Therapeutic Algorithm for Hypotension and/or Shock

Circulation Airway Breathing

Shock and/or MAP < 60 mm Hg*
Intubation and
mechanical ventilation
Respiratory distress,
hypoxemia, PCO2
mental status
Intubation and
mechanical ventilation
Hypovolemic shock Septic shock Obstructive shock Right ventricular MI
See Acute
myocardial infarction 2 (14-16 g) IVs or
cordis/central line
Elevate legs
2-3 liters NS over
10-20 min
PRBC if bleeding
2-3 liters NS over
10-30 min
Persistent shock?
Maintenance
fluids
200 500 ml NS
over 10-20 min
Persistent shock?
Specific Rx:
PE- thrombolysis if
not contraindicated
Pneumothorax
chest tube
Tamponade
pericardial tap
Constriction
pericardial stripping
No No Yes Yes
No Yes
Maintenance
fluids
Consider
RHC to
optimize CO
with fluids**
Dobutamine What is the systolic
BP?
If persistent shock,
consider IABP and
cardiac catheterization
< 70 70-100 >100
(nl DBP)
Levo Dopa +
Dobut
Dobut +
NTG or
NTP
Consider RHC to
guide therapy
1-2 liters NS / 20 min
Persistent shock?
Dopa to MAP > 60
Levo if refractory
ADH if refractory to
Levo and consider
stress-dose
steroids even if
ACTH stim is normal
Continue fluid
boluses until:
- shock resolves or
- CVP, S3, rales,
and PO2, then
insert RHC
Continue NS/PRBC
until shock resolves
Surgical consult if
bleeding
Maintenance fluids
Cardiogenic shock
IV, arterial access, Foley
catheter, EKG, + NG tube
Stratify based on
Diagnostic Algorithm for
Hypotension
If no CHF present:
100-500 ml NS/10 min
**How to do a fluid challenge to maximize cardiac output
PCWP Volume of NS to infuse over 5-10 min
< 12 500 ml
12-16 250 ml
> 16 100 ml
Observe the in
PCWP and SV
PCWP < 3-5 mm Hg PCWP > 5-7 mm Hg
SV > 15%
PCWP > 5-7 mm Hg
SV < 15%
STOP fluid challenges
If PCWP > 20,
consider diuresis
Repeat w/250-500 ml
bolus
Shock resolved?
No further CO?
PCWP > 18-20?
No Yes
Dopa dopamine 2-20 mcg/kg/min; Dobut dobutamine 5-15 mcg/kg/min; Levo levophed 2-30 mcg/min; NTG nitroglycerine 25-600 mcg/min
NTP nitroprusside -0.1-5 mcg/kg/min; ADH- vasopressin 0.04-0.12 u/min. (*MAP goal is 75% of baseline value)
MAP mean arterial pressure. DBP diastolic blood pressure. RHC right heart catheterization. SV stroke volume (cardiac output/heart
rate). NS normal saline. PRBC packed red blood cells. MI myocardial infarction. IABP intra-aortic balloon pump. CO cardiac output.

Hall JB et al. Principles of Critical Care 2
nd
ed., McGraw Hill, New York, 1998
Guidelines for cardiopulmonary resuscitation and emergency cardiac care. JAMA 268: 2171, 1992
Malay MB et al. Low-dose vasopressin in the treatment of vasodilatory septic shock. J Trauma 47(4):699-703, 1999