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Circulatory shock: an expert

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Circulatory Shock: An Expert

ghly time-sensitive emergency [1]. For its acute nature, circu- latory shock is usually managed by frontline physicians, who are, sometimes, of limited knowledge and experi- ence. Moreover, they may work in limited resource set- tings. Hence, having a clear, timely, easily memorizable appr...

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Hasanin et al. International Journal of Emergency Medicine (2024) 17:96 International Journal of
https://doi.org/10.1186/s12245-024-00660-y
Emergency Medicine

REVIEW Open Access

The MINUTES bundle for the initial 30 min
management of undifferentiated circulatory
shock: an expert opinion
Ahmed Hasanin1*, Filippo Sanfilippo2,3, Martin W Dünser4, Hassan M Ahmed5, Laurent Zieleskiewicz6,
Sheila Nainan Myatra7 and Maha Mostafa1

Abstract
Acute circulatory shock is a life-threatening emergency requiring an efficient and timely management plan, which
varies according to shock etiology and pathophysiology. Specific guidelines have been developed for each type of
shock; however, there is a need for a clear timeline to promptly implement initial life-saving interventions during
the early phase of shock recognition and management. A simple, easily memorable bundle of interventions could
facilitate standardized management with clear targets and specified timeline. The authors propose the “MINUTES”
acronym which summarizes essential interventions which should be performed within the first 30 min following
shock recognition. All the interventions in the MINUTES bundle are suitable for any patient with undifferentiated
shock. In addition to the acronym, we suggest a timeline for each step, balancing the feasibility and urgency of
each intervention. The MINUTES acronym includes seven sequential steps which should be performed in the first
30 min following shock recognition: Maintain “ABCs”, INfuse vasopressors and/or fluids (to support hemodynamic/
perfusion) and INvestigate with simple blood tests, Ultrasound to detect the type of shock, Treat the underlying
Etiology, and Stabilize organ perfusion.
Keywords Shock, Ultrasound, Vasopressors, Fluids, Norepinephrine, Hypotension, Congestion

Background
Acute circulatory shock is a life-threatening and highly
time-sensitive emergency [1]. For its acute nature, circu-
*Correspondence: latory shock is usually managed by frontline physicians,
Ahmed Hasanin who are, sometimes, of limited knowledge and experi-

1
Department of Anesthesia and Critical Care Medicine, Faculty of ence. Moreover, they may work in limited resource set-
Medicine, Cairo University, Cairo, Egypt tings. Hence, having a clear, timely, easily memorizable
2
University Hospital Policlinico, G. Rodolico - San Marco, Catania, Italy approach may facilitate their performance and finally
3
Department of Surgery and Medical-Surgical Specialties, University of
Catania, Catania, Italy improve patient’s management.
4
Department of Anaesthesiology and Intensive Care Medicine, Kepler According to the type of shock, clinical guidelines have
University Hospital and Johannes Kepler University, Krankenhausstrasse been developed and are regularly updated to optimize
9, Linz, Austria
5
Leeds Teaching Hospitals NHS Trust, Leeds, UK patient’s management. Once the specific diagnosis of
6
Service d’anesthésie réanimation hôpital nord Marseille APHM, C2VN Aix shock has been made, evidence-based management for
Marseille Université, Marseille, France each type (e.g., septic, hemorrhagic, cardiogenic shock)
7
Department of Anaesthesiology, Critical Care and Pain, Tata Memorial
Hospital, Homi Bhabha National University, Mumbai, India is well established by international guidelines [2–6].

© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use,
sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and
the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this
article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included
in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The
Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available
in this article, unless otherwise stated in a credit line to the data.

, Hasanin et al. International Journal of Emergency Medicine (2024) 17:96 Page 2 of 8

However, it is critical to minimize the time between shock not only the most important and initial actions but also
recognition and initiation of shock- or disease-specific to focus on the importance of a timely and sequential
therapies. Currently, specific recommendations for the approach for the main supportive and diagnostic steps.
management of shock due to any etiology in the initial We believe that under most circumstances, the bundle
few minutes are lacking. can be accomplished within the first 30 min after shock
All physicians, especially junior staff, may benefit from recognition.
a common pathway to manage patients with undifferen-
tiated shock during the first minutes. Such a common Do the current guidelines cover the early phase of
pathway should be applicable to all patients, indepen- shock adequately?
dently of what type of shock is subsequently diagnosed. Despite the presence of dedicated guidelines for several
In case of rapid clinical deterioration, it is widely types of shock, most of these represent recommenda-
accepted that provision of basic and advanced life sup- tions in separate statements without specific order of
port must be the first priority [7]. However, it is unclear interventions nor a timeframe for achieving each man-
how these first steps should be implemented, specifically agement step [2–6]. For instance, the Surviving Sepsis
regarding their timing and order. Campaign considers several interventions according to
The aim of this review is to propose a simplified bundle different sections (hemodynamic, infection, initial resus-
for the initial management of patients with undifferenti- citation, etc.), but a timely approach is not present for all
ated shock. Based on pathophysiological knowledge and interventions. Moreover, actions should be undertaken to
scientific evidence, the expert panel suggests an acronym stabilize the patient and decrease mortality and morbid-
that could help acute care physicians in this task by apply- ity before the cause of shock is recognized.
ing a bundle of sequential interventions. The acronym Indeed, several guidelines focus on the management
“MINUTES” was intentionally selected to summarize of the cause of shock. A summary of the existing guide-
lines for different types of circulatory shock and the
recommendations of its initial management is shown in
Table 1 Guidelines for different types of circulatory shock and
recommendations to be implemented within the first 30 min Table 1. Considering the identified potential gap in clin-
Latest guidelines Recommendations to be ically-oriented guidelines for the initial management of
implemented within the undifferentiated shock, the expert panel thinks that more
first 30–60 min attention is required towards common major supportive
Septic shock Surviving sepsis Measure lactate levels. steps. We think that the proposed first management steps
campaign 2021 [2] Obtain blood cultures before should be implemented independently from the cause of
administering antibiotics.
shock and before diagnosis is made, in order to reduce
Administer broad-spectrum
antibiotics. the period of “under-perfusion” and organ damage. Nota-
Begin to rapidly administer bly, the expert panel also suggests a timeframe for the
30 ml/kg crystalloid for hypo- accomplishment of each phase.
tension or lactate ≥ 4 mmol/L.
Cardiogenic shock American Heart No specific timeline The rationale of prioritizing an intervention over
Association 2022 recommendations
[3]
other in the bundle
Hypovolemic European Society Control any external bleeding
The initial management of patients with undifferentiated
hemorrhagic of Anaesthesiol- and maintain SBP < 90 mmHg shock needs a clear timeline with a pragmatic approach
shock ogy 2023 [4, 6] (higher target in patients with focusing on both the urgency of the interventions as well
brain trauma) until bleeding is as the feasibility of such interventions within given time
controlled frames. For example, emergency physicians, intensivists,
Hypovolemic No guidelines and anesthesiologists who care for patients with undif-
non-hemorrhagic identified
shock
ferentiated shock face the challenge of balancing two
Obstructive European Society No specific timeline guidelines
key priorities: (1) the need to treat the underlying cause
(pulmonary of Cardiology except of urgent echocardiog- of shock (etiological management); and (2) the need to
embolism) 2019 [5] raphy to detect RV failure for rapidly restore organ perfusion (pathophysiological man-
possible reperfusion. agement) [8]. Scientific evidence underlines the time
Obstructive (car- No guidelines sensitivity of the latter intervention (restoration of vital
diac tamponade) identified
and systemic organ perfusion). Indeed, every additional
Obstruc- No guidelines
minute of hypotension is associated with poor outcomes
tive (tension identified
pneumothorax) [9]. Moreover, certain causes of shock may require lon-
MAP: mean arterial pressure, RV: right ventricle, SBP: systolic arterial blood ger time to achieve diagnosis, hence it would be harm-
pressure ful to delay hemodynamic support until the etiology has

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