an angle of 30 to 6o degrees in the foot-up and head-ul) positions

STUDIES ON THE EFFEWCTS OF POSTURE IN SHOCK AND INJURY*GEORGE W. DUNCAN, MI.D., STANLEY J. SARNOFF, MI.D).,

AND

C. MARTIN RHODE, MI.L).BALTIMORE, MD.

FROM THE DEPARTMEN-T OF SURGERY, JOhINS HOPKINsS UNIVERSITY, AN-I) DEPARTM%ENT OFSURGERY, UNIVERSITY OF MARYLAN-D, BALTIMORE, MD.

THE SHOCK OR FOOT-UP position rather than the horizontal or the head-upposition is frequently employed in the treatmiient of shock or potential slhock,but experimental evidence of the relative effects of these positioins in injtire(lpersons is lacking. Widely differenit opinlionls haxve been exI)ressedl lby variousworkers in this field as to the value of the slhock position, but data presenlte(lhave been based chiefly on animiial experimiientationi or lpostural studies innormal persons. Hill1 recommiiiiended its use in the treatment of slhockon the basis of animal experimiients. Henderson and Haggard2 studied somleof the cardiovascular effects of lowering the head of a niormiial persoin to anangle of 30 to 45 degrees. They conclude(d that the foot-ulp Iosition wouldnot be beneficial in shock. Cannon,3 on the basis of his observations in\V'orld WVar 1, stated that the shock positioIn has Ino beineficial effect. Fromobservations also nmade in the First WN`orld WN ar, Porte r4 strongoly reconm-mended its use. Blalock5 advocates the shock position because of the effectof gravity in aiding venous return to the heart anid in aidinlg tlle circulationof the brain. Moon6 states that posture can haxe ino effect since the difficultylies in the capillaries. Asmussen, and his coworkers, after extensive studieson the effect of postture UPOI1 the circuatioin of the normiial lhtumiiani being atan angle of 30 to 6o degrees in the foot-up and head-ul) positions. state thatthe shock position may be beneficial in cases of circulatory insufhiciencv dtieto peripheral dilatation of vessels or to blood loss. Numlnerous other invxesti-gators have studied the effects of foot-up and head-up posture in inormialpersons at postural angles similar to those used by all of these inxestigators.

It was the purpose of this study to observe the effect of posture illpatients with varying degrees of injury anid shock both in the foot-up anldhead-up positions at aingles simiiilar to those produticed by tlle slhock blocksand the bed elevators used in most hospitals. These sttudies were contitnue(lby the senior author in collaboration with Dr. Dickinison Richards, and hisassociates, at Bellevue Hospital, in a sttudy of the effect of position tIpollcardiac output and other fuinctioIns. SoIm1e of the cases inicludle(d lhere wNereobserved with this group (Tables II aind IV) anid will be reporte(l elsewhle-ein greater detail in coinnection w%ith other studies.

* The work described in this paper was done under a contract, recommended bythe Committee on 'Medical Research, betw-een the Office of Scientific Research andDevelopment and Johns Hopkins University.

24

Name and InijuryD. WV. Bleeding pep-tic ulcer

I.M. Amputation ofshoulder

M. P. Stabwoundofchest. Hemopneumo-thorax

R. S. Multiple coin-pound fractures ofboth lower extremii-ties

I. L. Lacerations offace

R. 11.pelvis

Fracture of

S. H. Hemiorrliagefollowing gastric re-section

W. J. Bleeding pep-tic ulcer

J. KC. Bleeding pep-tic ulcer

TABLE I

EFFECTS OF POSTURAL CHANGE IN PATIENTS WITH MODERATE OR SEVERE INJURY OR HEMSORRIHAGE(GROUP :)

FOOT-UP POSITION

Arterial PressureMm. Hg.Pulse rate per mii.

Initial position changebefore or immediatelyafter treatment begun

Hori-zontal70/61

109

Art,erial pressure Initial position changeMIm. Hg. before or immediatelyPulse rate per minute after treatment begun

Arterial pressureMm. Hg.Pulse rate per minute

Foot-up86/61

105

Hori-zontal78/60

108

Repeated 40 minuteslater during Infusion of500 cc. plasma

95/68 87/64 Repeated one hour45 minutes later alter

136 136 1390cc.wholeblood

Initial position change 86/66 85/64before or immediatelyaftertreatmentbegun 107 112

Arterial pressure Initial position changeMmi. Hig. before or immediatelyPulse rate per miinute after treatment begun

158/98 146/90

130 130

Hori-zontal85/67

ill

Foot-up93/65

105

Hori-zontal89/70

113

128/83 128/84 126/80

128

Repeated 20 minutes 86/70 106/80later after 250 cc.whole blood 112 132

Repeated after opera-tion during which ar-terial pressure fell to80/50. Received 500cc. whole blood and2000 cc. normal maine

Arterial pressure Iniitial Positioni change 80/58 92/64 86/56 Repeated one hourMin. Hg. before or immediately later after 500 cc.Pulse rate per mlinute after treatment begun 103 98 105 whole blood

Repeated 40 minuteslater after total of 500cc. plasma and 500 cc.whole blood

Hori-zontal113/80

95

Foot-up113/79

91

Hori-zontal114/79

97

127 126 /

Repeated 33, hourslater after 1300 cc.whole blood

129/90 141/98 134/90 Repeated 1% hourslater after 500 cc.

126 125 128 wholeblood

119/75 121/75122 122

153/98 152/96 153/96125 124 128

116/84 117/81 122/86

97

Arterial pressure Initial positioni change 123/86 129/89 116/82 Repeated 40 minutesNMm. H1g. before or immediately later; no replacementPulse rate per miinute after treatment begun 91 89 91 therapy

95 97

127/88 119/84

Arterial pressure Initial position change 68/32 84/40Mm. Hg. before or immediatelyPulse rate per miinute after treatmient begun 144 140

Repeated three hours 134/87 128/87 12 6/88later following opera-tion. No replacementtherapy

Arterial pressure Initial position change 108/78 124/78Mm. Hg. before or immediateiyPulse rate per minute after treatment begun 100 100

Arterial pressure

Mm. Hg.

Pulse rate per minute

Initial position change

before or i:nmnediateiyafter treatment begun

100/70 110/68

126 126

HEAD-UP POSITION_ _ _ _ _ _ _ _ _ _ _ .11-k 1

Initial Position changebefore or immediatelyalter treatment begun

Hori-zontal77/60

108

Initial po-sition change 88/64before or immediatelyafter treatment begun 137

Initial position change 86/66before or immediatelyafter treatment begun 107

Head-up75/64

118

88/64

137

Hori-zontal84/67

108

Hori-zontal Head-up

Repeated one hour laterafter 500 cc. blood. 500cc. plasma & 500 cc.normal salineRepeated two hourslater alter 1390 cc.whole blood

112 /79

97

130/80

100

114/83

98

132 /79

101

Hori-zontal114/80

95

73/52 86/70 Repeated four hours. 120/77 112/69 110/7050 minutes later after

119 112 1500Occ.wholeblood 125 124 127

Initial position change 134/94 122/90 137/96 Repeated 30 minutes 153/96 141/90 148/96before or immediately later after 500 cc. wholeafter treatment begun 128 135 129 blood 138 142 130


Initial position change 116/82 77/61before or immediately 93after treatment begun


Repeated four hourslater following opera-tion. No replacementtherapy

136/88 144/90

104 103

Initial position chanigebefore or immediatelyafter treatment begun


LABORATORY STUDIES AND

REPLACEMENT THERAPY

Hematocrit Plasma Protein Total ReplacemenitInitial Final Initial Final Therapy28 26 5.7 5.8 SOOcc. plasma

500 cc. whole blood500 cc. normalsaline

25 41 7.2 7:9 1950 cc. wholeblood

27 31 6.1 5.9 1500 cc. whole blood1000 cc. 10 percentglucose

52 48 7.1 7.1 SOO cc. plasma950 cc. whole blood

2000 cc. normial saline

35 35 7.6 6:4 SOO cc. whole blood1000 cc. whole blood

38 33 6.8 6:8 No treatnient duritngstudy

37 37 6:3 6:4 2400 cc. whole bloodgiven slowly overperiod of 12 hours

19 27 4:8 5:6

27 5o0

1000 cc. whole blood

550 cc. whole blood

11

PCOSTURE IN SHOCK AND) INJURY

METHOD

Patients wvere seeni as early as possible after admiiissioni to the accidenitward in the cases of injur- or upon notification of the appearance of siginsof shock in postoperative cases. specimeni of blood was obtained fordeterminationi of plasma proteiin anid hemiatocrit values inmmiediately beforepostural studies wvere beguni, and(l subsequent samiiples were obtained during

the course of the stud- ancl at the eInd. In the patieints listed in Tables II

and Iv, postural studies were begun dtirinig the latter part of the deterimina-

HORIZONTAL SHOCK7 HORIZONTAL HID-P HORIZONTAL SHOCK HORIZONTA SHOCK HORIZONTAL HITAA-UPOSITION 7-9' POSITION 7-9' POSITION POSITION 7-EPsIIONT-

'20.

110-

1.i 100-

MY 90

IE

120-~ ~ ~ ~ ~~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~0

70O- Zi

10-

£ In~~~~~~~~~~~~~~~~~~C

00-~ ~ ~~ ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~~~c

CHIARr I.-DA..: l'ostural studies in l)atient in shock due to bleediing peptic tulcer showinig diminutitionof response to foot-tup positioni as treatmeint progressed.

tion of blood volume or immediately thereafter. Symptoms and sigIns suclhas the presence or absence of sweating, pallor, the degree of consciousiness,temperature of extremities to palpation. an(l appearaince of periplheral veinswere observed and reported. Three readings of arterial pressure and pulserate were made at two nminute intervals and recorded. TFhe patielnt was theniplaced immediately in the foot-up or shock positioin by elevation of the foot.of the bed or examining table on shock blocks measuring I2 inches inheight. The resulting angle measured approxiilmately 7 to 9 degrees withthe horizontal when the examininig table or bed measured 6 to 7.5 feet inlength. Because of the rapidity of the changes produced in somle of thepatients, observations on blood pressure, pulse rate, and other symptoms andsigns were made at one minute, three minutes. and five minutes after thechange in posture. The patient was immediately returned to the horizontal

25

V'olume 120Number 1

DUNCAN, SARNOFF AND RHODE

TABLE II

EFFECTS OF POSTURAL CHANGE IN PATIENTS WITH MODERATE OR MARKED DIMINUTION OF BLOOD VOLUME

(GROUP I)Arterial Pressure

Mm. Hg.-Pulse Blood Volume

(Optical Rate Sq. M. B.S.A.(Cuff) Manometer) Per - * -

Name and InjuryP. P.-Gunshot wound,of abdomen. Exposure

W. B.-Crushing injuryof chest. Contusion oflung. Hemothorax

Laceration of Foot-upneck Flat

Foot-upFlat

5imple fract. of FlatFoot-upFlatHead-up

- Hemorrhage Flatphageal varices Foot-up

FlatHead-up

Laceration of FlatFoot-upFlatFoot-upFlatFlatFoot-upFlat

- Fracture of FlatFoot-upFlat'Head-upFlatFoot-up

Brachial46/3060/40

74/4286/6188/6688/60

1 10/58122/60112/64110/63

135/89142/94122/80144/90

126/80110/7081 (mean)20 (mean)106/63107/6595/64101/65100/56108/59105/58101/61

60/4078/4680/4858/4060/4055/4067/4266/4161/3060/3978/5086/50

Flat 95/53Foot-up 100/5 1

Femoral33/2239/25

Min.6283

Plasma Blood1320 2100

57/34 7271/37 7576/44 7874/43 76

78828282

116117132128

116120

118/66 101116/64 9098/57 101110/64 102

153150162164

44/21 12052/24 11868/30 10386/36 10487/36 10677/31 9878/31 10066/2754/26 11249/25 11453/27 12047/26 12062/34 13466/33 132

78/40 12078/39 120

1230 2230

RemarksArterial pressure rose im-mediately when placed inshock position but immedi-ately began to dropRepeated 1 hours later.Had received 590 cc. blood1500 cc. crystalloids. Bleed-ing into peritoneal cavityRepeated 4 hours later. Hadreceived 1000 cc. crys. solu-tion & 1300 cc. blood.Bleeding into peritonealcavity. 40 minutes later ar-terial pressure had droppedto 90/50 and other clinicalsigns of shock were present

1160 1790 Repeated 5 hours later.Had received saline slowly.Thirty minutes later patientshowed evidence of clinicalshock & was given 1000 cc.whole blood

1350 2180 Developed clinical pictureof shock 15 minutes later30 minutes later. Notherapy

1170 2270

1810 2300

1030 1700

Repeated one hour later.Had received 350 cc. blood,1500 cc. N. saline

1800 2580 Repeated 1 hours laterafter 100 cc. blood & 1000cc. N. saline

1130 1670

Repeated three hours later.Had received 900 cc. blood,750 cc. N. salineRepeated 30 minutes later.-

1520 2300 Had received 100 cc. N.saline. Blood volume de-termination done one hourafter postural studies.Patient probably bleeding

26

Annals of SurgeryJuly, 1944

PostureFlatShock

FlatFoot-upFlatHead-upFlatShockFlatHead-up

FlatFoot-upFlatFoot-up

B. S.-]wrists &

R. C.-Sfemur

R. M. -from esop

A. R.-]seal

W. B. -pelvis

TABLE. III

EFrFECTS OF POSTURtAL CHANGE IN PATIENTS WITH LES SEVERE INJURY OR HEMORRIIAGE(GROUP 11)

Name and InJuryW. WV. Laceration ofneck and arm

B. D. Compoundfracture of skull

J. W. Compoundfracture of tibia

G. H. Chest inJury:multiple rib fractures;contusions of flank

V. N. Comminutedfracture of femur

J. P. LaceratIon offorearm

C. B. Simple frac-ture of tibia

H1. M. Gunshotwound of sacrum.withnerveroot injury

FOOT-UP POSITION

Arterial pressure Initial position changeMm. 1Ha. before or immediatelyPulse rate per minute after treatment begun

Hori-zotutal104/63

97

Foot-up102/58

96

Hori-zontal100/61

99

Arterial pressure Iniitial position change 120/86 124/78 124/82Mm. Hg. before or immediatelyPulse'rate per minute after treatment begun 64 62 61



Arterial PressureMm. Hg.Pulse rate per minute



Arterial pressureMin. Hg.1'lulse rate per minute



Initial po-sition changebefore or immediatelyafter treatment begun

Initial position changebefore or immediatelyafter treatmnent begun


Initial position chiangebefore or immediatelyafter treatment beguin

115/69 116/76 111/69

75 75 78

Repeated one hourlater. No replacementtherapy

Repeated six hourslater following opera-tion. No replacementtherapy

Repeated three hourslater following opera-tion. No replacementtherapy

Hori-zontalI1IS/79

Hori-Foot-up zontal112/81 107/76

Hori-zontal

85 85 89

108/71 106/70 108/72 Repeated two hours 105/64

later after 1500 cc.

117 116 normalsaline 102

105/62 108/64 100/65 Repeated three hours 99/65

later. No replacement

84 87 81 therapy 87

120/79 122/81 121/83 Repeated one hour 108/74 111/75 104/79


105 108 113 therapy 115 102

132 /75

68

142/79 134/78 Repeated 40 minutes


69 70 therapy

133/75 155/75 128/76

Repeated two hours. 45

minutes later following

operation and 500 cc.

whole blood

74 71 77

88/58 85/56 85/58 Repeated 15 minutes 46/38 44/38

later following collapse

100 99 100 In head-up position 84 84

Repeted one hour

later. Spontaneous im-

provement following re-

placing in horizontal

position. 000 cc. per

cent glucose

112/78 111/78 106/76

96 98 97

149/79 145/85 141/79

85 89 88

128/86 128/86 128/81

86 86 90

Horn-Foot-up zontal

105/60 103/68

99 100

Hori-zontal

Initial po-sition change 100/61before or immediatelyafter treatment begun 99

Initial position change 124/82before or immediatelyafter treatment begun 61

HEAD-UP POSITIONHorn-

Head-up zontalHori-zontal Head-up

73/5 1 79/57 Repeated three hours 107/76 99/65later. No replacement

100 91 therapy 89 91

114/82 124/80

67 72

98/65 102/63 Initial position change 111/69 104/66 112/73before or immediately

86 91 after treatment begun 78 77 74

112/74 114/78 120/85 Initial position change 121/81 109/76 118/81

before or immnediatelyI11 105 104 after treatment begun 113 116 112

Initial position change 124/78

before or imnmediatelyafter treatment begun 70

Initial position change

before or immediately

after treatment begun

120/77 138/76

Repeated six hourslater following opera-tion. No replacementtherapy

Repeated three hours 102/65later following opera-tion. No replacement 81therapy

Repeated four hours

later 'following opera-

tion and 500 cc. whole

blood

Hori-zontal103/70

91

107/72 106/70 113/74

119 119 114

99/64 108/60

86 85

120/85 118/85 118/85

104 107 99

76 72

85/60 Korotkow 46/40

sounds in-

100 audible. 84

Profuse

sweating.

pallor, coma

Repeated one hour 103/74

later after spontaneous

improvement and 1000

cc. per cent glucose

99/70 96/65

97 101

Initial position change 141/79 133/75 140/77


after treatment begun 88 82 85

Initial position change 128/81 78/49 117/76


after treatment begun 90 86 86

LABORATORY STUDIES AND

REPLACEMENT THERAPY

HematocritInitial Final42 39

40

Plasma Protein Total ReplacementInitial Final Therapy6.6 6.2 No treatment during

study

40 7.0 6.8 1500 cc. normalsalne

42 39 6.4 6.2 Notreatment duringstudy

45 43 7.1 7.0 SOO cc. plasma500 cc. whole blood

44 38 6.7 6. 1 No treatment duringstudy

40 36 7.4 6.5 1000 cc. 5 per centglucose500 cc. plasma

42 41 7.5 7.5 Notreatment duringstudy

41 40 7.6 7.6 Notreatment duringsitudy

F

Volume 120Number 1 POSTURE IN SHOCK AND INJURY

position, after which similar observations were made at the same intervals.This procedure was then carried out in the head-up position, the same anglebeing used. The effects of both foot-up and head-up positions were repeatedlyobserved in most patients over a period of several hours. This procedurewas followed in most instances, but occasionally because of therapeutic require-ments, it could not be followed precisely. -

Arterial pressure was determined in the patients listed in Tables I andIII by the auscultatory method in the arm, and in the patients listed inTables II and IV by both the auscultatory method in the brachial arteryand the optical manometric method of Hamilton8 in the femoral artery.In the determination of blood pressure in the arm, the arm was kept on thetable or the bed parallel to the trunik in all postures. In the auscultatorymethod, care was taken to read the expiratory level of systolic pressurebecause respiratory variation in arterial pressure was frequently greatlyincreased. The first distinct change in Korotkow sounds was taken as thodiastolic level. The heart rate was counted by arterial palpation or pre-cordial auscultation or fromii the mlanometric tracings. Hematocrit levelswere determined in duplicate with Wintrobe tubes. Plasma proteins weredetermined by the Barbour and Hamilton9 method, the formula of Weech,Reeves and Goettsch'0 being used for translation of plasma specific gravityinto plasma protein.

RESULTSFor convenience of description, the

cases observed will be divided into twogroups on the basis of the clinicaland laboratory evidence of shock andblood loss.

GROUP I: The patients comprising Xthis group showed greater degrees of |injury or hemorrhage. There werei6 patients in this group (Tables I rand II) and clinical signs of shockwere initially present or subsequentlydeveloped in all patients except one.The most frequently observed symp-toms and signs were lowered arterialpressure, increase in pulse rate, de-crease in pulse volume,, various de- igrees of sweating and pallor, cool tocold extremities, diminished filling ofperipheral veins, and narrowing of thefield of consciousness. In the one pa-tient who did not show definite clin-ical evidence of shock, a distinct fallin arterial pressure and other signs of

HORIZONTAL SHOCK HOZONIAL SKPOSITION 7-g9 POSITION 7-9'

PallorGeneralized

sweatingPoor pulse

volumeApathy

ImpremanWt Ofcolor, pulsevolume ondmental slateDecreaue insweoing

528 30 32 34 36 38 40PM

00

0

CoWe goodNo sweatingMaila ly cwPulse vohinenormal

lNo change

626 28 3052 34 36PM

CHART 2.-I.L.: Effect of foot-up poeition inpatient in shock due to hemorrhage trom lacer-ations.

27

DUNCAN, SARNOFF AND RHODE Annsls of StirgeryJuly, 1S44

collapse were induced by postural change, and the nature of the injuryand the blood studies indicate that he had considerable blood loss. Thispatient also showed a sharp decline in arterial pressure, bradycardia, sweating,and pallor during the passage of a urethral sound. In five patients the causeof shock was gastro-intestinal hemorrhage, skeletal trauma was responsiblein four patients, soft-tissue laceration with hemorrhage in three, hemopneumo-thorax in two, gunshot wound of the abdomen in one, and severe hemorrhageoccurring during a shoulder amputation in another. In the patients listed

120

100w

E 90

<aE 80

4 70

t&iIi I

0.en

CHART 3.-W.W.: Postural studies in patient with superficial lacerations of neck and arm. Pro-nounced fall in arterial pressure, sweating, pallor, and apathy occurred when head-up positiotn wasassunmed. No significant change was observed in foot-up position. Symptoms and signs disappearedwithout intravenous therapy.

in Table I hematocrit levels were lowered in all except one, and plasma proteinlevels were lowered in two. The hematocrit level showed hemoconcentrationin one patient (R. S.) while the plasma protein level was within normalrange. In the patients listed in Table II, studies in blood volume showedmoderate to marked diminution.A difference in arterial pressure in the horizontal and the foot-up position

was observed in all patients of this group except two. These two later showed28

Volume 120Number 1 POSTURE IN SHOCK AND INJURY

a difference in arterial pressure in the horizontal and the foot-up positionafter the blood volume had been partly replaced. The most frequent changeswere observed in systolic pressure, ranging from 6 to 22 Mm.Hg. in thebrachial artery and 6 to i8 Mm.Hg. in the femoral artery. In some patientsthe diastolic pressure rose significantly. The pulse rate slowed in severalpatients and showed moderate rise in one patient. In one patient (B. S.)a difference of 6i Mm.Hg. in mean arterial pressure in the two positionswas observed.

TABLE IV

EFFECTS OF POSTURAL CHANGE IN PATIENTS WITH SLIGHT DIMINUTION INBLOOD VOLUME AND NORMAL CONTROLS

(GROUP I1)Arterial Pressure Mm. Hg.

Name and Injury Posture

R. W. -Control ............. FlatFoot-upFlat.Head-tup

S. R.-Compound fract. oftibia and fibula ........... Flat

Foot-upFlatHead-up

A. J.-Stab wound of ab-dominal wall ............. Flat

Foot-upFlatHead-up

W. H. -Compound fract. oftibia .................... Flat

Foot-upFlatHead-up

S. R.-Fracture of ribs.Hemothorax .............. Flat

Foot-upFlatHead-up

1. W.-Intestinal obstruction. FlatFoot-up

T. M. - Pneumonectomy ..... FlatFoot-upFlatHead-up

I.N.-Control.............. FlatShockFlatHead-up

(Cuff)Brachial118/80119/80120/84118/84

152/94152/90150/90152/88

108/74109/78110/75108/80

130/73130/73128/76125/70

150/94150/94150/90155/9490/6491/6198/62

100/6297/6299/62

122/7312 1/76122/74118/74

(OpticalManometer)Femoral

134/75138/73139/76147/85

167 /8717 1/91

117/71116/72117/74127/79

154/71150/63150/69151/74

80/4678/41

155/73148/69152/72152/80

Blood VolumePulse Sq. M. B.S.A.Rate

Per Min. Plasma Blood79 1620 25607 57878

94989696

86878689

77727574

9694949211410910811610410447474850

1780 3300

1560 2690

1580 3040

1530 2460

1580 2640

1560 2600

Other changes were also evident when patients were placed in thefoot-up position from the horizontal or returned from the foot-up positionto the horizontal position. One of the most constant and striking ofthese observations was the improvement in mental state when the patientwas placed in the foot-up position. Color and pulse volume frequentlywere seen to improve and sweating to diminish. The response of arterial

29

DUNCAN, SARNOFF AND RHODE Annalsof Sugery

pressure and other findings to the foot-up position progressively diminishedas the blood volume was replaced. Because of the condition of three patients,the initial arterial pressure was determined and other observations were madewith the patients in the foot-up position, after which they were lowered tohorizontal position and the observations repeated.

The effects of the head-up position were observed in ninle patielnts ofthis group. In only three of these did significant fall in arterial pressureoccur. In three patients the pulse rate rose 7 to i2 per minute but showedIno noteworthy clhainge in the remainider of the cases. Some patients whiodid not show a fall in arterial pressure wheni placed in head-up positionishowed a rise to above its previous level wheni returned to the horizontalposition. No striking effect upon other sigins and symptoms of these patientswas noted. The head-up position was purposely avoided in some patieiitsbecause of the condition of the patient-and the evidence of vasomotor labilityexhibited in other positions.

GROUP II: Injury and blood loss were less severe in the patients of thisgroup than in the preceding group. The clinical picture seen in the patientsof Group I was not evident in this group, but some of the symptoms andphysical signs were produced in several of these patients by postural change.In 14 patients (Tables III and IV) injury consisted of soft tissue lacerationin three, multiple rib fracture in two, fracture of the sacrum due to gunshotwound in one, fracture of long bones in five, compound fracture of skullin one, one case of intestilnal obstruction, and one patient who had undergonepneumonectomy and had receivedI IOOO cc. of blood during operation andwhose blood volume was within normal range although arterial pressure wasslightly lowered. Initially, the hematocrit and plasma protein levels werewithin normal range in the patients listed in Table III; however, evidenceof hemodilution occurred in most instances between the initial and finalspecimens. In only three of these patients was replacement therapy carriedout during the period of study, and in two of these three, treatment was givento determine its effect on postural change. In the third, replacement therapywas given because of lowered arterial pressure which persisted for approxi-mately I 2 hours in spite of treatment. This hypotension was probablyrelated to the large quantity of alcohol which the patient had consumedduring the preceding 24 hours.

The foot-up position produced a rise in systolic pressure of io Mm.Hg.in one patient of this group. Examination of the injured extremity in thispatient showed pronounced swelling of the entire thigh and hemarthrosis ofthe knee. Repeated blood sttudies showed hemodilution. When the patientwas again placed in the foot-up positioni a few minutes later, no change inarterial pressure was observed. Diastolic rises of 6 and 7 Mm.Hg. wereobserved in two patients and a fall of 8 Mm. was noted in two others. Nosignificant change in pulse rate was observed, and no significant change inother symptoms and signs was observed in patients of this. group.

The head-nip position produiced sti-iking results in some of the patientts30

Volume 120 POSTURE IN SHOCK AND INJURYNumber 1

of this group. A fall in arterial pressure occurred in seven of eight patientslisted in Table III. The diastolic level fell from 4 to 6o Mm.Hg. in fivepatients, and the pulse rate rose 6 per minute in two patients and fell 4 and6 per minute in two others. The greatest and most frequent changes insystolic pressure, ranging from 7 to 50 Mm.Hg., were noted in six patients.In the seventh patient (J. P.), when the head-up position was assumed, thearterial pressure dropped precipitately to an unobtainable level, the radialpulse became impalpable, the precordial sounds became weak and distant,the heart rate slowed, the patient became comatose, pallor was evident, andsweating immediately became profuse and generalized. Upon resumptionof the horizontal position the patient returned to his previous conditionwithin a few minutes. Similar signs, including pallor, sweating, and narrow-ing of the field of consciousness, occurred in the other patients of this groupwho showed the greatest fall in arterial pressure in the head-up position.They also returned promptly to their previous state upon resumption of thehorizontal position. In the patients listed in Table IV the changes in thehead-up position were not so striking; a rise in femoral pressure wasobserved in one control and in one patient in whom the blood volume wasonly slightly diminished. The difference in the results obtained in the twogroups may be related to the fact that the patients of Table II were seenearlier and observations were made earlier after injury. Five of the eightpatients in Table III and two of those in'Table IV had had alcohol beforeinjury.

DISCUSSION

These observations would seem to be of both practical and theoreticalinterest. The position in which an injured patient is placed is an importantconsideration in the treatment of injuries since pronounced changes maybe rapidly produced in either mild or severe injury by only slight alterationin posture. Differences in response to postural change were observed inmildly injured and more severely injured patients. When patients withinjury and blood loss of moderate severity, or patients with severe injuryand blood loss whose blood volume had been partly replaced, were put in thefoot-up position, signs of improvement resulted. The most consistent effectsnoted were an increase in arterial pressure and improvement in mental state.Other signs of improvement, including diminution in sweating, improvementin color, increase in pulse volume, and decrease in pulse rate, were less con-stantly observed. The response of this group to head-up position was notso striking as in Group II, although its effect was not tried in all cases. Thepatients in the less severely injured group showed little or no response tofoot-up position in most cases, but dramatic effects were observed in someof these patients when they were placed in the head-up position, resultingin, or approaching, a state of collapse or syncope, probably from vasodilata-tion and pooling of blood in dependent areas and resultant cerebral anemia.The condition is similar to the vasomotor collapse produced by Weiss" and

31

DUNCAN, SARNOFF AND RHODE Aalsof Surgery

his associates by postural change following the administration of sodiumnitrite. Alcohol was prolbably contributory in some cases, but three patientswith acute alcoholism, without injury, have failed to show similar response.

Apparently, a state of vasomotor instability exists in the case of injurywhich was not found to be present in 20 normal controls and was seen todiminish and disappear in injured patients when they returned to normal.The degree of this vasomotor instability is indicated by the fact that thecardiovascular responses in these studies have been produced by relativelysmall postural angles as compared with the angles used by other investigatorsin studies in normal persons. The fact that the patients with the most severeinjury and blood loss failed to show this rapid response until the blood volumehad been partly replaced, suggests that vasoconstriction is more complete orconstant and, therefore, less instability can be demonstrated by posturalchange. The angles used in this study are more likely to be encounteredin the handling of injured patients dlurinig treatment or during various diag-nostic procedures.

When it was observed that a differenice in arterial pressure in the hori-zontal and the foot-up positioIn was associated with diminution of blood volum-and was not usually seen to occur in patients with less severe injuries and bloodloss, attempt was made to utilize this observation as a test for blood loss andpossibly for the diagnosis of preclinical or borderline shock. The persistence ofthis difference in arterial pressure, though diminishing until the blood volumehas been replaced, might prove useful in determining when therapy wasadequate, thereby conserving blood and plasma or preventing the reappearanceof signs and symptoms of shock. Considerable emphasis has been placed uponthe need for early diagnosis of shock because the picture from which theclinical diagnosis is usually made is relatively late. In three patients whosubsequently developed the clinical picture of shock (B. S., W.B., R.S.) adefinite difference in arterial pressure was observed in the horizontal andthe foot-up position before the decline in arterial pressure and other signsof shock had appeared. In another patient (P. P.), who had receivedtreatment and in whom clinical signs of shock had disappeared, intra-abdominalhemorrhage continued and a difference in arterial pressure in the two positionswas demonstrated before the fall in arterial pressure and other signs ofshock developed for the second time. This difference has not been observedthus far in patients with hypotension when the blood volume is normal, asevidenced by some of the cases in the accompanying tables. It has beenstated in a preceding paragraph that no response in arterial pressure and inother signs was obtained in patients with the greatest diminution in bloodvolume until the blood volume has been partly replaced. Differences in arterialpressure in the horizontal and the foot-up position could obviously occur inpatients seen soon after injury with evidence of so-called neurogenic shocksince spontaneous rises in arterial pressure may occur. Similar changesmight also be seen in any other patients with wide fluctuations in arterial

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V-olume 120Number 1 POSTURE IN SHOCK AND INJURY

pressure. Further studies will be required to prove the value of this labilityof arterial pressure as an indication of borderline shock or adequacy of treat-ment in the case of frank shock. These studies are being carried out at thepresent time.

SUMMARY

I. The effect of postural change on thirty patients with various degreesof injury is described.

2. Vasomotor instability was demonstrated in injured patients that wasnot present in normal controls and disappeared in injured patients when theyreturned to normal.

3. Different effects were nioted in response to the head-up or the foot-upposition in mild and severe injury or hemorrhage.

4. Some of the beneficial effects of the foot-up position in the treatment ofshock or potential shock as well as some of the adverse effects observed ininjuired patients in the head-uip position are described.

REFERENCES1 Hill, L.: The Influeiice of the Force of Gravity oni the Circulation of the Blood.

J. Physiol., i8, I5, I895.2 Henderson, Y., and Haggard, H. W.: The Circulation in Man in the Head-Down

Position: A Method for Measuring the Venous Return to the Heart. J. Pharma-col. & Exp. Therapeut., ii, I89, 19I8.

3 Cannon, W. B.: Traumatic Shock. New York, 1923, Appleton and Co.4 Porter, W. T.: Shock at the Front. Boston Med. & Surg. Jour., 175, 854, I9I6.

Blalock, A.: Principles of Surgical Care: Shock and Other Problems. St. Louis,1940, C. V. Mosby Co.

Moon, V.: Shock: Its Dynamics, Occurrence and Management. Philadelphia, I942,Lea and Febiger.

7 Asmussen, E., Christensen, E. H., and Nielson, M.: The Regulation of the Circulationin Different Postures. Surgery, 8, 604, I940.

8 Hamilton, W. F., Brewer, G., and Brotman, I.: Pressure Pulse Contours in the IntactAnimal. I-Analytical Description of a High Frequency Manometer. Am. J.Physiol., I07, 427, I934.

9 Barbour, H. G., and Hamilton, W. F.: Blood Specific Gravity: Its Significance anda New Method for Its Determination. Am. J. Physiol., 69, 654, 1924.

10 Weech, A. A., Reeves, E. B., and Goettsch, E.: The Relationship Between SpoificGravity and Protein Content in Plasma, Serum and Transudates from Dogs. Jour.Biol. Chem., II3, i67, I936.

1' Weiss, S., Wilkins, R. W., and Haynes, F. W.: The Nature of Circulatory CollapseInduced by Sodium Nitrite. J. Clin. Inivest., i6, 73, 1937.

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an angle of 30 to 6o degrees in the foot-up and head-ul) positions

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