In this episode I’ll review the medications used to support the treatment of shock from 12 different etiologies.

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During the treatment of shock, the patient’s life hangs in the balance while the care team quickly delivers interventions to identify and treat the underlying cause. Many of these interventions require medications to facilitate treatment.

I see the pharmacist’s role in the treatment of shock as “setting the table” by having the necessary medications immediately available so the rest of the team can deliver supportive care or other interventions to the patient.

Recognizing shock

Typical features for shock include:

– Altered mental status

– Tachycardia

– Hypotension

– Oliguria

– Cool, clammy skin

– Metabolic acidosis

Supportive care

Airway, breathing, and circulation need to be addressed immediately. Obtain medications to facilitate endotracheal intubation, IV fluids, and vasopressors to maintain circulation. You might not have a central line at first but this is not a reason to delay the administration of vasopressors.

Any (IV) port in a storm.

Types of shock

Here are 12 types of shock and the medications you’ll need at the bedside for treatment:

Anaphylactic shock

Anaphylactic shock occurs from an IgE-mediated allergic reaction to food, insect sting, or medication.

I covered the pharmacologic treatments for anaphylaxis in episode 46. The only drug that matters is epinephrine. It should be given IM 0.3 to 0.5 mg into the mid-outer thigh. If needed, this dose may be repeated every 5 to 15 minutes.

Tension pneumothorax

A tension pneumothorax is a build-up of air in the pleural space which obstructs venous return to the heart. Tension pneumothorax may occur after trauma, procedures, or mechanical ventilation. Treatment involves needle thoracostomy or the emergent placement of a chest tube to relieve the build-up of air. If the patient is awake and time allows, obtain 1% lidocaine for infiltration & local anesthesia.

Pericardial tamponade

Pericardial tamponade is caused by blood or fluid building up in the space between the myocardium and pericardial sac. Treatment involves emergent pericardiocentesis to drain the fluid. Sedation is rarely required. Obtain 1% lidocaine to anesthetize the puncture site & pericardium.

Hemorrhagic shock

Hemorrhagic shock may be traumatic or non-traumatic. Blood products and supportive care are the mainstays of treatment. Based on the history of present illness, reversal agents such as plasma, tranexamic acid, idarucizumab and 4-factor prothrombin complex concentrate may be called for. These agents reverse coagulopathies immediately but don’t lose sight of aggressive supportive care as hemostasis still takes several hours to achieve. Additional therapies to correct metabolic derangements and promote hemostasis include sodium bicarbonate and clotting factor 4 (also known as calcium).

Life-threatening tachyarrhythmia

Cardiovert life-threatening tachyarrhythmia!!! For synchronized cardioversion in a shocked patient with a tachyarrhythmia use the minimum amount of sedation necessary. I prefer etomidate ~0.1mg/kg IV but low doses of midazolam may also be used. If the tachyarrhythmia is regular and narrow-complex, obtain adenosine as well.

Life-threatening bradyarrhythmia

For life-threatening bradyarrhythmia, atropine will be the first treatment at a dose of 0.5 mg IV every 3 minutes to a max of 3mg. If this fails transcutaneous pacing may be used. If the patient is awake they will require sedation. I prefer the minimum dose necessary of IV benzodiazepine in this case. IV infusions of dopamine (2-10 mcg/kg/min) or epinephrine (2-10 mcg/min) may also be called for.

Septic shock

I covered the treatment for septic shock in episode 42. Be prepared to obtain IV fluids, antibiotics, vasopressors.

Cardiogenic shock from myocardial infarction

Patients with cardiogenic shock from myocardial infarction need to get to the cardiac catheterization lab. Obtain morphine and the antiplatelets & anticoagulants used in your local protocol.

Cardiogenic shock from acute aortic or mitral valve insufficiency

Cardiogenic shock from acute aortic or mitral valve insufficiency is a surgical emergency. Medical therapy might include nitroprusside and dobutamine.

Dissection of the ascending aorta

Dissection of the ascending aorta is another surgical emergency. Obtain IV morphine for pain relief. Hemodynamic parameters must be lowered to minimize aortic wall stress. Obtain IV labetalol or esmolol to reduce the heart rate to less than 60 beats per minute and systolic blood pressure to 100-120 mmHg. If the blood pressure is not at goal, nitroprusside should be used next.

Severe pulmonary embolism

Provided there are no contraindications, IV thrombolytics should be used for a patient with shock due to severe pulmonary embolism. I covered the three ways to administer IV thromblytics (infusion, bolus, catheter-directed therapy) in episode 17.

Adrenal crisis

Patients with shock and a history of glucocorticoid deficiency or withdrawal may have adrenal crisis. Obtain 4 mg IV dexamethasone. Ensure that appropriate lab tests (serum cortisol, ACTH, aldosterone, chemistries) have been drawn before giving the dexamethasone.

If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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