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Electric shock is also used as a medical therapy, under carefully controlled conditions:
- Electroconvulsive therapy or ECT is a psychiatric therapy for mental illness. The objective of the therapy is to induce a seizure for therapeutic effect. There is no conscious sensation of the electric shock because of the anesthesia used beforehand. Convulsive therapy was introduced in 1934 by Hungarian neuropsychiatrist Ladislas J. Meduna who, believing mistakenly that schizophrenia and epilepsy were antagonistic disorders, induced seizures first with camphor and then metrazol (cardiazol). The first patient was treated by Lucio Bini and Ugo Cerlettiin. ECT is generally administered three times a week for about 8-12 treatments.
- As a surgical tool for cutting or coagulation. An "Electrosurgical Unit" (or ESU) uses high currents (e.g. 10 amperes) at high frequency (e.g. 500 kHz) with various schemes of amplitude modulation to achieve the desired result - cut or coagulate - or both. These devices are safe when used correctly.
- As a treatment for fibrillation or irregular heart rhythms: see defibrillator and cardioversion.
- As a method of pain relief: see Transcutaneous Electrical Nerve Stimulator (more commonly referred to as a TENS unit).
- As an aversive punishment for conditioning of developmentally delayed individuals with severe behavioral problems. This controversial skin-shock method is employed only at the Judge Rotenberg Educational Center, a special needs school in Massachusetts.
- As a treatment for Hyperhidrosis with the device called iontophoresis
- As part of electrodiagnosis diagnostic tests including nerve conduction studies and electromyography.
- For genetic engineering and gene delivery using a non-viral vector system electroporation
Vasopressors may be used if blood pressure does not improve with fluids. There is no evidence of substantial superiority of one vasopressor over another; however, using dopamine leads to an increased risk of arrythmia when compared with norepinephrine. Vasopressors have not been found to improve outcomes when used for hemorrhagic shock from trauma but may be of use in neurogenic shock. Activated protein C (Xigris) while once aggressively promoted for the management of septic shock has been found not to improve survival and is associated with a number of complications. Xigris was withdrawn from the market in 2011, and clinical trials were discontinued. The use of sodium bicarbonate is controversial as it has not been shown to improve outcomes. If used at all it should only be considered if the pH is less than 7.0.
Aggressive intravenous fluids are recommended in most types of shock (e.g. 1–2 liter normal saline bolus over 10 minutes or 20 ml/kg in a child) which is usually instituted as the person is being further evaluated. Which intravenous fluid is superior, colloids or crystalloids, remains undetermined. Thus as crystalloids are less expensive they are recommended. If the person remains in shock after initial resuscitation packed red blood cells should be administered to keep the hemoglobin greater than 100 g/l.
For those with haemorrhagic shock the current evidence supports limiting the use of fluids for penetrating thorax and abdominal injuries allowing mild hypotension to persist (known as permissive hypotension). Targets include a mean arterial pressure of 60 mmHg, a systolic blood pressure of 70–90 mmHg, or until their adequate mentation and peripheral pulses.
Treatment guidelines call for the administration of broad-spectrum antibiotics within the first hour following recognition of septic shock. Prompt antimicrobial therapy is important, as risk of dying increases by approximately 10% for every hour of delay in receiving antibiotics. Time constraints do not allow the culture, identification, and testing for antibiotic sensitivity of the specific microorganism responsible for the infection. Therefore, combination antimicrobial therapy, which covers a wide range of potential causative organisms, is tied to better outcomes.
Among the choices for vasopressors, norepinephrine is superior to dopamine in septic shock. Norepinephrine is the preferred vasopressor, while epinephrine may be added to norepinephrine when needed. Low-dose vasopressin also may be used as an addition to norepinephrine, but is not recommended as a first-line treatment. Dopamine may cause rapid heart rate and arrhythmias, and is only recommended in combination with norepinephrine in those with slow heart rate and low risk of arrhythmia. In the initial treatment of low blood pressure in septic shock, the goal of vasopressor treatment is a mean arterial pressure (MAP) of 65 mm Hg. In 2017, the FDA approved angiotensin II injection for intravenous infusion to increase blood pressure in adults with septic or other distributive shock.
Electroshock weapons are incapacitant weapons used for subduing a person by administering electric shock to disrupt superficial muscle functions. One type is a conductive energy device (CED), an electroshock gun popularly known by the brand name "Taser", which fires projectiles that administer the shock through a thin, flexible wire. Although they are illegal for personal use in many jurisdictions, Tasers have been marketed to the general public. Other electroshock weapons such as stun guns, stun batons ("cattle prods"), and electroshock belts administer an electric shock by direct contact.
Electric fences are barriers that uses electric shocks to deter animals or people from crossing a boundary. The voltage of the shock may have effects ranging from uncomfortable, to painful or even lethal. Most electric fencing is used today for agricultural fencing and other forms of animal control purposes, though it is frequently used to enhance security of restricted areas, and there exist places where lethal voltages are used.
The main goals of treatment in distributive shock are to reverse the underlying cause and achieve hemodynamic stabilization. Immediate treatment involves fluid resuscitation and the use of vasoactive drugs, both vasopressors and inotropes. Hydrocortisone is used for patients whose hypotension does not respond to fluid resuscitation and vasopressors. Opening and keeping open the microcirculation is a consideration in the treatment of distributive shock, as a result limiting the use of vasopressors has been suggested. Control of inflammation, vascular function and coagulation to correct pathological differences in blood flow and microvascular shunting has been pointed to as a potentially important adjunct goal in the treatment of distributive shock.
Patients with septic shock are treated with antimicrobial drugs to treat the causative infection. Some sources of infection require surgical intervention including necrotizing fasciitis, cholangitis, abscess, intestinal ischemia, or infected medical devices.
Anaphylactic shock is treated with epinephrine.
The severity of this disease frequently warrants hospitalization. Admission to the intensive care unit is often necessary for supportive care (for aggressive fluid management, ventilation, renal replacement therapy and inotropic support), particularly in the case of multiple organ failure. The source of infection should be removed or drained if possible: abscesses and collections should be drained. Anyone wearing a tampon at the onset of symptoms should remove it immediately. Outcomes are poorer in patients who do not have the source of infection removed.
Antibiotic treatment should cover both "S. pyogenes" and "S. aureus". This may include a combination of cephalosporins, penicillins or vancomycin. The addition of clindamycin or gentamicin reduces toxin production and mortality.
With proper treatment, people usually recover in two to three weeks. The condition can, however, be fatal within hours.
Culture shock is an experience a person may have when one moves to a cultural environment which is different from one's own; it is also the personal disorientation a person may feel when experiencing an unfamiliar way of life due to immigration or a visit to a new country, a move between social environments, or simply transition to another type of life. One of the most common causes of culture shock involves individuals in a foreign environment. Culture shock can be described as consisting of at least one of four distinct phases: honeymoon, negotiation, adjustment, and adaptation.
Common problems include: information overload, language barrier, generation gap, technology gap, skill interdependence, formulation dependency, homesickness (cultural), infinite regress (homesickness), boredom (job dependency), response ability (cultural skill set). There is no true way to entirely prevent culture shock, as individuals in any society are personally affected by cultural contrasts differently.
CSC should be done as soon as possible when operations permit. Intervention is provided as soon as symptoms appear.
Septic shock is associated with significant mortality and is the leading non cardiac cause of death in intensive care units (ICUs).
Modern front-line combat stress treatment techniques are designed to mimic the historically used PIE techniques with some modification. BICEPS is the current treatment route employed by the U.S. military and stresses differential treatment by the severity of CSR symptoms present in the service member. BICEPS is employed as a means to treat CSR symptoms and return soldiers quickly to combat.
The following BICEPS program is taken from the USMC combat stress handbook:
At first, shell-shock casualties were rapidly evacuated from the front line – in part because of fear of their unpredictable behaviour. As the size of the British Expeditionary Force increased, and manpower became in shorter supply, the number of shell shock cases became a growing problem for the military authorities. At the Battle of the Somme in 1916, as many as 40% of casualties were shell-shocked, resulting in concern about an epidemic of psychiatric casualties, which could not be afforded in either military or financial terms.
Among the consequences of this were an increasing official preference for the psychological interpretation of shell shock, and a deliberate attempt to avoid the medicalisation of shell shock. If men were 'uninjured' it was easier to return them to the front to continue fighting. Another consequence was an increasing amount of time and effort devoted to understanding and treating shell shock symptoms.
By the Battle of Passchendaele in 1917, the British Army had developed methods to reduce shell shock. A man who began to show shell-shock symptoms was best given a few days' rest by his local medical officer. Col. Rogers, RMO 4/Black Watch wrote:
If symptoms persisted after a few weeks at a local Casualty Clearing Station, which would normally be close enough to the front line to hear artillery fire, a casualty might be evacuated to one of four dedicated psychiatric centres which had been set up further behind the lines, and were labelled as "NYDN – Not Yet Diagnosed Nervous" pending further investigation by medical specialists.
Even though the Battle of Passchendaele generally became a byword for horror, the number of cases of shell shock were relatively few. 5,346 shell shock cases reached the Casualty Clearing Station, or roughly 1% of the British forces engaged. 3,963 (or just under 75%) of these men returned to active service without being referred to a hospital for specialist treatment. The number of shell shock cases reduced throughout the battle, and the epidemic of illness was ended.
During 1917, "shell shock" was entirely banned as a diagnosis in the British Army, and mentions of it were censored, even in medical journals.
Specific treatments are not mentioned. The affected person may go to a medical clinic that specializes in sexual health. If no medical problems are found, therapy may be used to help deal with stress, or anxiety medicines may be used.
Disorders, who they affect, and how they affect are different within each culture. In order to diagnose someone, it is necessary to make the effort to understand their home culture. Whether it is a culture bound syndrome or not, a person’s background determines how they see and interpret their own symptoms and how it must be treated.
During the early stages of World War I, soldiers from the British Expeditionary Force began to report medical symptoms after combat, including tinnitus, amnesia, headaches, dizziness, tremors, and hypersensitivity to noise. While these symptoms resembled those that would be expected after a physical wound to the brain, many of those reporting sick showed no signs of head wounds. By December 1914 as many as 10% of British officers and 4% of enlisted men were suffering from "nervous and mental shock".
The term "shell shock" came into use to reflect an assumed link between the symptoms and the effects of explosions from artillery shells. The term was first published in 1915 in an article in "The Lancet" by Charles Myers. Some 60–80% of shell shock cases displayed acute neurasthenia, while 10% displayed what would now be termed symptoms of conversion disorder, including mutism and fugue.
The number of shell shock cases grew during 1915 and 1916 but it remained poorly understood medically and psychologically. Some doctors held the view that it was a result of hidden physical damage to the brain, with the shock waves from bursting shells creating a cerebral lesion that caused the symptoms and could potentially prove fatal. Another explanation was that shell shock resulted from poisoning by the carbon monoxide formed by explosions.
At the same time an alternative view developed describing shell shock as an emotional, rather than a physical, injury. Evidence for this point of view was provided by the fact that an increasing proportion of men suffering shell shock symptoms had not been exposed to artillery fire. Since the symptoms appeared in men who had no proximity to an exploding shell, the physical explanation was clearly unsatisfactory.
In spite of this evidence, the British Army continued to try to differentiate those whose symptoms followed explosive exposure from others. In 1915 the British Army in France was instructed that:
However, it often proved difficult to identify which cases were which, as the information on whether a casualty had been close to a shell explosion or not was rarely provided.
There are three basic outcomes of the Adjustment Phase:
- Some people find it impossible to accept the foreign culture and to integrate. They isolate themselves from the host country's environment, which they come to perceive as hostile, withdraw into an (often mental) "ghetto" and see return to their own culture as the only way out. These "Rejectors" also have the greatest problems re-integrating back home after return.
- Some people integrate fully and take on all parts of the host culture while losing their original identity. This is called cultural assimilation. They normally remain in the host country forever. This group is sometimes known as "Adopters" and describes approximately 10% of expatriates.
- Some people manage to adapt to the aspects of the host culture they see as positive, while keeping some of their own and creating their unique blend. They have no major problems returning home or relocating elsewhere. This group can be thought to be cosmopolitan. Approximately 30% of expats belong to this group.
Culture shock has many different effects, time spans, and degrees of severity. Many people are handicapped by its presence and do not recognize what is bothering them.
This disorder may resolve itself with time or may develop into a more severe disorder such as PTSD. However, results of Creamer, O'Donnell, and Pattison's (2004) study of 363 patients suggests that a diagnosis of acute stress disorder had only limited predictive validity for PTSD. Creamer et al. did find that re-experiences of the traumatic event and arousal were better predictors of PTSD. Early pharmacotherapy may prevent the development of posttraumtic symptoms.
Studies have been conducted to assess the efficacy of counselling and psychotherapy for people with ASD. Cognitive behavioral therapy which included exposure and cognitive restructuring was found to be effective in preventing PTSD in patients diagnosed with ASD with clinically significant results at 6 months follow-up. A combination of relaxation, cognitive restructuring, imaginal exposure, and in vivo exposure was superior to supportive counseling. Mindfulness based stress reduction programs also appear to be effective for stress management.
In a wilderness context where counseling, psychotherapy, and cognitive behavioral therapy is unlikely to be available, the treatment for acute stress reaction is very similar for the treatment of cardiogenic shock, vascular shock, and hypovolemic shock; that is, allowing the patient to lie down, providing reassurance, and removing the stimulus for the occurrence of the reaction. In traditional shock cases, this is generally the relieving of pain from injuries or the stopping of blood loss. In an acute stress reaction, this may be pulling a rescuer away from the emergency to calm down, or blocking the sight of an injured friend from a patient.
Emergency oxygen should be immediately employed to increase the efficiency of the patient's remaining blood supply. This intervention can be life-saving.
The use of intravenous fluids (IVs) may help compensate for lost fluid volume, but IV fluids cannot carry oxygen in the way that blood can; however, blood substitutes are being developed which can. Infusion of colloid or crystalloid IV fluids will also dilute clotting factors within the blood, increasing the risk of bleeding. It is current best practice to allow permissive hypotension in patients suffering from hypovolemic shock, both to ensure clotting factors are not overly diluted and also to stop blood pressure being artificially raised to a point where it "blows off" clots that have formed.
General anaesthesia is recommended for people with sepsis who require surgical procedures to remove the infective source. Inhalational and intravenous anaesthetics are used. Requirements for anaesthetics may be reduced. Inhalational anaesthetics can reduce the level of proinflammatory cytokines, altering leukocyte adhesion and proliferation, inducing apoptosis (cell death) of the lymphocytes, possibly with a toxic effect on mitochondrial function. Although etomidate has a minimal effect on the cardiovascular system, it is often not recommended as a medication to help with intubation in this situation due to concerns it may lead to poor adrenal function and an increased risk of death. The small amount of evidence there is, however, has not found a change in the risk of death with etomidate.
It is recommended that the head of the bed be raised if possible to improve ventilation. Paralytic agents should be avoided unless ARDS is suspected.
If the person has been sufficiently fluid resuscitated but the mean arterial pressure is not greater than 65 mmHg, vasopressors are recommended. Norepinephrine (noradrenaline) is recommended as the initial choice. If a single vasopressor is not enough to raise the blood pressure, epinephrine (adrenaline) or vasopressin may be added. Dopamine is typically not recommended. Dobutamine may be used if heart function is poor or blood flow is insufficient despite sufficient fluid volumes and blood pressure.
Fluid replacement is beneficial in hypovolemia of stage 2, and is necessary in stage 3 and 4. See also the discussion of shock and the importance of treating reversible shock while it can still be countered.
For a patient presenting with hypovolemic shock in hospital the following investigations would be carried out:
- Blood tests: U+Es/Chem7, full blood count, glucose, blood type and screen
- Central venous catheter or blood pressure
- Arterial line or arterial blood gases
- Urine output measurements (via urinary catheter)
- Blood pressure
- SpO2 Oxygen saturations
The following interventions would be carried out:
- IV access
- Oxygen as required
- Surgical repair at sites of hemorrhage
- Inotrope therapy (Dopamine, Noradrenaline) which increase the contractility of the heart muscle
- Fresh frozen plasma or whole blood
Vasopressors (like Norepinephrine, Dobutamine) should generally be avoided, as they may result in further tissue ischemia and don't correct the primary problem. Fluids are the preferred choice of therapy.
Beard, with his partner A.D. Rockwell, advocated first electrotherapy and then increasingly experimental treatments for people with neurasthenia, a position that was controversial. An 1868 review posited that Beard's and Rockwell's knowledge of the scientific method was suspect and did not believe their claims to be warranted.
William James was diagnosed with neurasthenia, and was quoted as saying, "I take it that no man is educated who has never dallied with the thought of suicide."
In 1895, Sigmund Freud reviewed electrotherapy and declared it a "pretense treatment." He emphasized the example of Elizabeth von R's note that "the stronger these were the more they seemed to push her own pains into the background."
Nevertheless, neurasthenia was a common diagnosis during World War I for "shell shock", but its use declined a decade later. Soldiers who deserted their post could be executed even if they had a medical excuse, but officers who had neurasthenia were not executed.
Depending on the severity of the patient's state, the management of peritonitis may include:
- General supportive measures such as vigorous intravenous rehydration and correction of electrolyte disturbances.
- Antibiotics are usually administered intravenously, but they may also be infused directly into the peritoneum. The empiric choice of broad-spectrum antibiotics often consist of multiple drugs, and should be targeted against the most likely agents, depending on the cause of peritonitis (see above); once one or more agents are actually isolated, therapy will of course be target on them.
- Gram positive and gram negative organisms must be covered. Out of the cephalosporins, cefoxitin and cefotetan can be used to cover gram positive bacteria, gram negative bacteria, and anaerobic bacteria. Beta-lactams with beta lactamase inhibitors can also be used, examples include ampicillin/sulbactam, piperacillin/tazobactam, and ticarcillin/clavulanate. Carbapenems are also an option when treating primary peritonitis as all of the carbapenems cover gram positives, gram negatives, and anaerobes except for ertapenem. The only fluoroquinolone that can be used is moxifloxacin because this is the only fluoroquinolone that covers anaerobes. Finally, tigecycline is a tetracycline that can be used due to its coverage of gram positives and gram negatives. Empiric therapy will often require multiple drugs from different classes.
- Surgery (laparotomy) is needed to perform a full exploration and lavage of the peritoneum, as well as to correct any gross anatomical damage that may have caused peritonitis. The exception is spontaneous bacterial peritonitis, which does not always benefit from surgery and may be treated with antibiotics in the first instance.
Depending on the type of cardiogenic shock, treatment involves infusion of fluids, or in shock refractory to fluids, inotropic medications. In case of an abnormal heart rhythm several anti-arrhythmic agents may be administered, e.g. adenosine.
Positive inotropic agents (such as dobutamine or milrinone), which enhance the heart's pumping capabilities, are used to improve the contractility and correct the low blood pressure. Should that not suffice an intra-aortic balloon pump (which reduces workload for the heart, and improves perfusion of the coronary arteries) or a left ventricular assist device (which augments the pump-function of the heart) can be considered. Finally, as a last resort, if the person is stable enough and otherwise qualifies, heart transplantation, or if not eligible an artificial heart, can be placed. These invasive measures are important tools- more than 50% of patients who do not die immediately due to cardiac arrest from a lethal abnormal heart rhythm and live to reach the hospital (who have usually suffered a severe acute myocardial infarction, which in itself still has a relatively high mortality rate), die within the first 24 hours. The mortality rate for those still living at time of admission who suffer complications (among others, cardiac arrest or further abnormal heart rhythms, heart failure, cardiac tamponade, a ruptured or dissecting aneurysm, or another heart attack) from cardiogenic shock is even worse around 85%, especially without drastic measures such as ventricular assist devices or transplantation.
Cardiogenic shock may be treated with intravenous dobutamine, which acts on β receptors of the heart leading to increased contractility and heart rate.