Identify poor perfusion, reassess fluid response, and recognize the cardiogenic branch.
OCEMS source summary · Updated 2026-09-16
Key cautions & base contact
Reassess before every fluid repeat; pulmonary edema changes the pathway.
Use the pediatric shock guide for children rather than adult 250 mL increments.
Assess the patient
Look for systolic BP at or below 90 with poor skin signs, altered mental status, tachycardia, or weak pulses. Search for hemorrhage, dehydration, infection, or a cardiac cause.
Monitor and document rhythm. If room-air SpO₂ is below 95%, give high-flow mask oxygen or nasal cannula at 6 L/min as tolerated. Obtain IV; consider IO for an unresponsive patient when peripheral IV cannot be established.
Clear lungs with poor perfusion
When lungs are clear and there is no evidence of CHF, give normal saline 250 mL and reassess. Repeat as indicated to a maximum 1 L to support perfusion.
Contact base if hypotension does not respond. Track the cumulative amount and watch for newly developing rales.
Rales or suspected acute MI
If rales suggest cardiogenic shock, contact base for further orders. Do not continue the clear-lung fluid pathway without reassessment.
Obtain a 12-lead for suspected acute MI/STEMI and contact base for CVRC destination. PR-230 governs current adult push-dose epinephrine preparation/eligibility; its April 2026 change does not cancel other contact requirements.
Transport and handoff
Provide rapid ALS transport with treatment en route when possible, to the nearest ERC or base-directed destination.
Report the suspected cause, BP/perfusion trends, lung findings, oxygenation, glucose when relevant, total fluids, and response. Consider sepsis even when an early set of vital signs is less dramatic.