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KEY
🔍- Deep Dive
📌- Clinical Application
🔸 - Weak Evidence
🔹 - Strong Evidence
📑 - Evidence summaries
✅ - Recommended treatment
⚠️ - Critical Information
I love resuscitating shock — it’s fun, fast, chaotic, and everything I love about EM. But it also comes with a ton of doubts. This post is a breakdown of all the questions that bothered me over the years, distilled into something I hope helps you too.
(Disclaimer: These recommendations DO NOT replace your clinical judgement. Every patient is unique.)
So let’s talk shock, or septic shock ( if you know,you know)
Step 1: Recognize Septic Shock?
According to the Surviving Sepsis Campaign (SSC)
“Septic shock is a subset of sepsis with circulatory and metabolic abnormalities large enough to substantially increase mortality.”
But more importantly for us:
Clinical definition = Sepsis + BOTH:
- Persistent hypotension needing vasopressors to maintain MAP ≥ 65, despite fluids
- Lactate ≥ 2 mmol/L
Once you recognize shock → resuscitation begins immediately.
Step 2: Fluids
How much?
🔸30 mL/kg crystalloid within the first 3 hours (SSC guideline)
But ER doctors must do better.
Fluid resuscitation must be individualized.
Assess:
- Fluid Responsiveness (FR)
- Fluid Tolerance (FT)
Quick & Oversimplified Guide
FT | FR | Management |
✔ | ✔ | Give fluids |
✘ | ✘ | Early pressors |
✔ | ✘ | Early pressors |
✘ | ✔ | Early pressors |
Low diastolic BP (DAP) → low vascular tone → start NE early
Not a fluid post — that’s coming next 😄
Let’s move on.
Step 3: 1st Vasopresor
Which Pressor First?
🔹Norepinephrine (Noradrenaline) (SSC guidelines)
Why?
- Potent α-1 + mild β-1 effect
- Raises MAP with minimal tachycardia
Why NOT the others first?
Dopamine
❌ More arrhythmias
❌ Higher mortality
→ No role in septic shock
Epinephrine
❌ Tachyarrhythmias
❌ Increases lactate
✔ Good in bradycardia / myocardial dysfunction
→ Second/third line
Vasopressin
Not first line because of:
❌ Cost
❌ Availability
✔ Excellent add-on to NE
When to start pressors?
Immediately if MAP < 65
Do NOT wait to finish 30 mL/kg.
Reassess after 10 mL/kg over 10 minutes:
If MAP is still low → start pressors early.
Why early norepinephrine (NE)?
Because septic shock ≠ pure hypovolemia.
- NE ↑ preload and cardiac output
- Less time in hypotension → less AKI
- Improves microcirculation
- Avoids fluid overload
- Early BP control = lower mortality
- CENSER Trial: early NE → better shock control at 6 hours
Peripheral or Central Line?
🔸SSC recommends: Start NE peripherally if needed.
Do NOT delay vasopressors waiting for a central line.
Do NOT give vasopressin peripherally.
What Dose of NE?
- Start: 0.1 mcg/kg/min
- Titrate to MAP ≥ 65
- No absolute “maximum” dose
Then why add a second pressor?
To reduce total catecholamine exposure:
- High NE doses may impair immunity
- Promote bacterial growth
- Cause myocardial injury
- Increase oxidative stress
This principle is called decatecholaminization.
Step 4: 2nd Vasopressor
When to Start the Second Pressor?
👉 When NE = 0.25–0.5 mcg/kg/min and MAP still inadequate.
Instead of escalating NE further.
Remember: Reduction of NE dose with MAP ≥ 65 by 6 hours → better outcomes.
Also: Always start steroids when you add a second pressor.
Which Pressor Next?
🔸Vasopressin - (SSC Guideline)
Why Vasopressin?
- Relative vasopressin deficiency in septic shock
- Less atrial fibrillation when added to NE
(McIntyre et al., JAMA 2018)
- Lower RRT requirement (VANISH)
- Improved survival in less severe shock (VASST subgroup)
- Catecholamine-sparing effect (less NE needed)
Dose
0.03 U/min
Vasopressin is never titrated.
Higher doses → cardiac, digital, and splanchnic ischemia.
Should you consider a loading bolus?
Why?
- Half-life: 15–20 minutes
- Infusion alone may take ~30 min to show effect
- 1-unit bolus → rapid MAP rise
- VALOR Trial: responders had MAP ↑ >18–22 mm + fewer ischemic complications
Why not?
- Overshoot MAP
- Ischemia (cardiac, digital. mesentric)
- VALOR Trial : Not a mortality study, Sample size relatively small
- No major guideline recommends this yet
When to AVOID Vasopressin
- Systemic hypoperfusion (cold extremities, mottling)
- High risk of digital or splanchnic ischemia
When Vasopressin Is GREAT
- Warm vasoplegic shock (low SVR, high CO)
- Tachyarrhythmias
- RV failure
A Caveat
🔸If myocardial dysfunction is present:
👉 Use epinephrine, or NE + dobutamine
(No evidence that dobutamine is superior to epinephrine.)
Step 5: 3rd Vasopressor
Still in Shock? Now what?
Before escalating, reconsider your diagnosis.
Remember Hickam’s dictum: “A patient can have as many diseases as he damn well pleases.”
🔸Epinephrine (SSC Guideline)
Especially useful in:
- Bradycardia
- Depressed systolic function
- Refractory shock
How to Choose Your Pressor (4-Question Method)
Now that you understand each drug, choose based on these:
1️⃣ Peripheral vs Central Access
- Vasopressin → avoid peripherally
- NE → safe peripherally short-term
2️⃣ Heart Rate & EF
- Bradycardia / low EF → NE, Epinephrine
- Tachycardia / good EF → Vasopressin
3️⃣ RV Failure
- NE may worsen RV afterload
- Choose Vasopressin or Epinephrine
4️⃣ When in doubt
👉 Start Norepinephrine.
Want to Read More?
- Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Critical Care Medicine 49(11):p e1063-e1143, November 2021. | DOI: 10.1097/CCM.0000000000005337
- Kattan, Eduardo, et al. "The emerging concept of fluid tolerance: a position paper." Journal of Critical Care 71 (2022): 154070.
- Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801–810. doi:10.1001/jama.2016.0287
- Permpikul, Chairat, et al. "Early use of norepinephrine in septic shock resuscitation (CENSER). A randomized trial." American journal of respiratory and critical care medicine 199.9 (2019): 1097-1105.
Disclaimer : For educational use only — always follow your clinical judgment and local protocols.
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