Intensive Care Unit, Prince of Wales Hospital, Chinese University of Hong Kong

MANAGEMENT OF SHOCK
Diagnosis of shock
Definition of Shock:
Hypotension associated with hypoperfusion abnormalities.
Evidence of hypoperfusion includes
- alteration in mental state, oliguria, organ dysfunction and lactic acidosis.
Different types of Shock:
1. hypovolaemic
2. cardiogenic
3. distributive
4. obstructive
Type of shock
Hypovolaemic
Cardiogenic
Distributive
Obstructive

CVP/PCWP

CO

/-/

SVR

clinically
cold and shut down
cold and shut down
warm and dilated

Management of Shock
Ensure oxygenation and maintain perfusion
Usually aim for MAP = 70-80mmHg
u/o 0.5ml/kg/hr
Hypovolaemic shock
- due to inadequate circulating fluid volume
- causes divided to haemorrhagic or non-haemorrhagic (major burns;
gastrointestinal losses: vomiting, fistulas; urinary losses: diabetes,
diabetes insipidus; evaporative losses with fever, abdominal surgery)
- fluid resuscitation
- colloid or crystalloid (do not use dextrose solution)
- replace blood loss
- review source of bleeding and stop bleeding
Cardiogenic shock
- causes acute myocardial infarction; myocardial contusions post-trauma;
myocarditis; acute valvular dysfunction; post-cardiopulmonary bypass;
cardiomyopathy
- control arrhythmia, reverse myocardial ischaemia, specific treatment for
myocarditis, open heart surgery for valvular repair
- preload a trial of fluid may be warranted in diastolic heart failure
(observe CVP/ BP /urine output and oxygenation)
- inotropes dobutamine indicated to augment myocardial contractility in

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Intensive Care Unit, Prince of Wales Hospital, Chinese University of Hong Kong

the presence of normal or slightly reduced blood pressure

- afterload - vasodilator will cause further hypotension
start noradrenaline to maintain perfusion
- consider invasive monitoring pulmonary artery catheter
- discuss with senior IABP and revascularization procedure may help
Distributive shock
- causes: septic shock; anaphylaxis; spinal shock; hyperthyroidism; severe
liver dysfunction
- fluids
- in our unit, the combination of agents usually used is dobutamine and
noradrenaline; adrenaline for anaphylaxis
- treat underlying cause e.g. sepsis
Obstructive shock
- causes cardiac tamponade; tension pneumothorax; pulmonary or air
embolism
- fluid resuscitation for temporary support
- inotropes for temporary support
- relief of obstruction e.g. pericardiocentesis for tamponade
chest drain for tension pneumothorax
thrombolysis, embolectomy
Common inotropes and vasopressors used in our unit
Drug
adrenaline
noradrenaline
dobutamine
dopamine
phenylephrine

Dilution and Dose

3mg in 50ml NS (single strength) up to 8th strength used
3mg in 50ml NS (single strength) up to 8th strength used
250mg in 50ml NS
2.5ug 10ug/kg/min
i.e. 2-10ml/hr
200mg in 50ml NS
2.5ug 20ug/kg/min
i.e. 2.5ml 20ml/hr
10mg in 500ml NS
Not usually used in ICU/usually for neurosurgical patients
start at to increase BP rapidly 100ug 180ug/min
when BP normalizes maintain 40ug 60ug/min

Use of steroids, vasopressin, activated protein C in septic shock discuss with

ICU senior.
(Activated protein C protocol available)

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