Shock

Shock is a life-threatening condition that needs urgent intervention, often in a critical care setting.

The patient with shock will look unwell and often have symptoms specific to the underlying cause (e.g., fever, chest pain, shortness of breath, abdominal pain, or altered mental status). This may be difficult to recognise in practice.

Use a <C> airway, breathing, circulation, disability, exposure (ABCDE) approach to diagnose shock in order to treat empirically. In patients with hypovolaemic shock caused by trauma with exsanguinating injuries, prioritising circulation over airway management significantly reduces mortality compared to the traditional airway, breathing, circulation (ABC) approach.

Rapidly identify and treat the underlying cause as soon as possible to reduce mortality.

This topic focuses on the diagnosis and management of shock in adults; ​​the diagnosis and management of shock in children is beyond the scope of this topic.

Shock is a life-threatening, generalised form of acute circulatory failure with inadequate oxygen delivery to, and consequently oxygen utilisation by, the cells.[1]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47(11):1181-247. https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC8486643 http://www.ncbi.nlm.nih.gov/pubmed/34599691?tool=bestpractice.com [2]Cecconi M, De Backer D, Antonelli M, et al. Consensus on circulatory shock and hemodynamic monitoring: task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2014 Dec;40(12):1795-815. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4239778 http://www.ncbi.nlm.nih.gov/pubmed/25392034?tool=bestpractice.com  

The term ‘shock’ describes a pathophysiological state with many different causes and is not a specific diagnosis.[2]Cecconi M, De Backer D, Antonelli M, et al. Consensus on circulatory shock and hemodynamic monitoring: task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2014 Dec;40(12):1795-815. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4239778 http://www.ncbi.nlm.nih.gov/pubmed/25392034?tool=bestpractice.com  It may be due to decreased blood perfusion of tissues, inadequate blood oxygen saturation, or increased oxygen demand from the tissues that results in decreased end-organ oxygenation and dysfunction. If left untreated, shock results in sustained multiple organ dysfunction, and end-organ damage with possible death. Tissue hypoperfusion may be present without systemic hypotension, but at the bedside shock is commonly diagnosed when both are present (arterial hypotension and organ dysfunction).[1]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47(11):1181-247. https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC8486643 http://www.ncbi.nlm.nih.gov/pubmed/34599691?tool=bestpractice.com [2]Cecconi M, De Backer D, Antonelli M, et al. Consensus on circulatory shock and hemodynamic monitoring: task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2014 Dec;40(12):1795-815. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4239778 http://www.ncbi.nlm.nih.gov/pubmed/25392034?tool=bestpractice.com [3]McDonagh TA, Metra M, Adamo M, et al. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com