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19.0 Shock

All Providers

  • Focused history and physical exam
    • Blood glucose, oxygen saturation, temperature assessment
    • Consider shock in one or more of the following:
      • Vital signs: HR greater than 100, SBP less than 90 mmHg for adults, less than 70 + (age in years x 2) mmHg for peds
      • Skin signs: cold, clammy skin, febrile, or delayed capillary refill
      • Mental statue: altered, lethargic, or irritable
  • Evaluate for possible source
    • Distributive
    • Hypovolemic
    • Neurologic
    • Cardiogenic
  • Continuous cardiac, pulse oximetry when available
  • Obtain a 12 lead EKG when available
  • Treatment Plan
    • Address the underlying cause if possible
    • Administer supplemental oxygen to maintain saturations of 92%
    • Ensure patient warmth, warm IV fluids when available

Adult

EMT
AEMT
  • AnaphylacticShock (Distributive) Protocol if necessary
  • Obtain Vascular Access
  • Traumatic Shock – Permissive Hypotension
    • If SBP greater than 90
      • No IV fluid bolus
      • Saline lock IV site
    • if SPB less than 90 lolus 500ml LR, reasses
  • Non-traumatic shock
    • Fluid bolus: 500 ml LR, repeat up to 2 liters prn
  • Cardiogenic Shock: CHF/Pulmonary edema
    • Apply Oxygen
    • Consider CPAP
Paramedic
  • Shock unresponsive to other measures:
    • Norepinephrine 2-20 mcg/min IV/IO. Titrate to maintain SBP >90 mmHg. Refractory shock: 8-30 mcg/kg/min
  • Nitroglycerin0.4 mg SL for pulmonary edema/CHF if SBP > 140 mmHg, may repeat x 3 every 5 minutes
  • Consider BiPAP for pulmonary edema/CHF

Pediatric
not to exceed adult dose

EMT
AEMT
  • Anaphylactic Shock (Distributive) Protocol if necessary
  • Obtain Vascular Access
  • Traumatic Shock – Permissive Hypotension
    • If SBP greater than 90
      • No IV fluid bolus
      • Saline lock IV site
    • if SPB less than 80 blolus 20ml/kg LR, reasses
  • Non-traumatic shock
    • Fluid bolus: 20ml/kg LR, reasses
  • Cardiogenic Shock: CHF/Pulmonary edema
    • Apply Oxygen
  • Pain Management Protocol
  • Shock Protocol if applicable
Paramedic
  • Shock unresponsive to other measures:
    • Norepinephrine 0.05-0.1 mcg/kg IV/IO, titrate to maintain SBP >70 + (age in years x 2) mmHg