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Signs of Shock

Does patient have signs of shock after receiving 60 mL/kg of fluid?



NS > 40-60 ml/kg administered without adequate clinical response

Titrate epinephrine infusion

Consider central venous line

Continue fluid boluses until perfusion improves or signs of fluid overload develop


Titrate epinephrine infusion

Starting dose 0.05 mcg/kg/min

High systemic vascular resistance, low cardiac output

Cold extremities, prolonged capillary refill (> 3 seconds)

Faint pulses

Normal or increased diastolic blood pressure

Narrow pulse pressure (< 30 mm Hg)


Titrate norepinephrine infusion

Starting dose 0.05 mcg/kg/min

If norepinephrine is not immediately available, use epinephrine.

Vasodilation, low systemic vascular resistance, high cardiac output

Warm extremities, flash capillaries < 1 second, bounding pulses

Decreased diastolic pressure, wide pulse pressure (> 40 mm Hg)

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These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.