The beginning student often erroneously believes that the heart is the sole determinant of cardiac output. In Chapter 14, we learned that the peripheral circulation also plays an important governing role in the circulation. The peripheral circulation controls the filling pressure of the heart as well as its afterload, two major determinants of the stroke volume. This interaction between the heart and the periphery is vividly illustrated by the shock syndrome. In its simplest form, circulatory shock can occur whenever the cardiac output is inadequate to meet the needs of the periphery. If this continues, the peripheral tissues will incur ischemic injury that will trigger a vicious cycle of events leading to circulatory collapse; this sequence of events is outlined in Fig. 4. Although war has been the scourge of mankind over his entire recorded existence, one benefit of war has been to provide physicians with large numbers of patients in hemorrhagic and traumatic shock to study. As a result, most of the advances in treatment have occurred during such conflicts. To illustrate how far our ability to treat circulatory shock has progressed, at the start of World War I the mortality rate for patients with a fractured femur was 70%, with virtually all of these deaths being due to circulatory shock. A death from such a fracture in a young man would be rare today.
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