ACLS Provider: Course

Shock Recognition and Management

Shock is a critical condition in which the body's tissues are inadequately perfused, leading to cellular dysfunction, metabolic acidosis, and eventual organ failure. In ACLS, rapid recognition and targeted intervention are essential to prevent deterioration into cardiac arrest.

Recognizing Shock

Shock is not a single disease but a syndrome marked by circulatory failure. Early identification is vital. Clinical signs may include:

  • Hypotension (SBP < 90 mmHg or MAP < 65 mmHg).
  • Tachycardia or bradycardia depending on etiology.
  • Altered mental status (confusion, agitation, unresponsiveness).
  • Cool, clammy extremities (except in distributive shock, which may present with warm skin).
  • Oliguria or decreased urine output.
  • Metabolic acidosis (elevated lactate).

Types of Shock in ACLS

Each type of shock presents with overlapping symptoms but has distinct underlying causes and treatment priorities. The most common types include:

1. Hypovolemic Shock

Caused by significant loss of intravascular volume (e.g., hemorrhage, dehydration, burns). These patients typically respond to volume replacement. Early fluid resuscitation with crystalloids (20–30 mL/kg) is first-line therapy.

2. Cardiogenic Shock

Results from pump failure — often post-MI or in severe arrhythmias. These patients typically have signs of pulmonary congestion, elevated JVP, and low cardiac output. Volume overload must be avoided; inotropes (e.g., dobutamine, epinephrine) are indicated to improve contractility.

3. Obstructive Shock

Caused by mechanical interference with circulation — including tension pneumothorax, cardiac tamponade, or massive pulmonary embolism. Treatment centers on relieving the obstruction (e.g., needle decompression, pericardiocentesis, thrombolytics).

4. Distributive Shock

Characterized by widespread vasodilation and relative hypovolemia. Most commonly septic, but can also be anaphylactic or neurogenic. Treatment begins with fluid resuscitation (30 mL/kg in sepsis), followed by vasopressors — norepinephrine is the preferred first-line agent in sepsis; epinephrine is used for anaphylaxis.

Systematic Management: ABCDE in Shock

A structured assessment ensures that no life-threatening step is missed. Use the ABCDE approach:

  • Airway: Secure as needed. Consider intubation if the patient has altered mental status or cannot protect their airway.
  • Breathing: Provide supplemental oxygen. Monitor oxygen saturation and end-tidal CO₂ if available.
  • Circulation: Begin IV fluid resuscitation in hypovolemic or distributive shock. Use vasopressors or inotropes as indicated. Establish IV/IO access early.
  • Disability: Assess neurologic status frequently. Look for improvement or deterioration in mental status.
  • Exposure: Look for sources of bleeding, signs of infection, rashes (anaphylaxis), or trauma.

Key Pharmacologic Interventions

  • Norepinephrine: First-line vasopressor for septic shock (2–30 mcg/min IV).
  • Epinephrine: Used for anaphylaxis and some cardiogenic shock (2–10 mcg/min IV).
  • Dobutamine: Inotrope for cardiogenic shock (2–20 mcg/kg/min IV).
  • Dopamine: Alternative vasopressor in bradycardic or cardiogenic patients (2–20 mcg/kg/min IV).

Escalation to ACLS Protocol

If shock progresses despite intervention, prepare for full resuscitation:

  • No palpable pulse → Start CPR immediately.
  • Severe hypotension with altered mental status or apnea → Initiate full ACLS protocol.

Clinical Considerations

  • Reassess frequently after each intervention to confirm effect.
  • Shock may have mixed or evolving causes — adapt treatment accordingly.
  • Failure to recognize cardiogenic causes early is a common pitfall — monitor for pulmonary edema or new arrhythmias.