MAX H.

WEIL
Current Concepts on the Management of Shock
Print ISSN: 0009-7322. Online ISSN: 1524-4539
Copyright 1957 American Heart Association, Inc. All rights reserved.
75231
is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX Circulation
doi: 10.1161/01.CIR.16.6.1097
1957;16:1097-1105 Circulation.
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CLINICAL PROGRESS
Cu r r e n t Co n c e p t s o n t h e Man age me n t o f Sh o c k
By \IAx H . W EIL, MU . D . , PH . D .
SH OCK i s a d e s c r i p t i v e t e r m u s e d b y c l i n i -
c i an s t o d e n o t e a s yn d r o me t h at i s c h ar -
ac t e r i z e d b y p r o t r ac t e d p r o s t r at i o n an d
h yp o t e n s i o n an d u s u al l y i s ac c o mp an i e d b y
p al l o r , c o l d n e s s an d mo i s t n e s s o f t h e s k i n ,
c o l l ap s e o f s u p e r f i c i al v e i n s , al t e r at i o n o f me n t al
s t at u s , an d s u p p r e s s i o n o f t h e f o r mat i o n o f
u r i n e . A v o l u mi n o u s l i t e r at u r e r e f l e c t s i n t e n s e
d i s agr e e me n t o v e r t h e me an i n g an d t h e s i g-
n i f i c an c e o f t h e t e r m. MIo s t o f t h i s , h o w e v e r ,
r e s u l t s f r o m t h e u s e o f a s i n gl e n ame t o d e -
s c r i b e a c o n d i t i o n p r o d u c e d b y man y u n r e l at e d
c au s e s ; o c c as i o n f o r d i s agr e e me n t d i s ap p e ar s i f
t h e t e r m s h o c k i s u s e d w i t h i n t h e l i mi t s o f i t s
d e f i n i t i o n n ame l y, t o i n d i c at e t h e c l i n i c al
s t at e o f t h e p at i e n t w i t h o u t s p e c i f i c i mp l i c at i o n
as t o t h e u n d e r l yi n g c au s e .
" V as o mo t o r c o l l ap s e " an d " p e r i p h e r al v as -
c u l ar f ai l u r e " ar e f r e q u e n t l y e mp l o ye d b y
au t h o r s t o c i r c u mv e n t t h e d i s p u t e ar o u s e d b y
u s e o f t h e t e r m s h o c k . T h e s e n ame s ar e s u b j e c t
t o t h e s ame mi s u n d e r s t an d i n g an d ad d h e mo -
d yn ami c i mp l i c at i o n s t h at may b e mi s l e ad i n g.
Sh o c k s i mp l y r e f e r s t o t h e p r e s e n t i n g s i gn s o f
t h e p at i e n t , an d w i t h i n t h i s l i mi t t h e t e r m i s
v al i d an d me an i n gf u l .
H EMOD YNAMIC MIECH AN- ISMS IN SH OCK
In o r d e r t o gi v e a p at i e n t t h e ad v an t age o f
r at i o n al an d e f f e c t i v e t r e at me n t , i t i s e s s e n t i al
t o d e t e r mi n e i n e ac h c as e t h e s p e c i f i c c au s e o f
s h o c k . Y e t , at t h e s ame t i me , i t i s p o s s i b l e
an d h e l p f u l t o t h i n k o f a ge n e r al me c h an i s m
t h at i s i n v o l v e d . T o i l l u s t r at e t h e r e l at i o n s h i p
b e t w e e n a s p e c i f i c me c h an i s m an d t h e ge n e r al
Re ad at t h e Co n t i n u at i o n Co u r s e o n Re c e n t Ad -
v an c e s i n In t e r n al Me d i c i n e at t h e U n i v e r s i t y o f
Mi n n e s o t a, Mar c h 1 5 , 1 9 5 7 .
Fr o m t h e Se c t i o n o f Ph ys i o l o gyr , Mayo Fo u n d a-
t i o n , Ro c h e s t e r , Mi n n . T h e Mayo Fo u n d at i o n i s
p ar t
o f t h e Gr ad u at e Sc h o o l o f T h e U n i v e r s i t y o f
Mi n n e s o t a.
me c h an i s m, t h e r e s u l t s o f s o me r e c e n t i n v e s t i -
gat i v e s t u d i e s may b e c i t e d .
Fr o m Ov e r w h e l mi n g In f e c t i o n . T h e c au s e o f
s h o c k t h at o c c u r s d u r i n g o v e r w h e l mi n g i n f e c -
t i o n s d u e t o gr am- n e gat i v e b ac t e r i a h as b e e n
s t u d i e d i n l ab o r at o r y d o gs af t e r i n t r av e n o u s
i n j e c t i o n o f e n d o t o xi n s d e r i v e d f r o m Br u c e l l a
me l i t e n s i s o r EYs c h e r i c h i a c o l i . 1 - 3 W i t h i n 1 mi n u t e
f o l l o w i n g s u c h an i n j e c t i o n , ar t e r i al p r e s s u r e
f al l s s h ar p l y an d p o r t al v e n o u s p r e s s u r e i n -
c r e as e s p r o n o u n c e d l y. T h e l i v e r an d i n t e s t i n e s
b e c o me e n go r ge d w i t h b l o o d , s u gge s t i n g t h at
t h e f al l i n ar t e r i al p r e s s u r e an d t h e e l e v at i o n
o f t h e p o r t al v e n o u s p r e s s u r e r e s u l t f r o m p o o l -
i n g t h e b l o o d i n t h e s p l an c h n i c v e n o u s b e d .
D i r e c t me as u r e me n t s o f t h e c h an ge o f w e i gh t
o f t h e l i v e r an d i n t e s t i n e s i n d i c at e t h at l ar ge
amo u n t s o f b l o o d ar e p o o l e d i n t h e s e o r gan s .
Me as u r e me n t o f v e n o u s f l o w i n t o t h e h e ar t
d e mo n s t r at e s t h at t h e v o l u me o f b l o o d r e -
t u r n e d t o t h e h e ar t i s c o r r e s p o n d i n gl y d e -
c r e as e d . W h e n t h e c ar d i ac o u t p u t i s
d e t e r mi n e d , a q u an t i t at i v e l y s i mi l ar d e c l i n e i s
o b s e r v e d w h i c h i s t h e d i r e c t c au s e o f t h e s h ar p
f al l i n ar t e r i al p r e s s u r e . A s e c o n d ar y an d l at e
f e at u r e i n v o l v e s e l e c t r o c ar d i o gr ap h i c e v i d e n c e
o f myo c ar d i al i s c h e mi a. T h i s i s at t r i b u t e d t o
r e d u c t i o n i n b l o o d f l o w t h r o u gh t h e c o r o n ar y
ar t e r i e s b e c au s e o f t h e s h ar p d e c l i n e i n ar t e r i al
p r e s s u r e . T h e r e s u l t i n g r e d u c t i o n i n c o r o n ar y
f l o w , i f s u f f i c i e n t l y p r o l o n ge d , l e ad s t o d e f e c t i v e
myo c ar d i al c o n t r ac t i l i t y. T h u s c ar d i ac o u t p u t
d e c l i n e s f u r t h e r an d ar t e r i al p r e s s u r e f al l s e v e n
l o w e r . T h e s e h e mo d yn ami c f e at u r e s , b e gi n n i n g
w i t h t h e r e d u c t i o n i n e f f e c t i v e v o l u me o f c i r -
c u l at i n g b l o o d c au s e d b y p o o l i n g, ar e p r e -
s e n t e d s c h e mat i c al l y i n f i gu r e 1 . It i s ap p ar e n t
t h at 2 v i c i o u s c i r c l e s ar e e s t ab l i s h e d . On e i s
r e l at e d t o p o o l i n g an d t h e o t h e r t o c o r o n ar y
i n s u f f i c i e n c y. T h e s e f ac t o r s may i n t e n s i f y an d
p r o p agat e t h e s t at e o f s h o c k l o n g af t e r t h e
i n i t i at i n g d i s t u r b an c e h as t ak e n p l ac e .
Ci c r t l at i o n , V o l u me X 1 V I, D e c e mb e r 1 9 5 7
1 0 9 7
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CLINICAL PROGRESS
Bl o o d V o l u me 5 I Re s i s t an c e Co r d i o c Ou t p u t
~ ~ ~ ~ ~ ~ Bl o o d
Ef f e c t i v e Co r o n o r y Fl o w
Bl o o d V o l u me !
4
~ ~ ~ ~ ~ ~ ~ Myo c o r d i o l Pu mp
V o s c u l o r Be d 1 + t V e n o u s Re t u r n
6'
FIG. 1 . A mo d e l o f t h e c i r c u l at o r y s ys t e m i l l u s -
t r at i n g t h e r e l at i o n s h i p o f c l i n i c al c o n d i t i o n s t o
h e mo d yn ami c d i s t u r b an c e s t h at may l e ad t o s h o c k .
T h e 6n u mb e r s i n t h i s f i gu r e r e f e r t o t h e 6c au s e s o f
s h o c k l i s t e d i n t ab l e 1 .
Fr o m Ot h e r Cau s e s . T h e s c h e ma s e r v e s
e q u al l y w e l l as a ge n e r al o u t l i n e o f t h e me c h -
an i s m i n v o l v e d i n t h e d e v e l o p me n t o f s h o c k
f r o m v ar i o u s c au s e s . T ab l e 1 p r o v i d e s a t e n t a-
t i v e c l as s i f i c at i o n o f t h e v ar i o u s t yp e s o f s h o c k
e n c o u n t e r e d i n c l i n i c al p r ac t i c e . Si x d i f f e r e n t
me c h an i s ms ar e l i s t e d , an d e ac h o f t h e m may
b e r e l at e d t o t h e ge n e r al me c h an i s m i n d i c at e d
i n t h e f i gu r e .
H yp o v o l e mi a r e s u l t s f r o m h e mo r r h age , d e h y-
d r at i o n , l o s s o f p r o t e i n , o r c ap i l l ar y l e ak age .
W h e n o n e t h i r d o f t o t al b l o o d f l u i d i s l o s t , a
c r i t i c al p o i n t i s r e ac h e d at w h i c h t h e v o l u me o f
b l o o d i s n o l o n ge r s u f f i c i e n t t o f i l l t h e v as c u l ar
b e d . 4 T h e v e n o u s r e t u r n an d c ar d i ac o u t p u t ar e
r e d u c e d t o a l e v e l w h e r e c o mp e n s at o r y v as o -
c o n s t r i c t i o n i s i n s u f f i c i e n t t o mai n t ai n t h e
ar t e r i al p r e s s u r e .
Car d i ac f ai l u r e may b e c au s e d b y myo c ar d i al
i n f ar c t i o n o r c ar d i ac d ys r h yt h mi a. Fai l u r e o f
t h e c ar d i ac p u mp r e d u c e s t h e c ar d i ac o u t p u t ,
s o me t i me s s e v e r e l y e n o u gh t o p r o d u c e s h o c k . 5 '6
H yp e r s e n s i t i v i t y an d , p ar t i c u l ar l y, an ap h y-
l ac t i c r e ac t i o n s ar e n o t c o mp l e t e l y u n d e r s t o o d .
Pr e s e n t e v i d e n c e , w h i c h i s al s o b as e d o n s t u d i e s
i n d o gs , i n d i c at e s t h at s h o c k as s o c i at e d w i t h
t h e s e p h e n o me n a i s mai n l y t h e r e s u l t o f s u d d e n
c o n s t r i c t i o n o f s mal l h e p at i c v e i n s f o l l o w e d b y
p o o l i n g o f l ar ge q u an t i t i e s o f b l o o d i n t h e
p o r t al v e n o u s b e d , w h i c h l e ad s t o s u d d e n
r e d u c t i o n i n v e n o u s r e t u r n an d c ar d i ac o u t -
p u t . 7 T h u s t h e i n i t i al h e mo d yn ami c d i s t u r b -
an c e i s s i mi l ar t o t h at o f s h o c k as s o c i at e d w i t h
b ac t e r e mi a, al r e ad y d e s c r i b e d i n s o me d e t ai l .
In t h e ab s e n c e o f n o r mal v as o c o n s t r i c t i v e
T ABLE 1 . - Cl as s i f i c at i o n o f Sp e c i f i c Cau s e s o f Sh o c k
1 . H yp o v o l e mi a
H e mo r r h age , d e h yd r at i o n , l o s s o f p r o t e i n
2 . Car d i ac f ai l u r e
Myo c ar d i al i n f ar c t i o n , c ar d i ac d ys r h yt h mi a
3 . H yp e r s e n s i t i v i t y
An ap h yl axi s , r e ac t i o n t o d r u gs
4 . Bac t e r e mi a
Bac t e r i al t o xi n s ( e n d o t o xi n )
5 . Ne u r o ge n i c f ac t o r s
V as o mo t o r p ar al ys i s , s p i n al s h o c k , gan gl i o n i c
b l o c k ad e
6. Imp e d i me n t t o b l o o d f l o w
Pu l mo n ar y e mb o l i s m, d i s s e c t i n g an e u r ys m
i mp u l s e s t h at f o l l o w t r an s e c t i o n o f t h e s p i n al
c o r d , s ymp at h e c t o my, ad mi n i s t r at i o n o f c e r -
t ai n an e s t h e t i c age n t s , o r d r u g- i n d u c e d gan -
gl i o n i c b l o c k ad e , n o r mal n e u r o ge n i c c o n t r o l o f
t h e c al i b e r o f b l o o d v e s s e l s i s l o s t . V as o d i l at a-
t i o n may i n t c r e as e t h e c ap ac i t y o f t h e p e r i p h e r al
v as c u l ar b e d , an d e s p e c i al l y t h e v e n o u s b e d ,
t o s u c h an e xt e n t t h at t h e v o l u me o f b l o o d i s
i n ad e q u at e t o f i l l t h i s l ar ge s p ac e . T h e c o n d i t i o n
r e s u l t s i n c r i t i c al r e d u c t i o n o f t h e v e n o u s r e t u r n
an d c ar d i ac o u t p u t . Co n t r ar y t o e ar l i e r c o n -
c e p t s , l o s s o f v e n o r n o t o r t o n e r at h e r t h an
d e c r e as e o f ar t e r i o l ar r e s i s t an c e ap p e ar s t o b e
t h e maj o r d e f e c t i n t h i s t yp e o f s h o c k . "
Fi n al l y, t h e r e i s a t yp e o f s h o c k t h at i s
b r o u gh t ab o u t b y p h ys i c al o b s t r u c t i o n o f a
mai n t h o r o u gh f ar e , s o t h at t h e t o t al b l o o d f l o w
i s i n ad e q u at e t o mai n t ai n c i r c u l at i o n , an d
t h e r e f o r e v e n o u s r e t u r n an d c ar d i ac o u t p u t
ar e i n s u f f i c i e n t . T h e b as i c me c h an i s m i s an al -
o go u s t o t h e c h ai n o f e f f e c t s f r o m s t e p p i n g o n
a gar d e n h o s e . Pu l mo n ar y e mb o l i s m an d d i s -
s e c t i n g an e u r ys m ar e e xamp l e s .
NX ASOPRi ESSOR AGENT S
T h e v al u e o f v as o p r e s s o r age n t s i n t h e t r e at -
me n t o f s o me p at i e n t s w i t h s h o c k h as b e e n
w i d e l y r e c o gn i z e d . Imp o r t an t c o n s i d e r at i o n s
ar e t h e s e l e c t i o n o f a s u i t ab l e p r e s s o r ami n e
an d t h e d e f i n i t i o n o f t h e s p e c i f i c c i r c u ms t an c e s
i n w h i c h t h i s t yp e o f d r u g i s i n d i c at e d .
T h e mo s t p o t e n t v as o p r e s s o r age n t s p r e s -
e n t l y av ai l ab l e ar e n o r e p i n e p h r i n e , o r l e N ar t e -
r e n o l ( Le v o p h e d ) , an d me t ar ami n o l ( Ar ami n e ) .
Le s s p o t e n t d r u gs s u c h as me t h o xami i n e
( V as o xyl ) , p h e n yl e p h r i n e ( Ne o s yn e p h r i n e )
an d
1 0 9 8
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CU RRENT CONCEPT S ON MANAGEMENT OF SH OCK
me p h e n t e r mi n e ( W yami n e ) , w h i c h ar e av ai l -
ab l e f o r t h e t r e at me n t o f mo r e t r an s i e n t f o r ms
o f h yp o t e n s i o n , w v i l l n o t b e d i s c u s s e d h e r e .
Ef f e c t s o f Le v ar t e r e n o l an d Me t ar ami n o l .
Le v ar t e r e n o l an d me t ar ami n o l ar e u s e f u l al l i e s
i n t h e t r e at me n t o f s h o c k c au s e d b y myo c ar d i al
i n f ar c t i o n , b ac t e r e mi a, o r h yp e r s e n s i t i v i t y
r e ac t i o n s , an d u s u al l y p r o v i d e a f av o r ab l e
e f f e c t agai n s t n e u r o ge n i c s h o c k . T h e b e n e f i c i al
e f f e c t s i n c ar d i o ge n i c s h o c k ar e r e l at e d o n l y i n
p ar t t o t h e i mp r o v e me n t o f c o r o n ar y b l o o d f l o w
t h at f o l l o w s e l e v at i o n o f t h e s ys t e mi c b l o o d
p r e s s u r e . Re c e n t s t u d i e s h av e s h o w n t h at b o t h
t h e s e d r u gs h av e a d i r e c t b e n e f i c i al e f f e c t o n
t h e myo c ar d i u m, i n c r e as i n g t h e c o n t r ac t i l i t y
o f t h e myo c ar d i al f i b e r s an d t h e r e b y i n c r e as i n g
c ar d i ac o u t p u t . 9 '1 0 In e xp e r i me n t s w i t h b ac -
t e r e mi c s h o c k i n d o gs , t h e s e d r u gs h av e b e e n
s h o w n t o r e me d y p o o l i n g b y r e d u c i n g o b s t r u c -
t i o n t o o u t f l o w f r o m t h e s p l an c h n i c Xv e n o u s
c h an n e l s i n w h i c h t h e l ar ge q u an t i t i e s o f b l o o d
ar e p o o l e d . 'Si mi l ar c o n s i d e r at i o n s p e r t ai n t o
t h e u s e o f p r e s s o r ami n e s i n t h e t r e at me n t o f
s h o c k c au s e d b y h yp e r s e n s i t i v i t y t o d r u gs o r
f o r e i gn p r o t e i n s . Fo r i mme d i at e t r e at me n t o f
ac u t e an ap h yl ac t i c s h o c k , w h i c h s o me t i me s i s
ac c o mp an i e d b y b r o n c h o c o n s t r i c t i o n an d i n -
c r e as e d r e s i s t an c e t o t h e f l o w o f b l o o d t h r o u gh
t h e l u n gs , e p i n e p h r i n e r at h e r t h an l e v ar t e r e n o l
o r me t ar ami n o l ap p e ar s t o b e t h e age n t o f
c h o i c e . Fo r n e u r o ge n i c h yp o t e n s i o n , l e v ar t e -
r e n o l an d me t ar ami n o l ar e p ar t i c u l ar l y ap t an d
h e l p f u l , as t h e y p r o d u c e v as o c o n s t r i c t i o n b y
s u b s t i t u t i n g t h e s ymp at h o mi me t i c
ac t i o n o f
t h e s e d r u gs f o r t h e v as o c o n s t r i c t i v e ac t i o n
t h at i s n o r mal l y s u p p l i e d b y t h e s ymp at h e t i c
n e r v o u s s ys t e m.
Se l d o m In d i c at e d i n H yp o v o l e mi a
an d Ci r c u t -
l at o r y Bl o c k . T h e u s e o f v as o p r e s s o r d r u gs
i n
t h e t r e at me n t o f h yp o v o l e mi c
s h o c k i s o n l y
o c c as i o n al l y j u s t i f i e d .
T r e at me n t i n t h e s e
p at i e n t s r e q u i r e s r e p l ac e me n t o f t h e f l u i d t h at
i s l o s t . Bl o o d , p l as ma, an d e l e c t r o l yt i c
f l u i d s
ar e u s e d i n amo u n t s t h at ar e c al c u l at e d t o
r e - e s t ab l i s h n o r mal v o l u me s an d c o n c e n t r at i o n s
i n t h e i n t r av as c u l ar s p ac e .
T h e c l i n i c i an w i l l
b e gu i d e d i n h i s s e l e c t i o n o f f l u i d s
b y
t h e h i s t o r y
o f f l u i d l o s s an d al s o b y l ab o r at o r y s t u d y
o f
t h e r e l at i v e v o l u me s an d c o n c e n t r at i o n s o f
b l o o d c e l l s , p l as ma,
an d e l e c t r o l yt e s .
In
s p i t e
o f i t s an t i ge n i c i t y, d e xt r an p o s s e s s e s mo s t o f
t h e at t r i b u t e s o f an i d e al p l as ma e xp an d e r . 2 '
U s e d as a 6p e r c e n t s o l u t i o n i n i s o t o n i c s al i n e s
i t i s an e xp e d i e n t me as u r e f o r t r e at me n t o f
h e mo r r h agi c s h o c k w h e n w h o l e b l o o d o r p l as ma
i s n o t i mme d i at e l y av ai l ab l e . If s h o c k p e r s i s t s
af t e r r e p l ac e me n t o f f l u i d s , s e c o n d ar y p o o l i n g
o f b l o o d an d myo c ar d i al f ai l u r e may b e r e s p o n i -
s i b l e i n t h e v i c i o u s c i r c l e s al r e ad y d e s c r i b e d . 3 ,
1 4
T h i s s i t u at i o n , w h i c h i s r e f e r r e d t o as " i r r e -
v e r s i b l e s h o c k " b y s o me au t h o r s , i s n o t u n l i k e
t h at w h i c h e xi s t s i n b ac t e r e mi c s h o c k , a f e at u r e
t h at h as b e e n s t r e s s e d b y Fi n e an d h i s c o -
w o r k e r s . '5 In s u c h i n s t an c e s , v as o p r e s s o r age n t s
may b e h e l p f u l .
In t h e s h o c k t h at r e s u l t s f r o m p h ys i c al
i mp e d i me n t t o b l o o d f l o w , d r u gs t h at p r o d u c e
ad d i t i o n al v as o c o n i s t r i c t i o n ar e n o t o r d i n ar i l y
i n d i c at e d .
Sp e c i al Ad v an t age s o f Me t ar ami n o l . Bo t h
l e v ar t e r e n o l an d me t ar ami n o l d i s p l ay t h e v as o -
c o n s t r i c t i v e e f f e c t s o f e p i n e p h r i i n e , b u t n e i t h e r
p r o d u c e s c ar d i ac ac c e l e r at i o n , s t i mu l at i o n o f
t h e c e n t r al n e r v o u s s ys t e m, o r d e p r e s s i o n o f
t h e ap p e t i t e . '6Le v ar t e r e n o l h as t h e u n f o r t u n at e
d i s ad v an t age o f i n j u r i n g t i s s u e s at t h e s i t e o f
i n j e c t i o n . D e e p u l c e r at i o n i n v o l v i n g t h e s k i n l
an d s u b c u t an e o u s t i s s u e s h as b e e n a d i s t u r b i n g
c o mp l i c at i o n o f i t s u s e an d
o n o c c as i o n h as
r e q u i r e d s u b s e q u e n t s k i n gr af t i n g an d e v e n i
amp u t at i o n . '7
1 S
In a r e c e n t r e p o r t , Cl o s e an d
Ko r y1 9 h av e i n d i c at e d t h at l o c al i n f i l t r at i o n o f
ad r e i n e r gi c b l o c k i n g age n t s s u c h as t o l az o l i n i e
h yd r o c h l o r i d e ( IPr i s c o l i n e ) o r p h e n t o l ami n e
h yd r o c h l o r i d e ( Re gi t i n e ) i s an e f f e c t i v e me an s
o f p r e v e n t i n g t h i s c o mp l i c at i o n . Ot h e r u i i d e -
s i r ab l e f e at u r e s o f t h e p r o l o n ge d
u s e o f l e v ar t e -
r e n o l i n c l u d e t h e t r an s i e n c y o f i t s ac t i o n , w h i c h
n e c e s s i t at e s ad mi n i s t r at i o n u i d e r c o n s t an t
n u r s i n g s u p e r v i s i o n , an d t h e n e e d f o r l ar ge
q u an t i t i e s o f f l u i d v e h i c l e w h e n t h i s may b e
u n d e s i r ab l e b e c au s e o f i n ad e q u at e e xc r e t i o n o f
u r i n e . MIe t ar ami n i o l , o n t h e o t h e r h an d , c au s e s
n o l o c al i n j u r y t o t i s s u e . It may b e i l l j e (
t e d b y
i n t r av e n o u s , i n t r amu s c u l ar , o r s u b c u t an e o u s
r o u t e s w i t h o u t ad d i t i o n al f l u i d v e h i c l e , an d i t
man i f e s t s a p r o l o n ge d p e r i o d o f ac t i o n
. '6
In l
ad d i t i o n , me t ar ami n o l r e p o r t e d l y p r o d u c e s
l e s s c o n s t r i c t i o n o f t h e r e n al v e s s e l s t h an
l e v ar t e r e n o l f o r a d o s e t h at p r o d u c e s
an e q u al
1 0 9 '3
by guest on April 24, 2014 http://circ.ahajournals.org/ Downloaded from
CLINICAL PROGRESS
p r e s s o r r e s p o n s e . 2 0 T h i s may b e o f p ar t i c u l ar
ad v an t age i n p at i e n t s i n w h o m r e n al c o mp l i c a-
t i o n s o f s h o c k c au s e t h e o u t p u t o f u r i n e t o b e
i n ad e q u at e , e v e n t h o u gh v as o p r e s s o r age n t s
ar e u s e d t o mai n t ai n b l o o d p r e s s u r e at a s at i s -
f ac t o r y l e v e l .
Fo l l o w i n g i n t r av e n o u s ad mi n i s t r at i o n , t h e
p r e s s o r e f f e c t o f me t ar ami n o l b e c o me s man i f e s t
i n 1 t o 2 mi n u t e s , i s maxi mal i n 5 mi n u t e s , an d
p e r s i s t s f o r 2 0 t o 2 5 mi n u t e s . Af t e r i n t r a-
mu s c u l ar o r s u b c u t an e o u s ad mi n i s t r at i o n , a
p r e s s o r r e s p o n s e i s o b s e r v ab l e i n 5 t o 1 2 mi n u t e s
an d maxi mal at ap p r o xi mat e l y 3 0 mi n u t e s .
T h e ac t i o n o f t h e i n t r amu s c u l ar d o s e p e r s i s t s
f o r o n l y 5 0 mi n u t e s , b u t t h e ac t i o n o f t h e s u b -
c u t an e o u s d o s e c o n t i n u e s f o r 9 0 mi n u t e s . Fo r
t h i s r e as o n , t h e s u b c u t an e o u s r o u t e h as b e e n
f av o r e d f o r t h e t r e at me n t o f p at i e n t s w h e n e v e r
p o s s i b l e . '6'
2 1
Ad mi n i s t r at i o n o f Me t ar ami n o l . T h e t r e at -
me n t o f a p at i e n t w i t h p r o f o u n d s h o c k may b e
s t ar t e d w i t h a s i n gl e i n t r av e n o u s i n j e c t i o n o f
3 t o 1 0 mg. o f me t ar ami n o l , w h i c h u s u al l y
p r o d u c e s a p r o mp t e l e v at i o n o f b l o o d p r e s s u r e .
W h e n t h e p e r i p h e r al v e i n s ar e c o l l ap s e d , t h e
age n t may b e i n j e c t e d d i r e c t l y i n t o t h e f e mo r al
v e i n , w h e r e u p o n t h e ar t e r i al p r e s s u r e i s e l e -
v at e d an d t h e p e r i p h e r al v e i n s b e c o me mo r e
n o r mal l y d i s t e n d e d . An i n t r av e n o u s i n f u s i o n
c an b e s t ar t e d t h e n w i t h o u t d i f f i c u l t y, an d t h u s
a t i me - c o n s u mi n g an d t r au mat i c c u t - d o w n p r o -
c e d u r e i s av o i d e d . In mo s t p at i e n t s , t h e b l o o d
p r e s s u r e i s w e l l mai n t ai n e d b y t h e s u b c u t an e o u s
ad mi n i s t r at i o n o f 3 t o 2 5 mg. o f me t ar ami n o l
w i t h i n j e c t i o n r e p e at e d e v e r y Ad t o 2 h o u r s .
In p at i e n t s w h o r e s p o n d p o o r l y, a c o n t i n u o u s
i n t r av e n o u s i n f u s i o n o f me t ar ami n o l i n a
d o s age u p t o 5 0 0 mg. p e r L. may b e ad mi n i s -
t e r e d . Af t e r s at i s f ac t o r y c o n t r o l h as b e e n
ac h i e v e d , t h e s u b c u t an e o u s r o u t e i s p r e f e r ab l e .
W i t h i mp r o v e me n t , t h e p r e s s o r r e s p o n s e t o
me t ar ami n o l b e c o me s mo r e i n t e n s e an d r e -
q u i r e s r e d u c t i o n i n d o s age . My c o l l e agu e s an d
I h av e f o u n d i t mo r e p r ac t i c al t o r e d u c e t h e
amo u n t o f i n j e c t i o n s r at h e r t h an t h e i r f r e -
q u e n c y u n t i l u s e o f t h e age n t i s e n t i r e l y d i s -
c o n t i n u e d .
Re v i e w o f Co n s i d e r at i o n s . T h e u s e o f v as o -
p r e s s o r age n t s h as b e e n c r i t i c i z e d o n t h e gr o u n d
t h at t h e y r e d u c e b l o o d f l o w b y e xc e s s i v e v as o -
c o n s t r i c t i o n . 2 2 Br u n s o n , Ec k man , an d Camp -
b e l l 2 3 h av e r e p o r t e d a h i gh c o r r e l at i o n b e t w e e n
t h e ad mi n i s t r at i o n o f s ymp at h o mi me t i c ami n e s
t o p at i e n t s w i t h s h o c k an d t h e f i n d i n g o f
h e p at i c n e c r o s i s at p o s t mo r t e m e xami n at i o n .
W h e n t h e s e d r u gs ar e gi v e n t o n o r mo t e n s i v e
an i mal s , v as c u l ar i n j u r y an d e xt e n s i v e t i s s u e
d amage may r e s u l t . 2 4 Ne v e r t h e l e s s , t h e r e i s
n o w ab u n d an t e v i d e n c e t h at t h e c o r r e c t u s e
o f t h e s e d r u gs i n s e l e c t e d p at i e n t s w i t h p r o -
f o u n d s h o c k i s n o t ac c o mp an i e d b y u n d u e r i s k
o f d amage t o v i t al o r gan s . In t h e p r e s e n c e o f
s e v e r e h yp o t e n s i o n an d t h e ab s e n c e o f h yp o -
v o l e mi a o r p h ys i c al o b s t r u c t i o n t o b l o o d f l o w ,
a p o i n t i s r e ac h e d b e yo n d w h i c h ad mi n i s t r a-
t i o n o f t h e s e age n t s r e s u l t s i n an i n c r e as e r at h e r
t h an a r e d u c t i o n i n b l o o d f l o w t o v i t al o r gan s . 2 5
INFLU ENCE OF Ac ID OSIS ON V ASOPRESSOR
RESPONSE
Cl i n i c al o b s e r v at i o n s h av e i n d i c at e d r e -
p e at e d l y t h at p at i e n t s w i t h c o - e xi s t e n t s h o c k
an d ac i d o s i s r e s p o n d p o o r l y t o v as o p r e s s o r
age n t s . In t h i s c o n n e c t i o n Bu r ge t an d V i s s c h e r 2 6
n o t e d i n 1 9 2 7 t h at t h e r e s p o n s e o f t h e v as c u l ar
s ys t e m o f t h e p i t h e d c at c o u l d b e al t e r e d b y
c h an gi n g t h e p H o f t h e b l o o d , an d t h at t h e
r e s p o n s e t o e p i n e p h r i n e p r o gr e s s i v e l y i n c r e as e d
as t h e p H w as i n c r e as e d f r o m 6. 9 t o 8 . 0 . Mo r e
r e c e n t l y, Page an d Ol ms t e d 2 7 d e mo n s t r at e d
t h at t h e p r e s s o r ac t i o n o f e p i n e p h r i n e an d
l e v ar t e r e n o l w as d i mi n i s h e d i n d o gs w i t h
r e s p i r at o r y ac i d o s i s . T h e s e f ac t s s u gge s t e d
t h at s i mi l ar c o n s i d e r at i o n s w o u l d p e r t ai n t o
p at i e n t s w i t h s h o c k an d ac i d o s i s .
Fi n d i n gs
i n D o gs . T o t e s t t h i s i d e a, e p i -
n e p h r i n e , l e v ar t e r e n o l , an d me t ar ami n o l w e r e
ad mi n i s t e r e d t o d o gs u n d e r c o n d i t i o n s o f
r e s p i r at o r y ac i d o s i s p r o d u c e d b y t h e i n h al at i o n
o f 3 0 p e r c e n t c ar b o n d i o xi d e , an d t h e i r r e ac -
t i o n s w e r e c o n t r as t e d t o t h e r e s p o n s e o b t ai n e d
w h e n t h e p H w as n o r mal . T h e p r e s s u r e an d
p H o f ar t e r i al b l o o d w e r e r e c o r d e d , an d an
e l e c t r o c ar d i o gr am w as o b t ai n e d . It w as f o u n d
t h at i n t h e p r e s e n c e o f ac i d o s i s t h e p r e s s o r
r e s p o n s e s t o e ac h o f t h e s ymp at h o mi me t i c
d r u gs w as s o me w h at d i mi n i s h e d . V e n t r i c u l ar
r h yt h m w as n o t af f e c t e d d u r i n g ac i d o s i s ,
al t h o u gh mar k e d d ys r h yt h mi a
f o l l o w e d ad mi n -
i s t r at i o n o f t h e s e age n t s t o d o gs i n t h e c o n t r o l
1 1 0 0
by guest on April 24, 2014 http://circ.ahajournals.org/ Downloaded from
CU RRENT CONCEPT S ON MIANAGEMIE1 J NT
OF SH OCK
s t at e . I'r e s s o r r e s p o n s e s an d c ar d i ac d ys r h yt h -
mi as p r o d u c e d b y e p i n e p h r i n e , n o r e p i n e p h r i n e ,
an d me t ar ami n o l w e r e al s o d i mi n i s h e d i n a
s i mi l ar gr o u p o f t e s t an i mal s u n d e r c o n d i t i o n s
o f me t ab o l i c ac i d o s i s p r o d u c e d b y i n t r av e n o u s
i n f u s i o n o f a d i l u t e s o l u t i o n o f h yd r o c h l o r i c
ac i d . 2 8
T h e s e c o i n c i d e n t f i n d i n gs w i t h r e s p e c t t o
c ar d i ac r h yt h m w e r e i n t e r e s t i n g i n t h e ms e l v e s ,
an d e s p e c i al l y s o i n r e l at i o n t o t h e r e c e n t s t u d -
i e s b y Be l l e t , W as s e r man , an d Br o d y. 2 9 T h e s e
au t h o r s r e p o r t e d t h at mo l ar s o l u t i o n o f s o d i u m
l ac t at e i n c r e as e s t h e v e n t r i c u l ar r at e i n p a-
t i e n t s w i t h St o k e s - Ad ams d i s e as e an d p r o p o s e d
i t f o r t h e t r e at me n t o f t h i s c o n d i t i o n . It s e e ms
l i k e l y t h at t h e e f f e c t i v e n e s s o f mo l ar s o l u t i o n s
o f l ac t at e i s d u e , at l e as t i n p ar t , t o t h e i n -
c r e as e d ac t i v i t y o f e n d o ge n o u s e p i n e p h r i n e
an d n o r e p i n e p h r i n e w h i c h i s b r o u gh t ab o u t b y
e l e v at i o n o f b l o o d p H .
In o r d e r t o s e p ar at e t h e e f f e c t o n c ar d i ac
r h yt h m f r o m v as o p r e s s o r e f f e c t , t h e s e s ame
age n t s w e r e ad mi n i s t e r e d t o d o gs s u b j e c t e d
t o t o t al c ar d i ac b yp as s . Af t e r t h e h e ar t w as
e xc l u d e d f r o m t h e c i r c u l at i o n , p r e s s o r r e s p o n s e s
u n d e r c o n d i t i o n s o f r e s p i r at o r y ac i d o s i s w e r e
u n i f o r ml y mu c h l e s s t h an t h o s e o b t ai n e d i n t h e
s ame an i mal af t e r t h e p H w as r e t u r n e d t o o r
n e ar n o r mal l e v e l s . 2 8
Ef f e c t o f Mo l ar Lac t at e i n Pat i e n t s . It w as
d e c i d e d t h e n t o s t u d y at t h e b e d s i d e t h e v al u e
o f c o r r e c t i n g t h e ac i d o s i s b y i n f u s i o n o f a mo l ar
s o l u t i o n o f l ac t at e . Si x p at i e n t s w h o h ad c o -
e xi s t i n g b ac t e r e mi c s h o c k an d ac i d o s i s w e r e
t r e at e d . Al l s i x h ad r e c e i v e d l ar ge d o s e s o f
l e v ar t e r e n o l o r me t ar ami n o l b e f o r e t h e s t u d i e s ,
b u t i n s p i t e o f t h i s t h e me an ar t e r i al b l o o d
p r e s s u r e w as r ar e l y mo r e t h an 4 0 t o 60 mm. H g.
T h e p H o f ar t e r i al b l o o d p r i o r t o t r e at me n t
w as as l o w as 7 . 0 6; f o l l o w i n g ad mi n i s t r at i o n
o f 3 0 0 t o 1 , 0 0 0 ml . o f mo l ar s o l u t i o n o f s o d i u m
l ac t at e , t h e p H w as e l e v at e d t o a maxi mal
v al u e o f 7 . 5 1 . D u r i n g an d af t e r t h e i n t r av e n o u s
ad mi n i s t r at i o n o f s o d i u m l ac t at e t h e b l o o d
p r e s s u r e r e t u r n e d t o n e ar t h e n o r mal r an ge
e v e n t h o u gh t h e i n f u s i o n o f v as o p r e s s o r age n t s
w as d e c r e as e d o r d i s c o n t i n u e d . No n e o f t h e
p at i e n t s s u r v i v e d f o r mo r e t h an 7 d ays i n s p i t e
o f t h i s t r e at me n t . H o w e v e r , i t w as s i gn i f i c an t
t h at r e s p o n s e
t o t h e v as o p r e s s o r age n t s
w as
r e s t o r e d b y s o d i u m l ac t at e af t e r t h e u s u al
me as u r e s h ad f ai l e d . 3 0
In v i e w o f t h e l i mi t e d ac c u mu l at i o n o f c l i n i -
c al e xp e r i e n c e o n t h e u s e o f s o d i u m l ac t at e i n
t h e t r e at me n t o f s h o c k , c o n c l u s i o n s r e gar d i n g
i t s v al u e an d t h e p o s s i b l e d an ge r s i n v o l v e d i n
i t s u s e mu s t aw ai t ad d i t i o n al o b s e r v at i o n s .
Fo r t h e p r e s e n t , i t s e e ms w o r t h y o f t r i al w h e n
al l e l s e h as f ai l e d . Mo l ar s o l u t i o n o f s o d i u m
l ac t at e i s ad mi n i s t e r e d b y c o n t i n u o u s i n t r a-
v e n o u s i n f u s i o n at a r at e o f 5 ml . p e r Kg. o f
b o d y w e i gh t p e r h o u r u n t i l a p H o f ap p r o xi -
mat e l y 7 . 5 0 i s ac h i e v e d . T h e av e r age t o t al
d o s e i n p at i e n t s w i t h mo d e r at e l y s e v e r e ac i d o s i s
i s b e l i e v e d t o b e ap p r o xi mat e l y 1 0 ml . p e r Kg.
o f b o d y w e i gh t .
AD ) REN OCORT ICAL H ORMONES
In s i f f i c i e n c y an d Sh o c k . T h e e as e w i t h w h i c h
s h o c k may b e p r e c i p i t at e d i l l ad r e n al e c t o mi z e d
an i mal s i s w e l l d o c u me n t e d . T h e i r e xt r e me
s u s c e p t i b i l i t y i s d i mi n i s h e d b u t n o t r e mo v e d
w h e n t h e s e an i mal s ar e s u s t ai n e d t h r o u gh
t r e at me n t w i t h s al i n e . W h e n t h e y ar e o p t i -
mal l y t r e at e d w i t h ad r e n o c o r t i c al h o r mo n e s ,
n o r mal s u s c e p t i b i l i t y i s r e - e s t ab l i s h e d . 3 'Si mi -
l ar c o n s i d e r at i o n s p e r t ai n t o h u man p at i e n t s
w i t h ad r e n o c o r t i c al i n s u f f i c i e n c y. T h u s t h e
ap p e ar an c e o f s h o c k d u r i n g al l ac u t e i l l n e s s o r
f o l l o w i n g a mi n o r i n j u r y may b e t h e p r e s e n t i n g
s i gn o f p r e v i o u s l y u n r e c o gn i z e d Ad d i s o n 's
d i s e as e . T h e ad mi n i s t r at i o n o f ad r e n al s t e r o i d s
i s s p e c i f i c t r e at me n t . Cl i n i c i an s r e c e n t l y h av e
b e c o me aw ar e o f ad r e n o c o r t i c al i n s u f f i c i e n c y i n
p at i e n t s w h o h av e b e e n t r e at e d w i t h l e n gt h y
c o u r s e s o f c o r t i s o n e o r o n e o f i t s an al o gs . Fat al
c i r c u l at o r y f ai l u r e h as f o l l o w e d e v e n mi n o r
s u r gi c al p r o c e d u r e s o n s u c h p at i e n t s
w h e n
s t e r o i d t h e r ap y w as w i t h h e l d i n t h e p o s t -
o p e r at i v e p e r i o d . 3 2 - 3 4 Sp e c i al p r e c au t i o n s
ar e
n e c e s s ar y t o as s u r e p r e o p e r at i v e
an d p o s t o p e r a-
t i v e ad mi n i s t r at i o n o f t h e s e h o r mo n e s ,
an d
s u c h p at i e n t s s h o u l d b e c ar e f u l l y o b s e r v e d an d
p r o mp t l y t r e at e d i f e v i d e n c e o f ac u t e ad r e n al
i n s u f f i c i e n c y b e c o me s man i f e s t .
T h e s e f ac t s n o t w i t h s t an d i n g, t h e r e i s n o c l e ar
e v i d e n c e t h at ad r e n al i n s u f f i c i e n c y u s u al l y
i s
i n v o l v e d i n t h e c au s at i o n o r p r o gr e s s i o n
o f
s h o c k . Re c e n t c l i n i c al r e p o r t s
h av e c r e at e d
d o u b t t h at ad r e n al i n s u f f i c i e n c y
d u e t o h e mo r -
1 1 0 1
by guest on April 24, 2014 http://circ.ahajournals.org/ Downloaded from
CLINICAL PROGRESS
r h age i n t o t h e ad r e n al gl an d s i s a maj o r f ac t o r
i n s h o c k as s o c i at e d w i t h ac u t e me n i n go c o c c al
s e p t i c e mi a ( W at e r h o u s e - Fr i d e r i c h s e n s yn -
d r o me ) . " , 3 6
U s e i n T r e at me n t o f Sh o c k . T h e c o r t i c o s t e r o i d
d r u gs n e v e r t h e l e s s h av e a d e f i n i t e p l ac e i n t h e
t r e at me n t o f c e r t ai n p at i e n t s w i t h s h o c k . An
i mp o r t an t t h e r ap e u t i c ac t i o n o f t h e s e h o r mo n e s
i s t h e s u p p r e s s i o n o f i n f l ammat i o n , an d p ar -
t i c u l ar l y t h e s u p p r e s s i o n o f t h e s ys t e mi c r e ac -
t i o n t o i n f l ammat i o n . Fo r t h i s r e as o n t h e y
h av e b e e n e mp l o ye d i n t h e t r e at me n t o f p a-
t i e n t s w i t h b ac t e r e mi c s h o c k o r s h o c k r e l at e d
t o a s e v e r e h yp e r s e n s i t i v i t y r e ac t i o n , an d , o n
o c c as i o n , s u r gi c al p at i e n t s w i t h s h o c k r e l at e d
t o e xt e n s i v e t i s s u e i n j u r y. 3 7 " 3 By s u p p r e s s i o n
o f t h e man i f e s t at i o n s o f i n f l ammat i o n i n a
c r i t i c al l y i l l p at i e n t w i t h h i gh f e v e r , r ap i d
p u l s e , an d h yp o t e n s i o n , a p e r i o d o f gr ac e i s
p r o v i d e d d u r i n g w h i c h n o r mal c i r c u l at o r y
ad j u s t me n t may b e r e - e s t ab l i s h e d an d s p e c i f i c
t r e at me n t i n s t i t u t e d . T h e s e c o n s i d e r at i o n s
ap p l y o n l y t o i n s t an c e s o f s h o c k i n w h i c h
i n f l ammat i o n p l ays an i mp o r t an t r o l e .
Cl i n i c al an d e xp e r i me n t al e v i d e n c e i n d i c at e s
t h at c o r t i c o s t e r o i d s may p o t e n t i at e t h e ac t i o n
o f v as o p r e s s o r age n t s . 4 0 4 2 T h e s t e r o i d d r u gs
h av e b e e n u s e d w i t h s o me s u c c e s s t o r e - e s t ab -
l i s h o r i n c r e as e r e s p o n s e t o v as o p r e s s o r age n t s
i n p at i e n t s w i t h s h o c k .
Sp i n k 3 'h as r e v i e w e d t h e i n d i c at i o n s f o r an d
t h e d an ge r s i n v o l v e d i n t h e u s e o f c o r t i c o t r o p i n
( ACT H ) an d t h e ad r e n al s t e r o i d s i n t h e s e
c r i t i c al l y i l l p at i e n t s . H e h as e mp h as i z e d t h at
t h e s t e r o i d d r u gs h av e p r o f o u n d me t ab o l i c
e f f e c t s t h at may b e av o i d e d b y gi v i n g t h e m
f o r o n l y b r i e f p e r i o d s . Al t h o u gh ACT H an d
t h e ad r e n al c o r t i c al h o r mo n e s aggr av at e i n f e c -
t i o n , t h e p r e s e n c e o f i n f e c t i o n s h o u l d n o t d e t e r
f r o m t h e i r u s e , p r o v i d e d t h at ap p r o p r i at e an t i -
b i o t i c t h e r ap y i s gi v e n c o n c o mi t an t l y.
Fo r t h e t r e at me n t o f t h e s e p at i e n t s an i n i t i al
i n t r av e n o u s i n j e c t i o n o f 5 0 t o 1 0 0 mg. o f h yd r o -
c o r t i s o n e s o d i u m s u c c i n at e ( So l u - c o r t e f ) i s
ad v i s e d . MIai n t e n an c e t h e r ap y f o r a p e r i o d o f
f r o m
1 2 t o 5 d ays i s p r o v i d e d b y t h e c o n t i n u o u s
i n t r av e n o u s i n f u s i o n o f h yd r o c o r t i s o n e ( f r e e
al c o h o l ) i n p r o p e r d i l u t i o n t o s u p p l y
t o 1 2
mg.
p e r h o u r .
IND ICAT IONS FOR U SE OF D IGIT ALIS
GLYCOSID ES AND AT ROPI'N- E
Be f o r e v as o p r e s s o r age n t s b e c ame av ai l ab l e ,
d i gi t al i s w as r at h e r o f t e n e mp l o ye d i n t r e at -
me n t o f h yp o t e n s i v e s t at e s . It i s ap p ar e n t n o w ,
h o w e v e r , t h at d i gi t al i s i s o n l y o c c as i o n al l y o f
v al u e an d t h at i t s h o u l d b e r e s e r v e d f o r t h o s e
i n s t an c e s i n w h i c h s p e c i f i c i n d i c at i o n e xi s t s -
n ame l y, c o n ge s t i v e h e ar t f ai l u r e an d c ar d i ac
d ys r h yt h mi a o f s u p r av e n t r i c u l ar o r i gi n . It s
u s e at o t h e r t i me s may c au s e f u r t h e r d e c l i n e
i n c ar d i ac o u t p u t an d t h e r e b y i n t e n s i f y s h o c k .
On o c c as i o n , s e v e r e h yp o t e n s i o n may b e
c au s e d i n p ar t b y e xc e s s i v e v agal ac t i v i t y.
T h i s s t at e ac t u al l y may b e w o r s e n e d b y t h e
u s e o f v as o p r e s s o r age n t s , f o r t h e y e xc i t e
i n c r e as e d v agal ac t i v i t y w i t h c ar d i ac s l o w i n g. '6
El e c t r o c ar d i o gr ap h i c s t u d y o f p at i e n t s i n t h i s
c o n d i t i o n may i n d i c at e b r ad ye ar d i a w i t h l ac k
o f i mp u l s e f o r mat i o n at t h e s i n u s n o d e . T h e
ad mi n i s t r at i o n o f 0 . 6mg. ( . 0 1 gr . ) o f at r o p i n e
s u l f at e h as p r o v i d e d gr at i f yi n g i mp r o v e me n t
i n p u l s e r at e an d ar t e r i al p r e s s u r e i n s u c h
i n s t an c e s . Fo r t u n at e l y o n l y t h e v ago t o n i c an d
n o t t h e v as o p r e s s o r ac t i o n o f l e v ar t e r e n o l an d
me t ar ami n o l i s i n h i b i t e d af t e r s u c h u s e o f
at r o p i n e . T h e e f f e c t i v e n e s s o f t h e p r e s s o r
ami n e s i s t h e r e f o r e n o t h amp e r e d . In s e l e c t e d
i n s t an c e s at r o p i n e c an b e o f r e mar k ab l e b e n e f i t
f o r t h e t r e at me n t o f p at i e n t s i n s h o c k .
PRESENT ST AT U S OF CH LORPROMAZ INE,
H EPARIN, H YPOT H ERMIA, AN!)
" H EAD - D OW N" POST U RE
Ch l o r p r o maz i n e h yd r o c h l o r i d e i s t h e p r i n c i -
p al i n gr e d i e n t o f Lab o r i t 's l yt i c c o c k t ai l , 4 3
w h i c h h as b e e n w i d e l y d i s c u s s e d , p ar t i c u l ar l y
i n p o p u l ar magaz i n e s an d n e w s p ap e r s , as t h e
" h i b e r n at i o n " t r e at me n t o f s h o c k . 1 Pr e t r e at -
me n t w i t h c h l o r p r o maz i n e r e d u c e s t h e mo r -
t al i t y o f an i mal s f o l l o w i n g h e mo r r h age o r
i n j e c t i o n o f e n d o t o xi n . 4 4 '
4 1
D e s p i t e i t s e xt e n -
s i v e u s e i n Fr an c e an d In d o c h i n a an d s o me
e n t h u s i as t i c r e p o r t s f r o m Eu r o p e an c e n t e r s ,
c o n v i n c i n g p r o o f o f i t s c l i n i c al v al u e i n t h e
t r e at me n t o f p at i e n t s w i t h s h o c k i s l ac k i n g.
Be c au s e c h l o r p r o maz i n e i t s e l f may mar k e d l y
l o w e r ar t e r i al p r e s s u r e t h r o u gh a gan gl i o n i c -
b l o c k i n g e f f e c t , an d b e c au s e t h i s d r u g r e d u c e s
1 1 0 2
by guest on April 24, 2014 http://circ.ahajournals.org/ Downloaded from
CU RRENT CONCEPT S ON MANAGEMIENT OF SH OCK
t h e s u b s e q u e n t e f f e c t i v e n e s s o f v as o p r e s s o r
age n t s , i t s u s e c an n o t b e r e c o mme n d e d at
p r e s e n t .
On t h e b as i s o f s t u d i e s i n d o gs , d e v e l o p me n t
o f " i r r e v e r s i b i l i t y" i n s h o c k h as b e e n at t r i b u t e d
t o t h e f o r mat i o n o f mi n u t e t h r o mb i t h at i m-
p e d e b l o o d f l o w t h r o u gh v i t al c ap i l l ar y b e d s ,
e s p e c i al l y i n t h e l u n g. 4 6In c r e as e d f i b r i n o l yt i c
ac t i v i t y o f p l as ma i s o b s e r v e d d u r i n g s h o c k an d
i s i n t e r p r e t e d b y s o me w o r k e r s as a c o mp e n s a-
t o r y r e s p o n s e t o s u c h i n t r av as c u l ar c l o t t i n g. 4 7
T h e i n c r e as e d c o agu l ab i l i t y may b e d u e t o t h e
r e l e as e o f t h r o mb o p l as t i c age n t s i n t h e b l o o d
s t r e am f r o m i n j u r e d an d i s c h e mi c t i s s u e .
Exp e r i me n t al p r o o f o f t h e s e e xp l an at i o n s i s
i n c o mp l e t e . Gr i f f i t h 4 8 s t at e d t h at h e p ar i n i z a-
t i o n o f p at i e n t s w i t h s h o c k i n c r e as e s t h e i r
c h an c e f o r s u r v i v al , p r e s u mab l y b y t h e p r e v e n -
t i o n o f t h r o mb o s i s i n s mal l v e s s e l s . As ye t ,
h o w e v e r , t h e v al u e o f t h i s mo d e o f t r e at me n t
i s u n c o n f i r me d .
Fav o r ab l e r e s u l t s h av e b e e n ac h i e v e d w i t h
t h e u s e o f h yp o t h e r mi a i n t h e t r e at me n t o f
s h o c k . T h e p r i n c i p l e o f i t s u s e i n t h i s s i t u at i o n
i s s i mi l ar t o t h at o f i t s u s e i n c ar d i ac s u r ge r y,
n ame l y t o mi n i mi z e t h e i n j u r y c au s e d b y
i n ad e q u at e b l o o d f l o w t o v i t al o r gan s . H yp o -
t h e r mi a h as b e e n r e p o r t e d t o i n c r e as e t h e
s u r v i v al o f d o gs s u b j e c t e d t o h e mo r r h agi c
s h o c k . 4 4 In t r e at me n t o f 3 p at i e n t s w i t h b ac -
t e r e mi c s h o c k an d h i gh f e v e r my c o l l e agu e s
at t h e U n i v e r s i t y o f Mi n n e s o t a H o s p i t al s an d
I h av e o b s e r v e d t h e u s e o f a r e f r i ge r at o r b l an k e t
as d e s c r i b e d b y Le w i s , Ri n g, an d Al d e n ; 4 9 i t
w as o u r i mp r e s s i o n t h at t h e c l i n i c al c o u r s e o f
t h e s e p at i e n t s w as f av o r ab l y i n f l u e n c e d ,
al t h o u gh o n l y 1 o f t h e m r e c o v e r e d . T h i s mo d e
o f t r e at me n t may h av e p r o mi s e b u t al s o
r e q u i r e s f u r t h e r e v al u at i o n .
T h e h e ad - d o w n o r s o - c al l e d T r e n d e l e n b u r g's
p o s i t i o n i s r o u t i n e l y u s e d i n man y h o s p i t al s
f o r p at i e n t s w i t h h yp o t e n s i o n .
T h i s
p o s t u r e
may b e e f f e c t i v e i n r e s t o r i n g c o n s c i o u s n e s s
af t e r a s yn c o p al e p i s o d e o r d u r i n g t h e i n i t i al
p e r i o d o f s h o c k t h at f o l l o w s l o s s o f b l o o d o r
v as o mo t o r p ar al ys i s . H o w e v e r , t h e r e i s s o me
d o u b t o f i t s u s e f u l n e s s f o r p r o l o n ge d p e r i o d s
af t e r mo r e s p e c i f i c t r e at me n t i s s t ar t e d . Em-
p i r i c al o b s e r v at i o n s i n p at i e n t s w i t h p r o t r ac t e d
h yp o t e n s i o n s u gge s t t h at t h e h e ad - d o w n p o s i -
t i o n may d e l ay r e c o v e r y, p r e s u mab l y b y p r e -
v e n t i n g r e t u r n o f n o r mal p o s t u r al v as o mo t o r
r e f l e xe s . 5 0 , 5 1 Fo r t h i s r e as o n as w e l l as t h e
c o mf o r t o f t h e p at i e n t an d t h e c o n v e n i e n c e o f
h i s n u r s i n g c ar e , a 1 5 - d e gr e e t o 3 0 - d e gr e e
h e ad - u p p o s i t i o n ap p e ar s t o b e mu c h mo r e
s at i s f ac t o r y, w i t h r e l i an c e o n mo r e s p e c i f i c
me as u r e s t o mai n t ai n b l o o d f l o w t o t h e b r ai n
an d o t h e r v i t al o r gan s .
SU MMARY
In t h e h an d l i n g o f a p at i e n t w i t h s h o c k i t i s
e s s e n t i al t o i d e n t i f y t h e u n d e r l yi n g c au s e i n
o r d e r t o p l an r at i o n al t r e at me n t . On t h e b as i s
o f i n f o r mat i o n p r e s e n t l y av ai l ab l e , t h e s p e c i f i c
c au s e s o f s h o c k h av e b e e n c l as s i f i e d i n t o 6
gr o u p s : h yp o v o l e mi a, c ar d i ac f ai l u r e , b ac -
t e r e mi a, h yp e r s e n s i t i v i t y, n e u r o ge n i c f ac t o r s ,
an d o b s t r u c t i o n t o b l o o d f l o w . T r e at me n t w as
d i s c u s s e d w i t h r e f e r e n c e t o t h e s e gr o u p s .
V as o p r e s s o r age n t s ar e h e l p f u l i n mo s t
i n s t an c e s o f s h o c k r e l at e d t o c ar d i ac f ai l u r e ,
b ac t e r e mi a, an d h yp e r s e n s i t i v i t y. T h e y u s u al l y
ar e c o n t r ai n d i c at e d i n s h o c k d u e t o v as c u l ar
o b s t r u c t i o n an d i n h yp o v o l e mi c s h o c k u n t i l
o p t i mal r e p l ac e me n t o f f l u i d h as b e e n ac h i e v e d .
Re c e n t s t u d i e s h av e i n d i c at e d t h at me t a-
r ami n o l may b e t h e p r e s s o r ami n e o f c h o i c e
b e c au s e i t i s t h e r ap e u t i c al l y e f f e c t i v e , s i mp l e
t o ad mi n i s t e r , w i t h o u t r i s k o f i n j u r y t o s k i n
an d s u b c u t an e o u s t i s s u e s , an d av ai l ab l e f o r
i n j e c t i o n w i t h o u t ad d i t i o n al f l u i d ( t h u s e s p e -
c i al l y s u i t ab l e f o r p at i e n t s w i t h r e n al f ai l u r e ) .
Ri go r o u s at t e n t i o n t o t h e f l u i d an d e l e c t r o -
l yt e s t at e i s o f s p e c i al i mp o r t an c e . In t h e p r e s -
e n c e o f ac i d o s i s , t h e r e s p o n s e t o v as o p r e s s o r
age n t s i s gr e at l y d i mi n i s h e d . T h e u s e o f mo l ar
s o l u t i o n o f s o d i u m l ac t at e t o r e - e s t ab l i s h t h i s
r e s p o n s i v e n e s s h as me t w i t h l i mi t e d s u c c e s s
an d s e e ms w o r t h y o f t r i al i n s e l e c t e d c as e s .
Ad r e n o c o r t i c al h o r mo n e s may b e o f s t r i k i n g
b e n e f i t i n s h o c k d u e t o b ac t e r e mi a o r h yp e r -
s e n s i t i v i t y w h e n an o v e r w h e l mi n g r e s p o n s e t o
i n f l ammat i o n t h r e at e n s l i f e . T h e s e d r u gs may
b e u s e d al s o t o au gme n t t h e e f f e c t i v e n e s s o f
v as o p r e s s o r d r u gs . Re l at i v e l y l i t t l e r i s k i s
i n v o l v e d , p r o v i d e d t h at t h e p e r i o d s o f e mp l o y-
me n t ar e s h o r t an d t h at an t i b i o t i c s ar e u s e d
c o n c u r r e n t l y.
T h e i n d i c at i o n s f o r t h e u s e o f d i gi t al i s gl yc o -
1 1 0 3
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CLINICAL PROGRESS
s i d e s i n s h o c k ar e t h e s ame as at o t h e r t i me s ,
an d t h e i r r o u t i n e u s e i s o f n o p r o v e d b e n e f i t
an d may b e i n j u r i o u s . At r o p i n e i s o f v al u e
w h e n e xc e s s i v e v agal ac t i v i t y w i t h b r ad ye ar d i a
p r o d u c e s o r c o mp l i c at e s t h e h yp o t e n s i v e s t at e .
Ch l o r p r o maz i n e i s o f n o p r o v e d w o r t h i n t h e
t r e at me n t o f s h o c k , an d p o s s i b l e b e n e f i t s
ac h i e v e d w i t h an t i c o agu l an t s ar e n o t e s t ab -
l i s h e d as ye t . Pr e l i mi n ar y o b s e r v at i o n s s u gge s t
t h at h yp o t h e r mi a may b e o f s o me v al u e . T h e
h e ad - d o w n p o s i t i o n p r o v i d e s o n l y t r an s i e n t
b e n e f i t i n p at i e n t s w i t h s h o c k , an d i t s p r o l o n ge d
o r r o u t i n e u s e may d e l ay r e c o v e r y.
ACKNOW N- LED ) GMEN'T
T h e au t h o r gr at e f u l l y ac k n o w l e d ge s t h e v e r y
ge n e r o u s i n t e r e s t o f D r s . H . F. H e l mh o l z , J r . , an d
H . B. Bu r c h e l l i n t h e p r e p ar at i o n o f t h i s r e v i e w .
REFERENCES
1
MACLEAN, L. D . , AND W EIL, M. H . : H yp o t e n s i o n
( s h o c k ) i n d o gs p r o d u c e d b y Es c h e r i c h i a c o l i
e n d o t o xi n . Ci r c u l at i o n Re s e ar c h 4 : 5 4 6, 1 9 5 6.
2 W EIL, M. H . , \IAc LEAN, L. D . , V ISSCH ER, MI. B. ,
AND SPINK, W V . W . : St u d i e s o n t h e c i r c u l at o r y
c h an ge s i n t h e d o g p r o d u c e d b y e n d o t o xi n f r o m
gr am- n e gat i v e mi c r o o r gan i s ms . J . Cl i n . In v e s t .
3 5 : 1 1 9 1 , 1 9 5 6.
M
AIACLEAN, L. D . , W EIL, M. H . , SPINK, W . W . ,
AND V ISSCH ER, AI. B. : Can i n e i n t e s t i n al an d
l i v e r w e i gh t c h an ge s i n d u c e d b y E. c o l i e n d o -
t o xi n . Pr o c . So c . Exp e r . Bi o l . & M\l e d . 9 2 : 60 2 ,
1 9 5 6.
4
W IGGERS, C. J . : Ph ys i o l o gy o f Sh o c k . Ne w Yo r k ,
T h e Co mmo n w e al t h Fu n d , 1 9 5 0 , 4 5 9 p p .
GILBERT , R. P. , GOLD BERG, M. , AND GRIFFIN, J . :
Ci r c u l at o r y c h an ge s i n ac u t e myo c ar d i al i n f ar c -
t i o n . Ci r c u l at i o n 9 : 8 4 7 , 1 9 5 4 .
6
CORD AY, E. , D E V ERA, L. B. , GOLD , H . , AND
GERT H , T . : Ef f e c t o f c ar d i ac ar r h yt h mi as o n
c o r o n ar y f l o w . Ab s t r ac t e d , Ci r c u l at i o n 1 4 : 9 2 2 ,
1 9 5 6.
7
ESSEX , H . E. , ANI) T H OMAS, W . D . : T h e r e s p o n s e
o f t h e h e p at i c v e n o u s c i r c u l at i o n t o c e r t ai n
s u b s t an c e s gi v e n i n t r av e n o u s l y. Pr o c . St af f
Me e t . , Mayo Cl i n . 2 5 : 3 4 , 1 9 5 0 .
8 SMIT H , J . R. , AND H OOBLER, S. W A. : Ac u t e an d
c h r o n i c c ar d i o v as c u l ar e f f e c t s o f p e n t o l i n i u m
i n h yp e r t e n s i v e p at i e n t s . Ci r c u l at i o n 1 4 : 1 0 61 ,
1 9 5 6.
9
GAZ ES, P. C. , GOLD BERG, L. I. , AND D ARBY, T . D . :
H e ar t f o r c e e f f e c t s o f s ymp at h o mi me t i c ami n e s
as a b as i s f o r t h e i r u s e i n s h o c k ac c o mp an yi n g
myo c ar d i al i n f ar c t i o n . Ci r c u l at i o n 8 : 8 8 3 , 1 9 5 3 .
1 0 SARNOFF, S. J . , CASE, R. B. , BERGLU ND , E. , AND
SARNOFF, L. C. : V e n t r i c u l ar f u n c t i o n : V . T h e
c i r c u l at o r y e f f e c t s o f Ar ami n e ; me c h an i s m o f
ac t i o n o f " v as o p r e s s o r " d r u gs i n c ar d i o ge n i c
s h o c k . Ci r c u l at i o n 1 0 : 8 4 , 1 9 5 4 .
1 1 AEIL, M. H . , H INSH AW , L B. , V 1 SSCH ER, MI. B. ,
SPINK, W . MV . , AND Ml ACLE. AN, L. 1 ) . : H e mo -
d yn ami c e f f e c t s o f v as o p r e s s o r age n t ( me t a-
r ami n o l ) o n h yp o t e n s i o n i n ( l o gs l ) r o d l u c e d b y
e n d o t o xi n . Pr o c . So c . Exp e r . Bi o l . & - Me d .
9 2 : 61 0 , 1 9 5 6.
1 2 LU ND Y, J . S. : On t h e p r e s e n t - d ay t h e r ap y o f s h o c k
f o r s u r gi c al p at i e n t s . Pr o c . St af f M\e e t . , MIayo
Cl i n . 3 0 : 4 4 6, 1 9 5 5 .
1 3 Z W EIFACH , B. AAr . , LEE, R. E_ . H YMAN, C. , AND
CH AMBERS, R. : Ome n t al c i r c u l at i o n i n mo r -
p h i n i z e d d o gs s u b j e c t e d t o gr ad e d h e mo r r h age .
An n . Su r g. 1 2 0 : 2 3 2 , 1 9 4 4 .
1 4 SARNOFF, S. J . , CASE, R. B. , W AIT H E, , P. E. AND
ISAACS, J . P. : In s u f f i c i e n t c o r o n ar y f l o w an d
myo c ar d i al f ai l u r e as a c o mp l i c at i n g f ac t o r i n
l at e h e mo r r h agi c s h o c k . Am. J . IPh ys i o l . 1 7 6:
4 3 9 , 1 9 5 4 .
1 5 J ACOB. S. , W V EIZ EL, H . , GORD ON, E. , KORMAN, H . ,
SCH W EINBU RG, F. , FRANK, H . , AND FINE, J . :
Bac t e r i al ac t i o n i n d e v e l o p me n t o f i r r e v e r s i -
b i l i t v t o t r an s f u s i o n i n h e mo r r h agi c s h o c k i n
t h e d o g. Am. J . Ph ys i o l . 1 7 9 : 5 2 3 , 1 9 5 4 .
1 6W EIL, M. H . , AND SPINK, W A. W . : Cl i n i c al s t u d i e s
o n a v as o p r e s s o r age n t : M\e t ar ami n o l ( Ar a-
mi n e ) . I. Ob s e r v at i o n s i n n o r mo t e n s i v e s u b -
j e c t s . Am. J . 2 M. Sc . 2 2 9 : 661 , 1 9 5 5 .
1 7 U RICCH 1 0 , J . F. , CALEND A, D . G. , AND CU T T S,
F. B. : U l c e r at i o n o f t h e s k i n f o l l o w i n g i n t r a-
v e n o u s u s e o f ar t e r e n o l . J . A. _ M. A. 1 5 2 : 60 7 ,
1 9 5 3 .
1 8 H ARD IE, G. H . , AND H U NT ER, D . C. , J R. : Sk i n
n e c r o s i s w i t h t h e i n t r av e n o u s u s e o f n o r - e p i -
n e p h r i n e . Mi c h i gan U n i v . AM. Bu l l . 2 1 : 2 1 3 ,
1 9 5 5 .
1 9 CLOSE, A. S. , AND KORY, R. C. : Cu t an e o u s n e c r o -
s i s d u e t o n o r e p i n e p h r i n e : \Me c h an i s m an d
p r e v e n t i o n . Cl i n i c al Re s e ar c h Pr o c e e d i n gs 4 :
2 4 1 , 1 9 5 6.
2 0
MOYER, J . H . , AND H AND LEY, C. A. : Bl o o d p r e s -
s u r e an d r e n al h e mo d yn ami c r e s p o n s e s t o
Ar ami n e an d t h e al t e r at i o n o f t h e s e r e s p o n s e s
b y ad l r e n e r gi c b l o c k ad e an d ( l i b e n z yl i n e . Am.
H e ar t J . 4 8 : 1 7 3 , 1 9 5 4 .
2 1
l AEIL, M\1 . H . : Cl i n i c al s t u d i e s o n a
x
as o p r e s s o r
age n t : Me t ar ami n o l ( Ar ami n e ) . II. Ob s e r v a-
t i o n s o n i t s u s e i n t h e man age me n t o f s h o c k .
Am. J . AM. Sc . 2 3 0 : 3 5 7 . 1 9 5 5 .
2 2 N1 CKERSON, MI. : Fac t o r s o f v as o c o n s t r i c t i o n an d
v as o d i l at i o n i n s h o c k . J . Mi c h i gan MI. So c . 5 4 :
4 5 , 1 9 5 5 .
2 3 BRU NSON, J . G. , ECKMAN, P. L. , ANI) CAMIPBELL,
J . B. : T h e i n c r e as i n g i n c i d e n c e o f
u n e xp l ai n e d
l i v e r n e c r o s i s . U n i v . Mi n n e s o t a M. Bu l l . 2 8 :
1 9 7 , 1 9 5 7 .
2 4 KING, W V . M. : Co n t r i b u t i o n s t o t h e p h ar mac o l o gy
an d p at h o l o gy o f l e v ar t e r e n o l an d r e l at e d d r u gs :
1 1 0 m4
by guest on April 24, 2014 http://circ.ahajournals.org/ Downloaded from
CU RRENT CONCEPT S ON MANAGEMAIENT OF SH OCK
I. Mo r p h o l o gi c al r e s p o n s e t o c e r t ai n o f t h e
s ymp at h o mi me t i c d r u gs . T h e s i s , Gr ad u at e
Sc h o o l , U n i v e r s i t y o f Mi n n e s o t a, 1 9 5 6.
2 5 Ed i t o r i al : I- No r ad r e n al i n e . Br i t . M. J . 1 : 1 3 4 9 ,
1 9 5 6.
2 6BU RGET , G. E. , AND V ISSCH ER, M. B. : V ar i at i o n s
o f t h e p H o f t h e b l o o d an d t h e r e s p o n s e o f t h e
v as c u l ar s ys t e m t o ad r e n al i n . Am. J . Ph ys i o l .
8 1 : 1 1 3 , 1 9 2 7 .
2
PAGE, I. H . , AND OLMST ED , F. : T h e i n f l u e n c e o f
r e s p i r at o r y gas mi xt u r e s o n ar t e r i al p r e s s u r e
an d v as c u l ar r e ac t i v i t y i n " n o r mal " an d h yp e r -
t e n s i v e d o gs . Ci r c u l at i o n 3 : 8 0 1 , 1 9 5 1 .
2 8
H OU LE, D . B. , W EIL, MI. H . , BROW N, E. B. , AND
CAMPBELL, G. S. : In f l u e n c e o f r e s p i r at o r y
ac i d o s i s o n E. C. G. an d p r e s s o r r e s p o n s e s t o
e p i n e p h r i n e ` n o r - e p i n e p h r i n e an d me t ar ami n o l .
Pr o c . So c . Exp e r . Bi o l . & M\e d . 9 4 : 5 61 , 1 9 5 7
2 9 BELLET , S. , W ASSERMAN, F. , AND BROD Y, J . I. :
Ef f e c t o f mo l ar s o d i u m l ac t at e i n i n c r e as i n g
c ar d i ac r h yt h mi c i t y: Cl i n i c al an d e xp e r i me n t al
s t u d y o f i t s u s e i n t h e t r e at me n t o f p at i e n t s
w i t h s l o w h e ar t r at e s , St o k e s - Ad ams s yn d r o me ,
an d e p i s o d e s o f c ar d i ac ar r e s t . J . A. M\. A. 1 60 :
1 2 9 3 , 1 9 5 6.
3 0 CAMPBELL, G. S. , H OU LE, D . B. , CRISP, N. W . ,
W EIL, A. H . , AND BROW N, E. B. : D e p r e s s e d
r e s p o n s e t o i n t r av e n o u s s ymp at h i c o mi me t i c
age n t s i n h u man s d u r i n g ac i d o s i s . D i s . Ch e s t .
In p r e s s .
3 1
GOLD ST EIN, AI. S. , RAMEY, E. R. , AND LEV INE, R. :
Re l at i o n o f mu s c u l ar f at i gu e i n t h e ad r e n al -
e c t o mi z e d d o g t o i n ad e q u at e c i r c u l at o r y ad j u s t -
me n t . Am. J . Ph ys i o l . 1 63 : 5 61 , 1 9 5 0 .
3 2
FRASER, C. G. , PREU SS, F. S. , AND BIGFORD ,
W . D . : Ad r e n al at r o p h y an d i r r e v e r s i b l e s h o c k
as s o c i at e d w i t h c o r t i s o n e t h e r ap y. J . A. 1 \I. A.
1 4 9 : 1 5 4 2 , 1 9 5 2 .
3 3 SALASSA, R. I. , BENNET T , W \. A. , KEAT ING, F. R. ,
J R. , AND SPRAGU E, R. G. : Po s t o p e r at i v e ad r e n al
c o r t i c al i n s u f f i c i e n c y: Oc c u r r e n c e i n
p at i e n t s
p r e v i o u s l y t r e at e d w i t h c o r t i s o n e . J . A. _ M. A.
1 5 2 : 1 5 0 9 , 1 9 5 3 .
3 H ARNAGEL, E. E. , AN!) KRAMER, W . G. : Se v e r e
ad r e n o c o r t i c al i n s u f f i c i e n c y f o l l o w i n g j o i n t
man i p u l at i o n : Re p o r t o f p at i e n t r e c e i v i n g c o r t i -
s o n e o r al l y. J . A. M. A. 1 5 8 : 1 5 1 8 , 1 9 5 5 .
3 T OBIN, J . L. : Co mp l i c at i o n s o f
me n i n go c o c c u s
i n f e c t i o n i n a s e r i e s o f s i xt y- t h r e e c o n s e c u t i v e
s p o r ad i c c as e s . Am. J . M. Sc . 2 3 1 :
2 4 1 , 1 9 5 6.
3 6KANT ER, D . M. , MAU RLELLE, D . A. , AND
LEARNER, N. : Ac u t e me n i n go c o c c e mi a w i t h
v as c u l ar c o l l ap s e :
An
an al ys i s o f 1 0 r e c e n t l y
t r e at e d c as e s . Am. J . MI. SC. 2 3 2 : 67 4 , 1 9 5 6.
3 7
KINSELL, L. W . , AND J AH N, J . P. : T h e u s e o f c o r t i -
c o i d s i n as s o c i at i o n w i t h an t i b i o t i c s i n t h e
man age me n t o f u n u s u al l y s e v e r e i n f e c t i o n s .
An n . Ne w Yo r k Ac ad . Sc . 61 : 3 9 7 , 1 9 5 5 .
3 8 RU KES, J . Al X . , ORR, R. H . , FORSH AM, P. H . , AND
GALENT E, Al . : T h e u s e o f i n t r av e n o u s h yd r o -
c o r t i s o n e i n maj o r s u r ge r y. An n . Ne w Yo r k
Ac ad . Sc . 61 : 4 4 8 , 1 9 5 5 .
3
SPINK, W . W . : Ad r e n o c o r t i c o t r o p h i c h o r mo n e an d
ad r e n al s t e r o i d s i n t h e man age me n t o f i n f e c t i o u s
d i s e as e s . An n . In t . M\e d . 4 3 : 68 5 , 1 9 5 5 .
4 0 FRIT Z , I. , AND LEV INE, R. : Ac t i o n o f ad r e n al c o r t i -
c al s t e r o i d s an d n o r - e p i n e p h r i n e o n v as c u l ar
r e s p o n s e s t o s t r e s s i n ad r e n al e c t o mi z e d r at s .
Am. J . Ph ys i o l . 1 65 : 4 5 6, 1 9 5 1 .
4 1 RAMEY, E. R. , GOLD ST EIN, M. S. , AN!) LEV INE, R. :
Ac t i o n o f n o r - e p i n e p h r i n e an d ad r e n al s t e r o i d s
o n b l o o d p r e s s u r e an d w o r k p e r f o r man c e o f
ad r e n al e c t o mi z e d d o gs . Am. J . Ph ys i o l . 1 65 :
4 5 0 , 1 9 5 1 .
4 2 KU RLAND , G. S. , AND FREED BERG, A. S. : T h e
p o t e n t i at i n g e f f e c t o f ACT H an d o f c o r t i s o n e
o n p r e s s o r r e s p o n s e t o i n t r av e n o u s i n f u s i o n o f
1 - n o r - e p i n e p h r i n e . Pr o c . So c . Exp e r . Bi o l . &
Me d . 7 8 : 2 8 , 1 9 5 1 .
4 3 LABORIT , H . , AND H U GU ENARD , P. : L'h i b e r n at i o n
ar t i f i c i e l l e c h e z l e gr an d c h o q u e . Pr e s s e me d .
61 : 1 0 2 9 , 1 9 5 3 .
4 4
OV ERT ON, R. C. , AND D E BAKEY, M. E. : Exp e r i -
me n t al o b s e r v at i o n s o n t h e i n f l u e n c e o f h yp o -
t h e r mi a an d au t o n o mi c b l o c k i n g age n t s o n
h e mo r r h agi c s h o c k . An n . Su r g. 1 4 3 : 4 3 9 , 1 9 5 6.
4 5 ABERNAT H Y, R. S. , AND H ALBERG, F. : Pr o t e c t i v e
ac t i o n o f c h l o r p r o maz i n e agai n s t Br u c e l l a e n d o -
t o xi n . Ab s t r ac t e d , J . Lab . & Cl i n . Me d . 4 6:
7 9 0 , 1 9 5 5 .
4 6CROW ELL, J . W . , AND READ , W . L. : H yp e r ac t i v i t y
o f t h e b l o o d c o agu l ab i l i t y c o n t r o l me c h an i s m
a p o s s i b l e c au s e o f i r r e v e r s i b l e s h o c k .
Ab s t r ac t e d , Am. J . AIl e d . 1 9 : 1 3 8 , 1 9 5 5 .
4 7 W INT ROBE, Al . M. : Cl i n i c al H e mat o l o gy. Ed . 4 ,
Ph i l ad e l p h i a, Le a & Fe b i ge r , 1 9 5 6, p . 8 8 7 .
4 "GRIFFIT H , G. C. : Q u o t e d b y Samp s o n , J . J . :
Sh o c k o f c ar d i ac o r i gi n . AIo d . Co n c e p t s Car d i o -
v as . D i s . 2 6: 3 7 9 , 1 9 5 7 .
4 1
LEW IS, F. J . , RING, D . M. , AND ALD EN, J . F. :
A t e c h n i q u e f o r t o t al b o d y c o o l i n g o f t h e f e b r i l e ,
gr av e l y i l l p at i e n t . Su r ge r y 4 0 : 4 65 , 1 9 5 6.
5 0 MACLEAN, A. R. , AND ALLEN, E. V . : Or t h o s t at i c
h yp o t e n s i o n an d o r t h o s t at i c t ac h yc ar d i a: T r e at -
me n t w i t h t h e " h e ad - u p " b e d . J . A. M. A. 1 1 5 :
2 1 62 , 1 9 4 0 .
5 W EIL, M. H . : Cl i n i c al s t u d i e s o n a v as o p r e s s o r
age n t : Me t ar ami n o l ( Ar ami n e ) . III. Ob s e r v a-
t i o n s o n i t s o r al u s e i n t h e t r e at me n t o f h yp o -
t e n s i o n . Am. J . Al . Sc . 2 3 3 : 3 67 , 1 9 5 7 .
1 1 0 5
by guest on April 24, 2014 http://circ.ahajournals.org/ Downloaded from