Hemorrhagic shock: In hemorrhagic shock, surgical control of bleeding is primary. Vigorous volume replacement accompanies rather than precedes surgical control. Blood transfusion is used for hemorrhagic shock unresponsive to 2 L (or 40 mL/kg in children) of crystalloid. Failure to respond usually indicates insufficient volume administration or unrecognized ongoing hemorrhage. Vasopressor agents are not indicated for treatment of hemorrhagic shock unless cardiogenic, obstructive, or distributive causes are also present.

出血性休克：出血性休克病人主要通过外科手术控制出血。大容量补液应在手术控制期间而不是控制前进行。输血用于2L（或儿童40mL)类晶体无反应的出血性休克病人。无反应通常表明输入容量不足或存在隐匿性出血。治疗出血性休克不需要血管加压药，除非同时存在心源性、阻塞性或分布性病因。

Distributive shock: Distributive shock with profound hypotension after initial fluid replacement with 0.9% saline may be treated with inotropic or vasopressor agents (eg, dopamine - see Table 3: Shock and Fluid Resuscitation: Inotropic and Vasoactive Catecholamines). Patients with septic shock also receive at least two broad-spectrum antibiotics. Patients with anaphylactic shock unresponsive to fluid challenge (especially if accompanied by bronchoconstriction) receive epinephrine 0.05 to 0.1 mg IV, followed by epinephrine infusion of 5 mg in 500 mL 5% D/W at 10 mL/h or 0.02 μg/kg/min.医学全在线www.med126.com

分布性休克：用0.9%生理盐水初步补液后的低血压分布性休克病人可用收缩性或血管加压药治疗（如多巴胺－见表3：休克和液体复苏：收缩性和血管加压儿茶酚胺类药)。败血症性休克病人至少也要服用两种广谱抗生素。输液无效的过敏性休克病人（尤其是伴有支气管收缩者)可先静脉给注肾上腺素0.05至0.1 mg，然后再用5 mg 肾上腺素加500 mL 5%葡萄糖液滴注，滴速10 mL/h or 0.02 μg/kg/min。

Cardiogenic shock: In cardiogenic shock, structural disorders (eg, valvular dysfunction, septal rupture) are repaired surgically. Coronary thrombosis is treated either by percutaneous interventions (angioplasty, stenting), coronary artery bypass surgery, or thrombolysis. Tachydysrhythmia (eg, rapid atrial fibrillation, ventricular tachycardia) is slowed by cardioversion or with drugs. Bradycardia is treated with a transcutaneous or transvenous pacemaker; atropine 0.5 mg IV up to 4 doses q 5 min may be given pending pacemaker placement. Isoproterenol (2 mg/500 mL 5% D/W at 1 to 4 μg/min [0.25 to 1 mL/min]) may occasionally be useful if atropine is ineffective, but it is not advised in patients with myocardial ischemia due to coronary artery disease.

心源性休克：心源性休克病人的的结构性病症（如瓣膜功能异常、室间隔破裂等)可通过手术修复。冠状动脉栓塞采用经皮手术（血管成形术、支架)、冠状动脉旁路手术或溶栓治疗。节律异常快速（如快速心房颤动、室性心动过速)通过心脏复律或药物缓解。心动过缓则用经皮或经静脉起搏器治疗，并根据起搏器使用情况IV补充阿托品0.5mg，每5分钟4次剂量。若阿托品无效，亦可偶尔使用异丙肾上腺素（2 mg5%葡萄糖液500 mL滴速1 to 4 μg/min [0.25 to 1 mL/min])。冠状动脉疾病引起的心肌缺血者不宜使用。

Shock after acute MI is treated with volume expansion if PAOP is low or normal; 15 to 18 mm Hg is considered optimal. If a pulmonary artery catheter is not in place, cautious volume infusion (250- to 500-mL bolus of 0.9% saline) may be tried while auscultating the chest frequently for signs of fluid overload. Shock after right ventricular MI will usually respond partially to volume expansion; however, vasopressor agents may be needed.

如PAOP低或正常，急性MI休克行扩容治疗，15－18 mm Hg较理想。如未配置肺动脉导管，可谨慎采用容量输液（0.9%生理盐水150－500 mL推注)，同时经常听诊胸部观察液体过剩体症。右室MI休克通常会对容量扩张起反应，但可能需要血管加压药。

If hypotension is moderate (eg, mean arterial pressure [MAP] 70 to 90 mm Hg), dobutamine infusion may be used to improve cardiac output and reduce left ventricular filling pressure. Tachycardia and arrhythmias occasionally occur during dobutamine administration, particularly at higher doses, necessitating dose reduction. Vasodilators (eg, nitroprusside, nitroglycerin), which increase venous capacitance or lower systemic vascular resistance, reduce the workload on the damaged myocardium and may increase cardiac output in patients without severe hypotension. Combination therapy (eg, dopamine or dobutamine with nitroprusside or nitroglycerin) may be particularly useful but requires close ECG and pulmonary and systemic hemodynamic monitoring.

中度低血压病人（MAP 70-90 mm Hg)可用多巴酚丁胺改善心排量，减少左室充盈压。作用多巴酚丁胺有时会引起心动过速和心律异常，特别是大剂量时，此时应减少剂量。血管扩张药（如硝普盐、硝酸甘油)增加静脉容量或减少全身血管阻力，减轻受损心肌负担，可增加无严重低血压病人的心排量。联合疗法（如多巴胺或多巴酚丁胺加硝普盐或硝酸甘油)尤为有效，但需要密切进行ECG、肺动脉和体循环血液动力学监测。

For more serious hypotension (MAP < 70 mm Hg), norepinephrine or dopamine may be given, with a target systolic pressure of 80 to 90 mm Hg (and not > 110 mm Hg). Intra-aortic balloon counterpulsation is valuable for temporarily reversing shock in patients with acute MI. This procedure should be considered as a bridge to permit cardiac catheterization and coronary angiography before possible surgical intervention in patients with acute MI complicated by ventricular septal rupture or severe acute mitral regurgitation who require vasopressor support for > 30 min.

低血压较重（MAP < 70 mm Hg)病人可用去国甲肾上腺素或多巴胺，使收缩压保持在80－90　mm Hg（不> 110 mm Hg)。主动脉内球囊反搏对临时逆转急性MI性休克很重要，它是急性MI并发室间隔破裂病人或严重急性二尖瓣反流需要＞30 min血管加压药支持病人术前进行心导管和冠状动脉造影的过渡桥梁。

In obstructive shock, cardiac tamponade requires immediate pericardiocentesis, which can be done at the bedside. Tension pneumothorax should be immediately decompressed with a catheter inserted into the second intercostal space, midclavicular line. Massive pulmonary embolism resulting in shock is treated with thrombolysis or surgical embolectomy.

阻塞性休克病人若出现心脏压塞，需立即进行心包穿刺术。该手术可以在床边进行。张力性气胸应立即在第二肋间隙、锁骨中线插管降压。肺动脉大块栓塞引起休克则采用溶栓或栓子切除术疗法。