechanical or cardiogenic shock, run IV TKO.
3. Low-Volume Shock (i.e. hemorrhagic shock, hypovolemic shock) administer 20 ml/kg
normal saline IV/IO boluses. Repeat as needed to a systolic BP of 80 mmHg in
adolescents and adults.
4. Patients with severe head injury (GCS < 8) and shock do not tolerate hypotension.
The goal of fluid resuscitation in these patients: SBP of 110 mmHg in adults, at least
90 mmHg in older children and at least 80 mmHg in preschool children.
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Shock
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C. Place on cardiac monitor. Refer to Dysrhythmia and Acute Syndrome Protocols as indicated.
D. Refer to Trauma Protocols for Tranexamic Acid (TXA) as indicated.
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Shock
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SHOCKPAIN /
ABDOMINAL
NAUSEA VOMITING
KEY
BASIC EMT
ADVANCED EMT
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PARAMEDIC
CONTROL
OPEN ANDLIFE-THREATENING
MANAGE AIRWAY HEMORRHAGE –
APPLY
TOURNIQUET,
ITCLAMP, AND/OR
MAINTAIN
O2 SATS >95%
HEMOSTATIC
AGENTCONDITION
IF INDICATED
EVALUATE PATIENT
ASSESS
AND
MANAGE
MONITOR
VITAL
SIGNSAIRWAY
MAINTAIN
O2 SATS >95%
o HYPOPERFUSION
(BP < 100 SYSTOLIC)
EVALUATE
PATIENT
CONDITION
OBTAIN MEDICAL
HISTORY
IF
SUSPECTED, SEE ALLERGIC
o ANAPHYLAXIS
NAUSEA/VOMITING
REACTION
/ ANAPHYLACTIC SHOCK PROTOCOL
o SURGERY
MONITOR
VITAL SIGNS
o TRAUMA
MAINTAIN
NORMAL
BODY TEMPERATURE
REASSURE
PATIENT
REASSURE
PATIENT
GIVE NOTHING
BY MOUTH
TRANSPORT
IN HORIZONTAL
OR
TRANSPORT PATIENT
IN POSTIION
OF COMFORT
SLIGHTLY HEAD-DOWN POSITION IF PATIENT
CONDITION ALLOWS
IF
ISTO
DUE
TO A TENSION
PNEUMOTHORAX,
IVSHOCK
NS (RUN
MAINTAIN
PERFUSION)
PERFORM
NEEDLE
DECOMPRESSION
– SEE
MONITOR ECG
NEEDLE
DECOMPRESSION
PROCEDURE.
CONSIDER PAIN MANAGEMENT PROTOCOL
IV NORMAL SALINE – ADMINISTER FLUID BOLUSES
OF 20 ML/KG TO MAINTAIN PERFUSION
MONITOR ECG
REFER TO
DYSRHYTHMIA
AND ACUTE
CORONARY
IF NAUSEA
AND VOMITING
PRESENT
SYNDROME PROTOCOLS AS INDICATED.
CONSIDER
TRANEXAMIC
ACID(ZOFRAN)
(TXA) IF INDICATED
ADMINISTER
ONDANSETRON
4MG SLOW IV
PUSH OR IM
MED CONTROL