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To help all that can be helped,
To defend all that can be defended,
To save all that can be saved,
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To stay alive as long as I can and stay free as long as I live.

John Dierking's article on shock prompted several readers of DIRECTIONS to write. We decided to reprint their letters along with John's reply since all are quite informative. --DL

Dear Editor:

After reading John Dierking's shock article in the Sept. DIRECTIONS, I was in SHOCK! Low blood pressure is a LATE sign of shock. Dr. Nancy Caroline, writing in EMERGENCY CARE IN THE STREETS (THE paramedic textbook) states the signs and symptoms of shock as (in order): Restlessness and anxiety, cold clammy skin, rapid thready pulse, rapid shallow breathing, thirst, confusion, and hypotension (low blood pressure). She further writes "falling blood pressure is a late sign in shock, signaling the collapse of all compensatory mechanisms. By the time blood pressure falls, the ball game is nearly over." Dr. Raymond Fowler, writing in BASIC TRAUMA LIFE SUPPORT (advanced pre-hospital care), also listed the order of shock sign and symptom development. Weakness, thirst, pallor, tachycardia (rapid heart rate) were listed a signs and symptoms of earl shock. Tachypnea (rapid breathing), sweating, decreased urine output, hypotension, and altered level of consciousness were signs of late shock. Although a delayed capillary blanch test can increase suspicion

of early shock, a normal refill (2 seconds or less) does not mean early shock can be ruled out. There may be excellent blood flowing to the nail beds, but an inadequate supply to the kidneys, brain, or other vital organs. The problem of quickly, simply, and reliably diagnosing shock is further complicated in pregnant patients, where the blood volume can increase up to 50 percent. This means that these patients can lose 35 percent of blood volume before the blood pressure would drop to levels normally associated with shock. Shock should be suspected, and treatment initiated immediately, in all injuries to the chest, abdomen, hade or spine, and in all illnesses with a continuing fluid loss (vomiting or diarrhea).

The safest method is to assume shock is present and treat the patient appropriately until shock can be completely ruled out.--

Jerry Reimer, Paramedic.

Dear Editor:

Reference the article "Shock" by John Dierking in the Sept. 1988 issue. The opening statement: "The first sign of shock is decreased blood pressure." He then describes how to recognize decreased blood pressure. As a technical matter, decreased blood pressure is a symptom—not a sign--and the decrease is measurable only by instrument. By observation of the mucus membranes and capillary refill, as described, you observe the signs which indicated the symptom. Technical matters aside, the opening statement may be incorrect, with fatal consequences. "Shock" is simply the failure of the body to adequately perfuse blood, whatever the cause of such failure (i.e., blood volume loss, cardiac standstill, disease, etc.).

In the case of children, the reaction of the body to trauma is to increase the blood pressure. With the relatively small volume of blood involved, the body's ability to maintain pressure is quite good even in the event of multi-system trauma. what then happens all too often is that given the good blood pressure the person attending the patient fails to effectively treat for shock. When the residual blood volume can no longer sustain the pressure (loss through either internal or external bleeding) the pressure starts to drop (the classical symptom) and it is too late to take effective action to intervene.

All children involved in trauma should be treated for shock. In the last paragraph, Dierking should also have indicated that elevating the feet is contraindicated in the even of actual or suspected head injury.

Sincerely, J. Connolly.

The writer replies:

My statement that "the first signs of shock is decreased blood pressure" is not in fact correct. My mistake was trying to explain in a simple concise way the physiological process of hemo-perfusion. Shock is the major killer when dealing with serious injury. Awareness and recognition can not be stressed enough. Early treatment by people untrained and unequipped can still save lives, especially when the support of the highly technical health care delivery system is unavailable. I do not suggest that something as complicated as medical care can be definitively addressed in a short article, what I am trying to do is increase the level of general knowledge among the essentially medically uneducated. The length and number of articles on objects of medical application are practically unlimited. The other members of Live Free that are trained and experienced in health care have the same opportunity to contribute to DIRECTIONS that I have taken. Both letters in response to what I wrote indicate the complexity and delicacy of the subject, and do not address the subject of simple, immediate treatment other than saying that it should be carried out. On this we agree....

Yours, John Dierking.

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