The treatment of wound shock / (instructions produced by the Medical Research Council Committees on Traumatic Shock and on Blood Transfusion, in co-operation with the Army Medical Service).

Date:
1944
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Licence: Public Domain Mark

Credit: The treatment of wound shock / (instructions produced by the Medical Research Council Committees on Traumatic Shock and on Blood Transfusion, in co-operation with the Army Medical Service). Source: Wellcome Collection.

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    General Measures Rest.—Rest in bed or on stretchers is an obvious essential ; except in cases of head and chest injuries, the foot of the bed should be elevated 9 inches, as this measure will often raise the blood pressure by 5-15 mm. Hg. While the patient is awaiting evacuation, the foot end of the stretcher should be similarly elevated. Warmth—Warmth has an important place inthe treatment of patients who are chilled by exposure to cold and wet. Sucha patient should have his wet and dirty clothes removed. He should be clad in warm pyjamas and placed in a bed warmed by hot-water bottles, and be given hot drinks. More elaborate heating arrangements are unnecessary, and it is always undesirable to over-heat the patient. Enough cover and warmth for comfort are now thought to be the optimum conditions. Vigorous heating beyond this point is harmful, probably because the vasodilatation in the skin accentuates the blood lack in other tissues, due to the existing oligaemia. If a tourniquet must be kept in place, or if the blood supply to a limb is seriously diminished by pressure bandages, the parts should be kept cool. Cooling decreases the rate of metabolism of the tissues, and reduces both the nutritional needs and the production of metabolites that may be injurious. Cooling must not be so severe as to risk frostbite. The appropriate environ- mental temperature is not below 50° F. If the atmospheric temperature is at this level, simple exposure of the limb will suffice ; if the air‘is colder, the limb must be protected once it has cooled to the desired degree. Stretcher-bearers should be familiar with the proper use of waterproof sheets and blankets, as described in R.A.M.C. Training Pamphlet No. 1 (1943). When ' blankets are not available, protective clothing should be placed between the canvas of the stretcher and the patient, rather than on top of the patient. Reltef of Pain, Restlessness and Apprehension.—Patients may be afraid of further injury by bombing or other enemy action, and much can be done to reassure them by the efficiency and bearing of the attendants. In addition, morphine may be required. Morphine is often necessary for the relief of pain: 4 grain given intravenously where possible is most satisfactory, for when the condition of the circulation is poor, absorption from the subcutaneous tissues is slow and unreliable. It will often be found that pain is not complained of until the blood pressure is recovering with transfusion, and the injection may then be made conveniently into the rubber tubing of the transfusion set, and thereby washed into the circulation. As far as possible, morphine should be reserved for pain and apprehension. Its routine use is undesirable, and there have undoubtedly been many cases of morphine poisoning from its too liberal use in the past. Slow absorption from the cold skin may lead the unwary into further subcutaneous administration, the large total dose being subsequently carried into the circulation as the latter improves. The practice of giving 4 grain subcutaneously soon after wounding is still far too frequent in the field. After resuscitation, morphine may, of course, be given subcutaneously. Dehydration.—Dehydration may on _ occasion eucitte ton* shock”: All wounded subjects can be assumed to be suffering from some degree of depletion of extravascular fluid reserves. All casualties, escept those who are unconscious or who are suffering from abdominal wounds, should. be given copious and repeated drinks; generally they are thirsty. If vomiting is troublesome, sips are better. Special orderlies or nurses should be detailed to encourage and assist patients to drink. Any delivery device which allows water to be swallowed with a minimum of effort and movement wil] be of value. Warm sweetened tea or coffee should be given whenever possible. If necessary, the rectal route may be used to supplement oral administration; warm,