#EMconf: Shock Pearls from Dr. Mallemat


Pearls When Approaching a Patient with Undifferentiated Shock: 


  • Shock is defined as circulatory dysfunction that leads to inadequate tissue / organ perfusion; the goal during resuscitation is to correct abnormal perfusion.
  • There are three components to tissue / organ perfusion: the pump (i.e., heart), the pipes (i.e., mean arterial pressure) and the tank (i.e., intravascular volume)
  • There are four categories of shock: 1) hypovolemic, 2) Obstructive, 3) Cardiogenic, 4) Distributive; each one of these classes affects the pump, pipes, and tank differently.
  • Because not all presentations of shock are obvious use the ultrasound to evaluate the pump, pipes, and tank. Then target your resuscitation to the specific component that needs help.
  • Other tips for resuscitation:
    • During large volume resuscitation, consider LR over normal saline as there are more adverse events with normal saline (e.g., renal injury). 
    • Always examine your patient's feet!  Warm feet = warm shock and Cold feet = cold shock.  
    • Have a low threshold for placing an A-line for hemodynamic monitoring and strongly consider the femoral site over radial (easier, faster, and more accurate)
    • Methylene blue can be considered for patients in vasopressor refractory septic shock (i.e., adequate IV fluids and requiring multiple vasopressors)