Shock is recognized at the bedside when hemodynamic instability leads to hypoperfusion
of several organ systems. Accordingly, shock is a clinical diagnosis. Successful management
of shock requires a primary survey directed at formulation of a working diagnosis
and urgent initial resuscitation. The clinical response to initial measures to restore
organ perfusion then confirms or changes the working diagnosis. This allows the clinician
a pause to ponder the broader differential diagnosis of the types of shock and the
pathophysiology of shock, which leads to early definitive therapy of the underlying
cause of shock. Shock has a hemodynamic component, which is the initial focus of resuscitation,
but shock also has a systemic inflammatory component that leads to multiple system
organ failure. In this article, we present a simplified approach to diagnosis and
management of shock and emphasize the tempo of resuscitation. The ultimate goal is
to restore tissue perfusion in a timely fashion to prevent the development of multiple
organ failure, which has a high mortality.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribers receive full online access to your subscription and archive of back issues up to and including 2002.
Content published before 2002 is available via pay-per-view purchase only.
Subscribe:
Subscribe to Clinics in Chest MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Pathophysiology, clinical manifestations, and prevention of ischemia-reperfusion injury.Anesthesiology. 2001; 94: 1133-1138
- Postinjury multiple organ failure: role of extrathoracic injury and sepsis in adult respiratory distress syndrome.New Horiz. 1993; 1: 538-549
- Does programmed cell death (apoptosis) play a role in the development of multiple organ dysfunction in critically ill patients? A review and a theoretical framework.Crit Care Med. 2000; 28: 537-549
- Distribution of respiratory muscle and organ blood flow during endotoxic shock in dogs.J Appl Physiol. 1985; 59: 1802-1808
- Colloids versus crystalloids for fluid resuscitation in critically ill patients.Cochrane Database Syst Rev. 2000; 2: CD000567
- Epinephrine impairs splanchnic perfusion in septic shock.Crit Care Med. 1997; 25: 399-404
- Early effects of catecholamine therapy on mucosal integrity, intestinal blood flow, and oxygen metabolism in porcine endotoxin shock.Ann Surg. 1998; 228: 239-248
- Norepinephrine: no more “leave 'em dead”?.Crit Care Med. 2000; 28: 3096-3098
- Lessons we have learned from the GUSTO trial. Global utilization of streptokinase and tissue plasminogen activator for occluded arteries.J Am Coll Cardiol. 1995; 25: 10S-17S
- Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism.Chest. 2002; 121: 877-905
- Early goal-directed therapy in the treatment of severe sepsis and septic shock.N Engl J Med. 2001; 345: 1368-1377
- Meta-analysis of hemodynamic optimization in high-risk patients.Crit Care Med. 2002; 30: 1686-1692
- Central venous oxygen saturation monitoring in the critically ill patient.Curr Opin Crit Care. 2001; 7: 204-211
- Abdominal compartment syndrome: recognition and management.Adv Surg. 2001; 35: 251-269
- Acute adrenal insufficiency presenting as shock after trauma and surgery: three cases and review of the literature.J Trauma. 1992; 32: 94-100
- Adrenal and pituitary emergencies.Emerg Med Clin N Am. 1989; 7: 903-925
- A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin.JAMA. 2000; 283: 1038-1045
- Thyroid crises.Med Clin N Am. 1991; 75: 179-193
- Pheochromocytoma.Cardiol Rev. 2002; 10: 44-50
- Current controversies in shock and resuscitation.Surg Clin North Am. 2001; 81: 1217-1262
- Low-volume fluid resuscitation for presumed hemorrhagic shock: helpful or harmful?.Curr Opin Crit Care. 2001; 7: 422-430
- Advanced trauma life support program for physicians: instructor manual. American College of Surgeons, Chicago1993: 75-110
- Experimental hemorrhagic shock.in: Physiology of shock. Commonwealth Fund, New York1950: 121-146
- The treatment of hemorrhagic shock.Surg Gynecol Obstet. 1966; 122: 967-978
- The detrimental effects of intravenous crystalloid after aortotomy in swine.Surgery. 1991; 110: 529-536
- The effect of prehospital fluids on survival in trauma patients.J Trauma. 1990; 30 ([discussion 1218–9]): 1215-1218
- Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries.N Engl J Med. 1994; 331: 1105-1109
- Immediate versus delayed fluid resuscitation in patients with trauma.N Engl J Med. 1995; 332: 681-683
- Resuscitation after uncontrolled venous hemorrhage: does increased resuscitation volume improve regional perfusion?.J Trauma. 1998; 44: 701-708
- Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988.N Engl J Med. 1991; 325: 1117-1122
- Trends in cardiogenic shock: report from the SHOCK Study. The should we emergently revascularize occluded coronaries for cardiogenic shock?.Eur Heart J. 2001; 22: 472-478
- Cardiogenic shock.Ann Intern Med. 1999; 131: 47-59
- Frequency of inclusion of patients with cardiogenic shock in trials of thrombolytic therapy.Am J Cardiol. 1994; 73: 149-157
- Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should we emergently revascularize occluded coronaries for cardiogenic shock.N Engl J Med. 1999; 341: 625-634
- One-year survival following early revascularization for cardiogenic shock.JAMA. 2001; 285: 190-192
- American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.Crit Care Med. 1992; 20: 864-874
- 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference.Crit Care Med. 2003; 31: 1250-1256
- Has the mortality of septic shock changed with time?.Crit Care Med. 1998; 26: 2078-2086
- Corticosteroid treatment for sepsis: a critical appraisal and meta-analysis of the literature.Crit Care Med. 1995; 23: 1430-1439
- Corticosteroids for septic shock.Crit Care Med. 2001; 29: S117-S120
- Adrenal insufficiency during septic shock.Crit Care Med. 2003; 31: 141-145
- Immunologic and hemodynamic effects of “low-dose” hydrocortisone in septic shock: a double-blind, randomized, placebo-controlled, crossover study.Am J Respir Crit Care Med. 2003; 167: 512-520
- What test for hypothalamic-pituitary adrenocortical insufficiency?.Lancet. 1999; 354: 179-180
- Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock.JAMA. 2002; 288: 862-871
- Severe sepsis–a new treatment with both anticoagulant and antiinflammatory properties.N Engl J Med. 2001; 344: 759-762
- Efficacy and safety of recombinant human activated protein C for severe sepsis.N Engl J Med. 2001; 344: 699-709
- Identifying patients with severe sepsis who should not be treated with drotrecogin alfa (activated).Am J Surg. 2002; 184: S19-S24
- Guidance on patient identification and administration of human recombinant activated protein C for the treatment of severe sepsis.Can J Infect Dis. 2002; 13: 361-372
- An economic evaluation of activated protein C treatment for severe sepsis.N Engl J Med. 2002; 347: 993-1000
- Physiology of vasopressin relevant to management of septic shock.Chest. 2001; 120: 989-1002
- Beneficial effects of short-term vasopressin infusion during severe septic shock.Anesthesiology. 2002; 96: 576-582
- Sepsis: is there room for vasopressin?.Sepsis. 2001; 4: 169-175
- Sodium bicarbonate for the treatment of lactic acidosis.Chest. 2000; 117: 260-267
- Bicarbonate does not improve hemodynamics in critically ill patients who have lactic acidosis. A prospective, controlled clinical study.Ann Intern Med. 1990; 112: 492-498
- Effects of bicarbonate therapy on hemodynamics and tissue oxygenation in patients with lactic acidosis: a prospective, controlled clinical study.Crit Care Med. 1991; 19: 1352-1356
- The pathogenesis of vasodilatory shock.N Engl J Med. 2001; 345: 588-595
Article info
Footnotes
☆Support was provided by the Heart & Stroke Foundation of British Columbia and Yukon. Dr. Walley is a B.C. Michael Smith Foundation for Health Research Distinguished Scholar.
Identification
Copyright
© 2003 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
