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Tension gastrothorax is a form of obstructive shock resulting from increased intrathoracic pressure due to a distended herniated stomach. The clinical features of tension gastrothorax are similar to the clinical features of the more common tension pneumothorax. Clinical recognition of this trauma has remained difficult especially in the tropics where most responders are not specialists. We managed a 31-year-old male who, in addition to typical features of obstructive shock secondary to increased intrathoracic pressures, had a recent meal prior to the trauma and a scaphoid abdomen at presentation. We argue that a history of a recent meal before trauma and an unusually scaphoid abdomen could be suggestive of tension gastrothorax and may help to differentiate it from tension pneumothorax. We recommend improved emergency preparedness to help recognise and treat this pathology.

Background: Fluid resuscitation is a fundamental intervention in patients with hypovolemic shock resulting from trauma. Appropriate fluid resuscitation in trauma patients could reduce organ failure, until blood components are available, and hemorrhage is controlled. We conducted a systematic review and meta-analysis assessing the effect of hypertonic saline/dextran or hypertonic saline for fluid resuscitation on patient outcomes restricted to adults with hypovolemic shock. Methods: We conducted a search of electronic information sources, including PubMed, Embase, Web of Science, Cochrane library and bibliographic reference lists to identify all randomized controlled trials (RCTs) investigating outcomes of crystalloids versus colloids in patients with hypovolemic shock. We calculated the risk ratio (RR) or mean difference (MD) of groups using fixed or random-effect models. Results: Fifteen studies including 3264 patients met our inclusion criteria. Survival to hospital discharge rate between research groups varied and amounted to 71.2% in hypertonic saline/dextran group vs. 68.4% for isotonic/normotonic fluid (NS) solutions (odds ratio [OR] = 1.19; 95% confidence interval [CI] 0.97–1.45; I 2 = 48%; p = 0.09). 28- to 30-days survival rate for hypertonic fluid solutions was 72.8% survivable, while in the case of isotonic fluid (NS) — 71.4% (OR = 1.13; 95% CI 0.75–1.70; I 2 = 43%; p = 0.56). Conclusions: This systematic review and meta-analysis, which included only evidence from RCTs hypertonic saline/dextran or hypertonic saline compared with isotonic fluid did not result in superior 28- to 30-day survival as well as in survival to hospital discharge. However, patients with hypotension who received resuscitation with hypertonic saline/dextran had less overall mortality as patients who received conventional fluid.

This is a case of a 47-year-old woman with a spontaneous haemoperitoneum secondary to uterine leiomyomas (fibroids), an important differential diagnosis in patients with uterine fibroids and hypovolaemic shock. Uterine fibroids are very common in women of reproductive age, yet little is taught about their potential to cause hypovolaemic shock. Although it is a rare complication, given the prevalence of fibroids, it is important to bear this life-threatening differential in mind to optimise the care for these women. Presentation typically involves abdominal pain, syncope, haemodynamic instability and an intra-abdominal mass. CT of the abdomen and pelvis can be helpful in identifying the source of the haemoperitoneum, but should not delay surgery, which is the definitive management.

Background Shock affects one-third of patients admitted to intensive care and is associated with increased mortality. Vasopressor medications are used to maintain blood pressure in shock. Central venous catheters are associated with serious complications and pose logistical difficulties for insertion. Delivery of vasopressors via peripheral intravenous cannula may be a safe alternative. Methods This is a retrospective cohort study comparing safety profile and outcomes of vasopressor delivery via peripheral and central routes in critically ill patients over a 12-month period in a mixed medical-surgical intensive care unit. Demographics, clinical characteristics, treatments, and safety outcome data were extracted from medical records. Patients were classified into three groups: vasopressor infusions via peripheral intravenous cannula, combined peripheral intravenous cannula followed by central venous catheter, and central venous catheter only. Groups were compared using the Kruskal–Wallis test for continuous variables and Fisher's exact test for categorical variables. The impact of duration of vasopressor infusion on complication rates was assessed using logistic regression. Results We identified 212 patients who received vasopressor infusion, 39 received via peripheral only (Group 1), 155 via peripheral followed by central (Group 2), and 18 via central only (Group 3). There were some baseline differences between groups. Group 1 had the lowest median Acute Physiology and Chronic Health Evaluation III score (64, interquartile range = 44–77), and Group 3, the highest (86, interquartile range = 57–101). Duration of vasopressor infusion was shortest in Group 1 and longer in Groups 2 and 3. There were no major complications; however, minor complications such as leakage, extravasation, and erythema occurred in 41% of Group 1 and 28% of Group 2 patients. Duration of peripheral vasopressor infusion was not associated with an increased risk of complications. Conclusions Administration of vasopressor infusions for short duration in critically ill patients via a peripheral venous cannula may be feasible, with low rates of complications, and offers a safe alternative to central venous access.

Background Non-operative management (NOM) is the standard of care for the majority of children with blunt liver and spleen injuries (BLSI). The shock index pediatric age-adjusted (SIPA) was previously shown to predict the need for blood transfusions in pediatric trauma patients with BLSI. We combined SIPA with base deficit (BD) and International Normalized Ratio (INR) to create the BIS score. We hypothesized that the BIS score would predict the need for blood transfusions and/or failure of NOM in pediatric trauma patients with BLSI. Methods Patients (≤ 18 years) who presented to our Level I pediatric trauma center with BLSI from 2009 to 2019 were identified. BIS scores were calculated by giving 1 point for each of the following: base deficit ≤ -8.8, INR ≥ 1.5, or elevated SIPA. Receiver operating characteristic curves (ROC) were generated for BIS scores ≥ 1, ≥ 2, and ≥ 3. Area under the curve (AUC), sensitivity, and specificity of each score were calculated for ability to predict need for blood transfusions and/or failure of NOM. Results Of 477 children included, 19.9% required a blood transfusion and 6.7% failed NOM. A BIS score ≥ 1 was the best predictor of the need for blood transfusions with an AUC of 0.81 and a sensitivity of 96.0%. A BIS score ≥ 1 was also the best predictor of failure of NOM with an AUC of 0.72 and a sensitivity of 97.0%. Conclusion The BIS score is a highly sensitive tool that identifies pediatric patients with BLSI at risk for blood transfusions and/or failure of NOM. Level of evidence Level III. Type of study Retrospective comparative study.

BACKGROUND/PURPOSE The utility of thrombelastography (TEG) in pediatric trauma remains unknown, and differences in coagulopathy between blunt and penetrating mechanisms are not established. We aimed to compare TEG patterns in pediatric trauma patients with blunt solid organ injuries (BSOI) and penetrating injuries to determine the role of mechanism in coagulopathy. METHODS Highest-level pediatric trauma activations with BSOI or penetrating injuries and admission TEG at two pediatric trauma centers were included. TEG abnormalities were defined by each institution's normative values and compared separately by injury mechanism and evidence of shock (elevated SIPA) using Kruskal-Wallis or Fisher's exact tests. RESULTS Of 118 patients included, 64 had BSOI and 54 had penetrating injuries. There were no significant differences in TEG abnormalities between the BSOI and penetrating injury groups. Patients with shock were more likely to have decreased alpha-angles (30.9% vs. 8.0%, p = 0.01) and decreased maximum amplitude (MA) (44.1% vs. 8.0%, p

Background: The ideal timing of a durable assist device implantation in patients with end-stage heart failure presenting with INTERMACS profile I is still controversial. The data on extracorporeal life support (ECLS) bridge to durable left ventricular assist device (LVAD) in these patients is limited. Materials and methods: We retrospectively analyzed the outcomes of 35 patients in acute cardiogenic shock (CS) who, between December 2013 and September 2020, were bridged with ECLS to durable LVAD. The mean age was 52.3 ± 12.0 years. The primary endpoints of this study were in-hospital, 30-day, 6-month, and 1-year mortality. The secondary endpoint was the development of any postoperative adverse events and other characteristics during the follow-up period. We also assessed the impact of the rescue ECLS on the recovery of the end-organ function. Results: In-hospital, 30-day, 6-month, and 1-year survival was 65.6%, 75.9%, 69.2%, and 62.7% respectively. The median time on ECLS was 7 days (IQR 5.0–13.0). We observed a high incidence of a severe right heart failure (22.9%), acute kidney injury on dialysis (68.6%), and respiratory failure (77.1%). Bridge with ECLS provided a significant recovery of liver and kidney function prior to durable LVAD implantation. Conclusion: The concept of bridging patients presenting in end-stage heart failure and cardiogenic shock with ECLS prior to durable LVAD implantation is a feasible method to ensure acceptable survival rates and significant recovery of the end-organ function.

Background Neutropenic enterocolitis is uncommon but potentially life-threatening, with the cornerstone of treatment being medical management (MM), and surgical intervention reserved for clinical deterioration or bowel perforation. We hypothesized that the Shock Index Pediatric Age-Adjusted (SIPA) is elevated in patients who are at greatest risk for surgical intervention and mortality. We also sought to identify computed tomography (CT) findings associated with surgical intervention and mortality. Methods A single-center cancer registry was reviewed for neutropenic enterocolitis patients from 2006 -2018. Survival models compared patients with normal versus elevated SIPA throughout their hospitalizations for the time to surgical management (SM), as well as in-hospital mortality. Results Seventy-four patients with neutropenic enterocolitis were identified; 7 underwent surgery. In-hospital mortality was 12% in MM and 29% in SM; mortality among patients with elevated SIPA was 4.7 times higher compared to those with normal SIPA (95% CI: 1.1, 19.83, p = 0.04). CT findings of bowel obstruction, pneumatosis, and a greater percentage of large bowel involvement were associated with surgical intervention (all ps Conclusion Select pre-operative CT findings were associated with need for operative management. Elevated SIPA was associated with increased mortality. Elevated SIPA in pediatric cancer patients with neutropenic enterocolitis may help to identify those with more severe disease and expedite beneficial interventions.

We herein report a case of mitochondrial disease with heart and intestinal tract involvement resulting in hemodynamic collapse. A 66-year-old woman was transferred to our hospital because of cardiogenic shock. Vasopressors were administered, and a circulatory support device was deployed. However, her hemodynamics did not improve sufficiently, and we detected abdominal compartment syndrome caused by the aggravation of chronic intestinal pseudo-obstruction as a complication. Insertion of a colorectal tube immediately decreased the intra-abdominal pressure, improving the hemodynamics. Finally, we diagnosed her with mitochondrial disease, concluding that the resulting combination of acute heart failure and abdominal compartment syndrome had aggravated the hemodynamics.

Background In non-traumatic respiratory failure, pre-hospital application of CPAP reduces the need for intubation. Primary blast lung injury (PBLI) accompanied by haemorrhagic shock is common after mass casualty incidents. We hypothesised that pre-hospital CPAP is also beneficial after PBLI accompanied by haemorrhagic shock. Methods We performed a computer-based simulation of the cardiopulmonary response to PBLI followed by haemorrhage, calibrated from published controlled porcine experiments exploring blast injury and haemorrhagic shock. The effect of different CPAP levels was simulated in three in silico patients who had sustained mild, moderate, or severe PBLI (10%, 25%, 50% contusion of the total lung) plus haemorrhagic shock. The primary outcome was arterial partial pressure of oxygen (Pao2) at the end of each simulation. Results In mild blast lung injury, 5 cm H2O ambient-air CPAP increased Pao2 from 10.6 to 12.6 kPa. Higher CPAP did not further improve Pao2. In moderate blast lung injury, 10 cm H2O CPAP produced a larger increase in Pao2 (from 8.5 to 11.1 kPa), but 15 cm H2O CPAP produced no further benefit. In severe blast lung injury, 5 cm H2O CPAP inceased Pao2 from 4.06 to 8.39 kPa. Further increasing CPAP to 10–15 cm H2O reduced Pao2 (7.99 and 7.90 kPa, respectively) as a result of haemodynamic impairment resulting from increased intrathoracic pressures. Conclusions Our modelling study suggests that ambient air 5 cm H2O CPAP may benefit casualties suffering from blast lung injury, even with severe haemorrhagic shock. However, higher CPAP levels beyond 10 cm H2O after severe lung injury reduced oxygen delivery as a result of haemodynamic impairment.

Accurate assessment of blood pressure is fundamental to the provision of safe obstetrical care. It is simple, cost effective, and life-saving. Treatments for preeclampsia, including antihypertensive drugs, magnesium sulfate, and delivery, are available in many settings. However, the instigation of appropriate treatment relies on prompt and accurate recognition of hypertension. There are a number of different techniques for blood pressure assessment, including the auscultatory method, automated oscillometric devices, home blood pressure monitoring, ambulatory monitoring, and invasive monitoring. The auscultatory method with a mercury sphygmomanometer and the use of Korotkoff sounds was previously recommended as the gold standard technique. Mercury sphygmomanometers have been withdrawn owing to safety concerns and replaced with aneroid devices, but these are particularly prone to calibration errors and regular calibration is imperative to ensure accuracy. Automated oscillometric devices are straightforward to use, but the physiological changes in healthy pregnancy and pathologic changes in preeclampsia may affect the accuracy of a device and monitors must be validated. Validation protocols classify pregnant women as a "special population," and protocols must include 15 women in each category of normotensive pregnancy, hypertensive pregnancy, and preeclampsia. In addition to a scarcity of devices validated for pregnancy and preeclampsia, other pitfalls that cause inaccuracy include the lack of training and poor technique. Blood pressure assessment can be affected by maternal position, inappropriate cuff size, conversation, caffeine, smoking, and irregular heart rate. For home blood pressure monitoring, appropriate instruction should be given on how to use the device. The classification of hypertension and hypertensive disorders of pregnancy has recently been revised. These are classified as preeclampsia, transient gestational hypertension, gestational hypertension, white-coat hypertension, masked hypertension, chronic hypertension, and chronic hypertension with superimposed preeclampsia. Blood pressure varies across gestation and by ethnicity, but gestation-specific thresholds have not been adopted. Hypertension is defined as a sustained systolic blood pressure of ≥140 mm Hg or a sustained diastolic blood pressure of ≥90 mm Hg. In some guidelines, the threshold of diagnosis depends on the setting in which blood pressure measurement is taken, with a threshold of 140/90 mm Hg in a healthcare setting, 135/85 mm Hg at home, or a 24-hour average blood pressure on ambulatory monitoring of >126/76 mm Hg. Some differences exist among organizations with respect to the criteria for the diagnosis of preeclampsia and the correct threshold for intervention and target blood pressure once treatment has been instigated. Home blood pressure monitoring is currently a focus for research. Novel technologies, including early warning devices (such as the CRADLE Vital Signs Alert device) and telemedicine, may provide strategies that prompt earlier recognition of abnormal blood pressure and therefore improve management. The purpose of this review is to provide an update on methods to assess blood pressure in pregnancy and appropriate technique to optimize accuracy. The importance of accurate blood pressure assessment is emphasized with a discussion of preeclampsia prediction and treatment of severe hypertension. Classification of hypertensive disorders and thresholds for treatment will be discussed, including novel developments in the field.

Objective Organ donation after circulatory death (DCD) is a potential solution for the shortage of suitable organs for transplant. Heart transplantation using DCD donors is not frequently performed due to the potential myocardial damage following warm ischemia. Heat shock protein (HSP) 90 has recently been investigated as a novel target to reduce ischemia/reperfusion injury. The objective of this study is to evaluate an innovative HSP90 inhibitor (HSP90i) as a cardioprotective agent in a model of DCD heart. Methods A DCD protocol was initiated in anesthetized Lewis rats by discontinuation of ventilation and confirmation of circulatory death by invasive monitoring. Following 15 minutes of warm ischemia, cardioplegia was perfused for 5 minutes at physiological pressure. DCD hearts were mounted on a Langendorff ex vivo heart perfusion system for reconditioning and functional assessment (60 minutes). HSP90i (0.01 μmol/L) or vehicle was perfused in the cardioplegia and during the first 10 minutes of ex vivo heart perfusion reperfusion. Following assessment, pro-survival pathway signaling was evaluated by western blot or polymerase chain reaction. Results Treatment with HSP90i preserved left ventricular contractility (maximum + dP/dt, 2385 ± 249 vs 1745 ± 150 mm Hg/s), relaxation (minimum –dP/dt, –1437 ± 97 vs 1125 ± 85 mm Hg/s), and developed pressure (60.7 ± 5.6 vs 43.9 ± 4.0 mm Hg), when compared with control DCD hearts (All P = .001). Treatment abrogates ischemic injury as demonstrated by a significant reduction of infarct size (2,3,5-triphenyl-tetrazolium chloride staining) of 7 ± 3% versus 19 ± 4% (P = .03), troponin T release, and mRNA expression of Bax/Bcl-2 (P Conclusions The cardioprotective effects of HSP90i when used following circulatory death might improve transplant organ availability by expanding the use of DCD hearts.

Aims To assess differences in long-term outcome and functional status of patients with cardiogenic shock (CS) treated by percutaneous mechanical circulatory support (pMCS) and intra-aortic balloon pump (IABP). Methods and results Long-term follow-up of the multicentre, randomized IMPRESS in Severe Shock trial (NTR3450) was performed 5-year after initial randomization. Between 2012 and 2015, a total of 48 patients with severe CS from acute myocardial infarction (AMI) with ST-segment elevation undergoing immediate revascularization were randomized to pMCS by Impella CP (n = 24) or IABP (n = 24). For the 5-year assessment, all-cause mortality, functional status, and occurrence of major adverse cardiac and cerebrovascular event (MACCE) were assessed. MACCE consisted of death, myocardial re-infarction, repeat percutaneous coronary intervention, coronary artery bypass grafting, and stroke. Five-year mortality was 50% (n = 12/24) in pMCS patients and 63% (n = 15/24) in IABP patients (relative risk 0.87, 95% confidence interval 0.47–1.59, P = 0.65). MACCE occurred in 12/24 (50%) of the pMCS patients vs. 19/24 (79%) of the IABP patients (P = 0.07). All survivors except for one were in New York Heart Association Class I/II [pMCS n = 10 (91%) and IABP n = 7 (100%), P = 1.00] and none of the patients had residual angina. There were no differences in left ventricular ejection fraction between the groups (pMCS 52 ± 11% vs. IABP 48 ± 10%, P = 0.53). Conclusions In this explorative randomized trial of patients with severe CS after AMI, there was no difference in long-term 5-year mortality between pMCS and IABP-treated patients, supporting previously published short-term data and in accordance with other long-term CS trials., Graphical Abstract

Objectives: Procalcitonin (PCT) is an early diagnosis marker of sepsis/bacteremia. However, some reports refer to its lower responsiveness to gram-positive bacteremia. We retrospectively evaluated the PCT values at the onset of bacteremia in relation to severity index. Methods: Patients with bacteremia caused by two gram-negative bacteria (46 E. coli and 50 Klebsiella pneumoniae) and three gram-positive bacteria (45 S. aureus, 56 S. epidermidis, and 10 S. mitis) were studied. The plasma PCT and C-reactive protein (CRP) levels were compared between species and different Sequential Organ Failure Assessment (SOFA) score groups. Results: The median PCT level was higher in gram-negative than in gram-positive bacteremia in overall (13.09 vs. 0.50 ng/mL, p

Graphical abstract, Highlights • McConnell’s sign may be an early sign of acute RV strain in amniotic fluid embolus. • TTE could be considered to facilitate timely diagnosis of amniotic fluid embolus. • The presence of RV dysfunction on TTE may help guide hemodynamic therapies.

Cardiogenic shock (CS) is a complex multifactorial clinical syndrome, developing as a continuum, and progressing from the initial insult (underlying cause) to the subsequent occurrence of organ failure and death. There is a large phenotypic variability in CS, as a result of the diverse aetiologies, pathogenetic mechanisms, haemodynamics, and stages of severity. Although early revascularization remains the most important intervention for CS in settings of acute myocardial infarction, the administration of timely and effective antithrombotic therapy is critical to improving outcomes in these patients. In addition, other clinical settings or non‐acute myocardial infarction aetiologies, associated with high thrombotic risk, may require specific regimens of short‐term or long‐term antithrombotic therapy. In CS, altered tissue perfusion, inflammation, and multi‐organ dysfunction induce unpredictable alterations to antithrombotic drugs' pharmacokinetics and pharmacodynamics. Other interventions used in the management of CS, such as mechanical circulatory support, renal replacement therapies, or targeted temperature management, influence both thrombotic and bleeding risks and may require specific antithrombotic strategies. In order to optimize safety and efficacy of these therapies in CS, antithrombotic management should be more adapted to CS clinical scenario or specific device, with individualized antithrombotic regimens in terms of type of treatment, dose, and duration. In addition, patients with CS require a close and appropriate monitoring of antithrombotic therapies to safely balance the increased risk of bleeding and thrombosis.

Background: Very low birth weight infants are at increased risk of language, cognition delay and also hearing impairment disorder. Identification is essential for early intervention. Aims and Objectives: To estimate the burden of language, cognition delay and hearing impairment at 24 months of corrected gestation and to test the association of examination at 6 months and 12 months with the language and cognitive outcome of very low birth weight (VLBW) infants at 24 months and to identify the perinatal and neonatal risk factors for atypical outcome. Materials and Methods: It is a prospective cohort study. Consecutive 120 VLBW infants were enrolled in a single centre level III neonatal unit of a teaching hospital. Hearing assessment was done before discharge and 3 monthly. Language and cognitive assessment was done by DASII Scale neu at 6 months and BSIDIII Scale at 12 months and 24 months at neurodevelopmental clinic. Language assessment was further done by REELS-3 Subscale at 24 months. All assessment ages were corrected for prematurity. Results: At 24 months 7.8% infants developed Language delay and 4.7% had cognition delay. Four infants developed cerebral palsy at 24 months. Shock in neonatal period had significant association with suboptimal Hearing, Language and Cognitive outcome at 12 months of corrected gestation. Conclusion: Early anticipation and early identification of abnormal hearing, language and cognitive outcome of VLBW infants can be used as simple and cost-effective measures for preventing long-term morbidity at resource limited countries.

Purpose To evaluate whether echocardiographic assessment using the subcostal-only window (EASy) compared with focused transthoracic echocardiography (FTTE) using three windows (parasternal, apical, and subcostal) can provide critical information to serve as an entry-point technique for novice sonographers. Methods We conducted a retrospective study to compare diagnostic information acquired during EASy and FTTE examinations on qualitative left ventricular (LV) size, LV contractility, right ventricular (RV) size, RV contractility, interventricular septal position, and the presence of a significant pericardial effusion. Anesthesiology residents (novice users) performed FTTE for hemodynamic instability and/or respiratory distress or to define volume status in the perioperative setting, and later collected images were grouped into EASy and FTTE examinations. Both examinations were reviewed independently by a board-certified cardiologist and an anesthesiologist proficient in critical care echocardiography. FTTE and EASy findings were compared utilizing Gwet’s AC1 coefficient to consider disagreement due to chance. Results We reviewed 102 patients who received FTTE over a period of 14 months. Of those, 82 had usable subcostal views and were included in the analysis. There was substantial agreement for qualitatively evaluating RV size (Gwet’s AC1, 0.70; 95% confidence interval [CI], 0.54 to 0.85), LV size (Gwet’s AC1, 0.73; 95% CI, 0.58 to 0.88), and LV contractility (Gwet’s AC1, 0.73; 95% CI, 0.58 to 0.88) utilizing EASy and FTTE. Additionally, there was an almost perfect agreement when assessing the presence of pericardial effusion (Gwet’s AC1, 0.98; 95% CI, 0.95 to 1.0) and RV contractility (Gwet’s AC1, 0.84; 95% CI, 0.74 to 0.95) and evaluating the motion of the interventricular septum (Gwet’s AC1, 0.92; 95% CI, 0.85 to 0.99). Conclusions When images could be obtained from the subcostal window (the EASy examination), qualitative diagnostic information was sufficiently accurate compared with information obtained during FTTE examination. Our findings suggest that the EASy examination can serve as the entry point technique to FTTE for novice clinicians. Supplementary Information The online version contains supplementary material available at 10.1007/s12630-021-02152-6.

OBJECTIVES To study the incidence, clinical profile, and predictors of mortality in neonatal shock. METHODS We enrolled consecutive inborn neonates, who developed shock during hospital stay (between 1st January 2018 to 31st December 2019) at a tertiary-care, research center of northern India. We retrieved the clinical data from our electronic database, case record files, nursing charts, and laboratory investigations from the hospital's Health Information System. Non-survivors were compared with survivors to identify independent predictors of mortality. RESULTS We had 3271 neonatal admissions during the study period. We recorded 415 episodes of neonatal shock in 392 neonates [incidence 12.0% (95% confidence interval: 10.9- 13.2%)]. Of 415 episodes, 237 (57%) episodes were identified as septic shock, 67 (16%) episodes as cardiogenic shock, and six (1.4%) episodes as obstructive shock. Remaining 105 (25%) episodes were contributed by more than one etiology of shock. There were 242 non-survivors among 392 neonates with shock (case fatality rate: 62%). On univariate analysis, gestational age, birth weight, incidence of hyaline membrane disease, early-onset sepsis, Acinetobacter sepsis, and cardiogenic shock were significantly different between survivors and non-survivors. Female gender and small for gestational age (SGA) neonates showed a trend of significance. On multivariable regression analysis, we found gestational age, SGA neonates, female gender, and Acinetobacter sepsis to have an independent association with mortality. CONCLUSIONS Septic shock was the commonest cause of neonatal shock at our center. Neonatal shock had very high case fatality rate. Gestational age, SGA, female gender, and Acinetobacter sepsis independently predicted mortality in neonatal shock.

Physiologic-based management of hemodynamic instability is proven to guide the logical selection of cardiovascular support and shorten the time to clinical recovery compared to an empiric approach that ignores the heterogeneity of the hemodynamic instability related mechanisms. In this report, we classified neonatal hemodynamic instability, circulatory shock, and degree of compensation into five physiologic categories, based on different phenotypes of blood pressure (BP), other clinical parameters, echocardiography markers, and oxygen indices. This approach is focused on hemodynamic instability in infants with normal cardiac anatomy.Conclusion: The management of hemodynamic instability is challenging due to the complexity of the pathophysiology; integrating different monitoring techniques is essential to understand the underlying pathophysiologic mechanisms and formulate a physiologic-based medical recommendation and approach. What is Known: • Physiologic-based assessment of hemodynamics leads to targeted and pathophysiologic-based medical recommendations. What is New: • Hemodynamic instability in neonates can be categorized according to the underlying mechanism into five main categories, based on blood pressure phenotypes, systemic vascular resistance, and myocardial performance. • The new classification helps with the targeted management and logical selection of cardiovascular support.

Sport participation is an important part of the development, both physically and mentally, of children and adolescents in the United States. Illness and injury associated with sport and physical activities may occur in the school setting. Although most sport-related illness and injury in students are considered minor emergencies, life-threatening illnesses or injuries may occur. It is important for the school nurse to recognize potential life-threatening emergencies associated with sport and physical activity, to initiate stabilization of the student with life-threatening symptoms, and to triage these students to an appropriate level of care (back to the classroom, home with their guardian with follow up at their primary healthcare provider’s office, or directly to the closest emergency department via Emergency Medical Services). This article specifically describes the initial assessment and management of three potentially life-threatening conditions associated with sport and physical activity, namely sudden cardiac arrest, hypovolemic shock, and spinal cord injury.

Background/aims Despite evidence that preferential use of balanced/buffered fluids may improve outcomes compared with chloride-rich 0.9% saline, saline remains the most commonly used fluid for children with septic shock. We aim to determine if resuscitation with balanced/buffered fluids as part of usual care will improve outcomes, in part through reduced kidney injury and without an increase in adverse effects, compared to 0.9% saline for children with septic shock. Methods The Pragmatic Pediatric Trial of Balanced versus Normal Saline Fluid in Sepsis (PRoMPT BOLUS) study is an international, open-label pragmatic interventional trial being conducted at > 40 sites in the USA, Canada, and Australia/New Zealand starting on August 25, 2020, and continuing for 5 years. Children > 6 months to Discussion PRoMPT BOLUS will provide high-quality evidence for the comparative effectiveness of buffered/balanced crystalloids versus 0.9% saline for the initial fluid management of children with suspected septic shock in emergency settings. Trial registration PRoMPT BOLUS was first registered at ClinicalTrials.gov (NCT04102371) on September 25, 2019. Enrollment started on August 25, 2020.

Background Previous reports about risk factors for linezolid-induced thrombocytopenia have been insufficient, often due to the variability in study design and population, and some factors have not yet been studied. Aim The aims of this study are to determine potential risk factors for linezolid-induced thrombocytopenia, and to analyze the influencing factors of different thrombocytopenia definitions. Method This retrospective study involved patients who were administered intravenous linezolid for ≥ 1 day between January 1, 2015 and January 1, 2021. Their demographic and clinical data were extracted from electronic medical records. Thrombocytopenia was defined as: ①thrombocytopenia with platelet count

Background: The COVID-19 outbreak has put an unprecedented strain on Emergency Departments (EDs) and other critical care resources. Early detection of patients that are at high risk of clinical deterioration and require intensive monitoring, is key in ED evaluation and disposition. A rapid and easy risk-stratification tool could aid clinicians in early decision making. The Shock Index (SI: heart rate/systolic blood pressure) proved useful in detecting hemodynamic instability in sepsis and myocardial infarction patients. In this study we aim to determine whether SI is discriminative for ICU admission and in-hospital mortality in COVID-19 patients.Methods: Retrospective, observational, single-center study. All patients >= 18 years old who were hospitalized with COVID-19 (defined as: positive result on reverse transcription polymerase chain reaction (PCR) test) between March 1, 2020 and December 31, 2020 were included for analysis. Data were collected from electronic medical patient records and stored in a protected database. ED shock index was calculated and analyzed for its discriminative value on in-hospital mortality and ICU admission by a ROC curve analysis.Results: In total, 411 patients were included. Of all patients 249 (61%) were male. ICU admission was observed in 92 patients (22%). Of these, 37 patients (40%) died in the ICU. Total in-hospital mortality was 28% (114 patients). For in-hospital mortality the optimal cut-off SI >= 0.86 was not discriminative (AUC 0.49 (95% CI: 0.43-0.56)), with a sensitivity of 12.3% and specificity of 93.6%. For ICU admission the optimal cut-off SI >= 0.57 was also not discriminative (AUC 0.56 (95% CI: 0.49-0.62)), with a sensitivity of 78.3% and a specificity of 34.2%.Conclusion: In this cohort of patients hospitalized with COVID-19, SI measured at ED presentation was not discriminative for ICU admission and was not useful for early identification of patients at risk of clinical deterioration. (C) 2021 Elsevier Inc. All rights reserved.

Background Lower gastrointestinal bleeding (LGIB) is a common presentation of surgical admissions, imposing a significant burden on healthcare costs and resources. There is a paucity of standardised clinical predictive tools available for the initial assessment and risk stratification of patients with LGIB. We propose a simple clinical scoring model to prognosticate patients at risk of severe LGIB and an algorithm to guide management of such patients. Methods A retrospective cohort study was conducted, identifying consecutive patients admitted to our institution for LGIB over a 1-year period. Baseline demographics, clinical parameters at initial presentation and treatment interventions were recorded. Multivariate logistic regression was performed to identify factors predictive of severe LGIB. A clinical management algorithm was developed to discriminate between patients requiring admission, and to guide endoscopic, angiographic and/or surgical intervention. Results 226/649 (34.8%) patients had severe LGIB. Six variables were entered into a clinical predictive model for risk stratification of LGIB: Tachycardia (HR ≥ 100), hypotension (SBP Conclusion Early diagnosis and management of severe LGIB remains a challenge for the acute care surgeon. The predictive model described comprises objective clinical parameters routinely obtained at initial triage to guide risk stratification, disposition and inpatient management of patients.

Patients experiencing vasoplegia, a type of distributive shock, have limited options when conventional vasopressors are not appropriate or sufficient. This is especially true for patients with cardiac dysfunction, whether after heart transplant or ventricular assist device (VAD) implantation. Angiotensin II has been used in various clinical settings for distributive shock; however, its role in patients after orthotopic heart transplant or VAD implantation is not well studied. We present two cases where angiotensin II played a vital role in correcting vasoplegia for critical cardiac patients.

The shock index pediatric age-adjusted (SIPA) predicts the need for increased resources and mortality among pediatric trauma patients without incorporating neurological status. A new scoring tool, rSIG, which is the reverse shock index (rSI) multiplied by the Glasgow Coma Scale (GCS), has been proven superior at predicting outcomes in adult trauma patients and mortality in pediatric patients compared with traditional scoring systems. We sought to compare the accuracy of rSIG to Shock Index (SI) and SIPA in predicting the need for early interventions in civilian pediatric trauma patients.Patients (aged 1-18 years) in the 2014 to 2018 Pediatric Trauma Quality Improvement Program database with complete heart rate, systolic blood pressure, and total GCS were included. Optimal cut points of rSIG were calculated for predicting blood transfusion within 4 hours, intubation, intracranial pressure monitoring, and intensive care unit admission. From the optimal thresholds, sensitivity, specificity, and area under the curve were calculated from receiver operating characteristics analyses to predict each outcome and compared with SI and SIPA.A total of 604,931 patients with a mean age of 11.1 years old were included. A minority of patients had a penetrating injury mechanism (5.6%) and the mean Injury Severity Score was 7.6. The mean SI and rSIG scores were 0.85 and 18.6, respectively. Reverse shock index multiplied by Glasgow Coma Scale performed better than SI and SIPA at predicting early trauma outcomes for the overall population, regardless of age.Reverse shock index multiplied by Glasgow Coma Scale outperformed SI and SIPA in the early identification of traumatically injured children at risk for early interventions, such as blood transfusion within 4 hours, intubation, intracranial pressure monitoring, and intensive care unit admission. Reverse shock index multiplied by Glasgow Coma Scale adds neurological status in initial patient assessment and may be used as a bedside triage tool to rapidly identify pediatric patients who will likely require early intervention and higher levels of care.Prognostic, level III.

Purpose This study evaluates the indications, safety and clinical outcomes associated with the administration of blood products prior to arrival at a pediatric trauma center (prePTC). Methods Children (≤ 18 years) who were highest level activations at an ACS level 1 pediatric trauma center (PTC) from 2009–2019 were divided into groups:(1) patients with transport times

Background Ralstonia mannitolilytica can cause opportunistic infections. Reports on this pathogen identified in the bloodstream are rare worldwide, especially in China. Case Description We describe a 48-year-old man who developed sepsis due to bloodstream Ralstonia mannitolilytica infection after surgery for a perianal abscess. His condition deteriorated into multiple organ dysfunction syndromes until susceptible antibiotics (ceftriaxone and levofloxacin) were administrated based on the drug sensitivity test results. The patient had a satisfactory recovery with no complications during a 6-month follow-up period. Conclusion Ralstonia mannitolilytica blood-borne infection in patients evolves rapidly. The inconsistent sensitivity to antibiotics makes timely treatment difficult and can lead to serious complications. We report the clinical presentations and treatment outcomes for this patient here to remind clinicians about this rare opportunistic pathogen and to highlight the importance of bacterial culture, especially for immunocompromised patients.

Introduction . Shock-index (SI) and systolic blood pressure (SBP) are metrics for identifying children and adults with hemodynamic instability following injury. The purpose of this systematic review was to assess the quality of these metrics as predictors of outcomes following pediatric injury. Materials and methods We conducted a literature search in Pubmed, SCOPUS, and CINAHL to identify studies describing the association between shock metrics on the morbidity and mortality of injured children and adolescents. We used the data presented in the studies to calculate the sensitivity and specificity for each metric. This study was registered with Prospero, protocol CRD42020162971. Results Fifteen articles met the inclusion criteria. seven studies evaluated SI or SIPA score, an age-corrected version of SI, as predictors of outcomes following pediatric trauma, with one study comparing SIPA score and SBP and one study comparing SI and SBP. The remaining eight studies evaluated SBP as the primary indicator of shock. The median sensitivity for predicting mortality and need for blood transfusion was highest for SI, followed by SIPA, and then SBP. The median specificity for predicting these outcomes was highest for SBP, followed by SIPA, and then SI. Conclusions Common conclusions were that high SIPA scores were more specific than SI and more sensitive than SBP. SIPA score had better discrimination for severely injured children compared to SI and SBP. An elevated SIPA was associated with a greater need for blood transfusion and higher in-hospital mortality. SIPA is specific enough to exclude most patients who do not require a blood transfusion.

Background: Very low birth weight infants are at increased risk of developmental disorder. Early identification is necessary for planning and implementation of early intervention. Aims and Objective: To test the association of neurological examination at 40 weeks and 3 months with neuro motor outcome of VLBW infants at 24 months and to identify the perinatal and neonatal risk factors for atypical neurological outcome. Materials and Methods: It is a prospective cohort study. Consecutive 120 VLBW infants were enrolled in a single centre level III neonatal unit of a teaching hospital. Neuro motor assessment was done by Dubowitz neurological examination at 40 weeks and by Hammersmith infant neurological examination (HINE) at 3 months and 12 months at neurodevelopmental clinic. Motor assessment were performed by Alberta Infant Motor Scale (AIMS) at 6 and 12 months and by Bayley Scale of Infant & Toddler scale, (BSID) 3rd edition at 6,12 and 24 months respectively. All assessment ages were corrected for prematurity. Results: At 12 months 4.5% infants developed abnormal tone and 5.6% had motor delay. Four infants developed cerebral palsy at 24 months. Shock in neonatal period had significant association with suboptimal motor outcome at 12 months. Suboptimal HINE score at 12 months was rightly predicted at 3 months by HINE. Conclusion: Early anticipation and early identification of abnormal neuro motor outcome of VLBW infants can be used as simple and cost-effective measures for preventing long term neuro motor morbidity at resource limited countries.

No abstract available. Article truncated after 150 words. History of Present Illness: A 55-year-old man with a past medical history significant for endocarditis secondary to intravenous drug use, osteomyelitis of the right lower extremity was admitted for ankle debridement. Pre-operative assessment revealed no acute illness complaints and no significant findings on physical examination except for the ongoing right lower extremity wound. He did well during the approximate one-hour “incision and drainage of the right lower extremity wound”, but became severely hypotensive just after the removal of the tourniquet placed on his right lower extremity. Soon thereafter he experienced pulseless electrical activity (PEA) cardiac arrest and was intubated with return of spontaneous circulation being achieved rapidly after the addition of vasopressors. He remained intubated and on pressors when transferred to the intensive care unit for further management. PMH, PSH, SH, and FH: • S/P Right lower extremity incision and drainage for suspected osteomyelitis as above • Distant history of endocarditis related …

Intoxication from calcium channel blockers exhibits almost 50% mortality rates. Amlodipine is a long-acting dihydropyridine and inappropriate dosage poses a great threat for profound vasodilation, hypotension, and refractory vasopressor-resistant shock. A 72-year-old woman with unremarkable medical history presented to the emergency department due to amlodipine overdose after a suicide attempt attributed to COVID-19 pandemic severe anxiety disorder. Vital signs at presentation: heart rate 82 beats/ min, arterial pressure 72/55 mmHg, and oxygen saturation 98%. Resuscitation was initiated with intravenous infusion of normal saline 0,9%, noradrenaline, and calcium chloride, while activated charcoal was orally administrated; however, blood pressure remained at 70/45 mmHg. Abruptly, she experienced acute pulmonary edema and was finally intubated. We commenced high-dose insulin infusion with Dextrose 10% infusion to maintain euglycemic hyperinsulinemia. Hemodynamic improvement occurred after 30 min, systolic blood pressure raised to 95 mmHg, and decongestion was achieved with intravenous furosemide. Insulin effect was dose-dependent and patient's hemodynamic status improved after insulin uptitration. Eight days later, the patient was weaned from the mechanical ventilation and she was successfully discharged after 14 days. High-dose intravenous infusion of insulin up to 10 units/kg per hour appears as an inotropic agent possibly through alterations in myocardial metabolism of fatty acids and augmentation of insulin secretion and uptake. This regimen possibly exhibits additional vasotropic properties. We conclude that euglycemic hyperinsulinemia is a potentially advantageous treatment in CCB toxicity.

Cryptic shock is a poorly identified clinical entity, and it still describes a patient with signs of tissue hypoperfusion without affecting blood pressure. In the emergency department, it is important to identify signs of hypoperfusion and evaluate various hidden sources of infection by taking a complete medical history, a thorough physical examination, and, if necessary advanced imaging. It is necessary to conclude that the importance of the timely diagnosis of this clinical entity helps to improve the prognosis significantly. El shock críptico es una entidad clínica poco identificada, describe aún paciente con signos de hipoperfusión tisular sin afectación de la presión arterial. En el departamento de emergencia es importante identificar signos de hipoperfusión y evaluar diversas fuentes ocultas de infección realizando una historia clínica completa, un examen físico exhaustivo y de ser necesario imagenología avanzada. Es necesario concluir que la importancia del diagnóstico oportuno de esta entidad clínica ayuda a mejorar significativamente el pronóstico.

We report three cases of multisystem inflammatory syndrome in children (MIS-C) during July 2020 from a tertiary care hospital with different clinical presentations and course of management. This will guide in better management of children with MIS-C. All three patients, aged 1 to 12 years old, were critically ill. They presented with common features of MIS-C, such as fever, conjunctival congestion, gastrointestinal involvement, and skin manifestations. Clinical features were suggestive of shock, coagulopathy, and multiorgan involvement. Laboratory findings revealed raised inflammatory markers, including C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and D-dimers (DD). All patients required intensive care with oxygen therapy, fluid resuscitation, inotropic agents, and broad-spectrum antibiotics. All patients received steroids, and two patients were given intravenous immunoglobulin. One patient died, and the remaining two patients were discharged. Our findings confirmed that COVID-19 may cause severe disease in children, and the presentation may vary, requiring early recognition and timely management.

Background:. Functional mitral regurgitation (FMR) is common in critically ill patients and may cause left atrial (LA) pressure elevation. This study aims to explore the prognostic impact of synergistic LA pressure elevation and FMR in patients with shock. Methods:. We retrospectively screened 130 consecutive patients of 175 patients with shock from April 2016 to June 2017. The incidence and impact of FMR and early diastolic transmitral velocity to early mitral annulus diastolic velocity ratio (E/e’) ≥ 4 within 6 h of shock on the prognosis of patients were evaluated. Finally, the synergistic effect of FMR and E/e’ were assessed by combination, grouping, and trend analyses. Results:. Forty-four patients (33.8%) had FMR, and 15 patients (11.5%) had E/e’ elevation. A multivariate analysis revealed FMR and E/e’ as independent correlated factors for 28-day mortality (P = 0.043 and 0.028, respectively). The Kaplan-Meier survival analysis revealed a significant difference in survival between patients with and without FMR (χ2 = 7.672, P = 0.006) and between the E/e’ ≥ 14 and E/e’ < 14 groups (χ2 = 19.351, P

Objectives To describe the unassisted return of spontaneous circulation following withdrawal of life-sustaining treatment in a child. Design Case report based on clinical observation and medical record review. Setting Community Children's Hospital. Patient Two-year old child. Interventions Following hypoxic-ischemic brain injury, the child was taken to the operating room for withdrawal of life-sustaining treatment during controlled donation after circulatory determination of death. Measurements and main results In addition to direct observation by experienced pediatric critical care providers, the child was monitored with electrocardiography, pulse oximetry, and invasive blood pressure via femoral arterial catheter in addition to direct observation by experienced pediatric critical care providers. Unassisted return of spontaneous circulation occurred greater than 2 minutes following circulatory arrest and was accompanied by return of respiration. Conclusions We provide the first report of unassisted return of spontaneous circulation following withdrawal of life-sustaining treatment in a child. In our case, return of spontaneous circulation occurred in the setting of controlled donation after circulatory determination of death and was accompanied by return of respiration. Return of spontaneous circulation greater than 2 minutes following circulatory arrest in our patient indicates that 2 minutes of observation is insufficient to ensure that cessation of circulation is permanent after withdrawal of life-sustaining treatment in a child.

Aim Chest compressions delivered by a load distributing band (LDB) induce artefacts in the electrocardiogram. These artefacts alter shock decisions in defibrillators. The aim of this study was to demonstrate the first reliable shock decision algorithm during LDB compressions. Methods The study dataset comprised 5813 electrocardiogram segments from 896 cardiac arrest patients during LDB compressions. Electrocardiogram segments were annotated by consensus as shockable (1154, 303 patients) or nonshockable (4659, 841 patients). Segments during asystole were used to characterize the LDB artefact and to compare its characteristics to those of manual artefacts from other datasets. LDB artefacts were removed using adaptive filters. A machine learning algorithm was designed for the shock decision after filtering, and its performance was compared to that of a commercial defibrillator's algorithm. Results Median (90% confidence interval) compression frequencies were lower and more stable for the LDB than for the manual artefact, 80 min−1 (79.9–82.9) vs. 104.4 min−1 (48.5–114.0). The amplitude and waveform regularity (Pearson's correlation coefficient) were larger for the LDB artefact, with 5.5 mV (0.8–23.4) vs. 0.5 mV (0.1–2.2) (p Conclusion Compared to other cardiopulmonary resuscitation artefacts, removing the LDB artefact was challenging due to larger amplitudes and lower compression frequencies. The machine learning algorithm achieved clinically reliable shock decisions during LDB compressions.

Background and purpose Previous studies have identified that the reverse shock index multiplied by the Glasgow Coma Scale score (rSIG) is a good predictor of mortality in trauma patients. However, it is unknown if rSIG has utility as a predictor for massive transfusion (MT) in trauma patients. The present study evaluated the ability of rSIG to predict MT in trauma patients. Methods This was a retrospective, observational study performed at a level 1 trauma center. Consecutive patients who presented to the trauma center emergency department between January 2016 and December 2018 were included. The predictive ability of rSIG for MT was assessed as our primary outcome measure. Our secondary outcome measures were the predictive ability of rSIG for coagulopathy, in-hospital mortality, and 24-h mortality. We compared the prognostic performance of rSIG with the shock index, age shock index, and quick Sequential Organ Failure Assessment. Results In total, 1627 patients were included and 117 (7.2%) patients received MT. rSIG showed the highest area under the receiver operating characteristic (AUROC) curve (0.842; 95% confidence interval [CI], 0.806–-0.878) for predicting MT. rSIG also showed the highest AUROC for predicting coagulopathy (0.769; 95% CI, 0.728–0.809), in-hospital mortality (AUROC 0.812; 95% CI, 0.772–0.852), and 24-h mortality (AUROC 0.826; 95% CI, 0.789–0.864). The sensitivity of rSIG for MT was 0.79, and the specificity of rSIG for MT was 0.77. All tools had a high negative predictive value and low positive predictive value. Conclusion rSIG is a useful, rapid, and accurate predictor for MT, coagulopathy, in-hospital mortality, and 24- h mortality in trauma patients.

BACKGROUND AND AIM OF THE STUDY Although dopamine and norepinephrine are recommended as first-line agents in the treatment of shock, it is unclear which is the optimal vasoactive inotropic agent (VIA) to manage postcardiotomy circulatory shock. This single-center, randomized clinical trial aimed to investigate the efficacy and safety of dopamine versus norepinephrine in postcardiotomy circulatory shock. METHODS We randomly assigned the patients with postcardiotomy circulatory shock to receive either dopamine or norepinephrine. When shock persisted despite the dose of 20 μg/kg/min of dopamine or the dose of 0.2 μg/kg/min of norepinephrine, epinephrine or vasopressin could be added. The primary endpoint was new-onset tachyarrhythmic event during drug infusion. Secondary endpoints included requirement of additional VIAs, postoperative complications, and all-cause mortality within 30 days of drug initiation. RESULTS At the planned interim analysis of 100 patients, the boundary for the benefit of norepinephrine has been crossed, and the study was stopped early. Excluding two patients withdrawing a consent, 48 patients were assigned to dopamine and 50 patients to norepinephrine. New-onset tachyarrhythmic event occurred in 12 (25%) patients in the dopamine and one (2%) patient in the norepinephrine group (p = .009). The requirement for additional VIAs was more common in the dopamine group (p

Background: Matrix Metalloproteinases (MMP) respond to tissue damage during sepsis. Higher plasma concentrations of MMPs and the tissue-inhibitor of matrix metalloproteinases (TIMP) have been reported in sepsis compared with healthy controls. The objective of this study was to examine if plasma levels of MMP-3, MMP-9, and TIMP-1 associate with mortality and organ dysfunction during sepsis. Methods: We conducted a prospective cohort study of critically ill patients with sepsis adjudicated per Sepsis-3 criteria at a tertiary academic medical center. We measured plasma concentrations of MMP-3, MMP-9, and TIMP-1 on intensive care unit admission. We phenotyped the subjects for shock, acute respiratory distress syndrome (ARDS), acute kidney injury (AKI), and mortality at 30 days. We used logistic regression to test the associations between the MMPs and TIMP-1 with shock, ARDS, AKI, and mortality. Results: Higher plasma TIMP-1 levels were associated with shock (odds ratio [OR] 1.51 per log increase [95% CI 1.25, 1.83]), ARDS (OR 1.24 [95% CI 1.05, 1.46]), AKI (OR 1.18 [95% CI 1.01, 1.38]), and mortality (OR 1.20 [95% CI 1.05, 1.46]. Higher plasma MMP-3 concentrations were associated with shock (OR 1.40 [95% CI 1.12, 1.75]) and mortality (OR 1.24 [95% CI 1.03, 1.48]) whereas MMP-9 levels were not associated with outcomes. Higher plasma TIMP-1 to MMP-3 ratios were associated with shock (OR 1.41 [95% CI 1.15, 1.72], P = 0.02). Conclusion: Elevated plasma concentrations of TIMP-1 associate with organ dysfunction and mortality in sepsis. Higher plasma levels of MMP-3 associate with shock and mortality. Plasma MMP and TIMP-1 may warrant further investigation as emerging sepsis theragnostic biomarkers.

Background The implantable cardiac defibrillator is the cornerstone of prevention of sudden cardiac death in non‐ischemic cardiomyopathy. The Selvester score, which is frequently investigated in ischemic cardiomyopathy, has not been investigated in the field of non‐ischemic cardiomyopathy. Aim The aim of this study was to evaluate the Selvester score for determining appropriate implantable cardiac defibrillator shocks in non‐ischemic cardiomyopathy patients. Materials and methods In all, 131 non‐ischemic cardiomyopathy patients were included in the study. A simplified Selvester score was calculated from ECG data. Patients were divided into two groups according to whether they received ICD shock. Results Of the patients, 28.2% received appropriate implantable cardiac defibrillator shock. The Selvester score was significantly higher in patients receiving appropriate shock when compared to patients with no implantable cardiac defibrillator shocks (8.8 ± 4.6 vs 7.2 ± 3.3, P = .040). The median QRS duration was significantly longer in patients receiving appropriate shock than in patients with no shocks (130.14 ± 35.08 ms vs 120.12 ± 20.57 ms, P = .045). We determined that the cutoff value for the Selvester score to predict ICD shocks was 6.5 with a sensitivity of 72.0% and a specificity of 83% (AUC = 0.717; %95 GA: 0.627‐0.807, P, Selvester score was higher in patients receiving appropriate shock than in patients who did not recieve any implantable cardiac defibrillator shock. In the selection of patients undergoing implantable cardioverter defibrillator for primer prevention of sudden cardiac death with nonischemic cardiomyopathy, the Selvester score may be used in addition to left ventricular ejection fraction.

An octogenarian presented to our hospital in shock after being "found down" at home. She was dehydrated, hypernatremic, and suffering from a urinary tract infection. Findings of a murmur and those on electrocardiography led to the performance of echocardiography, with all findings consistent with a diagnosis of hypertrophic obstructive cardiomyopathy. The patient was volume resuscitated and administered antibiotics; after stabilization, she was started on a low-dose beta-blocker. Hypertrophic cardiomyopathy is a common genetic disorder that is usually diagnosed in the second to fifth decades of life. It is an uncommon cause or contributor to shock and is unusually initially diagnosed at an advanced age. We briefly review the diagnosis and management of hypertrophic cardiomyopathy in older adults, particularly in the setting of shock.

Supplemental Digital Content is available in the text., TRIAL REGISTRATION: NCT04420468. OBJECTIVES: Severe acute respiratory syndrome coronavirus 2–related multisystem inflammatory syndrome in children is frequently associated with shock; endothelial involvement may be one of the underlying mechanisms. We sought to describe endothelial dysfunction during multisystem inflammatory syndrome in children with shock and then assess the relationship between the degree of endothelial involvement and the severity of shock. DESIGN: Observational study. SETTING: A PICU in a tertiary hospital. PATIENTS: Patients aged under 18 (n = 28) with severe acute respiratory syndrome coronavirus 2–related multisystem inflammatory syndrome in children and shock, according to the Centers for Disease Control and Prevention criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Correlations between endothelial marker levels and shock severity were assessed using Spearman coefficient. The median (interquartile range) age was 9 years (7.5–11.2 yr). Sixteen children presented with cardiogenic and distributive shock, 10 presented with cardiogenic shock only, and two presented with distributive shock only. The median left ventricular ejection fraction, troponin level, and lactate level were, respectively, 40% (35–45%), 261 ng/mL (131–390 ng/mL), and 3.2 mmol/L (2–4.2 mmol/L). Twenty-five children received inotropes and/or vasopressors; the median Vasoactive and Inotropic Score was 8 (5–28). Plasma levels of angiopoietin-2 (6,426 pg/mL [2,814–11,836 pg/mL]), sE-selectin (130,405 pg/mL [92,987–192,499 pg/mL]), von Willebrand factor antigen (344% [288–378%]), and the angiopoietin-2/angiopoietin-1 ratio (1.111 [0.472–1.524]) were elevated and significantly correlated with the Vasoactive and Inotropic Score (r = 0.45, p = 0.016; r = 0.53, p = 0.04; r = 0.46, p = 0.013; and r = 0.46, p = 0.012, respectively). CONCLUSIONS: Endothelial dysfunction is associated with severe acute respiratory syndrome coronavirus 2–related multisystem inflammatory syndrome in children with shock and may constitute one of the underlying mechanisms.