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
Catalogue details

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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    Intramedullary Administration In certain cases, the intravenous route may be impracticable, owing to the severity of the injuries, or because of venous spasm. This is particularly true in the case of burns. Fluids may then be administered into the marrow cavity. In adults, and in children over 2 years, the sternum is the most convenient site ; in infants the tibia may be used. If necessary, the needle may be inserted through a burned area. Instead of the usual administering needle, the Salah sternal puncture needle, or a shortened administering or taking needle, may be used. If nothing else is available, a sawn off lumbar puncture needle is effective. Sternum The patient should, if possible, lie flat in bed, the head being supported with one pillow. The manubrium is chosen for preference, but, if necessary, the first or second part of the sternum may be used. After cleaning the skin, infiltrate it, the subcutaneous tissues and the periosteum, over a point in the midline, with local anaesthetic, using about 2 c.c. Taking the needle in the right hand, insert it vertically with a slight rotary movement through the infiltrated area into the marrow cavity. It should be remembered that,in young adults considerable force may be required; the risk of going through into the mediastinum is slight, since the passage of the needle through the bone into the marrow cavity is usually readily appreciated even by an onlooker. There is a sudden “ give,’’ and often an actual ‘‘scrunch”’ is heard, as the: cavity is reached. If a Salah needle is used, as soon as the cavity is entered the stilette is withdrawn, a syringe attached, and in order to determine that the marrow cavity has been entered, a small amount of marrow tissue is withdrawn by suction. In some individuals it may be necessary to apply repeated suction with the syringe before marrow is obtained. The sensation of entering the cavity is so characteristic that failure to withdraw marrow should not prevent the continuation of the transfusion. By means of the syringe, the cavity of the needle should be filled with saline or citrate solution, and a connection with the rest of the administering unit, prepared as for an ordinary intravenous transfusion, may then be made. If the rate of flow is too slow, pressure may be exerted by means of a Higginson’s syringe or other pressure device. As much as 14 litres of fluid have been given by this route over a period of days to one patient. If the flow stops, it may be restarted by shifting the position of the needle without withdrawing it, or by disconnecting the administering unit and first aspirating a little marrow or else inserting some sterile citrate solution by means of a syringe. Tibia Splint the leg with a straight splint applied to the outer aspect of the leg, and keep in position by ties from the foot to mid-tibia and from the lower to the upper thigh. The site of puncture is the antero-medial surface of the tibia at the level of the tibial tubercle, which can be easily felt even in the youngest infant. The skin is cleaned with soap and water, and an antiseptic, and a local anaesthetic injected into the skin, subcutaneous tissues and periosteum. The puncture needle is then inserted at right angles to the plane of the antero-medial surface of the tibia, as nearly as possible half-way between the anterior and medial borders of the bone. The needle should be inserted distally, i.e. away from the epiphyseal line, but a needle absolutely vertical in all planes should miss the epiphyseal line. The soft bone of an infant is punctured easily, and gives the feeling of stale cheese ; no marked “ give”’ is noted when the marrow cavity is entered. Entry is usually attained about one-eighth to three-sixteenths of an inch below the periosteum, and can be proved by the aspiration of marrow. The procedure is then the same as for sternal puncture, The transfusion tends to be slow at first, and to increase in rate spontaneously after 5 to 10 minutes. The transfusion, therefore, in infants usually has to be slowed from time to time, rather than quickened as in the adult.
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