Treatment

Specific guidelines for the treatment of shock, which is often quite complex, are beyond the scope of this text. General guidelines are as follows:

• The EMS system should be activated, or the patient should be transferred to an emergency department.

• The patient should be positioned supine, with the legs elevated.

• Supplemental oxygen should be administered to enhance tissue oxygenation. Mechanical ventilation may be necessary to maintain the Po2 at normal levels and to prevent respiratory acidosis.

• Fluid resuscitation with IV infusion of a crystalloid solution (ie, normal saline or Ringer’s lactate) should be administered rapidly.

• Vasopressor drugs (norepinephrine first) may be necessary for augmentation of systemic vascular tone and/or cardiac output to help perfuse vital organs after an adequate circulating volume is established. Vasopressin, or antidiuretic hormone (ADH), has been suggested for septic shock because of its potent vasoconstrictor effect but it should only be reserved for salvage therapy. In December 2017, the US Food and Drug Administration approved synthetic human angiotensin II (Giapreza) for adults with septic or other distributive shock.

• If sepsis is suspected, blood cultures should be drawn and antibiotic therapy initiated promptly.

• Sodium bicarbonate, given intravenously, is indicated for correction of severe metabolic acidosis.

Experimental drugs used in the treatment of septic shock include polyclonal IV immunoglobulin, because it can bind endotoxin, but no existing studies substantiate its use.

• Genga KR, Russell JA. Update of sepsis in the intensive care unit. J Innate Immun. 2017;9(5):441–455.

• Jones AE, Puskarich MA. The Surviving Sepsis Campaign guidelines 2012: update for emergency physicians. Ann Emerg Med. 2014;63(1):35–47.

• Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017;43(3):304–377.

Excerpted from BCSC 2020-2021 series: Section 1 - Update on General Medicine. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.