Anaphylaxis

Anaphylactic shock can be rapidly fatal and requires

immediate treatment. Administer normal saline boluses,

N antihistamines, and N corticosteroids to all patients.

Give intramuscular epinephrine (1:1,000 solution) in 0.3-

to 0.5-mg doses as needed to maintain systemic perfusion.

In patients refractive to the preceding, administer 0.3- to

0.5-mg doses of N epinephrine (1:10,000 solution) over a

2- to 3-minute duration. Actively search for and remove

any ongoing allergen exposure ( eg, retained soft tissue bee

stinger).

SHOCK

� Obstructive Shock

Cardiac Tamponade

Administer 1-2 L of normal saline followed by emergent

bedside pericardiocentesis. Perform an emergency department

thoracotomy in patients with penetrating thoracic trauma

who fail to respond.

Pulmonary Embolism

Administer small boluses of normal saline (250-500 mL)

followed by vasopressor support in unstable patients.

Fibrinolysis is the treatment of choice for massive PE presenting with profound hypotension (MAP <60), severe

refractive hypoxemia (Sp02 <90 despite supplemental 02),

or cardiac arrest.

Tension Pneumothorax

Administer 1-2 L of normal saline while performing

emergent needle thoracostomy followed by chest tube

placement.

� Cardiogenic Shock

The goal of treatment is to improve cardiac output while

at the same time reducing myocardial workload.

Administer IV fluids judiciously to avoid undesired elevations in the left ventricular preload and secondary pulmonary edema. Begin inotropic and vasopressor support in

patients who remain hypotensive despite IV fluids. Firstline therapy is often a combination of dopamine and

dobutamine (as dobutamine monotherapy will exacerbate

hypotension), with norepinephrine reserved for patients

who fail to respond. Of note, all of the aforementioned

modalities are temporizing measures pending definitive

revascularization (ie, percutaneous coronary intervention

or fibrinolysis).

DISPOSITION

Admit all patients in shock to a critical care bed.

SUGGESTED READING

Cherkas D. Traumatic hemorrhagic shock: Advances in fluid

management. Emerg Med Pract. 20 1 1;13:1-20.

Dellinger, RP, Levy, MM, et al. Surviving Sepsis Campaign:

International guidelines for management of severe sepsis and

septic shock: 2008. Grit Care Med. 2008;36:296-327.

Otero RM, Nguyen HB, Rivers EP. Approach to the patient in

shock. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ,