ACLS FOR SHOCK
Shock is a life-threatening condition where the body’s organs and tissues do not receive adequate oxygen and nutrients due to impaired circulation. If untreated, shock can rapidly lead to multi-organ failure and cardiac arrest.
Why It’s Important:
Shock is a precursor to cardiac arrest—early recognition and intervention are critical. Different types of shock require different treatments (fluids, vasopressors, inotropes). ACLS providers must stabilize circulation while addressing the underlying cause.
RECOGNIZING SHOCK
Signs & Symptoms of Shock
Hypotension (SBP < 90 mmHg or MAP < 65 mmHg). Tachycardia (HR > 100 bpm, compensatory response). Altered mental status (confusion, agitation, unconsciousness). Cool, clammy, pale skin (except in distributive shock, where skin may be warm). Weak or absent peripheral pulses. Oliguria (decreased urine output). Metabolic acidosis (due to lactic acid buildup from anaerobic metabolism).
Key Takeaway: Shock is a state of circulatory failure—identify it early to prevent cardiac arrest!
TYPES OF SHOCK & ACLS MANAGEMENT
Different types of shock require different treatments—incorrect management can worsen outcomes!
| Type of Shock | Cause | Signs & Symptoms | Treatment |
|---|---|---|---|
| Hypovolemic Shock | Loss of blood or fluids (hemorrhage, dehydration, burns) | Tachycardia, hypotension, cold skin, weak pulses, oliguria | IV fluids (crystalloids 20-30 mL/kg), blood transfusion if hemorrhagic |
| Cardiogenic Shock | Heart pump failure (MI, arrhythmias, CHF) | Hypotension, pulmonary edema, JVD, weak pulses | Inotropes (Dobutamine, Epinephrine), diuretics (if pulmonary congestion), treat underlying cause |
| Obstructive Shock | Mechanical obstruction (PE, tension pneumothorax, cardiac tamponade) | Sudden hypotension, distended neck veins, dyspnea, absent lung sounds (pneumothorax) | Relieve obstruction (thoracostomy for pneumothorax, pericardiocentesis for tamponade, thrombolytics for PE) |
| Distributive Shock (Septic, Anaphylactic, Neurogenic) | Widespread vasodilation (infection, allergic reaction, spinal injury) | Warm skin (septic/anaphylactic), cold skin (late septic shock), bradycardia (neurogenic shock) | Fluids (30 mL/kg for sepsis), vasopressors (Norepinephrine), epinephrine (for anaphylaxis) |
Key Takeaway: The wrong treatment can worsen shock—identify the type before intervening!
ACLS MANAGEMENT OF SHOCK (ABCDE APPROACH)
Step 1: Airway – Secure & Maintain Oxygenation
- Assess airway patency (Intubate if necessary).
- Provide oxygen to maintain SpO₂ ≥ 94%.
Step 2: Breathing – Optimize Ventilation
- Monitor respiratory effort & EtCO₂ (Goal: 35-45 mmHg).
- Consider mechanical ventilation for respiratory failure.
Step 3: Circulation – Restore Perfusion
- Hypovolemic Shock: Give IV fluids first (NS or LR 20-30 mL/kg).
- Cardiogenic Shock: Avoid excessive fluids—use inotropes (Dobutamine, Epinephrine).
- Obstructive Shock: Remove the obstruction (e.g., needle decompression for pneumothorax).
- Distributive Shock: Vasopressors (Norepinephrine for septic shock, Epinephrine for anaphylaxis).
Step 4: Disability – Assess Neurological Function
- Check mental status (Glasgow Coma Scale, responsiveness).
- Treat seizures if present (Benzodiazepines).
Step 5: Exposure – Identify the Underlying Cause
- Look for signs of bleeding, infection, or trauma.
- Monitor vital signs & urine output (goal: >0.5 mL/kg/hr).
Key Takeaway: Systematic assessment ensures no reversible cause is missed!
VASOPRESSORS & INOTROPES IN SHOCK MANAGEMENT
Fluids alone may not be enough—vasopressors and inotropes are needed in some cases!
| Drug | Class | Used For | Dose |
|---|---|---|---|
| Norepinephrine | Vasopressor | Septic shock (first-line drug) | 2-30 mcg/min IV |
| Epinephrine | Vasopressor/Inotrope | Anaphylaxis, cardiogenic shock | 2-10 mcg/min IV |
| Dopamine | Vasopressor/Inotrope | Bradycardia, cardiogenic shock | 2-20 mcg/kg/min IV |
| Dobutamine | Inotrope | Cardiogenic shock (increases contractility) | 2-20 mcg/kg/min IV |
| Phenylephrine | Vasopressor | Neurogenic shock | 40-200 mcg/min IV |
Key Takeaway: The choice of vasopressor/inotrope depends on the type of shock!
WHEN TO INITIATE ACLS FOR SHOCK?
Initiate ACLS if the patient deteriorates into cardiac arrest!
Signs of Deterioration:
- Profound hypotension (SBP < 70 mmHg).
- Severe respiratory distress, altered mental status.
- No palpable pulse → Start CPR immediately!
Key Takeaway: Shock can quickly progress to cardiac arrest—be prepared to intervene!
COMMON MISTAKES & HOW TO AVOID THEM
| Mistake | Impact | Prevention |
|---|---|---|
| Delaying fluids in hypovolemic shock | Leads to worsening hypoperfusion | Give 20-30 mL/kg IV crystalloids immediately! |
| Giving too much fluid in cardiogenic shock | Worsens pulmonary edema | Use inotropes instead of fluids! |
| Not treating the underlying cause | Causes ongoing deterioration | Always address the primary cause (bleeding, infection, obstruction)! |
| Using the wrong vasopressor | Worsens hemodynamic instability | Match the vasopressor to the type of shock! |
Key Takeaway: Incorrect treatment can worsen shock—always reassess response to therapy!
SUMMARY: MASTERING ACLS FOR SHOCK
Identify the type of shock (hypovolemic, cardiogenic, obstructive, distributive). Use the ABCDE approach to stabilize airway, breathing, circulation. Fluid resuscitation is first-line in most cases—EXCEPT cardiogenic shock! Use vasopressors & inotropes appropriately based on the type of shock. Monitor closely for deterioration—be ready to initiate ACLS if needed.
Takeaway: Early recognition and targeted treatment of shock save lives—don’t delay interventions!