A new approach to the control of shock

Abstract

THE solution to the problem*of shock may have been wathin our grasp ever since sympathetic blockade first occurred as a corollary to spinal analgesia. Labat's monograph in 1931 cites the use of spinal analgesia without a pressor drug to combat shock resullang from crushing mlury (1). Since the c~rculatory system is dependent cinefly on gravity in lngh subm achnoid block, anaemia of the brain is prevented by the Trendelenburg posation. In ttus position It ~S both neurologically and anatormcally impossible for the solution to diffuse to the respiratory centres ( 1 ) We can produce autonomic block w~th "total spinal," with Hexamethonium compounds and Arfonad| or wath Chlorpromazme The latter are easy to use, readily transportable and can be admlnlsttered without further moving of the patient. We have done a large volume of chnical 'work with "total spinal" induced hypotenslon, using the techmque introduced by Grl~ths and Gilhes (2, 3 ). The spinal reduced hypotenslon ,s capable of bloclang the sympathetics, establishing analgesia, giving anuscle relaxation and control of haemorrhage by positioning, all in a single manoeuvre The Hexamethomum technique calls for a relaxant and an anaesthetic drug ~f reparative smgery is contemplated (25,26,27). Chlorpromazme acts as an autonomic blockade, a hypothalamlc depressant, and 1s an excellent pre-mechcation agent (4, 5, 6, 7)Immediately following injury the alarm goes out to the clrettlatory system to preserve the blood volume Anatomically one th_mks of the vascular tree as a single system Physiologically It lmmechately b~comes two systems (10). a "peripheral" pool winch can be spared, ~md a "central" pool, winch must be preserved. After injury, a preferentaal blood shift takes place, and the pei~pheral blood pressure drops, as measured over the brachial artery by cuff and manometer When a total sympathetic block is induced m man the peripheral blood pressure also drops, but for a wholly dzffeient reason That is why one speaks of induced hypotenslon rather than ganghomc block, although this is only the most spectacular effect Tbas drop in peripheral pres:sure is lust as capable of kflhng the palaent as trauma or actual blood loss because the body no longer has the ability to decide where the blood is most needed We must make the decision and can then maintain an adequate blood supply to the vital organs by a complete head-down'tilt of the body in a 15-degree Trendelenburg position. If this is not possible, raising the legs above the level of the trunk with the head t~lat will suffice. In the unconscious intact human with a ganghomc block to the first thoracic nerve root, placed in a 15-degree Trendelenburg position, the systolic pressure is read by oscillation between 90 and 120 ram. Hg. This appea:rs to be irrespective of previous hypertension or hypotenslon, as we have observed in 680 cases given spinal analgesia without a pressor drug to the level of the first