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Background: Acute spontaneous bleeding from renal angiomyolipoma (AML) is one of the causes of Wunderlich syndrome, a rare and potentially fatal clinical condition. Clinical deterioration will occur if there is a delay in urgent management. There are several management options for renal angiomyolipoma rupture. However, until now little is known about the case of recanalization from post-coil embolization of renal angiomyolipoma. There is no guideline about embolization technique for the management of recurrent bleeding after embolization or coil recanalization of renal angiomyolipoma. Case presentation: A 55-year-old male has Wunderlich syndrome caused by recurrent bleeding of giant AML of the left renal due to coil recanalization compounded by a pseudoaneurysm and other bleeding site in bilateral giant renal angiomyolipoma which is showed by contrast-enhanced abdominal computed tomography scan. The patient underwent urgent transarterial embolization and some blood transfusion. Clinical improvement occurred and the patient discharged several days later. Conclusions: Embolization for spontaneous bleeding or rebleeding of renal pseudoaneurysms may become the first choice of treatment in bilateral multiple renal angiomyolipoma rather than other managements which are available to preserve renal function. [ABSTRACT FROM AUTHOR]

Waveform capnography is a noninvasive measurement of ventilation and perfusion commonly employed in the prehospital setting. It is easy to apply, and modern cardiac monitors are equipped with the necessary ports and capability to display results. Despite its ease of use, end-tidal CO2 monitoring has not yet achieved widespread adoption within the hospital setting. It is routinely used in the emergency department and by anesthesiologists, but its application could support ICU management in critically ill patients. Its use is routinely supported by multiple professional societies, and it has been recommended as a requirement in all cardiac arrests. Careful analysis of the waveform and expired carbon dioxide can guide therapy for patients experiencing respiratory emergencies, hemodynamic compromise, metabolic acidosis, and shock due to trauma, hypovolemia, or sepsis. Use of capnography throughout the hospital could improve patient outcomes and prevent unidentified deterioration. [ABSTRACT FROM AUTHOR]

This article focused on the experiences of women who underwent medical termination of their pregnancies. The study adopted a qualitative phenomenological research design with a sample of 20 pregnant women. Data were collected between April and June 2022 using a personal information form and a semistructured individual interview. The qualitative data were analyzed into 4 categories: "psychosocial impacts," "impacts on functionality," "coping," and "expectations." These categories comprised 8 themes and 24 subthemes. Nurses play a crucial role in adopting family-centered approaches to offer holistic care. They should prioritize providing physical care throughout the medical termination, while also assessing the psychological impact of fetal loss. Perinatal palliative care and bereavement counseling should be integrated into care practices. [ABSTRACT FROM AUTHOR]

Objective: Vasoplegic shock, sometimes referred to as distributive shock, is a life-threatening clinical syndrome involving systemic vasodilation and is associated with significant morbidity and mortality in intensive care unit (ICU) patients. The most common etiology is sepsis; others include post-cardiac bypass vasoplegia and various toxidromes. Key components of management include fluid resuscitation and vasopressors to restore vascular tone. Methylene blue selectively targets inducible nitric oxide synthase, a key component of early vasodilation in response to inflammation. We investigated whether the timing of administration of methylene blue influences clinical response, as measured by subsequent vasopressor requirements, fluid resuscitation, organ system function, and mortality. Design: This study was a retrospective case series including 33 cases. Data were collected for each case, including timing of administration, vasopressor and fluid requirements, Sequential Organ Failure Assessment (SOFA) scores, and inhospital mortality. A Spearman's rank correlation was performed to assess the correlation between the timing of administration of methylene blue and improvement in relevant clinical parameters. Setting: A large metropolitan Intensive Care Unit (47 beds). Patients and participants: Included in this study were adult patients who received methylene blue in the participating ICU between 2020 and 2022 for managing vasoplegic shock. Interventions: Administration of intravenous methylene blue. Measurements and results: No correlation between the timing of administration and reduction in vasopressor requirements was observed. Administration of methylene blue within 8 hours of the onset of shock refractory to 5 mcg/min of noradrenaline was found to weakly correlate with reduced total SOFA score on Day 1 (Rs=0.39, p=0.04), and patients who received methylene blue within eight hours had a lower mortality (60.0% vs 78.2%). Conclusions: These findings suggest that a prolonged period of vasoplegic shock before consideration of methylene blue should not discourage its use. A prospective randomized control study will be a valuable direction for future research. [ABSTRACT FROM AUTHOR]

Pediatric liver transplantation is the main therapeutic modality for patients with liver cirrhosis secondary to biliary atresia. Unfortunately, approximately 22% will require a retransplantation. We present the case of a 15‑month‑old male patient diagnosed with biliary atresia, who received a liver transplant, which was complicated with hepatic artery thrombosis. For this reason, he received a retransplantation. Afterward, he had gastric varices and portal vein stenosis, which were resolved successfully by interventional radiology. Currently, liver with normal function, and adequate psychomotor development. It is very important to quickly identify and manage biliary atresia and to be aware of early and late complications of transplantation; once identified, it is necessary to perform the appropriate treatment for complications to avoid fatal outcomes. [ABSTRACT FROM AUTHOR]

Endotracheal intubation for airway management is a common procedure in the ICU. Intubation may be difficult due to anatomic airway abnormalities but also due to physiologic derangements that predispose patients to cardiovascular collapse during the procedure. Results of studies demonstrate a high incidence of morbidity and mortality associated with airway management in the ICU. To reduce the likelihood of complications, medical teams must be well versed in the general principles of intubation and be prepared to manage physiologic derangements while securing the airway. In this review, we present relevant literature on the approach to endotracheal intubation in the ICU and provide pragmatic recommendations relevant to medical teams performing intubations in patients who are physiologically unstable. [ABSTRACT FROM AUTHOR]

This review article provides a comprehensive overview of common medical emergencies that can occur in pregnant patients. We summarize the key diagnostic and management steps for each emergency to assist health care professionals in identifying and treating these potentially life-threatening conditions. The medical emergencies discussed in this article include postpartum hemorrhage: hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome; acute fatty liver of pregnancy: amniotic fluid embolism: pulmonary embolism; acute respiratory distress syndrome, and shock. Each condition is described in detail, with a focus on the clinical presentation, diagnostic workup, and treatment options. The information presented in this review article is based on current best practices and guidelines from leading medical organizations. We hope this article will serve as a valuable resource for health care professionals who care for pregnant patients and help improve outcomes for these patients in emergency situations. [ABSTRACT FROM AUTHOR]

The article highlights on the efficacy of the subcutaneous implantable cardioverter-defibrillator (S-ICD) in a real-world population based on an FDA-mandated post-approval study. The study found that the S-ICD system demonstrated excellent safety and efficacy over a five-year period, with high overall shock efficacy and a low rate of complications.

Background: The COVID-19 outbreak presents challenges to the emergency care system. Advanced age is a risk factor formortality. This study aimed to investigate whether the shock index (SI) is an early pre- dictor of adverse outcomes in geriatric patients with COVID-19. Methods: Patients aged ≤ 60 yearswith COVID-19 betweenMay 1, 2021, and February 1, 2022,were in- cluded in a retrospective cohort study. These patients were divided into two groups based on ICU ad- mission. Variables were compared for the two groups. The receiver operating characteristic analysis of the SI and age--SI (ASI) was used to detect deteriorating outcomes early. Results: In total, 156 patients were included, and the mean age was 68.52 ± 7.25 years. ICU admission, intubation, andmortality were recorded in 46 (29.49%), 32 (20.51%), and 16 (10.26%) patients, respec- tively. Themean body weight, pulse rate, respiratory rate, pulse oximetry, SI, and ASI were significantly different between the two groups (p = 0.018, 0.032, 0.007, < 0.001, 0.004, and 0.007, respectively). CRP, LDH, ALT, ferritin, D-dimer, and sodiumlevels were significantly associated with ICU admission. Regard- ing ICU admission, intubation, and mortality, the areas under the curve (AUC) of the SI and ASI showed acceptable discrimination. The predictive power of the ASI was significantly higher than that of the SI for mortality (AUC difference, 0.088 ± 0.036 (95% CI 0.017--0.160); p = 0.016). Conclusion: The ASI is a useful triage tool for mortality prediction in geriatric patients with COVID-19. The SI and ASI can be used in conjunction with vital signs, oxygen saturation, and laboratory biomarkers for the early detection of ICU admission. [ABSTRACT FROM AUTHOR]

Diabetic Ketoacidosis (DKA) is a serious complication of insulin deficiency. It is typically seen in children and young people with Type 1 Diabetes Mellitus, either at first presentation, or in established disease, for instance due to poor compliance, equipment failure, or concurrent illness. Insulin deficiency leads to hyperglycaemia causing osmotic fluid loss, dehydration and electrolyte derangement. Osmotic symptoms of polyuria and polydipsia due to hyperglycaemia may give way to oliguria or anuria as circulatory insufficiency develops. Unable to utilise glucose, cells default to alternative mechanisms of energy production resulting in the accumulation of ketone bodies. Kussmaul breathing may compensate partially for the worsening acidosis. Untreated, DKA results in progressively worsening acidosis, development of shock, coma and ultimately death. Clear guidelines for the management of DKA in children and young people exist once a diagnosis is made. However, evidence for these guidelines is limited and remains the subject of ongoing debate. Diligence is required to ensure that fluid and insulin is delivered appropriately, and to identify early the complications of both DKA and its treatment, such as cerebral oedema. In this article we review the current state of DKA management with key practice points. [ABSTRACT FROM AUTHOR]

Copyright of Revista Ciencias de la Salud is the property of Colegio Mayor de Nuestra Senora del Rosario and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The law has changed, over the past century, in respect of how it sees the legal subject. From the 1980s, the law began to articulate an understanding of the “mind” of those who came before the courts. This is evident in decisions around nervous shock in negligence law. The law also began to articulate a distinction between the “mind” and the “body” – evident in the law of consent to health treatment. The engagement of the courts with the development of the capacity of children to consent, in particular, when tied with the idea of “abstraction”, allows for an in-depth exploration of the concepts. The assessment of the law in the two areas, in turn, facilitates an exploration of the law’s understanding of the “autonomy” and the bodily “integrity” of the legal subject. [ABSTRACT FROM AUTHOR]

Introduction: Although traumatic diaphragmatic ruptures are rare, intra-abdominal organ herniation occurs more commonly in the left diaphragm because the right diaphragm is held by the liver and ligaments underneath. Additionally, right diaphragmatic injuries are sometimes delayed or missed because other comorbidities cover them. This study examined a 10-year experience with traumatic diaphragmatic injuries to better understand the clinical characteristics according to diaphragmatic injury location and improve future treatments. Methods: This retrospective study enrolled 29 patients with traumatic diaphragmatic rupture admitted to the Chungbuk National University Hospital, South Korea, between January 2011 and December 2020. The patients' clinical characteristics and treatment outcomes were analyzed using the chi-square test and independent t-test. Results: The injury severity score showed that left diaphragmatic ruptures (31.36, standard deviation [SD] 10.89) were higher than right-sided ruptures (29.33, SD 10.21), but the difference was not statistically significant (p=0.61). Abdominal organ herniations were more common on the left side, and there were two cases of hollow viscus injuries as left-side ruptures and eight cases of abdominal solid organ injuries as rightside ruptures, but there was no statistical difference between the two groups. There was no significant difference between the two groups in the state of shock during the emergency room visits, intensive care unit, and ventilator care, and no difference was observed in survival. Conclusion: Depending on the location of the diaphragmatic rupture, there were differences in the number of abdominal organ herniation and surgical methods, but there was no difference in injury severity or outcome. [ABSTRACT FROM AUTHOR]

In neonates with more than one clinical abnormalities, we always look for a unifying diagnosis that explains the entire clinical presentation. In rare instances, two conditions can co-exist. Here, we report a neonate born out of consanguineous marriage presenting at 48 hours of life with microcephaly, encephalopathy, hypertonia. He had excessive weight loss, persistent hyperkalaemia, shock and elevated level of 17- hydroxyprogesterone. Steroids were started for adrenal insufficiency. Magnetic resonance imaging (MRI) of the brain revealed T2 hyperintensity of cerebral white matter, hypomyelination and parenchymal volume loss causing microcephaly. Clinical exome sequencing (CES) revealed a pathogenic homozygous missense variation of CYP21A2 gene responsible for congenital adrenal hyperplasia and also the presence of a homozygous missense variant of unknown significance (VUS) of VARS gene implicated in neurodevelopmental disorder with microcephaly, seizures, and cortical atrophy (NDMSCA). Baby was neurologically abnormal at discharge. In the setting of consanguinity, there is a possibility of two genetic conditions. Clinical exome sequencing test is useful in demystifying the diagnosis in complex clinical presentation. [ABSTRACT FROM AUTHOR]

Shock is a life-threatening condition of circulatory failure that causes an imbalance between cellular oxygen supply and demand resulting in organ dysfunction. It is important to recognize promptly as it is reversible in earlier stages but will transition to an irreversible phase if left untreated. This will result in multiorgan failure and subsequent death. The clinician should therefore consider shock in the differential for all patients with new organ failure. This article will review the pathophysiology, classification, evaluation, and management of shock. [ABSTRACT FROM AUTHOR]

Aims: The COVID‐19 pandemic resulted in a decrease in patients' follow‐up and interventions with cardiovascular disease. In Portugal, the consequences on emergent pacemaker implantation rates are largely unknown. We sought to analyze the impact of the COVID‐19 pandemic on emergent pacemaker implantation rate and patient profile. Methods: We retrospectively reviewed the clinical profile of the 180 patients who had pacemakers implanted in our hospital in an emergent setting from March 18, 2020, to May 17, 2020 ("lockdown") and May 19 to July 17, 2020 ("postlockdown"). This data was then directly compared to the homologous periods from the year before. Results: Urgent pacemaker implantation rates during "lockdown" was lower than its homologous period (−23.7%), and cases in "postlockdown" were significantly increased (+106.9% vs. "lockdown"; +13.2% vs. May–July 2019). When comparing "lockdown" and "postlockdown," there was a tendency for a higher number of temporary pacemaker use (p =.076). Patients during "lockdown" were 7.57 times more likely to present with hypotension/shock (odds ratio 7.57; p =.013). We also noted a higher tendency for hypotension on presentation during "lockdown" (p =.054) in comparison to 2019. In comparison to its homologous 2019 period, "postlockdown" saw more patients presenting with bradycardia (p =.026). No patients were admitted to the emergency department during "lockdown" for anomalies detected on ambulatory tests. Conclusion: Our data show that the COVID‐19 pandemic had a real impact on urgent pacemaker implantation. Patients with bradyarrhythmias are at particular risk for severe complications and should seek medical care regardless of the pandemic. [ABSTRACT FROM AUTHOR]

Rationale: Peptic ulcer disease and variceal bleeding are two of the most common causes of gastrointestinal (GI) bleeding. GI bleeding can present with symptoms of hemodynamic instability such as tachycardia and shock. Patient's Concern: A 33-year-old man with confusion and hypotension (blood pressure: 70/40 mmHg and pulse rate: 140/min) was brought by emergency medical services from home to the emergency department without any companion. The patient was in undifferentiated shock. His hypotension was assessed with inferior vena cava (IVC) size and collapsibility, and rapid ultrasound in shock and hypotension (RUSH) protocol was used to investigate the cause of his shock. Following the RUSH protocol when scanning the IVC, parts of the stomach were seen in its vicinity and suspended heterogeneous particles were observed in the fluid. After seeing these particles, we suspected GI bleeding. Diagnosis: Endoscopy confirmed GI bleeding. Interventions: After placing an orogastric tube and suction, about 2 L of coffee-ground fluid with clots was removed. We started intravenous proton-pump inhibitors 80 mg bolus, followed by a continuous infusion of 8 mg/h. The patient received about 2 L of normal saline and 2 units of packed red blood cells to correct his hypotension. Outcomes: After being admitted to the GI ward and treated for three days, the patient was discharged from the hospital with a hemoglobin level of 11 g/dL and continued to have an outpatient follow-up at the clinic. Lessons: The use of gastric ultrasound in conjunction with the RUSH protocol can help to diagnose undifferentiated hypotensive shock. The components of the RUSH exam are the heart (H), IVC (I), Morrison's/FAST abdominal views with the aorta (MA), and pulmonary and pipes scanning (P), and can be memorized with the mnemonic: HI-MAP. We would like to introduce a new mnemonic: Hi-MAPS, adding stomach (S) to the RUSH protocol in undifferentiated hypotension and shock to evaluate upper GI bleeding. [ABSTRACT FROM AUTHOR]

Thick soft-tissue and redundant skin folds seen in obese patients may lead to difficulties during central venous catheter (CVC) insertion. Here, we describe the case of a morbidly obese patient (298 kilograms) in respiratory failure and shock in whomwe performed central venous catheterization via the mid-thigh femoral vein to administer fluids and drugs, while also executing a tracheostomy. We found that CVC insertion via the mid-thigh femoral vein is a fast and feasible alternate procedure in cases where catheterization of the internal jugular vein or the subclavian vein are challenging or contraindicated. Importantly, we show that dressings were clean and easy to maintain. [ABSTRACT FROM AUTHOR]

Fetal anaemia is a relatively rare occurrence, with a varied aetiology. Although it may cause a reduction in fetal activity, or the development of hydrops detected by chance on ultrasound scanning, it may also present with stillbirth, or neonatal anaemia (with or without newborn haemodynamic compromise). Broadly speaking, anaemia is caused by one, or a combination, of the following problems: (i) a failure of red cell production; (ii) accelerated red cell destruction; (iii) loss of red blood cells (bleeding). This is also the case for fetal anaemia. Anaemia caused by an acute loss of blood will be accompanied by hypotension and shock, and a significant risk of sudden death, or critical neurological and visceral ischaemia. Conversely, the chronic development of anaemia in the fetus carries no risk of haemodynamic compromise, but will eventually lead to high output cardiac failure, hypoxia, metabolic acidosis and hydrops. The management of fetal anaemia will be determined by the underlying cause, the severity, and the gestation. A conservative 'wait and see' approach is suitable in select cases, whereas immediate delivery is mandated in others. Intrauterine transfusion is a highly successful treatment, but is not always considered appropriate, carries some degree of risk, and requires subspecialist skills. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background: Hemorrhage is a leading cause of early mortality following trauma. A massive transfusion protocol (MTP) to guide resuscitation while bleeding is definitively controlled may improve outcomes. Prompts to initiate massive transfusion (MT) include shock index (SI) and the Assessment of Blood Consumption (ABC) score. Objective: To compare SI with the ABC score for association with transfusion requirement, need for emergency hemorrhage interventions, and early mortality. Methods: A retrospective cohort analysis of trauma MTP activations at our Level I trauma center was conducted from January 1, 2012, to December 31, 2016. The study data were obtained from the Trauma Registry and the blood bank. An SI cutoff of 1.0 was chosen for comparison with the positive ABC score. Results: The study cohort included 146 patients. Shock index ≥ 1 had significant association with MT requirement (p =.002) whereas a positive ABC score did not (p =.65). More patients with SI ≥ 1 required bleeding control interventions (67% surgery, 47% interventional radiology) than patients having a positive ABC score (49% surgery, 29% interventional radiology). For geriatric patients who received MT, 65% had SI ≥ 1 but only 30% had a positive ABC score. Three-hour mortality following emergency department arrival was similar (60% SI ≥ 1, 62% positive ABC score). Conclusion: Shock index ≥ 1 outperformed a positive ABC score for association with MT requirement. Shock index is a simple tool registered nurses can independently utilize to anticipate MT. [ABSTRACT FROM AUTHOR]

Pulmonary embolism (PE) is a condition with a high rate of morbidity and mortality if it is not recognized and treated in a timely fashion. Point-of-care ultrasound (POCUS) is a useful tool that can help clinicians make prompt diagnosis. We present a case where we diagnosed massive PE through visualizing an intracardiac thrombus in transit, and we highlight some important ultrasonographic features. [ABSTRACT FROM AUTHOR]

BACKGROUND: Until now, transfusion-related acute lung injury (TRALI) has been considered the leading cause of blood transfusion-related diseases and death. In addition, there is no clinically effective treatment plan for TRALI. The aim of this study was to systematically summarize the literature on risk factors for TRALI in critical patients. METHODS: Electronic searches (up to March 2020) were performed in the Cochrane Library, Web of Knowledge, Embase, and PubMed databases. We included studies reporting on the risk factors of TRALI for critical patients and extracted risk factors. A total of 13 studies met the inclusion criteria. RESULTS: We summarized and analyzed the potential risk factors of TRALI for critical patients in 13 existing studies. Host-related factors were age (odds ratio [OR] 1.16 [95% CI 1.08-1.24]), female sex (OR 1.26 [95% CI 1.16-1.38]), tobacco use status (OR 3.82 [95% CI 1.91-7.65]), chronic alcohol abuse (OR 3.82 [95% CI 2.97-26.83]), positive fluid balance (OR 1.24 [95% CI 1.08-1.42]), shock before transfusion (OR 4.41 [95% CI 2.38-8.20]), and American Society of Anesthesiologists (ASA) score of the recipients (OR 2.72 [95% CI 1.43-5.16]). The transfusion-related factors were the number of transfusions (OR 1.40 [95% CI 1.14-1.72]) and units of fresh frozen plasma (OR 1.21 [95% CI 1.01-1.46]). The device-related factor was mechanical ventilation (OR 4.13 [95% CI 2.20-7.76]). CONCLUSIONS: The risk factors that were positively correlated with TRALI in this study included number of transfusions and units of fresh frozen plasma. Age, female sex, tobacco use, chronic alcohol abuse, positive fluid balance, shock before transfusion, ASA score, and mechanical ventilation may be potential risk factors for TRALI. Our results suggest that host-related risk factors may play a more important role in the occurrence and development of TRALI than risk factors related to blood transfusions. [ABSTRACT FROM AUTHOR]

Fluid resucitation plays a crucial role in pediatric resuscitation. Predicting fluid responsiveness is important as excessive fluid may decrease cardiac efficiency, and even induce overload. Various pathophysiology of shock suggest that fluid only benefit in optimizing preload. Various methods to assess fluid responsiveness includes measurement of static preload indices, dynamic indices to estimate volume status, and the use of protocols such as fluid challenge and passive leg raising technique. This paper highlights the mechanisms behind each measurements and summarized their use as predictor of fluid responsiveness in pediatric patients. [ABSTRACT FROM AUTHOR]

Ectopic Pregnancy (EP) occurs in around 1–2% of all pregnancies, and is associated with significant morbidity and mortality. Over 98% implant in the Fallopian tube. The mainstay of diagnosis is by transvaginal ultrasound supported by serial serum human chorionic gonadotrophin (hCG) measurements. Management of tubal EP has moved away from surgery with growing experience with medical (methotrexate) and expectant management for selected women. Surgery will always have a role in the management of women with EP who are acutely unwell or where medical management is unlikely to be, or has already been unsuccessful. Ultrasound diagnostic criteria for non-tubal EP have been established and these cases are best managed on an individual basis. Future areas of improvement include the critical need to teach healthcare professionals to consider pregnancy related causes of collapse in all women of reproductive age. [ABSTRACT FROM AUTHOR]

Objective: To identify the role of left ventricular end-diastolic volume index as a predictor of fluid responsiveness in children. Design: This was a diagnostic study in children with shock in the Emergency Room and Pediatric Intensive Care Unit of Cipto Mangunkusumo Hospital from June to November 2018. The left ventricular end-diastolic volume index measurements were performed using ultrasonic cardiac output monitor and compared to the increase in stroke volume of ≥15% after fluid challenge as fluid responsiveness criteria. Samples were categorized into fluid responsive and non-responsive. Results: Out of 40 subjects, 60 fluid challenge samples were obtained. There were 31 and 29 . samples in the fluid responsive and non-responsive group, respectively. There was no significant difference in mean left ventricular end-diastolic volume index between the two groups (p=0.161). The area under the receiver operating characteristic (AUROC) of the left ventricular end-diastolic volume index was 40.9% with a cutoff value of 68.95 ml/m². The sensitivity and specificity were 45.16% and 44.83%, respectively. At the left ventricular end-diastolic volume index value of 81.10 ml/m2, the specificity was 72.41% with 22.6% sensitivity. Conclusion: This study cannot justify the use of left ventricular end-diastolic volume index can act as a predictor of fluid responsiveness in children. [ABSTRACT FROM AUTHOR]

Critically ill patients are those with life threatening illness who, without adequate medical interventions, will suffer from severe morbidity and occasionally mortality. One of the most frequent cause of morbidity and mortality in critically ill patients is distributive or vasogenic shock. After liberal fluid resuscitation, an increase in microvascular hydrostatic pressure, fluid accumulation of interstitial compartment, and impaired organ function occur. Normally this phase, called ebb phase, will return to flow phase where inflammatory mediators homeostasis occurs, plasma oncotic pressure restored, diuresis, extravascular fluid mobilized and negative fluid balance occur. In certain group of patients, there is persistent systemic inflammation, plasma leakage, and failure to achieve flow phase spontaneously, which lead to fluid overload and global increased permeability syndrome (GIPS). GIPS causes venous resistance of organs within compartment, resulting in decreased perfusion pressure and organ failure. In this condition, it is necessary to remove the fluid actively and one of the drugs that can be used is furosemide. This literature review will describe what happens in critically ill patients, how furosemide works, what its benefits are in critically ill patients, what side effects and potential toxicities of furosemide. [ABSTRACT FROM AUTHOR]

Purpose: Maternal Fetal Intensive Care Unit (MFICU), which provides intensive care to high-risk mothers with increasing maternal age and high-risk newborns, has become a new field of nursing work in South Korea. The present study was conducted to identify the educational needs and self-assessing clinical competence of nurses in MFICU. Methods: The education needs and competencies of MFICU nurses were measured through prepared questionnaires by researchers based on the previous studies on job analysis of nurses in MFICU. Data were collected from January 2019 to March 2019. The study involved 168 nurses working in MFICUs at 12 hospitals nationwide as study subjects. The data were analyzed using the SPSS WIN 23.0 program. Results: The education needs of nurses in MFICU had an average of 4.21 points (±0.50) and their nursing competence was average 3.38 points (±0.60). The items reported as high education needs but low competency by nurses in MFICU were as following: 'postpartum hemorrhage and shock,' 'cardiopulmonary resuscitation (CPR) for neonate,' 'CPR during pregnancy,' 'disseminated intravascular coagulation,' 'sepsis,' and 'mechanical ventilation during pregnancy.' Conclusion: Based on these results, it is proposed that a comprehensive education program for nurses in MFICU should be developed by considering low capabilities among MFICU nurses as a priority factor. [ABSTRACT FROM AUTHOR]

Background: Biomarkers, shock index and modified early warning score (MEWS) are of public health importance because identification and prompt attention to them have been found to reduce mortality among older patients on admission. Objectives: A study was undertaken to determine the biomarkers, shock index and MEWS that predict mortality on admission among older medical hospital inpatients. Methods: This was a prospective study of 450 patients (≥ 60 years) on the medical wards of University College Hospital, Ibadan. Biomarkers recommended by the National Institute on Aging such as blood pressure, heart rate and pulse rate (cardiovascular functioning); cholesterol and triglycerides (metabolic processes); T-cell counts (immune system status) and weight, body mass index and waist-to-hip ratio (indicators of obesity, chronic metabolic disorders and fat deposits) were assessed. Vital signs were recorded on admission and used to calculate the shock index and MEWS. Multivariate and survival analyses were carried out at p < 0.05. Results: Baseline temperature ≥ 39.0°c (p = 0.049), pulse rate ≥ 100 beats/minute (p = 0.034), systolic blood pressure (SBP) < 120 mmHg (p = 0.048), shock index ≥1.0 (p = 0.041), age shock index (p = 0.032) and critical illness score (MEWS ≥5) p = 0.019 were significantly associated with mortality. Independent predictors of mortality on Cox regression analysis were temperature ≥ 39.0°C (HR = 3.317 [1.281–8.590]) and SBP < 120 mmHg (HR = 1.845 [1.025–3.322]). Conclusion: Prompt identification and management of fever and low blood pressure should improve the survival of older medical hospital inpatients. [ABSTRACT FROM AUTHOR]

Objective: Shock in dengue hemorrhagic fever (DHF) is mostly caused by plasma leakage. Hemodynamic monitoring is essential for improving the quality of management and the outcome. We sought to find the hemodynamic profile of dengue hemorrhagic fever children with shock. Design: a cohort prospective study. Setting: Pediatric Intensive Care Unit (PICU) at tertiary general hospital in Surabaya, Indonesia. Patients and participants: Children <18-year-old admitted to the PICU with diagnosis DHF with shock. Intervention: All patients underwent measurement of hemodynamic profile with electrical cardiometry ICON OsypkaTM after the first fluid resuscitation. Measurements and results: There were 37 patients with DHF grade 3. All patients had normal blood pressure on first examination, with the mean of systolic and diastolic blood pressure were 82.5±9.21 mmHg and 51.8±16.32 mmHg, respectively. They had low stroke volume (66.7%), high heart rate (60.6%), low cardiac output (49%), and high systemic vascular resistance (55%). Mean resuscitation fluid volume was 35.30±31.99 ml/kg, where referral patient had significantly higher resuscitation fluid volume (49.45±39.46 ml/kg) than non-referral (19.75±0.60 ml/kg), p=0.002. Thoracic fluid content were significantly higher in referral (75%) than those in non-referral patients (16.7%), p=0.001. Conclusion: After first fluid resuscitation, children with DHF grade 3 obtained normal blood pressure but still in hypovolemic state. Referral patients had higher fluid volume resuscitation and thoracic fluid content than those in nonreferral. [ABSTRACT FROM AUTHOR]

Background: A systolic blood pressure (SBP) lower than the heart rate (HR) could indicate a poor condition in trauma patients. In such scenarios, the reversed shock index (RSI) is < 1, as calculated by the SBP divided by the HR. This study aimed to clarify whether RSI could be used to identify high-risk adult patients with isolated traumatic brain injury (TBI).Methods: This retrospective study reviewed 1216 hospitalized adult patients with isolated TBI at a Level I trauma center between January 1, 2009 and December 31, 2015. The patients were grouped and analyzed according to RSI (<1 or ≥ 1). Subgroups of patients with severe TBI (Glasgow Coma Scale [GCS] ≤ 8) or non-severe TBI (GCS > 8) were also compared. The primary outcome was in-hospital mortality. The odds ratios (ORs) of categorical variables were calculated by chi-square tests with 95% confidence intervals (CIs). Mann-Whitney U-tests were used to analyze non-normally distributed continuous data.Results: Among patients with isolated TBI, those with an RSI <1 had higher mortality (44.7% vs. 7.1%, OR: 10.5, 95% CI: 5.36-20.75; P < 0.001) than those with an RSI ≥1. An RSI <1 indicated a higher risk of mortality (OR: 5.1, 95% CI: 2.08-12.49; P < 0.001) in patients with severe isolated TBI but not in patients with non-severe isolated TBI (OR: 3.6, 95% CI: 0.45-28.71; P = 0.267).Conclusion: Patients with isolated TBI may be at risk for shock. In trauma patients with severe isolated TBI, an SBP lower than the HR indicates a poor outcome. [ABSTRACT FROM AUTHOR]

Background: Sudden Infant Death Syndrome (SIDS) mechanisms of death remains obscured. SIDS' Triple Risk Model assumed coexistence of individual subtle vulnerability, critical developmental period and stressors. Prone sleeping is a major risk factor but provide no clues regarding the mechanism of death. The leading assumed mechanisms of death are either an acute respiratory crisis or arrhythmias but neither one is supported with evidence, hence both are eventually speculations. Postmortem findings do exist but are inconclusive to identify the mechanism of death. WHAT DOES THE PROPOSED HYPOTHESIS BASED ON?: 1. The stressors (suggested by the triple risk model) share a unified compensatory physiological response of decrease in systemic vascular resistant (SVR) to facilitate a compensatory increase in cardiac output (CO). 2. The cardiovascular/cardiorespiratory control of the vulnerable infant during a critical developmental period may be impaired. 3. A severe decrease in SVR is associated with hyper-dynamic state, high output failure and distributive shock.the Hypothesis: Infant who is exposed to one or more stressors responds normally by decrease in SVR which increases CO. In normal circumstances once the needs are met both SVR and CO are stabilized on a new steady state. The incompetent cardiovascular control of the vulnerable infant fails to stabilize SVR which decreases in an uncontrolled manner. Accordingly CO increases above the needs to hyper-dynamic state, high output heart failure and hyper-dynamic shock.Conclusions: The proposed hypothesis provides an appropriate alternative to either respiratory crises or arrhythmia though both speculations cannot be entirely excluded. [ABSTRACT FROM AUTHOR]

Copyright of African Journal of Reproductive Health is the property of Women's Health & Action Research Centre and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Childhood injury is the largest cause of paediatric hospitalisation in Australia. Parents' psychological wellbeing is important in enabling them to support their children's recovery, however little is known about parents' psychosocial support needs during their child's admission to the emergency department. This study explores the experiences and support needs of parents of critically injured children in the emergency department. An exploratory qualitative approach was used. Semi-structured face to face interviews were conducted with 40 parents of 30 critically injured children aged 0–12 years across 4 Australian hospitals. Transcribed data were managed using NVivo 10 and qualitative content analysis was performed. Four themes of parent experience emerged from analysis: being in shock and distress; feeling challenged by the ed environment; dealing with urgent priorities; and having immediate needs met. There is a need for easy-to-understand information for parents in the ED following their child's injury. Recommendations include use of a checklist for emergency clinicians on what information to provide parents and provision of anticipatory guidance to parents on what to expect psychologically following injury. A dedicated family support coordinator is needed to support parents and children throughout the injury trajectory. [ABSTRACT FROM AUTHOR]

International guidelines recommend that interruptions to chest compressions are minimised during defibrillation. As a result, some resuscitation educators have adopted a more structured approach to defibrillation. One such approach is the 'C.O.A.C.H.E.D.' cognitive aid (Continue compressions, Oxygen away, All others away, Charging, Hands off, Evaluate, Defibrillate or Disarm). To date, there are no studies assessing the use of this cognitive aid. This study utilised an Emergency Department in situ simulated model of cardiac arrest. The defibrillator used was a proprietary R-Series (Zoll, PA, USA) connected to a CS1201 rhythm generator (Symbio, Beaverton, OR, USA). The study cohorts were interdisciplinary advanced life support (ALS) providers. Paired providers were enrolled in a mechanical CPR (M-CPR) training programme with no feedback related to defibrillation performance. As part of this 6-month programme, serial defibrillation performance was assessed. The outcome measures were the length of 'peri-shock' pause and 'safety' of defibrillation practice. Comparative statistical analysis using the Mann–Whitney U -test was made between groups of providers with 'correct use or near correct' or 'entirely incorrect or absent' use of the cognitive aid. The C.O.A.C.H.E.D. cognitive aid was applied correctly in 92 of 109 defibrillations. Providers with correct cognitive aid use had a median length of peri-shock pause time of 6.0 s (IQR 5.0–7.0). Providers with 'entirely incorrect or absent' cognitive aid use had a peri-shock pause time of 8.0 s (IQRF 6.6–10.0) (p ≤ 0.001). No unsafe defibrillation practices were observed. In this observational study of defibrillation performance, the use of the C.O.A.C.H.E.D. cognitive aid was associated with a significant decrease in the length of peri-shock pause. Therefore, we conclude that the use of a cognitive aid is appropriate for teaching and performing defibrillation. [ABSTRACT FROM AUTHOR]

To stabilize critically ill patients, emergency and critical care medicine providers often require rapid diagnosis and intervention. The demand for a safe, timely diagnostic device, alongside technological innovation, led to the advent of point-of-care ultrasonography (POCUS). POCUS allows the provider to gain invaluable clinical information with a high level of accuracy, leading to better clinical decision-making and improvements in patient safety. We have outlined the history of POCUS adaptation in emergency and critical care medicine and various clinical applications of POCUS described in literature. [ABSTRACT FROM AUTHOR]

Background: Postoperative re-exploration for bleeding (RB) is a frequent complication following cardiac surgery. We aim to assess incidence, risk factors, and prognostic significance of RB in a large cohort of cardiac patients.Materials and Methods: We reviewed prospectively collected data for all patients who underwent cardiac surgery at our institution from 2007 to 2015. Logistic regression analysis was used to identify independent predictors of RB and specific outcomes. Propensity matching using a 1:1-ratio compared outcomes of patients who had RB with patients who did not.Results: During the study period, 7381 patients underwent cardiac operations. Of them, 189 (2.6%) underwent RB. RB was an independent predictor of in-hospital mortality (Odds Ratio (OR):2.62 Confidence Interval (CI):1.38-4.96; p = 0.003), major adverse events (OR:3.94, CI:2.79-5.62; p < 0.001), gastrointestinal events (OR:3.54 CI:1.73-7.24), renal failure (OR:2.44, CI:1.23-4.82), prolonged ventilation (OR:3.83, CI:2.60-5.62, p < 0.001), and sepsis (OR:2.50, CI:1.03-6.04, p = 0.043). Preoperative shock (OR:3.68, CI:1.66-8.13; p = 0.001), congestive heart failure (OR:1.70 CI:1.24-2.32; p = 0.001), and urgent and emergent status (OR:2.27, CI:1.65-3.12 and OR:3.57, CI:1.89-6.75; p < 0.001 for both) were predictors of RB operative mortality. Operative mortality, incidence of major adverse events, gastrointestinal events, and respiratory failure were all significantly higher in the propensity matched RB group (p = 0.050, p < 0.001, p = 0.046, and p < 0.001 respectively).Conclusions: RB significantly increases in-hospital mortality and morbidity after cardiac surgery. [ABSTRACT FROM AUTHOR]

We report a case of severe type I hyperlipoproteinemia caused by autoimmunity against lipoprotein lipase (LPL) in the context of presymptomatic Sjögren's syndrome. A 7-year-old mixed race (Caucasian/African American) girl was admitted to the intensive care unit at Vanderbilt Children's Hospital with acute pancreatitis and shock. She was previously healthy aside from asthma and history of Hashimoto's thyroiditis. Admission triglycerides (TGs) were 2191 mg/dL but returned to normal during the hospital stay and in the absence of food intake. At discharge, she was placed on a low-fat, low-sugar diet. She did not respond to fibrates, prescription fish oil, metformin, or orlistat, and during the following 2 years, she was hospitalized several times with recurrent pancreatitis. Except for a heterozygous mutation in the promoter region of LPL, predicted to have no clinical significance, she had no further mutations in genes known to affect TG metabolism and to cause inherited type I hyperlipoproteinemia, such as APOA5, APOC2 , GPIHBP1 , or LMF1 . When her TG levels normalized after incidental use of prednisone, an autoimmune mechanism was suspected. Immunoblot analyses showed the presence of autoantibodies to LPL in the patient's plasma. Autoantibodies to LPL decreased by 37% while patient was on prednisone, and by 68% as she subsequently transitioned to hydroxychloroquine monotherapy. While on hydroxychloroquine, she underwent a supervised high-fat meal challenge and showed normal ability to metabolize TG. For the past 3 years and 6 months, she has had TG consistently <250 mg/dL, and no symptoms of, or readmissions for, pancreatitis. [ABSTRACT FROM AUTHOR]

The coexisting conditions of traumatic injury coupled with a comorbid condition such as heart failure create a complex scenario for the trauma nurse to manage. Initial care of the trauma patient includes following the Advanced Trauma Life Support guidelines and managing the airway, breathing, and circulation (ABC) of the patient. Once the airway is secure and breathing is managed, the team addresses circulation. At this point in the patient's care, the team typically does not know which, if any, comorbid conditions exist. Managing circulation for a hypotensive or hypoperfused patient will most likely include 1-2 L of crystalloid solution being given intravenously. Although most patients can tolerate this fluid volume challenge, excess volume can be difficult for a patient with heart failure. This article describes the monitoring and management techniques that are recommended for patients presenting with trauma and the comorbid condition of heart failure. [ABSTRACT FROM AUTHOR]

The purpose of this descriptive, one-group posttest study was to explore the nursing staff's perception of the benefits of using high-fidelity simulation during mandated obstetrical hemorrhage mock code training. In addition, the use of video-assisted debriefing was used to enhance the nursing staff's evaluation of their communication and teamwork processes during a simulated obstetrical crisis. The convenience sample of 84 members of the nursing staff consented to completing data collection forms and being videotaped during the simulation. Quantitative results for the postsimulation survey showed that 93% of participants agreed or totally agreed that the use of SimMan made the simulation more realistic and enhanced learning and that debriefing and the use of videotaped playback improved their evaluation of team communication. Participants derived greatest benefit from reviewing their performance on videotape and discussing it during postsimulation debriefing. Simulation with video-assisted debriefing offers hospital educators the ability to evaluate team processes and offer support to improve teamwork with the ultimate goal of improving patient outcomes during obstetrical hemorrhage. [ABSTRACT FROM AUTHOR]

Spinal cord injury without radiological abnormalities (SCIWORA) has been defined as a direct trauma to the spinal cord, with no radiological or tomographic abnormalities, although there is a deficit, whether motor, sensory or both. (1) To establish the final diagnosis, shock, obstetrical complications, penetrating trauma to the spine and congenital malformations should be excluded. (2) [ABSTRACT FROM AUTHOR]

Background: The severity of dengue hemorrhagic fever (DHF) can be seen from bleeding and plasma leakage manifestations. Albumin level is one of the markers of plasma leakage in dengue infection. Whether albumin can be used as a predictor of shock in DHF patients or of recurrent shock in dengue shock syndrome (DSS) patients still need to be further evaluated. Objective: To determine serum albumin level as a predictor of shock in DHF and of recurrent shock in DSS. Design: A cohort prospective study. Setting: Department of Child Health, Prof. Dr. RD Kandou Hospital, Manado, Indonesia. Patients and participants: Sixty-seven DHF patients and 58 DSS patients aged 1- to 14-yearold were enrolled in our study. Sampling was done with consecutive sampling method. The inclusion criteria were patients diagnosed with DHF/DSS based on World Health Organization (WHO) criteria (2011). The exclusion criteria were patients who received corticosteroids, blood transfusion, albumin infusion and patients with severe malnutrition. The dependent variables were shock and recurrent shock. The independent variable was serum albumin level. The relation between serum albumin level and shock or recurrent shock were analyzed using logistic regression test, power 0.80, α 0.05 and was significant if p<0.05. We used receiver operating characteristic (ROC) curve to determine prognostic factors. Data was analyzed using software SPSS v 21.0. Results: There was significant correlation between albumin level and shock in DHF patients (p=0.0001, area under the curve (AUC) 0.865, cut-off 3.05, odds ratio (OR) 17.4, sensitivity 79%, specificity 81%), but there was no correlation between albumin level and recurrent shock in DSS patients. Conclusions: Serum albumin level can be used as a predictor of shock in DHF patients but it cannot be used as predictor of recurrent shock in DSS patients. [ABSTRACT FROM AUTHOR]

Background: Secondary dengue infection (SDI), in the form of two sequential infections by different serotypes, will lead to severe dengue. Concomitant organ failure in particular cardiovascular (CVS) and central nervous system (CNS) carries further rise in the mortality rate. Case report: We report a confirmed SDI in a 27- year-old man who presented with hypovolemic shock due to persistent vomiting and diarrhoea. He was stabilized after fluid resuscitation. However, he developed sudden onset of seizure and myocarditis with unstable haemodynamic thereafter. After stabilization, his gag and cough reflexes were absent with dilated pupils. Imaging of the brain showed extensive cerebral oedema with poor flow beyond the internal carotid arteries and its branches above circle of Willis. He remained comatose with subsequent complications of diabetes insipidus, secondary bacterial infection, and acute kidney injury. He passed away after 19 days of admission. Discussion: There is a higher risk of severe dengue with SDI as it is associated with antibodydependent enhancement (ADE) mechanism. The pre-existing dengue antibodies enhance virus replication by activating memory T-cells causing surges in inflammatory cytokines. The increased capillary permeability with massive vascular leak most likely led to the extensive cerebral oedema in this patient. The concomitant cardiovascular failure also led to his irreversible outcome. Conclusion: Severe cardiovascular and neurological manifestations can occur in SDI with resultant in the fatality. Therefore, early recognition of risk factors in the early phase of severe dengue is important to prevent the irreversible outcome. [ABSTRACT FROM AUTHOR]

Vasodilators are a potential therapeutic option for patients with persisting microcirculatory disorders despite adequate cardiac output and mean arterial pressure due to conventional haemodynamic stabilization. Venous vasodilation may decrease post-capillary venular pressure and thus increase capillary flow resulting in reduced extravasation and oedema formation. Arteriolar vasodilation may increase microvascular flow by 'opening' the microcirculation. In particular, inodilators that combine vasodilation with positive inotropy may be promising. The present article summarizes the impact of different vasodilators (nitroglycerin, calcium antagonists and prostaglandins) and inodilators (dobutamine, phosphodiesterase-inhibitors and levosimendan) on haemodynamic coherence in the treatment of shock and microvascular dysfunction. In summary, there is presently no hard evidence to recommend any vasodilator for routine practice. If used in selected patients, microvascular monitoring before and during this therapy is a pre-requisite to indicate and guide vasodilator therapy. Further clinical trials are necessary to generate more evidence in the above-mentioned patient population. [ABSTRACT FROM AUTHOR]

Background: Shock remains one leading cause of morbidity and mortality in hospitalized children. Delta shock index is a simple tool to assess and evaluate shock. Objective: To investigate whether delta shock index might be related to mortality in children with shock. Methods: Prospective cohort study. Setting: Emergency Room (ER) and Pediatric Intensive Care Unit (PICU) of Sanglah University Hospital, Bali from March 2015 to March 2016. Patients and participants: Children aged 1- month to 12-year-old that were diagnosed with shock during admission or during hospitalization. Subjects were divided into delta shock index (DSI)≤0 group and DSI>0. Results: From March 2015 to March 2016 a total of 80 subjects were recruited. There were 40 cases with DSI≤0 and 40 cases with DSI>0. Mortality was found in 28 (70%) patients with DSI≤0 group. Chi-square analysis showed significant association between DSI and mortality (RR 1.9, 95%CI:1.2-2.9; p=0.004). Survival analysis showed median time survival was 5 days for the group with DSI≤0 and 7 days for the group with DSI>0 (log-rank 0.03). Cox regression analysis showed that DSI≤0 (RR 1.895, 95%CI:0.989-3.623; p=0.037) and age (RR 0.988, 95%CI:0.979-0.997; p=0.015) were risk factors for mortality in children with shock. Conclusion: DSI≤0 was associated with mortality in children with shock. [ABSTRACT FROM AUTHOR]