SHOCK
Inclusion Criteria: Any patient experiencing signs and symptoms consistent with shock and hypoperfusion. Refer also to TRAUMA, specific arrhythmia, and ALLERGIC REACTION Guidelines, and to the NEEDLE THORACOSTOMY Special Procedure.
Basic Level
- Assess and support ABCs.
- Initiate SPINAL MOTION RESTRICTION, if indicated. Place the patient supine and elevate the legs, unless contraindicated.
- Control any obvious external hemorrhage.
- Cover the patient to avoid heat loss, but do not over-bundle.
- Administer oxygen via non-rebreather mask at 10-15 lpm (100% NRBM) or assist ventilations via BVM, if indicated.
- Begin transport as soon as possible.
Advanced Level
- Continuously monitor ECG, SpO2 and ETCO2.
- Establish one large bore IV and infuse Normal Saline according to the following guidelines:
Hypovolemic/Hemorrhagic shock:
Adult
- Administer 20 mL/kg boluses, as needed, to maintain radial pulses (do not exceed systolic BP of 90 mmHg).
- Examine area of controlled hemorrhage frequently to determine that hemorrhage remains controlled.
Pediatric
- Infuse Normal Saline bolus IV/IO: 20 mL/kg.
- Repeat twice if systolic BP remains below 70 mm Hg and there are no signs of volume overload.
- Contact BioTel if additional boluses are needed, especially for DKA.
- If the patient is unconscious and peripheral IV access is unavailable, consider early use of IO infusion.
Cardiogenic Shock - Assure heart rate and rhythm are adequate, then:
Adult
- Infuse a single 20 mL/kg IV/IO bolus, unless pulmonary edema is present.
- Consider one repeat bolus while preparing norepinephrine drip, IF there is no evidence of pulmonary edema.
- Norepinephrine bitartrate drip 8 to12 mcg/min, if there is no response to fluid bolus.
Pediatric
- Run fluid at TKO rate.
- Contact BioTel for vasopressor dosing and possible IV/IO fluid bolus (5 to 10 mL/kg).
All Other Forms of Shock (Except Tension Pneumothorax):
Adult
- Infuse 20 mL/kg boluses and reassess, titrating to achieve a systolic BP of 90 mmHg.
- Do not exceed 1 L under standing orders.
Pediatric
- Infuse Normal Saline bolus IV/IO: 20 mL/kg.
- Repeat twice if systolic BP remains below 70 mm Hg and there are no signs of volume overload.
- Contact BioTel if additional boluses are required, especially for DKA, cardiac history, or signs of pulmonary edema (e.g. rales).
- If the patient is unconscious and peripheral IV access is unavailable, consider early use of IO infusion.
Obstructive Shock due to Tension Pneumothorax
(Pneumothorax, with Hypotension and Severe Hemodynamic Compromise):
Adult
Pediatric
- Perform needle thoracostomy.
- Contact BioTel as soon as possible.
- Refer to the NEEDLE THORACOSTOMY Special Procedure.
- Continuously monitor vital signs, ECG, SpO2, ETCO2 and neurological status during transport.
- For additional patient care considerations not covered under standing orders, consult BioTel.