Management principle: Shock is a race between tissue injury and restoration of oxygen delivery. Every patient needs immediate supportive care and rapid treatment of the mechanism: stop bleeding, restore appropriate volume, treat infection, reverse anaphylaxis, support the failing pump or relieve obstruction. Resuscitation is dynamic—give an intervention, reassess perfusion, then continue, change or stop it.
Safety notice: Use current Uganda Clinical Guidelines, local blood/fluids/vasopressor protocols and senior medical direction. The exact fluid volume, medicine concentration, transfusion ratio, airway decision and vasopressor target depend on age, pregnancy, comorbidities, cause and available monitoring. Never allow a protocol number to override clinical deterioration or fluid overload.
Learning outcomes
- Describe universal first-contact and resuscitation priorities for every shocked patient.
- Manage hypovolaemic, septic/distributive, anaphylactic, neurogenic, cardiogenic and obstructive shock by cause.
- Explain medical/pharmacological, nursing, monitoring, referral and prevention actions.
- Recognise treatment failure, fluid overload, worsening acidosis and the need for surgery/critical care.
- Deliver a structured handover and document every resuscitation decision and response.
1. Universal management: first contact to definitive care
- Scene safety/PPE: protect staff from traffic, violence, chemicals, infection, blood and electrical hazards.
- Call for the right team: resuscitation/ALS, trauma, blood bank, theatre, obstetrics, paediatrics, cardiology, ICU, toxicology or surgery.
- ABCDE: open airway, oxygenate/ventilate, assess circulation/bleeding, check disability/glucose and expose for hidden cause.
- Position and warmth: supine if tolerated, recovery position if vomiting/unconscious and breathing, legs raised only when safe; prevent hypothermia.
- Monitoring: ECG, pulse oximetry, BP/MAP, RR, temperature, mental state, capillary refill, urine and ETCO2/ABG where available.
- Access and samples: two large-bore IVs or IO, glucose, blood gas/lactate, FBC, electrolytes, renal/liver, coagulation, group/crossmatch and cultures where indicated.
- Support circulation: control haemorrhage, use cause-appropriate fluids/blood, consider vasopressor/inotrope support and reassess after each intervention.
- Source control/transfer: definitive surgery, drainage, reperfusion, antidote, antibiotics or advanced airway/ICU care.
Reassessment loop: Intervention → repeat ABCDE → check perfusion/mental state/urine/lactate → document response → escalate or modify treatment.
2. Goals of shock management
| Goal | How to judge it |
|---|---|
| Patent airway and adequate ventilation | Speech/airway protection, chest rise, improving SpO2/ETCO2/ABG, reduced work of breathing. |
| Effective perfusion | Improved mental state, pulse, capillary refill, warmth, BP/MAP appropriate to patient and falling lactate. |
| Renal perfusion | Urine output improving; no obstruction and no fluid overload. |
| Cause controlled | Bleeding stopped, infection treated/source controlled, allergy reversed, pump/obstruction addressed. |
| No treatment harm | No pulmonary oedema, worsening acidosis, hypothermia, dilutional coagulopathy or extravasation. |
3. Universal medical and nursing actions
- Keep an accurate fluid, blood-product, urine, drain, vomit and medication balance.
- Use aseptic technique and label all lines/infusions; double-check high-alert medicines.
- Prevent aspiration, pressure injury, hypothermia, infection and unnecessary movement.
- Provide analgesia carefully; untreated pain increases sympathetic stress, but opioids can worsen hypotension/respiratory depression.
- Explain care, preserve dignity, involve family appropriately and assess consent/capacity.
- Escalate any patient who is worsening despite initial treatment or requires increasing oxygen/vasopressor support.
4. Hypovolaemic and haemorrhagic shock
Aim: stop the loss, restore oxygen-carrying volume, prevent hypothermia/coagulopathy and obtain definitive source control. Shock from bleeding may be internal; never wait for visible blood or a low haemoglobin.
Pre-hospital and first aid
- Apply direct pressure, wound packing/hemostatic dressing or tourniquet when trained; reassess bleeding after movement.
- Stabilise suspected pelvic/long-bone injury, use a spinal/trauma plan and avoid unnecessary log-rolling.
- Keep the patient supine/warm, give oxygen for hypoxaemia and assist ventilation if needed.
- Do not give oral fluids; obtain rapid transport and pre-alert trauma/surgical/blood team.
- Document mechanism, estimated blood loss, tourniquet time, vital trends and response.
Hospital management
- Activate major haemorrhage/massive transfusion protocol when indicated; obtain blood group/crossmatch without delaying emergency blood.
- Use warmed blood components and appropriate balanced resuscitation under local protocol; monitor temperature, calcium, potassium, pH and coagulation.
- Use crystalloid cautiously as a bridge when blood is unavailable; repeated large volumes can dilute clotting factors and worsen hypothermia/acidosis.
- Seek definitive control: theatre, endoscopy, interventional radiology, obstetric intervention, chest decompression or pelvic surgery.
- Consider tranexamic acid early in appropriate traumatic/obstetric bleeding according to local protocol and contraindications.
- Reassess for ongoing internal bleeding even when BP temporarily improves.
| Monitor | Why | Danger trend |
|---|---|---|
| Pulse/BP/perfusion | Response to haemorrhage control and volume/blood. | Persistent tachycardia, narrowing pulse pressure, hypotension, cold/mottled skin. |
| Temperature | Hypothermia worsens coagulopathy. | Falling core temperature despite warming. |
| Calcium/electrolytes | Citrate in transfusion and tissue injury affect calcium/potassium. | Arrhythmia, hypotension, tetany or ECG changes. |
| Urine/lactate/ABG | Organ perfusion and metabolic response. | Oliguria, rising lactate, worsening acidosis. |
5. Non-haemorrhagic volume loss
Vomiting, diarrhoea, fever, burns, poor intake, diuretics and third spacing cause hypovolaemia without obvious blood. Replace measured and ongoing losses using prescribed fluid type/rate, correct electrolytes, treat infection or burns and reassess after small, appropriate challenges. In severe malnutrition, children, heart failure or renal disease, aggressive fluid can be harmful and specialist protocols are essential.
- Record oral/IV intake, urine, diarrhoea/vomit, drains, burns and weight.
- Check sodium, potassium, chloride, bicarbonate, urea/creatinine, glucose and lactate.
- Assess lungs, JVP, oedema and oxygen requirement after each bolus.
- Correct the cause: antiemetic/antidiarrhoeal plan, infection treatment, endocrine therapy, burn care or relief of obstruction.
6. Septic shock
Aim: recognise infection with organ dysfunction, obtain cultures where this does not delay treatment, start effective antimicrobials promptly, support perfusion and control the source. WHO emphasises early diagnosis and timely antimicrobial/fluid management; current sepsis guidance supports crystalloid resuscitation followed by vasopressor support when hypotension persists.
- ABCDE, oxygen/ventilation, ECG, glucose, temperature, lactate and repeated perfusion assessment.
- Take blood cultures and source samples if this does not create a dangerous delay; do not wait for results before prescribed antibiotics in septic shock.
- Give an appropriate crystalloid bolus only when hypoperfusion is present and reassess lungs, BP, capillary refill, urine and lactate.
- If hypotension persists or fluid overload develops, start prescribed vasopressor support—norepinephrine is commonly first-line in adult septic shock—and transfer to critical care.
- Control the source: drain abscess, remove infected device, debride tissue, operate, treat obstruction or manage pneumonia/meningitis.
- Monitor glucose, electrolytes, coagulation, urine, mental state, temperature and antibiotic toxicity.
Fluid caution: A patient with heart/renal failure, pulmonary oedema, severe malnutrition or obvious fluid responsiveness failure needs smaller reassessed boluses and earlier senior/vasopressor review.
7. Anaphylactic shock
- Stop exposure/infusion, call for help and lay flat with legs raised if tolerated; allow a breathless patient to sit with legs extended.
- Give IM adrenaline/epinephrine immediately into the outer thigh using the local concentration and age/weight protocol; repeat if airway, breathing or circulation problems persist.
- Give oxygen, establish IV/IO access and provide rapid crystalloid for persistent hypotension according to protocol.
- Treat bronchospasm with prescribed bronchodilator; antihistamines may relieve skin symptoms but do not replace adrenaline.
- Prepare suction, BVM and advanced airway support because airway oedema can progress rapidly.
- Observe for biphasic reaction, document trigger/response and arrange allergy follow-up/autoinjector education when appropriate.
8. Neurogenic shock
Neurogenic shock follows loss of sympathetic vascular tone, usually high spinal cord injury. It may present with hypotension, relative bradycardia, warm dry skin and impaired temperature control. Distinguish it from haemorrhage, which can coexist in trauma.
- Protect the airway and spine according to trauma protocol; maintain oxygenation and avoid hypoxia/hypotension.
- Control obvious bleeding and search for occult haemorrhage before attributing shock to spinal injury.
- Use cautious fluids to support preload; persistent vasodilation requires prescribed vasopressor support.
- Treat symptomatic bradycardia according to ALS protocol; prevent hypothermia and pressure injury.
- Urgent spinal imaging, neurosurgical/trauma consultation and ICU monitoring are required.
9. Cardiogenic shock
Aim: improve myocardial oxygen supply and cardiac output without causing pulmonary oedema, while urgently treating MI, arrhythmia, valve failure or myocarditis.
- Position for breathing, give oxygen for hypoxaemia and use NIV/ventilation if pulmonary oedema or fatigue develops.
- Obtain a 12-lead ECG, continuous rhythm monitoring, troponin pathway, glucose and bedside echo when available.
- Give only cautious, reassessed fluid if preload depletion is suspected; large empiric boluses can worsen congestion.
- Activate urgent reperfusion/cardiology pathway for ACS; treat life-threatening dysrhythmia with cardioversion/pacing/antiarrhythmic protocol.
- Use vasopressor/inotrope support under critical-care direction for persistent hypotension or low output.
- Correct hypoxia, acidosis, potassium/magnesium abnormalities and medication causes; arrange ICU/mechanical support if refractory.
| Do | Avoid |
|---|---|
| ECG, reperfusion, oxygenation, analgesia when safe, cautious preload assessment, vasoactive support and ICU. | Routine large fluids, unmonitored sedatives, delayed ECG or assuming all hypotension is dehydration. |
10. Obstructive shock
| Cause | Immediate management | Definitive hospital treatment |
|---|---|---|
| Tension pneumothorax | Oxygen/ventilation, immediate decompression by trained provider when clinically indicated; do not wait for imaging in arrest/rapid collapse. | Chest drain, imaging, trauma/respiratory review. |
| Cardiac tamponade | ABCDE, cautious support, avoid delays and urgent echo/surgical consultation. | Pericardiocentesis or surgical drainage. |
| Massive pulmonary embolism | Oxygen/ventilation, cautious fluids, ECG/echo, anticoagulation/thrombolysis pathway by senior team. | Thrombolysis, embolectomy or catheter intervention when indicated. |
| Dynamic hyperinflation | Disconnect briefly from ventilator if instructed, allow exhalation, treat bronchospasm and call airway/ICU support. | Ventilator adjustment, bronchodilator, drainage if pneumothorax and critical care. |
11. Mixed shock and treatment failure
- Trauma may combine haemorrhage, tension pneumothorax, spinal injury, pain and hypothermia.
- Sepsis can cause vasodilation, capillary leak, myocardial depression, AKI and respiratory failure.
- Cardiogenic shock may develop after excessive fluids in a patient initially thought to be hypovolaemic.
- Anaphylaxis can cause bronchospasm, vasodilation, capillary leak and cardiac arrest simultaneously.
- Failure to improve after a reasonable intervention means reassess the diagnosis, search for obstruction/ongoing bleeding and call senior/ICU/surgical help.
12. Nursing interventions and ongoing monitoring
| Area | Interventions | Escalate when |
|---|---|---|
| Airway/breathing | Position, suction, oxygen/ventilation, airway checks, SpO2/ETCO2/ABG and lung assessment. | Increasing support, fatigue, rising CO2, hypoxia or aspiration. |
| Circulation | ECG/BP/MAP, access, fluids/blood/vasopressor checks, bleeding/drain observation. | Persistent hypotension, arrhythmia, cool mottled skin or no response. |
| Renal/fluid | Hourly urine where indicated, strict intake/output, weight, electrolytes and renal review. | Oliguria/anuria, overload, rising creatinine or severe potassium/pH change. |
| Neurology | GCS/AVPU, pupils, glucose, pain, delirium and seizure precautions. | Falling consciousness, focal sign, seizure or new agitation. |
| Temperature/infection | Warm patient, cultures/antibiotics, aseptic lines, wound/source observation. | Persistent fever/hypothermia, worsening lactate or suspected source failure. |
| Safety/psychosocial | Explain care, protect dignity, pressure care, family communication and documentation. | Capacity/safeguarding concern, distress, refusal or communication barrier. |
13. Prevention of shock and recurrent deterioration
- Early recognition and treatment of infection, bleeding, dehydration, allergy, chest pain and breathing difficulty.
- Safe medication reconciliation, anticoagulant monitoring and education about steroid/adrenal suppression.
- Vaccination, infection prevention, food/water safety, malaria/arbovirus prevention and prompt wound care where relevant.
- Fall/trauma prevention, occupational PPE, safe transport and early pregnancy/obstetric referral.
- Discharge education: hydration, warning signs, medication adherence, allergy plan and follow-up.
14. Clinical scenarios
Scenario 1 — Haemorrhage: A patient with a stab wound is pale, tachycardic and confused. Apply direct pressure/packing, call trauma team, oxygenate, gain access, activate blood pathway, keep warm and transfer for surgery. Do not delay for a “normal” early haemoglobin.
Scenario 2 — Septic shock: A febrile patient is hypotensive with lactate 5 and low urine. Start sepsis bundle, cultures/antibiotics as directed, cautious crystalloid with reassessment, early norepinephrine/ICU if hypotension persists and urgent source control.
Scenario 3 — Cardiogenic shock: A patient with MI has pulmonary oedema, cool skin and hypotension. Oxygen/NIV, ECG/reperfusion, cautious fluids only if indicated, vasoactive support and cardiology/ICU—not a routine large fluid bolus.
Scenario 4 — Anaphylaxis: After an antibiotic, a patient develops wheeze, urticaria and collapse. Give IM adrenaline immediately, position safely, oxygenate, support circulation and monitor for recurrence; antihistamine alone is not adequate.
Scenario 5 — Tension pneumothorax: A ventilated trauma patient suddenly has unilateral absent breath sounds, hypotension and rising airway pressure. Suspect obstruction; call for immediate decompression by a trained provider and continue BVM/critical-care support.
15. Documentation and handover
- Suspected shock type, onset/mechanism, comorbidities, allergies, medicines, pregnancy and baseline.
- Serial ABCDE, vital signs, ECG, SpO2/oxygen, glucose, lactate/ABG, urine and fluid balance.
- Bleeding control, fluid/blood products, antibiotic/antidote, adrenaline, vasopressor/inotrope and exact times.
- Response, adverse effects, complications, escalation calls, destination and outstanding source-control plan.
16. Revision questions
- What is the first priority in every type of shock?
- How does fluid management differ between haemorrhagic and cardiogenic shock?
- When should vasopressor support be considered in septic shock?
- Why is IM adrenaline first-line in anaphylactic shock?
- What definitive treatments relieve the main causes of obstructive shock?
- Which findings suggest fluid overload during resuscitation?
- What nursing observations should be repeated after every intervention?
- How does mixed shock complicate diagnosis and treatment?
- What prevention advice reduces recurrent shock?
- What must be included in a shock handover?
17. Key take-home points
- Support ABCDE while treating the mechanism—volume loss, vasodilation, pump failure or obstruction.
- Control bleeding and source infection early; use fluids/blood/vasopressors thoughtfully.
- Reassess perfusion, lungs, urine, mental state, lactate and treatment harm after every intervention.
- Cardiogenic and obstructive shock require cause-specific therapy; large fluids can worsen both.
- Detailed documentation and early specialist communication improve survival.
Selected authoritative resources
- Resuscitation Council UK ABCDE approach.
- Surviving Sepsis Campaign adult guidelines.
- WHO Emergency Care Toolkit.
- MSD Manual: shock and fluid resuscitation.
For EMT practice: Shock treatment is a sequence of support, source control, targeted resuscitation, reassessment and escalation. Give only what the patient needs—and keep checking whether it is helping.