Common causes | Important clinical findings | Interventions | Prevention/preparation |
High intrathoracic pressure - Poor BMV ventilation technique
- Improper mechanical ventilation settings
| - Normal or elevated airway pressures
- Abnormal breath sounds (eg, wheezing, diminished)
| - Slow ventilation rate (≤8 bpm)
- Reduce ventilation force (for BMV)
- Increase expiration time
- IV bolus isotonic fluid
| - Avoid overly rapid or forceful ventilation
|
Induction agent effects | - Occurs within minutes of drug administration
- Transient effect
- Resolves with IVF bolus and time
| - IV bolus isotonic fluid
- Norepinephrine infusion
- Exclude other serious causes
- Monitor for resolution
| - Prepare norepinephrine infusion prior to giving induction agent to patient with hypotension or signs of hemodynamic instability
- Consider push-dose pressor*
|
Significant prior or ongoing fluid loss | - Signs of shock
- SI >0.8
- POCUS shows decreased IVC diameter and hyperdynamic heart
| - IV bolus isotonic fluid; repeat as needed
| - In hypotensive or high-risk patients, give IVF bolus prior to administering RSI medications
|
Significant prior or ongoing hemorrhage | - Blood loss
- Signs of shock
- Pallor
| - Blood transfusion
- Hemorrhage control/surgical consultation
| - In patients with hemorrhagic shock or at risk for hemodynamic instability, initiate blood transfusion prior to administering RSI medications
|
Obstructive shock |
| - Possible hypoxemia
- Lower extremity swelling
- Dilated RV on POCUS or bedside echo
| - Norepinephrine infusion
- iNO or epoprostenol (reduce PVR)
| - Give norepinephrine early as needed
- Consider push-dose pressor*
- For shock caused by PE, avoid intubation if possible; use BPAP or iNO to improve oxygenation/ventilation
- Ketamine is preferred induction agent for patients in non-cardiogenic shock; avoid propofol
- Reduce dose of induction agent¶
- In hypotensive or high-risk patients with tamponade, give IVF bolus prior to administering RSI medications
|
| - Distended neck veins, if patient not volume depleted
- POCUS shows pericardial effusion and compression of RA and RV
| - IV bolus isotonic fluid
- Pericardiocentesis
|
Cardiogenic shock | - Crackles, distended neck veins, cool extremities
- ECG may show ischemia
- POCUS shows poor contractility, B lines
- Chest radiograph may show signs of ADHF
| - Minimize PEEP
- Vasopressor (norepinephrine) and inotrope (dobutamine) infusions
- Interventional cardiology consult (catheterization; IABP; LVAD)
| - BPAP as indicated before RSI
- Etomidate is preferred induction agent for patients in cardiogenic shock; avoid propofol
- Prepare norepinephrine infusion prior to giving induction agent
- Consider push-dose pressor*
|
Distributive shock |
| - Fever, hypotension, tachycardia, focal signs of infection
| - IV bolus isotonic fluid; repeat as needed
- Norepinephrine infusion for sepsis
| - In hypotensive or high-risk patients, give IVF bolus prior to administering RSI medications
- Ketamine is preferred induction agent for patients in non-cardiogenic shock; avoid propofol
- Give norepinephrine for sepsis early as needed
- Reduce dose of induction agent¶
- Consider push-dose pressor*
|
| - Skin and mucosal signs (hives, flushing, edema)
- Respiratory signs (wheeze, cough, congestion)
| - IV bolus isotonic fluid; repeat as needed
- Epinephrine for anaphylaxis
|
Older adult patient with poor CV reserve | - Frail appearing
- ECG may show ischemia
- History of CAD or reduced EF
| - IV bolus isotonic fluid
- Norepinehrine infusion
| - Prepare norepinephrine infusion prior to giving induction agent
- Reduce dose of induction agent¶
- Consider push-dose pressor*
|