A 35-Year-Old Woman With Placenta Previa and Postpartum Cardiovascular Collapse.

CASE PRESENTATION: A 35-year-old woman at 36 weeks and 4 days gestation with known complete anterior placenta previa and no other medical history presented for routine obstetric follow-up. She reported increasing fatigue in the prior week but otherwise endorsed no new concerns. She denied recent vaginal bleeding or discharge, abdominal pain, contractions, or extremity swelling. On evaluation, her BP was 126/74 mm Hg with a heart rate of 72 beats per min. The results from the physical examination were normal. There was a category II fetal heart rate tracing and a 6/10 biophysical profile (ie, no fetal breathing movements, nonreactive nonstress test), which prompted referral to the hospital. On admission, sonogram confirmed cephalic presentation and redemonstrated complete anterior placenta previa with no evidence of hemorrhage. She received antenatal steroids and was scheduled for a cesarean section delivery. She received bupivacaine spinal anesthesia for the procedure. The surgical procedure progressed with a low transverse uterine incision and subsequent delivery of the baby with no complications noted. Immediately after delivery of the baby and during gentle traction of the placenta, the patient experienced rapid cardiovascular collapse in the form of hypotension and bradycardia.

Shock Simulation Day: Medical Decision-Making and Communication Skills for Managing a Hypotensive Adult in a Rapid Response.

Introduction: Shock is a life-threatening condition amongst hospitalized patients and requires urgent management to avoid mortality. Early exposure is vital for educational and patient safety purposes. Methods: We developed a 90-minute shock day session that provided internal medicine interns with a cognitive framework for the initial diagnosis and management of shock, which they applied to two simulations. The first simulation involved a patient with septic shock, and the second involved a patient with cardiogenic shock. Critical action checklists were used to assess learners and guide structured debriefs after each simulation. Medical decision-making and communication frameworks were presented through a presession video and a chalk talk. The curriculum was evaluated using pre- and postintervention surveys to assess knowledge and confidence. Results: Forty-eight interns participated in the session in 2022 and 2023. We observed an increase in the percentage of learners correctly answering a knowledge-based question regarding the amount of fluid administered to a patient in septic shock (pre: 33%, post: 62%, p < .01), as well as increases in learner-reported confidence in leading a rapid response (pre: 9%, post: 62%) and in managing undifferentiated shock (pre: 13%, post: 56%), septic shock (pre: 20%, post: 83%), cardiogenic shock (pre: 2%, post: 54%), hemorrhagic shock (pre: 20%, post: 73%), and anaphylactic shock (pre: 22%, post: 54%, all ps < .01). Discussion: Employing a variety of pedagogical methods, we demonstrated that intern knowledge and confidence regarding the management of a hypotensive patient during a rapid response can be increased through participation in our curriculum.

Kawasaki disease with shock as the primary manifestation: How to distinguish from toxic shock syndrome?: A case report and literature review.

RATIONALE: Kawasaki disease (KD) is a vasculitis syndrome of small to medium-sized arteries that has typical clinical characteristics such as fever, rash, cervical lymphadenopathy, conjunctivitis, and mucosal changes. Cardiac manifestations, including coronary artery aneurysms, myocarditis, myocardial infarction, and sudden cardiac death, are the most serious complications observed in KD. On rare occasions, it may accompanied with reduced organ perfusion due to systolic hypotension, a condition known as Kawasaki disease shock syndrome (KDSS). KDSS is a serious complication that can be presented to the emergency department as an initial feature when typical clinical symptoms of KD have not be detected. PATIENT CONCERNS: We report the case of a 12-year-old boy admitted with prolonged fever, bilateral non-purulent conjunctivitis, and signs of shock such as hypotension and tachycardia. Laboratory findings showed elevated inflammatory markers, hypoalbuminemia, and sterile pyuria. He was initially treated with intravenous cefotaxime and vancomycin considering the possible diagnosis of toxic shock syndrome, while the treatment was not effective. Subsequent chest computerized tomography and ultrasound identified pulmonary consolidation and polyserous effusion. Echocardiography revealed mild biatrial dilatation and mild valvular regurgitation with preserved left ventricular function. DIAGNOSIS: After a multidisciplinary consultation, a diagnosis of KDSS was made. INTERVENTIONS: To prevent coronary artery lesions and other severe complications, the patient immediately received immunoglobulin, corticoid, and acetylsalicylic acid. OUTCOMES: Soon afterwards, he showed significant improvement, with the temperature dropped to normal and hypotension corrected about 24 hours post-intravenous immunoglobulin therapy. Polyserous effusions also disappeared before discharge. Follow-up echocardiography revealed normal results. LESSONS: Clinicians should maintain a high index of suspicion for KD and consider pulmonary involvement and polyserous effusions as potential complications. For children with KD, any symptoms pointing to infection should be carefully considered. When there is no etiologic evidence, antibiotics should be used with caution. Our case also highlights the importance of considering KDSS as a differential diagnosis in children presenting with prolonged fever and shock. Early recognition, timely treatment, and close monitoring are key to preventing severe complications and ensuring favorable outcomes in patients with KDSS.

Kidney Blood Flow and Renin-Angiotensin-Aldosterone System Measurements Associated With Kidney and Cardiovascular Dysfunction in Pediatric Shock.

IMPORTANCE: Pediatric acute kidney injury (AKI) is a prevalent and morbid complication of shock. Its pathogenesis and early identification remain elusive. OBJECTIVES: We aim to determine whether renal blood flow (RBF) measurements by point-of-care ultrasound (POCUS) and renin-angiotensin-aldosterone system (RAAS) hormones in pediatric shock associate with vasoactive requirements and AKI. DESIGN, SETTING, AND PARTICIPANTS: This is a single-center prospective, noninterventional observational cohort study in one tertiary PICU in North American from 2020 to 2022 that enrolled children younger than 18 years with shock without preexisting end-stage renal disease. MAIN OUTCOMES AND MEASURES: RBF was measured by POCUS on hospital days 1 and 3 and plasma RAAS hormone levels were measured on day 1. The primary outcome was the presence of AKI by Kidney Disease Improving Global Outcomes criteria at first ultrasound with key secondary outcomes of creatinine, blood urea nitrogen (BUN), Vasoactive-Inotrope Score (VIS), and norepinephrine equivalent dosing (NED) 48 hours after first ultrasound. RESULTS: Fifty patients were recruited (20 with AKI, mean age 10.5 yr, 48% female). POCUS RBF showed lower qualitative blood flow (power Doppler ultrasound [PDU] score) and higher regional vascular resistance (renal resistive index [RRI]) in children with AKI (p = 0.017 and p = 0.0007). Renin and aldosterone levels were higher in the AKI cohort (p = 0.003 and p = 0.007). Admission RRI and PDU associated with higher day 3 VIS and NED after adjusting for age, day 1 VIS, and RAAS hormones. Admission renin associated with higher day 3 creatinine and BUN after adjusting for age, day 1 VIS, and the ultrasound parameters. CONCLUSIONS AND RELEVANCE: In pediatric shock, kidney blood flow was abnormal and renin and aldosterone were elevated in those with AKI. Kidney blood flow abnormalities are independently associated with future cardiovascular dysfunction; renin elevations are independently associated with future kidney dysfunction. Kidney blood flow by POCUS may identify children who will have persistent as opposed to resolving AKI. RAAS perturbations may drive AKI in pediatric shock.

Composite Pulmonary Embolism Shock Score and Risk of Adverse Outcomes in Patients With Pulmonary Embolism.

BACKGROUND: In hemodynamically stable patients with acute pulmonary embolism (PE), the Composite Pulmonary Embolism Shock (CPES) score predicts normotensive shock. However, it is unknown if CPES predicts adverse clinical outcomes. The objective of this study was to determine whether the CPES score predicts in-hospital mortality, resuscitated cardiac arrest, or hemodynamic deterioration. METHODS: Patients with acute intermediate-risk PE admitted from October 2016 to July 2019 were included. CPES was calculated for each patient. The primary outcome was a composite of in-hospital mortality, resuscitated cardiac arrest, or hemodynamic decompensation. Secondary outcomes included individual components of the primary outcome. The association of CPES with primary and secondary outcomes was evaluated. RESULTS: Among the 207 patients with intermediate-risk PE (64.7% with intermediate-high risk PE), 29 (14%) patients had a primary outcome event. In a multivariable model, a higher CPES score was associated with a worse primary composite outcome (adjusted hazard ratio [aHR], 1.81 [95% CI, 1.29-2.54]; P=0.001). Moreover, a higher CPES score predicted death (aHR, 1.76 [95% CI, 1.04-2.96]; P=0.033), resuscitated cardiac arrest (aHR, 1.99 [95% CI, 1.17-3.38]; P=0.011), and hemodynamic decompensation (aHR, 1.96 [95% CI, 1.34-2.89]; P=0.001). A high CPES score (≥3) was associated with the worse primary outcome when compared with patients with a low CPES score (22% versus 2.4%; P=0.003; aHR, 6.48 [95% CI, 1.49-28.04]; P=0.012). CPES score provided incremental prognostic value for the prediction of primary outcome over baseline demographics and European Society of Cardiology intermediate-risk subcategories (global Χ2 value increased from 0.63 to 1.39 to 13.69; P=0.005). CONCLUSIONS: In patients with acute intermediate-risk PE, the CPES score effectively risk stratifies and prognosticates patients for the prediction of clinical events and provides incremental value over baseline demographics and European Society of Cardiology intermediate-risk subcategories.

Ion Channels Remodeling in the Regulation of Vascular Hyporesponsiveness During Shock.

Shock is characterized with vascular hyporesponsiveness to vasoconstrictors, thereby to cause refractory hypotension, insufficient tissue perfusion, and multiple organ dysfunction. The vascular hyporeactivity persisted even though norepinephrine and fluid resuscitation were administrated, it is of critical importance to find new potential target. Ion channels are crucial in the regulation of cell membrane potential and affect vasoconstriction and vasodilation. It has been demonstrated that many types of ion channels including K+ channels, Ca2+ permeable channels, and Na+ channels exist in vascular smooth muscle cells and endothelial cells, contributing to the regulation of vascular homeostasis and vasomotor function. An increasing number of studies suggested that the structural and functional alterations of ion channels located in arteries contribute to vascular hyporesponsiveness during shock, but the underlying mechanisms remained to be fully clarified. Therefore, the expression and functional changes in ion channels in arteries associated with shock are reviewed, to pave the way for further exploring the potential of ion channel-targeted compounds in treating refractory hypotension in shock.

Severe Vasoplegic Shock After Heart Transplant Successfully Treated With Multimodal Therapeutic Approach.

Vasoplegia describes a constellation of low vascular resistance and normal cardiac output. Vasoplegia is common after cardiac surgery in general and in heart transplant recipients more specifically and occurs in over one-half of all heart transplant recipients with a varying degree of severity. The pathophysiology of vasoplegia is multifactorial and associated with a cascade of inflammatory mediators. Routine treatment of vasoplegia is based on medical vasopressor therapy, but in severe cases this may be insufficient to maintain adequate blood pressure and does not address the underlying pathophysiology. We report a case of severe vasoplegic shock in a heart transplant recipient who was successfully managed with a multimodal therapy combination of methylene blue, immunoglobulins enriched with immunoglobulin M, cytokine adsorption, and broad-spectrum antibiotics. This represents a promising therapeutic approach for heart transplant patients with vasoplegia.

Hypovolemic Shock And The Need For Invasive Mechanical Ventilation On A Patient With Congenital Heart Disease.

Techniques of venoarterial-extracorporeal membrane oxygenation (VA-ECMO) have improved over the decades, with numerous applications.1 Those with reversible low cardiac output benefit most from this support.1 Case of 21-year-old male, history of congenital heart disease (severe right ventricle hypoplasia and pulmonary artery stenosis with extracardiac cavo-pulmonary shunt (Fontan surgery), and atrial septal defect). Brought to the Emergency Department due to a Mallory-Weiss syndrome, upper-endoscopy "laceration at esophagogastric junction (EGJ) with active bleeding", clips were applied. However, worsening shock, repeated melenas and hematemesis, hemoglobin drop, lactate 2.8mmol/L, and needing noradrenaline (1.21mcg/kg/min). Due to active blood loss and worsening shock, the patient was intubated to maintain airway protection. Repeated upper-endoscopy "voluminous live red clot at EGJ, 4-clips and active bleeding of mucosa between, injection of polidocanol". Despite the implemented strategy, high risk of rebleeding remained. Following invasive mechanical ventilation (IMV), sustained hypotension having to increase noradrenaline (1.52mcg/kg/min) and lactate (5.8mmol/l), despite fluid resuscitation. Echocardiogram evidenced severe ventricular dysfunction, and fixed inferior vena cava (IVC) of 20mm. The heart defect combined with positive intrathoracic pressure, contributed to the worsened shock, as Fontan circulation is dependent on low vascular resistance to maintain output2. Needing VA-ECMO and admitted to ICU, volemia optimization, adjusting ventilation to lower intrathoracic pressure and started on milrinone and sildenafil. Another upper-endoscopy showed laceration at EGJ, with placement of clips. Echocardiogram revealed "Normal left ventricle. Hypoplastic right ventricle. Mild mitral regurgitation; aortic VTi 19cm. IVC 22mm. RV/RA gradient 70mmHg. Interatrial bidirectional shunt". Favorable evolution permitted extubation, suspension of milrinone and sildenafil, followed by decannulation. With rescue ECMO, congenital heart disease are salvageable despite sudden decompensation3. This case, positive intrathoracic pressure impairs the Fontan circulation, dependent on preload and higher central venous pressure to maintain cardiac output, as the ventricle is unable to compensate increased demands2, and worsening shock.

Analysis of hemodynamics and impedance using bioelectrical impedance analysis in hypovolemic shock-induced swine model.

To treat hypovolemic shock, fluid infusion or blood transfusion is essential to address insufficient volume. Much controversy surrounds resuscitation in hypovolemic shock. We aimed to identify the ideal fluid combination for treating hypovolemic shock-induced swine model, analyzing bioelectrical impedance and hemodynamics. Fifteen female three-way crossbred pigs were divided into three different groups. The three resuscitation fluids were (1) balanced crystalloid, (2) balanced crystalloid + 5% dextrose water, and (3) balanced crystalloid + 20% albumin. The experiment was divided into three phases and conducted sequentially: (1) controlled hemorrhage (1 L bleeding, 60 min), (2) resuscitation phase 1 (1 L fluid infusion, 60 min), and (3) resuscitation phase 2 (1 L fluid infusion, 60 min). Bioelectrical impedance analysis was implemented with a segmental multifrequency bioelectrical impedance analyzer. A total of 61 impedance measurements were assessed for each pig at six different frequencies in five segments of the pig. Pulse rate (PR), mean arterial pressure (MAP), stroke volume (SV), and stroke volume variation (SVV) were measured using a minimally invasive hemodynamic monitoring device. The three-dimensional graph showed a curved pattern when infused with 1 L of balanced crystalloid + 1 L of 5% dextrose water and 1.6 L of balanced crystalloid + 400 ml of 20% albumin. The 1M impedance increased in all groups during the controlled hemorrhage, and continuously decreased from fluid infusion to the end of the experiment. Only balanced crystalloid + 20% albumin significantly restored MAP and SV to the same level as the start of the experiment after the end of fluid infusion. There were no significant differences in MAP and SV from the time of recovery to the initial value of 1M impedance to the end of fluid infusion in all groups. The change and the recovery of hemodynamic indices such as MAP and SV coincide with the change and the recovery of 1M impedance. Using balanced crystalloid mixed with 20% albumin in hypovolemic shock-induced swine model may be helpful in securing hemodynamic stability, compared with balanced crystalloid single administration.

The ROX, shock and diastolic shock indexes in the prediction of mortality in COVID-19.

OBJECTIVES: The aim of this study is to determine the role of Respiratory Rate Oxygenation (ROX), shock, and diastolic shock indexes ​​in predicting mortality in coronavirus disease 2019 (COVID-19) patients admitted to the emergency department. BACKGROUND: The COVID-19 spread worldwide in a short time and caused a major pandemic. The ROX, shock, and diastolic shock indexes are used in various life-threatening clinical situations. The use of these indexes in triage at emergency departments can accelerate the determination of COVID-19 patients' severity. METHODS: The ROX, shock and diastolic shock indices were calculated and recorded. Patients were divided into three groups; 1) who were discharged from the hospital, 2) who were admitted to the hospital and 3) who were admitted to the intensive care unit. RESULTS: Increased diastolic shock index and decreased ROX index were found to be independent risk factors for mortality. In the prediction of mortality, the sensitivity and specificity of the diastolic shock index were 61.2% and 60.8%, respectively. However, the sensitivity and specificity of ROX index was 73.1% and 71.5%, respectively. CONCLUSION: In conclusion, we found that the ROX index had higher sensitivity and specificity than other indexes in predicting mortality in the evaluation of COVID-19 patients (Tab. 3, Fig. 2, Ref. 18).

Predicting severe outcomes in pediatric trauma patients: Shock index pediatric age-adjusted vs. age-adjusted tachycardia.

INTRODUCTION: When an injured patient arrives in the Emergency Department (ED), timely and appropriate care is crucial. Shock Index Pediatric Age-Adjusted (SIPA) has been shown to accurately identify pediatric patients in need of emergency interventions. However, no study has evaluated SIPA against age-adjusted tachycardia (AT). This study aims to compare SIPA with AT in predicting outcomes such as mortality, severe injury, and the need for emergent intervention in pediatric trauma patients. MATERIAL AND METHODS: This is a retrospective cross-sectional analysis of patient data abstracted from the Trauma Quality Improvement Program Participant Use Files (TQIP PUFs) for years 2013-2020. Patients aged 4-16 with blunt mechanism of injury and injury severity score (ISS) > 15 were included. 36,517 children met this criteria. Sensitivity, specificity, overtriage, and undertriage rates were calculated to compare the effectiveness of AT and elevated SIPA as predictors of severe injuries and need for emergent intervention. Emergent interventions included craniotomy, endotracheal intubation, thoracotomy, laparotomy, or chest tube placement within 24 h of arrival. RESULTS: AT classified 59% of patients as "high risk," while elevated SIPA identified 26%. Compared to AT patients, a greater proportion of patients with elevated SIPA required a blood transfusion within 24 h (22% vs. 12%, respectively; p < 0.001). In-hospital mortality was higher for the elevated SIPA group than AT (10% vs. 5%, respectively; p < 0.001) as well as the need for emergent operative interventions (43% vs. 32% respectively; p < 0.001). Grade 3 or higher liver/spleen lacerations requiring blood transfusion were also more common among elevated SIPA patients than AT patients (8% vs. 4%, respectively; p < 0.001). AT demonstrated greater sensitivity but lower specificity compared to SIPA across all outcomes. AT showed improved overtriage and undertriage rates compared to SIPA, but this is attributed to identifying a large proportion of the sample as "high risk." CONCLUSIONS: AT outperforms SIPA in sensitivity for mortality, injury severity and emergent interventions in pediatric trauma patients while the specificity of SIPA is high across these outcomes.

Retrospective evaluation of shock index and mortality in dogs with head trauma (2015-2020): 86 cases.

OBJECTIVE: To assess the relationship between shock index (SI) and mortality in dogs with head trauma (HT). A secondary objective was to compare SI with the animal trauma triage (ATT) score and Modified Glasgow Coma Scale (MCGS) score in HT cases. A tertiary aim was to assess if SI is predictive of survival to discharge or improvement in presenting neurologic signs. DESIGN: Retrospective study from January 2015 to December 2020. SETTING: Tertiary referral level II veterinary trauma center. ANIMALS: Eighty-six dogs with evidence of HT presenting through emergency for various traumas compared to 60 healthy control dogs. MEASUREMENTS AND MAIN RESULTS: SI was calculated using the quotient of heart rate over systolic blood pressure measured on presentation. SI was significantly higher in HT patients than healthy controls (P = 0.0019). SI was not significantly different between traumatic brain injury dogs that died or were euthanized and HT dogs that lived until the time of discharge (P = 0.98). SI was not significantly different between HT dogs that were neurologically normal at the time of discharge and HT dogs that were static or improved but not normal neurologically at the time of discharge (P = 0.84). In HT dogs, SI did not correlate with ATT score (P = 0.16) or MGCS score (P = 0.75). There was no significant difference in SI and length of hospitalization until death or discharge (P = 0.78). CONCLUSIONS: SI was significantly higher in HT patients compared to control patients. Interestingly, SI was not correlated with ATT score or MGCS score. The use of SI in HT patients warrants further investigation to assess the efficacy in predicting mortality.

Shock index and shock index, pediatric age-adjusted as predictors of mortality in pediatric patients with trauma: A systematic review and meta-analysis.

This study aimed to assess the predictive ability of the shock index (SI) and the shock index, pediatric age-adjusted (SIPA) for mortality among pediatric patients with trauma (aged ≤ 18 years). A systematic search used PubMed, Embase, and Cochrane Library databases to identify pertinent articles published from their inception to 13 February 2023. For each SI and SIPA, the pooled sensitivity, specificity, diagnostic odds ratio (DOR), and area under the summary receiver operating characteristic curve (AUC) with the corresponding 95% confidence intervals were calculated. We planned a priori meta-regression analyses to explore heterogeneity using the following covariates: country, clinical setting, type of center, data source, and cutoff value. Twelve studies were included based on the inclusion criteria. Among them, nine studies with 195,469 patients were included for the SIPA at the hospital, four studies with 4,970 patients were included for the pre-hospital SIPA, and seven studies with 606,445 patients were included to assess the ability of the SI in predicting mortality. The pooled sensitivity and specificity with 95% confidence interval for predicting mortality were as follows: 0.58 (0.44-0.70) and 0.72 (0.60-0.82), respectively, for the SIPA at the hospital; 0.61 (0.47-0.74) and 0.67 (0.61-0.73), respectively, for the pre-hospital SIPA; and 0.71 (0.59-0.81) and 0.45 (0.31-0.59), respectively for the SI. The DOR were 3.80, 3.28, and 2.06 for the SIPA at the hospital, pre-hospital SIPA, and SI, respectively. The AUC were 0.693, 0.689, and 0.618 for the SIPA at the hospital, pre-hospital SIPA, and SI, respectively. The SI and SIPA are simple predictive tools with sufficient accuracy that can be readily applied to pediatric patients with trauma, but SIPA and SI should be utilized cautiously due to their limited sensitivity and specificity, respectively.

The use of peripheral vasopressors and its implications for hospital medicine.

Vasopressor medications for circulatory shock have historically been administered through central venous catheters due to concern for extravasation injury when given peripherally. However, recent studies have demonstrated the safety of peripheral administration of vasopressor medications at lower doses and for a limited duration. Peripheral use of vasopressors is appealing to both patients and providers, as obtaining central access is an invasive procedure associated with the risk of pneumothorax, bleeding, and infection. Furthermore, waiting to initiate these medications until central access is obtained can lead to delays in care. Conversely, valid concerns remain regarding the risk of tissue extravasation associated with peripheral vasopressors, which can be life and limb threatening. We discuss the guidelines and data for optimal dose, duration, intravenous line (IV) size, IV location, and nursing IV site monitoring for peripheral vasopressors. We then explore adverse events associated with peripheral vasopressors. Finally, we describe how this practice change may impact hospital medicine providers.

Usefulness of Transesophageal Echocardiography in Diagnosing the Cause of Circulatory Collapse During Reoperation for an Inferior Vena Cava-Left Atrium Shunt After Atrial Septal Defect Closure: A Case Report.

Iatrogenic inferior vena cava (IVC)-left atrium (LA) shunt is a rare complication in atrial septal defect (ASD) surgery, caused by mistaking the Eustachian valve for the lower margin of the ASD. In this report, we describe the case of a 45-year-old woman who experienced circulatory collapse at termination of cardiopulmonary bypass during surgical IVC-LA shunt repair. Transesophageal echocardiography helped identify stenosis between the IVC and the right atrium, caused by a residual original incorrectly placed ASD patch. Removal of most of the patch led to improvement in circulatory failure.