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Sci Rep ; 14(1): 13395, 2024 06 11.
Artigo em Inglês | MEDLINE | ID: mdl-38862533


The shock index (SI) has been associated with predicting transfusion needs in trauma patients. However, its utility in penetrating thoracic trauma (PTTrauma) for predicting the Critical Administration Threshold (CAT) has not been well-studied. This study aimed to evaluate the prognostic value of SI in predicting CAT in PTTrauma patients and compare its performance with the Assessment of Blood Consumption (ABC) and Revised Assessment of Bleeding and Transfusion (RABT) scores. We conducted a prognostic type 2, single-center retrospective observational cohort study on patients with PTTrauma and an Injury Severity Score (ISS) > 9. The primary exposure was SI at admission, and the primary outcome was CAT. Logistic regression and decision curve analysis were used to assess the predictive performance of SI and the PTTrauma score, a novel model incorporating clinical variables. Of the 620 participants, 53 (8.5%) had more than one CAT. An SI > 0.9 was associated with CAT (adjusted OR 4.89, 95% CI 1.64-14.60). The PTTrauma score outperformed SI, ABC, and RABT scores in predicting CAT (AUC 0.867, 95% CI 0.826-0.908). SI is a valuable predictor of CAT in PTTrauma patients. The novel PTTrauma score demonstrates superior performance compared to existing scores, highlighting the importance of developing targeted predictive models for specific injury patterns. These findings can guide clinical decision-making and resource allocation in the management of PTTrauma.

Transfusão de Sangue , Traumatismos Torácicos , Humanos , Masculino , Feminino , Transfusão de Sangue/métodos , Adulto , Estudos Retrospectivos , Traumatismos Torácicos/terapia , Pessoa de Meia-Idade , Prognóstico , Escala de Gravidade do Ferimento , Ferimentos Penetrantes/terapia , Hemorragia/terapia , Hemorragia/etiologia , Hemorragia/diagnóstico , Choque/terapia , Choque/etiologia , Choque/diagnóstico
J Med Case Rep ; 18(1): 273, 2024 Jun 09.
Artigo em Inglês | MEDLINE | ID: mdl-38851740


BACKGROUND: Bradycardia, renal failure, atrioventricular (AV) node blocking, shock, and hyperkalemia syndrome is a potentially life-threatening clinical condition characterized by bradycardia, renal failure, atrioventricular (AV) node blocking, shock, and hyperkalemia. It constitutes a vicious circle in which the accumulation of pharmacologically active compounds and hyperkalemia lead to hemodynamic instability and heart failure. CASE PRESENTATION: A 66-year-old Caucasian female patient was admitted to the emergency department presenting with fatigue and bradycardia. Upon examination, the patient was found to be anuric and hypotensive. Laboratory investigations revealed metabolic acidosis and hyperkalemia. Clinical evaluation suggested signs of digoxin toxicity, with serum digoxin concentrations persistently elevated over several days. Despite the implementation of antikalemic measures, the patient's condition remained refractory, necessitating renal dialysis and administration of digoxin immune fab. CONCLUSION: Bradycardia, renal failure, atrioventricular (AV) node blocking, shock, and hyperkalemia syndrome is a life-threatening condition that requires prompt management. It is important to also consider potential coexisting clinical manifestations indicative of intoxication from other pharmacological agents. Specifically, symptoms associated with the accumulation of drugs eliminated via the kidneys, such as digoxin. These manifestations may warrant targeted therapeutic measures.

Bradicardia , Digoxina , Hiperpotassemia , Diálise Renal , Humanos , Feminino , Idoso , Digoxina/efeitos adversos , Hiperpotassemia/induzido quimicamente , Bradicardia/induzido quimicamente , Insuficiência Renal/induzido quimicamente , Antiarrítmicos/efeitos adversos , Síndrome , Acidose/induzido quimicamente , Choque/induzido quimicamente , Bloqueio Atrioventricular/induzido quimicamente , Fragmentos Fab das Imunoglobulinas
J Emerg Med ; 67(1): e31-e41, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38789351


BACKGROUND: Vasopressor medications raise blood pressure through vasoconstriction and are essential in reversing the hypotension seen in many critically ill patients. Previously, vasopressor administration was largely limited to continuous infusions through central venous access. OBJECTIVES OF THE REVIEW: This review addresses the clinical use of vasopressors in various shock states, including practical considerations and innovations in vasopressor administration. The focus is on the clinical administration of vasopressors across a range of shock states, including hypovolemic, distributive, cardiogenic, and obstructive shock. DISCUSSION: Criteria for starting vasopressors are not clearly defined, though early use may be beneficial. A number of physiologic factors affect the body's response to vasopressors, such as acidosis and adrenal insufficiency. Peripheral and push-dose administration of vasopressors are becoming more common. Distributive shock is characterized by inappropriate vasodilation and vasopressors play a crucial role in maintaining adequate blood pressure. The use of vasopressors is more controversial in hypovolemic shock, as the preferred treatment is correction of the volume deficit. Evidence for vasopressors is limited in cardiogenic shock. For obstructive shock, vasopressors can temporize a patient's blood pressure until definitive therapy can reverse the underlying cause. CONCLUSION: Across the categories of shock states, norepinephrine has wide applicability and is a reasonable first-line agent for shock of uncertain etiology. Keeping a broad differential when hypotension is refractory to vasopressors may help to identify adjunctive treatments in physiologic states that impair vasopressor effectiveness. Peripheral administration of vasopressors is safe and facilitates early administration, which may help to improve outcomes in some shock states.

Choque , Vasoconstritores , Humanos , Vasoconstritores/uso terapêutico , Choque/tratamento farmacológico , Medicina de Emergência/métodos , Norepinefrina/uso terapêutico , Norepinefrina/administração & dosagem , Norepinefrina/farmacologia , Hipotensão/tratamento farmacológico , Pressão Sanguínea/efeitos dos fármacos , Choque Cardiogênico/tratamento farmacológico
Clin Neurol Neurosurg ; 241: 108294, 2024 06.
Artigo em Inglês | MEDLINE | ID: mdl-38692116
Med. intensiva (Madr., Ed. impr.) ; 48(5): 263-271, mayo.-2024. graf, tab
Artigo em Inglês | IBECS | ID: ibc-ADZ-390


Objective In this study, we aimed to evaluate the death risk factors of patients included in the sepsis protocol bundle, using clinical data from qSOFA, SIRS, and comorbidities, as well as development of a mortality risk score. Design This retrospective cohort study was conducted between 2016 and 2021. Setting Two university hospitals in Brazil. Participants Patients with sepsis. Interventions Several clinical and laboratory data were collected focused on SIRS, qSOFA, and comorbidities. Main variable of interest In-hospital mortality was the primary outcome variable. A mortality risk score was developed after logistic regression analysis. Results A total of 1,808 patients were included with a death rate of 36%. Ten variables remained independent factors related to death in multivariate analysis: temperature ≥38 °C (odds ratio [OR] = 0.65), previous sepsis (OR = 1.42), qSOFA ≥ 2 (OR = 1.43), leukocytes >12,000 or <4,000 cells/mm3 (OR = 1.61), encephalic vascular accident (OR = 1.88), age >60 years (OR = 1.93), cancer (OR = 2.2), length of hospital stay before sepsis >7 days (OR = 2.22,), dialysis (OR = 2.51), and cirrhosis (OR = 3.97). Considering the equation of the binary regression logistic analysis, the score presented an area under curve of 0.668, is not a potential model for death prediction. Conclusions Several risk factors are independently associated with mortality, allowing the development of a prediction score based on qSOFA, SIRS, and comorbidities data, however, the performance of this score is low. (AU)

Objetivo En este estudio, nuestro objetivo fue evaluar los factores de riesgo de muerte de los pacientes incluidos en el protocolo de sepsis, utilizando datos clínicos de qSOFA, SIRS y comorbilidades, así como el desarrollo de un puntaje de riesgo de mortalidad. Diseño Este estudio de cohorte retrospectivo se llevó a cabo entre 2016 y 2021. Ámbito Dos hospitales universitarios en Brasil. Participantes Pacientes con sepsis. Intervenciones Se recopilaron varios datos clínicos y de laboratorio centrados en SIRS, qSOFA y comorbilidades. Variable de interésprincipales La mortalidad intrahospitalaria fue la variable de resultado primaria. Se desarrolló un puntaje de riesgo de mortalidad después del análisis de regresión logística. Resultados Se incluyeron un total de 1,808 pacientes con una tasa de mortalidad del 36%. Diez variables permanecieron como factores independientes relacionados con la muerte en el análisis multivariado: temperatura ≥38 °C (odds ratio [OR] = 0.65), sepsis previa (OR = 1.42), qSOFA≥2 (OR = 1.43), leucocitos >12,000 o <4,000 células/mm3 (OR = 1.61), accidente cerebrovascular encefálico (OR = 1.88), edad >60 años (OR = 1.93), cáncer (OR = 2.2), duración de la estancia hospitalaria antes de la sepsis >7 días (OR = 2.22), diálisis (OR = 2.51) y cirrosis (OR = 3.97). Considerando la ecuación del análisis de regresión logística binaria, el puntaje presentó un área bajo la curva de 0.668, un modelo débil para la predicción de la muerte. Conclusiones Varios factores de riesgo se asocian de forma independiente con la mortalidad, lo que permite el desarrollo de una puntuación de predicción basada en datos de qSOFA, SIRS y comorbilidades; sin embargo, el rendimiento de esta puntuación es bajo. (AU)

Humanos , Sepse , Antibacterianos , Insuficiência de Múltiplos Órgãos , Síndrome de Resposta Inflamatória Sistêmica , Choque
Med. intensiva (Madr., Ed. impr.) ; 48(5): 282-295, mayo.-2024. graf, tab
Artigo em Espanhol | IBECS | ID: ibc-ADZ-392


El shock cardiogénico (SC) es un síndrome heterogéneo con elevada mortalidad y creciente incidencia. Se trata de una situación en la que existe un desequilibrio entre las necesidades tisulares de oxígeno y la capacidad del sistema cardiovascular para satisfacerlas debido a una disfunción cardiaca aguda. Históricamente, los síndromes coronarios agudos han sido la causa principal de SC; sin embargo, los casos no isquémicos han aumentado en incidencia. Su fisiopatología implica el daño isquémico del miocardio, una respuesta tanto simpática como del sistema renina-angiotensina-aldosterona e inflamatoria, que perpetúan la situación de hipoperfusión tisular conduciendo finalmente a la disfunción multiorgánica. La caracterización de los pacientes con SC mediante una valoración triaxial y la universalización de la escala SCAI ha permitido una estandarización de la estratificación de la gravedad del SC que, sumada a la detección precoz y el enfoque Hub and Spoke, podrían contribuir a mejorar el pronóstico de los pacientes en SC. (AU)

Cardiogenic shock (CS) is a heterogeneous syndrome with high mortality and increasing incidence. It is a condition where there is an imbalance between tissue oxygen demands and the cardiovascular system's capacity to meet them due to acute cardiac dysfunction. Historically, acute coronary syndromes have been the primary cause of CS; however, non-ischemic cases have seen a rise in incidence. Its pathophysiology involves myocardial ischemic damage, a sympathetic, renin–angiotensin–aldosterone system, and inflammatory response, perpetuating the situation of tissue hypoperfusion, ultimately leading to multiorgan dysfunction. Characterizing CS patients through a triaxial assessment and the widespread use of the SCAI scale has allowed standardization of CS severity stratification, which, coupled with early detection and the “Hub and Spoke” approach, could contribute to improve the prognosis of CS patients. (AU)

Humanos , Choque Cardiogênico , Infarto do Miocárdio , Insuficiência Cardíaca , Choque , Fisiologia
Clin Nutr ESPEN ; 61: 28-36, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38777444


Shock is a common critical illness characterized by microcirculatory disorders and insufficient tissue perfusion. Patients with shock and hemodynamic instability generally require vasopressors to maintain the target mean arterial pressure. Enteral nutrition (EN) is an important therapeutic intervention in critically ill patients and has unique benefits for intestinal recovery. However, the initiation of early EN in patients with shock receiving vasopressors remains controversial. Current guidelines make conservative and vague recommendations regarding early EN support in patients with shock. Increasing studies demonstrates that early EN delivery is safe and feasible in patients with shock receiving vasopressors; however, this evidence is based on observational studies. Changes in gastrointestinal blood flow vary by vasopressor and inotrope and are complex. The risk of gastrointestinal complications, especially the life-threatening complications of non-occlusive mesenteric ischemia and non-occlusive bowel necrosis, cannot be ignored in patients with shock during early EN support. It remains a therapeutic challenge in critical care nutrition therapy to determine the initiation time of EN in patients with shock receiving vasopressors and the safe threshold region for initiating EN with vasopressors. Therefore, the current review aimed to summarize the evidence on the optimal and safe timing of early EN initiation in patients with shock receiving vasopressors to improve clinical practice.

Estado Terminal , Nutrição Enteral , Choque , Vasoconstritores , Humanos , Vasoconstritores/uso terapêutico , Vasoconstritores/administração & dosagem , Nutrição Enteral/métodos , Choque/terapia , Estado Terminal/terapia , Cuidados Críticos/métodos , Fatores de Tempo
Allergol Immunopathol (Madr) ; 52(3): 60-64, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38721956


Delayed anaphylaxis after ingestion of red meat because of galactose-alpha-1,3-galactose (alpha-gal) syndrome has increased in recent years. The mechanism involves an immunoglobulin E reaction to alpha-gal, a molecule found in mammalian meat, dairy products, medications and excipients containing mammalian-derived components, and tick salivary glycans. Sensitization occurs due to the bite of a lone star tick and the transmission of alpha-gal molecules into person's bloodstream. We describe a case of alpha-gal syndrome with severe food, drug, and perioperative allergy in which anaphylaxis with hypovolemic shock occurred immediately after an emergency surgical procedure, when a gelatin-containing drug was injected. This case study confirms that the clinical manifestations of alpha-gal syndrome could be different depending on the route of administration, with immediate reactions if an alpha-gal-containing drug is injected and delayed type allergic manifestations occurring several hours after oral intake. The purpose of this report is to highlight the importance of risk communication in case of exposure to medical products and surgical procedures of patients with alpha-gal syndrome and to encourage drug manufacturers to indicate clearly the origin of excipients in product literature.

Anafilaxia , Hipersensibilidade Alimentar , Choque , Humanos , Anafilaxia/diagnóstico , Anafilaxia/terapia , Anafilaxia/etiologia , Hipersensibilidade Alimentar/diagnóstico , Hipersensibilidade Alimentar/complicações , Hipersensibilidade Alimentar/imunologia , Choque/etiologia , Choque/diagnóstico , Hipersensibilidade a Drogas/diagnóstico , Hipersensibilidade a Drogas/terapia , Masculino , Animais , Imunoglobulina E/imunologia , Excipientes/efeitos adversos , Dissacarídeos/imunologia , Dissacarídeos/efeitos adversos , Feminino , Trissacarídeos/imunologia , Gelatina/efeitos adversos , Síndrome
Shock ; 61(3): 331-332, 2024 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-38783402
Shock ; 61(1): 1-3, 2024 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-38783405
Shock ; 61(5): 647-649, 2024 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-38783415

Choque , Humanos
Shock ; 61(2): 165-166, 2024 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-38783419
Shock ; 61(4): 495-497, 2024 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-38783414

Choque , Humanos
Shock ; 61(6): 803-804, 2024 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-38788125
Am J Emerg Med ; 80: 149-155, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38608467


OBJECTIVE: The shock index (SI), the ratio of heart rate to systolic blood pressure, is a clinical tool for assessing injury severity. Age-adjusted SI models may improve predictive value for injured children in the out-of-hospital setting. We sought to characterize the proportion of children in the prehospital setting with an abnormal SI using established criteria, describe the age-based distribution of SI among injured children, and determine prehospital interventions by SI. METHODS: We performed a multi-agency retrospective cross-sectional study of children (<18 years) in the prehospital setting with a scene encounter for suspected trauma and transported to the hospital between 2018 and 2022 using the National Emergency Medical Services (EMS) Information System datasets. Our exposure of interest was the first calculated SI. We identified the proportion of children with an abnormal SI when using the SI, pediatric age-adjusted (SIPA); and the pediatric SI (PSI) criteria. We developed and internally validated an age-based distributional model for the SI using generalized additive models for location, scale, and shape to describe the age-based distribution of the SI as a centile or Z-score. We evaluated EMS interventions (basic airway interventions, advanced airway interventions, cardiac interventions, vascular access, intravenous fluids, and vasopressor use) in relation to both the SIPA, PSI, and distributional SI values. RESULTS: We analyzed 1,007,863 pediatric EMS trauma encounters (55.0% male, median age 13 years [IQR, 8-16 years]). The most common dispatch complaint was for traffic/transport related injury (32.9%). When using the PSI and SIPA, 13.1% and 16.3% were classified as having an abnormal SI, respectively. There were broad differences in the percentage of encounters classified as having an abnormal SI across the age range, varying from 5.1 to 22.8% for SIPA and 3.7-20.1% for PSI. The SIPA values ranged from the 75th to 95th centiles, while the PSI corresponded to an SI greater than the 90th centile, except in older children. The centile distribution for SI declined during early childhood and stabilized during adolescence and demonstrated a difference of <0.1% at cutoff values. An abnormal PSI, SIPA and higher SI centiles (>90th centile and >95th centiles) were associated with interventions related to basic and advanced airway management, cardiac procedures, vascular access, and provision of intravenous fluids occurred with greater frequency at higher SI centiles. Some procedures, including airway management and vascular access, had a smaller peak at lower (<10th) centiles. DISCUSSION: We describe the empiric distribution of the pediatric SI across the age range, which may overcome limitations of extant criteria in identifying patients with shock in the prehospital setting. Both high and low SI values were associated with important, potentially lifesaving EMS interventions. Future work may allow for more precise identification of children with significant injury using cutpoint analysis paired to outcome-based criteria. These may additionally be combined with other physiologic and mechanistic criteria to assist in triage decisions.

Serviços Médicos de Emergência , Choque , Ferimentos e Lesões , Humanos , Criança , Estudos Retrospectivos , Masculino , Feminino , Pré-Escolar , Estudos Transversais , Adolescente , Lactente , Ferimentos e Lesões/terapia , Ferimentos e Lesões/diagnóstico , Choque/diagnóstico , Choque/terapia , Frequência Cardíaca/fisiologia , Pressão Sanguínea/fisiologia , Recém-Nascido
Burns ; 50(6): 1463-1474, 2024 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-38584006


INTRODUCTION: Burn patients in rural areas may encounter poorer outcomes associated with barriers to care; however, residence has not been studied in a large sample. The association between rural-versus-urban residence and outcomes after burn was examined using the National Inpatient Sample (NIS) database. METHODS: Using the 2019 NIS database, patients over 18 years with a primary diagnosis of burn or corrosive injury were included. Level of urbanization was categorized into six groups. Outcomes after burn such as in-hospital mortality, multifactorial shock, prolonged mechanical ventilation, length of stay, and total costs were analyzed after adjusting for demographic factors and hospital characteristics. RESULTS: We included 4671 records, which represented a weighted population of 23,085 patients. Rural residence was associated with higher percentage of prior transfer but not in-hospital mortality. Compared to the most urbanized counties, encounters from the most rural counties were associated with higher odds of shock (aOR:2.62, 99% CI: 1.04-6.56, p = 0.007). CONCLUSION: Burn encounters from less urbanized counties did not experience differences in mortality, rates of skin grafting, prolonged mechanical ventilation, length of stay, or overall costs. However, odds of shock were higher among the least urbanized counties. Despite improved triage and transportation systems across the US, disparities and challenges exist for burn patients from rural residence.

Queimaduras , Bases de Dados Factuais , Mortalidade Hospitalar , Tempo de Internação , Respiração Artificial , População Rural , População Urbana , Humanos , Queimaduras/epidemiologia , Queimaduras/terapia , Masculino , Feminino , Pessoa de Meia-Idade , População Rural/estatística & dados numéricos , Adulto , Estados Unidos/epidemiologia , Tempo de Internação/estatística & dados numéricos , População Urbana/estatística & dados numéricos , Idoso , Respiração Artificial/estatística & dados numéricos , Transplante de Pele/estatística & dados numéricos , Adulto Jovem , Choque/epidemiologia , Adolescente , Transferência de Pacientes/estatística & dados numéricos
PLoS One ; 19(4): e0298342, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38557873


OBJECTIVE: In this retrospective case series, survival rates in different indications for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and differential diagnoses of COVID-19 associated refractory circulatory failure are investigated. METHODS: Retrospective analysis of 28 consecutive COVID-19 patients requiring VA-ECMO. All VA-ECMO's were cannulated peripherally, using a femoro-femoral cannulation. RESULTS: At VA-ECMO initiation, median age was 57 years (IQR: 51-62), SOFA score 16 (IQR: 13-17) and norepinephrine dosing 0.53µg/kg/min (IQR: 0.35-0.87). Virus-variants were: 61% wild-type, 14% Alpha, 18% Delta and 7% Omicron. Indications for VA-ECMO support were pulmonary embolism (PE) (n = 5, survival 80%), right heart failure due to secondary pulmonary hypertension (n = 5, survival 20%), cardiac arrest (n = 4, survival 25%), acute heart failure (AHF) (n = 10, survival 40%) and refractory vasoplegia (n = 4, survival 0%). Among the patients with AHF, 4 patients suffered from COVID-19 associated heart failure (CovHF) (survival 100%) and 6 patients from sepsis associated heart failure (SHF) (survival 0%). Main Complications were acute kidney injury (AKI) 93%, renal replacement therapy was needed in 79%, intracranial hemorrhage occurred in 18%. Overall survival to hospital discharge was 39%. CONCLUSION: Survival on VA-ECMO in COVID-19 depends on VA-ECMO indication, which should be considered in further studies and clinical decision making. A subgroup of patients suffers from acute heart failure due to inflammation, which has to be differentiated into septic or COVID-19 associated. Novel biomarkers are required to ensure reliable differentiation between these entities; a candidate might be soluble interleukin 2 receptor.

COVID-19 , Oxigenação por Membrana Extracorpórea , Insuficiência Cardíaca , Choque , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Oxigenação por Membrana Extracorpórea/efeitos adversos , COVID-19/complicações , COVID-19/terapia , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/terapia , Insuficiência Cardíaca/diagnóstico , Choque/etiologia
J Int Med Res ; 52(4): 3000605241239469, 2024 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-38603615


Hepatic portal venous gas is often referred to as the "sign of death" because it signifies a very poor prognosis if appropriate treatments are not promptly administered. The etiologies of hepatic portal venous gas are diverse and include severe complex abdominal infections, mesenteric ischemia, diving, and complications of endoscopic surgery, and the clinical manifestations are inconsistent among individual patients. Thus, whether emergency surgery should be performed remains controversial. In this report, we present three cases of hepatic portal venous gas. The patients initially exhibited symptoms consistent with severe shock of unknown etiology and were treated in the intensive care unit upon admission. We rapidly identified the cause of each individual patient's condition and selected problem-directed intervention measures based on active organ support, antishock support, and anti-infection treatments. Two patients recovered and were discharged without sequelae, whereas one patient died of refractory infection and multiple organ failure. We hope that this report will serve as a valuable reference for decision-making when critical care physicians encounter similar patients.

Veia Porta , Choque , Humanos , Veia Porta/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Insuficiência de Múltiplos Órgãos/etiologia , Unidades de Terapia Intensiva