Editing Shock (circulatory) (section)

==Management==
Treatment of shock is based on the likely underlying cause.<ref name="ATLS2018" /> An open [[airway]] and sufficient [[breathing]] should be established.<ref name="ATLS2018" /> Any ongoing bleeding should be stopped, which may require surgery or [[embolization]].<ref name="ATLS2018" /> [[Intravenous fluid]], such as [[Ringer's lactate]] or [[packed red blood cells]], is often given.<ref name="ATLS2018" /> Efforts to maintain a normal [[body temperature]] are also important.<ref name="ATLS2018" /> [[Vasopressors]] may be useful in certain cases.<ref name="ATLS2018" /> Shock is both common and has a high risk of death.<ref name="Tab2010">{{Cite book |last1=Tabas |first1=Jeffrey |url=https://books.google.com/books?id=Ac_XI7P3CKwC&pg=PA58 |title=High Risk Emergencies, An Issue of Emergency Medicine Clinics |last2=Reynolds |first2=Teri |date=2010 |publisher=Elsevier Health Sciences |isbn=978-1455700257 |page=58 |format=E-book}}</ref> In the United States about 1.2 million people present to the emergency room each year with shock and their risk of death is between 20 and 50%.<ref name="Tab2010" />

The best evidence exists for the treatment of [[septic shock]] in adults. However, the pathophysiology of shock in children appears to be similar so treatment methodologies have been extrapolated to children.<ref name="EMB05" /> Management may include securing the airway via [[intubation]] if necessary to decrease the work of breathing and for guarding against respiratory arrest. [[Oxygen therapy|Oxygen supplementation]], [[Intravenous therapy|intravenous fluids]], [[Passive leg raising test|passive leg raising]] (not [[Trendelenburg position]]) should be started and [[blood transfusion]]s added if blood loss is severe.<ref name="Tint10" /> In select cases, compression devices like [[non-pneumatic anti-shock garment]]s (or the deprecated [[military anti-shock trousers]]) can be used to prevent further blood loss and concentrate fluid in the body's head and core.<ref name="non-pneumo pants">{{Cite journal |last1=Mbaruku |first1=Godfrey |last2=Therrien |first2=Michelle Skaer |last3=Tillya |first3=Robert |last4=Mbuyita |first4=Selemani |last5=Mtema |first5=Zacharia |last6=Kinyonge |first6=Iddajovana |last7=Godfrey |first7=Ritha |last8=Temu |first8=Silas |last9=Miller |first9=Suellen |date=December 2018 |title=Implementation project of the non-pneumatic anti-shock garment and m-communication to enhance maternal health care in rural Tanzania |journal=[[Reproductive Health (journal)|Reproductive Health]] |volume=15 |issue=1 |pages=177 |doi=10.1186/s12978-018-0613-5 |pmc=6194579 |pmid=30340602 |doi-access=free}}</ref> It is important to keep the person warm to avoid [[hypothermia]]<ref name="Nolan Pullinger pp. bmj.g1139–bmj.g1139">{{Cite journal |vauthors=Nolan JP, Pullinger R |date=March 2014 |title=Hypovolaemic shock |journal=BMJ |volume=348 |issue=mar07 1 |pages=g1139 |doi=10.1136/bmj.g1139 |pmid=24609389 |s2cid=45691590}}</ref> as well as adequately manage pain and anxiety as these can increase oxygen consumption.<ref name="Tint10" /> Negative impact by shock is reversible if it's recognized and treated early in time.<ref name="UpToDate 2019" />

===Fluids===
Aggressive intravenous fluids are recommended in most types of shock (e.g. 1–2 liter [[normal saline]] bolus over 10 minutes or 20&nbsp;mL/kg in a child) which is usually instituted as the person is being further evaluated.<ref>{{Cite book |last=American College of Surgeons |title=ATLS, Advanced Trauma Life Support Program for Doctors |publisher=[[American College of Surgeons|Amer College of Surgeons]] |year=2008 |isbn=978-1-880696-31-6 |page=58}}</ref> [[Colloids]] and [[Crystalloid fluid|crystalloids]] appear to be equally effective with respect to outcomes.,<ref name="Lew2018">{{Cite journal |vauthors=Lewis SR, Pritchard MW, Evans DJ, Butler AR, Alderson P, Smith AF, Roberts I |date=August 2018 |title=Colloids versus crystalloids for fluid resuscitation in critically ill people |journal=The Cochrane Database of Systematic Reviews |volume=8 |issue=8 |pages=CD000567 |doi=10.1002/14651858.CD000567.pub7 |pmc=6513027 |pmid=30073665}}</ref> Balanced crystalloids and normal saline also appear to be equally effective in critically ill patients.<ref>{{Cite journal |last1=Liu |first1=C |last2=Lu |first2=G |last3=Wang |first3=D |last4=Lei |first4=Y |last5=Mao |first5=Z |last6=Hu |first6=P |last7=Hu |first7=J |last8=Liu |first8=R |last9=Han |first9=D |last10=Zhou |first10=F |date=November 2019 |title=Balanced crystalloids versus normal saline for fluid resuscitation in critically ill patients: A systematic review and meta-analysis with trial sequential analysis. |journal=The American Journal of Emergency Medicine |volume=37 |issue=11 |pages=2072–78 |doi=10.1016/j.ajem.2019.02.045 |pmid=30852043 |doi-access=free}}</ref> If the person remains in shock after initial resuscitation, [[packed red blood cells]] should be administered to keep the [[hemoglobin]] greater than 100&nbsp;g/L.<ref name=Tint10/>

For those with hemorrhagic shock, the current evidence supports limiting the use of fluids for penetrating thorax and abdominal injuries allowing mild [[hypotension]] to persist (known as [[permissive hypotension]]).<ref name="Rosen2010">{{Cite book |last=Marx |first=J |title=Rosen's emergency medicine: concepts and clinical practice 7th edition |publisher=Mosby/Elsevier |year=2010 |isbn=978-0-323-05472-0 |location=Philadelphia, PA |page=2467}}</ref> Targets include a [[mean arterial pressure]] of 60&nbsp;mmHg, a [[systolic blood pressure]] of 70–90&nbsp;mmHg,<ref name=Tint10/><ref name=EMB11/> or until the patient has adequate [[mentation]] and peripheral pulses.<ref name="EMB11">{{Cite journal |last=Cherkas |first=David |date=Nov 2011 |title=Traumatic Hemorrhagic Shock: Advances In Fluid Management |url=http://www.ebmedicine.net/store.php?paction=showProduct&catid=8&pid=244 |url-status=dead |journal=Emergency Medicine Practice |volume=13 |issue=11 |pages=1–19; quiz 19–20 |pmid=22164397 |archive-url=https://web.archive.org/web/20120118152838/http://www.ebmedicine.net/store.php?paction=showProduct&catid=8&pid=244 |archive-date=2012-01-18}}</ref> [[Tonicity#Hypertonic solution|Hypertonic fluid]] may also be an option in this group.<ref>{{Cite journal |vauthors=Wu MC, Liao TY, Lee EM, Chen YS, Hsu WT, Lee MG, Tsou PY, Chen SC, Lee CC |date=November 2017 |title=Administration of Hypertonic Solutions for Hemorrhagic Shock: A Systematic Review and Meta-analysis of Clinical Trials |journal=Anesthesia and Analgesia |volume=125 |issue=5 |pages=1549–57 |doi=10.1213/ANE.0000000000002451 |pmid=28930937 |s2cid=39310937}}</ref>

===Medications===
[[File:Epipen.jpg|thumb|Old version of the Epinephrine auto-injector]]
[[Vasopressors]] may be used if blood pressure does not improve with fluids. Common vasopressors used in shock include: [[Norepinephrine (medication)|norepinephrine]], [[phenylephrine]], [[dopamine]], and [[dobutamine]].{{cn|date=February 2025}}

There is no evidence of substantial benefit of one vasopressor over another;<ref>{{Cite journal |last1=Gamper |first1=Gunnar |last2=Havel |first2=Christof |last3=Arrich |first3=Jasmin |last4=Losert |first4=Heidrun |last5=Pace |first5=Nathan Leon |last6=Müllner |first6=Marcus |last7=Herkner |first7=Harald |date=2016-02-15 |title=Vasopressors for hypotensive shock |journal=The Cochrane Database of Systematic Reviews |volume=2 |issue=2 |pages=CD003709 |doi=10.1002/14651858.CD003709.pub4 |issn=1469-493X |pmc=6516856 |pmid=26878401}}</ref> however, using dopamine leads to an increased risk of arrhythmia when compared with norepinephrine.<ref>{{Cite journal |vauthors=Gamper G, Havel C, Arrich J, Losert H, Pace NL, Müllner M, Herkner H |date=February 2016 |title=Vasopressors for hypotensive shock |journal=The Cochrane Database of Systematic Reviews |volume=2 |issue=2 |pages=CD003709 |doi=10.1002/14651858.CD003709.pub4 |pmc=6516856 |pmid=26878401}}</ref> Vasopressors have not been found to improve outcomes when used for [[hemorrhagic shock]] from [[Trauma (medical)|trauma]]<ref>{{Cite journal |vauthors=Diez C, Varon AJ |date=December 2009 |title=Airway management and initial resuscitation of the trauma patient |journal=Current Opinion in Critical Care |volume=15 |issue=6 |pages=542–47 |doi=10.1097/MCC.0b013e328331a8a7 |pmid=19713836 |s2cid=19918811}}</ref> but may be of use in [[neurogenic shock]].<ref name="Trauma07">{{Cite journal |vauthors=Cocchi MN, Kimlin E, Walsh M, Donnino MW |date=August 2007 |title=Identification and resuscitation of the trauma patient in shock |journal=Emergency Medicine Clinics of North America |volume=25 |issue=3 |pages=623–42, vii |citeseerx=10.1.1.688.9838 |doi=10.1016/j.emc.2007.06.001 |pmid=17826209}}</ref> [[Activated protein C]] (Xigris), while once aggressively promoted for the management of [[septic shock]], has been found not to improve survival and is associated with a number of complications.<ref name=":marti-carvajal">{{Cite journal |vauthors=Martí-Carvajal AJ, Solà I, Gluud C, Lathyris D, Cardona AF |date=December 2012 |title=Human recombinant protein C for severe sepsis and septic shock in adult and paediatric patients |journal=The Cochrane Database of Systematic Reviews |volume=2018 |issue=12 |pages=CD004388 |doi=10.1002/14651858.CD004388.pub6 |pmc=6464614 |pmid=23235609}}</ref> Activated protein C was withdrawn from the market in 2011, and clinical trials were discontinued.<ref name=":marti-carvajal" /> The use of [[sodium bicarbonate]] is controversial as it has not been shown to improve outcomes.<ref name="bicarb08">{{Cite journal |vauthors=Boyd JH, Walley KR |date=August 2008 |title=Is there a role for sodium bicarbonate in treating lactic acidosis from shock? |journal=Current Opinion in Critical Care |volume=14 |issue=4 |pages=379–83 |doi=10.1097/MCC.0b013e3283069d5c |pmid=18614899 |s2cid=22613993}}</ref> If used at all it should only be considered if the blood pH is less than 7.0.<ref name="bicarb08" />

People with anaphylactic shock are commonly treated with [[Epinephrine autoinjector|epinephrine]]. [[Antihistamine]]s, such as [[Benadryl]] ([[diphenhydramine]]) or [[ranitidine]] are also commonly administered. [[Albuterol]], normal saline, and steroids are also commonly given.{{cn|date=February 2025}}

===Mechanical support===
* [[Intra-aortic balloon pump]] (IABP) – a device inserted into the aorta that mechanically raises the blood pressure. Use of Intra-aortic balloon pumps is not recommended in cardiogenic shock.<ref>{{Cite journal |last1=Vincent |first1=Jean-Louis |last2=De Backer |first2=Daniel |date=2013-10-31 |editor-last=Finfer |editor-first=Simon R. |editor2-last=Vincent |editor2-first=Jean-Louis |title=Circulatory Shock |journal=New England Journal of Medicine |volume=369 |issue=18 |pages=1726–34 |doi=10.1056/NEJMra1208943 |issn=0028-4793 |pmid=24171518 |s2cid=6900105 |doi-access=free}}</ref>
* [[Ventricular assist device]] (VAD) – A mechanical pump that helps pump blood throughout the body. Commonly used in short term cases of refractory primary cardiogenic shock.{{cn|date=February 2025}}
* [[Artificial heart]] (TAH)<ref>{{Cite web |date=2023-04-12 |title=Total Artificial Heart - What Is Total Artificial Heart? {{!}} NHLBI, NIH |url=https://www.nhlbi.nih.gov/health/total-artificial-heart |access-date=2025-03-05 |website=www.nhlbi.nih.gov |language=en}}</ref>
* [[Extracorporeal membrane oxygenation]] (ECMO) – an external device that completely replaces the work of the heart.{{cn|date=February 2025}}

===Treatment goals===
The goal of treatment is to achieve a urine output of greater than 0.5&nbsp;mL/kg/h, a [[central venous pressure]] of 8–12&nbsp;mmHg and a [[mean arterial pressure]] of 65–95&nbsp;mmHg. In trauma the goal is to stop the bleeding which in many cases requires surgical interventions. A good urine output indicates that the kidneys are getting enough blood flow.