Chapter II
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=Treatment.=--The treatment of shock consists essentially in measures directed toward raising the lowered blood pressure. At the outset reaction should not be established too quickly, lest it be succeeded by overaction, with attendant disasters in the shape of secondary hemorrhage, etc. Patients should not be expected to swallow nor act as they would under other circumstances. They should not drink strong liquors, for the irritating fluid may escape into the larynx and induce coughing, which might prove fatal. The same is true of inhalations of strong volatile stimulants, like ammonia. These measures, therefore, should all be resorted to with great care and discretion. Warm, stimulating drinks, if they can be swallowed, are useful; and whisky, brandy, etc., should be given dilute and warm rather than strong and cold. External heat is advisable, and can be supplied by immersing the patient in a bath-tub of warm water, care being taken to keep the face out of the water. When this is not at hand, bottles and other receptacles for warm water may be used, but with caution, since too much heat has been the cause of serious burns.
Numerous drugs have been recommended in the treatment of shock. There are but two or three which are worthy of confidence. Crile, of Cleveland, subjected a large number of animals to tests in regard to the effect of various drugs in influencing blood pressure. He found, for example, that alcohol apparently produces more depression, and in deep shock is dangerous. Nitroglycerin and amyl nitrite seem to increase shock and lower pressure. Digitalis may produce a temporary rise in pressure, but in considerable doses impairs or arrests respiration, and it seemed to him that cases of severe shock treated with it did not live as long as the control animals. Strychnine has been one of the main reliances in these conditions. Crile found that if enough were given to cause increased excitability of the spinal cord it raised the blood pressure, while small doses had little or no effect. Pressure was raised by doses large enough to produce convulsions; repeated smaller doses had little effect, tending rather to increase shock.
These were the experimental results in the treatment of shock, and are to be distinguished from what may be done with the same drugs in the way of fortification and preparation as against shock. Thus strychnine always exalts susceptibility of the cord of the medulla and digitalis may temporarily supplement its use; together they may help to sustain pressure or to fortify as against depressing agencies. They are like whip or spur to a jaded horse.
Morphine alone, or in combination with ether as a general anesthetic, reduces susceptibility to shock, and appears to be an equalizer of pressure and a tranquillizer of an excited heart. Nitroglycerin and the nitrites usually fail to raise or even sustain pressure. _Saline infusion_ and _adrenalin_ are the _reliable and efficient means_ to be used in combating shock and collapse; _they always raise blood pressure_, and the latter is the most powerful of all known vasomotor constrictors. Adrenalin always produces rise of blood pressure, even after cocainization of the medulla and cord or destruction of the medulla, division of the splanchnics, or arrest of the heart by powerful electrical currents (2300 volts, alternating). Even after death by decapitation and an interval of fifteen minutes, adrenalin salt solution thrown into the veins causes a rise of blood pressure. If this be combined with artificial respiration and rhythmic pressure over the heart, resuscitation is possible in most extreme cases. In one case, reported by Crile, a human heart which had stopped beating for nine minutes was made to resume its pulsation for thirty-two minutes. From all this it will appear that the heart stimulants, so called, have a very limited applicability.
Crile further experimented by raising the atmospheric pressure surrounding the animal, and found that blood pressure was somewhat exalted. The reverse was also found to be true. When he so arranged his experiment that an animal inhaled air under increased pressure he found the tendency was rather to impairment of heart action, blocking the circulation and reducing pressure. Changing the experiment and causing the animal to breathe air at normal pressure while the body was under increased atmospheric pressure, blood pressure was notably raised, but respiration became labored and the heart’s action impaired. After death the heart and the pulmonary vessels were found engorged.
This has its practical interest because it concerns not alone the general treatment of shock, but the management of those cases where the thorax must be opened, as in the surgery of the heart, the lungs, the esophagus, etc., and the mechanical devices recently suggested for maintaining differences of atmospheric pressure, and preventing a traumatic collapse of the lungs.
These experiments also suggested the so-called “_pneumatic suit_” devised by Dr. Crile, which is in effect a double-layered garment of rubber cloth. The patient is enveloped in the suit, which can be inflated with an ordinary bicycle pump, so that pressure is made upon the surface of the body, and at the same time evenly distributed. By such pressure accumulation of blood in the venous reservoirs is prevented, and the emptying of the arteries, especially those in the brain, is prevented. This is a more perfect and ideal application of the idea underlying the practice of _bandaging the extremities_ or raising them, in extreme conditions of shock; the former requires an elaborate and expensive outfit, while for the latter purpose cotton bandages or rubber may suffice. The latter, however, must be used with great caution lest pressure be overdone. When the bandages are removed they should be taken off slowly, and from one limb at a time, lest the change be too abrupt.
Two other expedients are of the greatest value in conditions of this kind; the first is _artificial respiration_. This cannot be carried out, as is done on experimental animals, in a well-furnished laboratory, by opening the trachea and making connection with a pump; it must be effected by the usual methods, coupled with the aid afforded by the improved Fell apparatus. If oxygen can be administered at the same time it will enhance the effect.
The second expedient is _rhythmic pressure_ made over the lower part of the thorax, or beneath the ribs, by which is produced a stimulus to contraction of the heart. This may be made slowly at first, but may approximate a rate corresponding to a slow pulse.
The temptation is to use the adrenalin solution too strong or in too large doses. It may be administered in doses of 4 or 5 minims in a small syringeful of salt solution, but when the symptoms are profound and the case urgent, 300 to 500 Cc. of sterilized salt solution, containing the same amount, should be injected beneath the skin into the subcutaneous cellular tissue about the shoulder-blade, the buttock, behind the breast, or into a convenient vein. Much larger amounts, even up to 1000 Cc., may be used, but the adrenalin should never be mixed until just before using it, as it is quickly oxidized and changed, and should be used in the freshest possible condition. With salt solution containing 1 to 50,000 of adrenalin and continuously administered, Crile has kept a decapitated dog alive for over ten hours--that is, the heart continued its action. One may agree with him, then, in the statement that “_control of blood pressure is the control of life itself_.”
Mathews, after a careful study of the osmotic behavior of blood plasma and saline solutions, has shown that the ordinary salt solution, which has been usually made in proportion of 6 to 1000, is not the best which can be used for purposes of saline infusion. Many observers have added potassium and calcium salts to such a mixture, the latter, especially, because of its property of increasing the coagulability of the blood.
The following mixture meets the indications for what may be called the “balanced” physiological solution: Sodium chloride 0.9, potassium chloride 0.03, calcium chloride 0.02, water 100.[6]
[6] To the fluid for hypodermoclysis (salt solution) there may be added a proportion of grape sugar, by which much is gained of true nutritive value, which may be enhanced by the addition of pure pepsin peptone free from albumose. Thus if every four hours there be injected beneath the skin 100 Cc. of water containing 2 grams each of grape sugar and table salt to 4 grams of pepsin peptone, the necessity for further nourishment may be almost obviated, at least for a period of two or three days at a time; as for instance when intense nausea of severe peritonitis prevents the ingestion of anything possessing food value. Credé recommends for the same purpose a preparation containing soluble albumin in the strength of 95 per cent., with traces of iron and salt. This preparation is called by him kalodol, and much resembles blood albumin, which is why it is so easily assimilated. According to Credé, four injections of kalodol a day will suffice for ordinary needs.
It must not be forgotten that indiscriminate resort to intravenous infusion may do great harm. It is a minor procedure which requires skill. When the lungs are congested from the irritating effect of ether, and the right heart is embarrassed, a too sudden flushing with saline solution may further embarrass it or even check its activity. So with a patient in the Trendelenburg posture, the intestines are crowded up against the diaphragm and its natural downward play impeded, though the brain is better supplied with blood in this than in any other position.
Much may be done in the way of _prevention_ when shock can be foreseen. This includes the general fortification of the patient by overcoming any auto-intoxication which may have been previously noticed, by improving elimination, and by stimulating the heart’s action with strychnine, digitalis, cactus, etc. Atropine is especially a stimulant to the respiratory centres.
Once the operation is begun, and remembering that the depressing influences which tend to reduce blood pressure are transmitted through the afferent nerves, we may take advantage of Crile’s suggestions and temporarily paralyze them, by exposing them and injecting directly into the nerve trunks two or three drops of 1 per cent. cocaine solution. This should be done before division of the main trunks and at a point above the line of section. It is possible during an amputation, by taking a little extra time and pains, to “block off,” as it is called, the nerves in this way and prevent their conveying any depressing sensation. At other times, as in operations on the mouth, and especially the larynx, cocaine solution may be used locally, as by the spray, and the same effect produced. Cocaine seems to be a protoplasmatic poison which inhibits nerve action.
In the description of the treatment of shock there has been little reference made to the result of loss of blood as such. In cases where this has already occurred, or cannot be prevented, it should be atoned for by the infusion of saline solution, either by intravenous introduction or by hypodermoclysis, _i. e._, its injection into the loose connective tissues in various parts of the body. While a special apparatus has been devised for this purpose, a sterile fountain syringe with an ordinary aspirator needle will be found to be sufficient for nearly all purposes.
The erethistic, or extremely restless type of shock, may be profitably treated by small doses of morphine given subcutaneously.
The _question of immediate operation or delay_ should be carefully considered. Shock is often alleviated by prompt removal of mutilated limbs or parts whose fragments, while still connected with the trunk, seem rather to perpetuate the condition, especially if the principal nerve trunks are cocainized. In serious cases intravenous infusion should be practised.
After commencing with the anesthetic, while scrubbing and cleansing the field of operation it is advisable to scrub an arm where it may be necessary to expose a vein, or the skin at several points, where a needle may be entered, so that there may be no delay for this purpose should infusion or hypodermoclysis be suddenly required.
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