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Background: Bleeding is a serious cause of hypotension and tachycardia after childbirth and should always be considered. Case presentation: A healthy woman in her thirties who had previously undergone caesarean section, underwent induction and operative vaginal delivery. Postpartum, she experienced chest pain, hypotension and tachycardia, and had signs of ischaemia on electrocardiogram. A CT scan showed a large intraperitoneal haematoma. The patient underwent immediate laparotomy and received a massive blood transfusion. However, no large haematoma was found. The chest pain was attributed to a myocardial infarction caused by hypovolaemic shock. After discharge, the patient experienced significant vaginal bleeding and was transferred to a different university hospital. A CT scan revealed a large retroperitoneal haematoma. Emergency surgery was performed based on the suspicion of active bleeding, but only an older haematoma was found. Re-evaluation of the initial CT scan revealed that the haematoma was in fact located retroperitoneally and was thereby not found in the first operation. Interpretation: This case highlights the importance of bleeding as an important cause in unstable postpartum patients. Additionally, it is a reminder that retroperitoneal haematomas can occur in obstetric patients and can mask typical symptoms of uterine rupture such as abdominal pain. also hindering perioperative diagnosis.
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Dolor en el Pecho , Hematoma , Choque , Humanos , Femenino , Adulto , Hematoma/diagnóstico por imagen , Hematoma/etiología , Hematoma/diagnóstico , Dolor en el Pecho/etiología , Choque/etiología , Choque/diagnóstico , Tomografía Computarizada por Rayos X , Embarazo , Trastornos Puerperales/diagnóstico , Trastornos Puerperales/etiología , Trastornos Puerperales/diagnóstico por imagen , Espacio Retroperitoneal/diagnóstico por imagen , Cesárea/efectos adversos , Electrocardiografía , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/complicaciones , Hemorragia Posparto/etiología , Hemorragia Posparto/diagnósticoRESUMEN
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.
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Placenta Previa , Humanos , Femenino , Adulto , Embarazo , Placenta Previa/cirugía , Placenta Previa/diagnóstico , Cesárea/métodos , Choque/etiología , Choque/diagnóstico , Periodo PospartoRESUMEN
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.
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Síndrome Mucocutáneo Linfonodular , Choque Séptico , Choque , Humanos , Masculino , Síndrome Mucocutáneo Linfonodular/complicaciones , Síndrome Mucocutáneo Linfonodular/diagnóstico , Síndrome Mucocutáneo Linfonodular/tratamiento farmacológico , Niño , Diagnóstico Diferencial , Choque Séptico/diagnóstico , Choque Séptico/etiología , Choque/etiología , Choque/diagnóstico , EcocardiografíaRESUMEN
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.
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Servicio de Urgencia en Hospital , Puntaje de Gravedad del Traumatismo , Choque , Taquicardia , Humanos , Niño , Masculino , Femenino , Estudios Retrospectivos , Adolescente , Estudios Transversales , Preescolar , Taquicardia/diagnóstico , Choque/mortalidad , Choque/diagnóstico , Triaje/métodos , Heridas y Lesiones/mortalidad , Heridas y Lesiones/complicaciones , Heridas y Lesiones/terapia , Heridas no Penetrantes/mortalidad , Heridas no Penetrantes/complicaciones , Heridas no Penetrantes/terapia , Heridas no Penetrantes/diagnósticoAsunto(s)
Valor Predictivo de las Pruebas , Embolia Pulmonar , Humanos , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/diagnóstico por imagen , Factores de Riesgo , Medición de Riesgo , Técnicas de Apoyo para la Decisión , Pronóstico , Reproducibilidad de los Resultados , Choque/fisiopatología , Choque/diagnósticoRESUMEN
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.
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Paro Cardíaco , Hemodinámica , Mortalidad Hospitalaria , Valor Predictivo de las Pruebas , Embolia Pulmonar , Choque , Humanos , Embolia Pulmonar/mortalidad , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/fisiopatología , Masculino , Femenino , Anciano , Medición de Riesgo , Persona de Mediana Edad , Factores de Riesgo , Paro Cardíaco/mortalidad , Paro Cardíaco/diagnóstico , Paro Cardíaco/fisiopatología , Paro Cardíaco/terapia , Pronóstico , Estudios Retrospectivos , Choque/mortalidad , Choque/diagnóstico , Choque/fisiopatología , Factores de Tiempo , Anciano de 80 o más Años , Técnicas de Apoyo para la DecisiónRESUMEN
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.
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Choque , Heridas y Lesiones , Humanos , Niño , Choque/mortalidad , Choque/diagnóstico , Heridas y Lesiones/mortalidad , Adolescente , Curva ROC , Preescolar , PronósticoRESUMEN
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.
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Trasplante de Corazón , Azul de Metileno , Vasoplejía , Humanos , Trasplante de Corazón/efectos adversos , Vasoplejía/tratamiento farmacológico , Vasoplejía/etiología , Vasoplejía/fisiopatología , Vasoplejía/diagnóstico , Resultado del Tratamiento , Terapia Combinada , Índice de Severidad de la Enfermedad , Antibacterianos/uso terapéutico , Masculino , Citocinas , Persona de Mediana Edad , Choque/fisiopatología , Choque/etiología , Choque/diagnóstico , Choque/terapia , Choque/tratamiento farmacológicoRESUMEN
Background: Kawasaki disease shock syndrome (KDSS) is a critical manifestation of Kawasaki disease (KD). In recent years, a logistic regression prediction model has been widely used to predict the occurrence probability of various diseases. This study aimed to investigate the clinical characteristics of children with KD and develop and validate an individualized logistic regression model for predicting KDSS among children with KD. Methods: The clinical data of children diagnosed with KDSS and hospitalized between January 2021 and December 2023 were retrospectively analyzed. The best predictors were selected by logistic regression and lasso regression analyses. A logistic regression model was built of the training set (n = 162) to predict the occurrence of KDSS. The model prediction was further performed by logistic regression. A receiver operating characteristic curve was used to evaluate the performance of the logistic regression model. We built a nomogram model by visualizing the calibration curve using a 1000 bootstrap resampling program. The model was validated using an independent validation set (n = 68). Results: In the univariate analysis, among the 24 variables that differed significantly between the KDSS and KD groups, further logistic and Lasso regression analyses found that five variables were independently related to KDSS: rash, brain natriuretic peptide, serum Na, serum P, and aspartate aminotransferase. A logistic regression model was established of the training set (area under the receiver operating characteristic curve, 0.979; sensitivity=96.2%; specificity=97.2%). The calibration curve showed good consistency between the predicted values of the logistic regression model and the actual observed values in the training and validation sets. Conclusion: Here we established a feasible and highly accurate logistic regression model to predict the occurrence of KDSS, which will enable its early identification.
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Síndrome Mucocutáneo Linfonodular , Humanos , Síndrome Mucocutáneo Linfonodular/diagnóstico , Síndrome Mucocutáneo Linfonodular/sangre , Masculino , Femenino , Preescolar , Lactante , Estudios Retrospectivos , Modelos Logísticos , Niño , Choque/etiología , Choque/diagnóstico , Curva ROC , Nomogramas , Pronóstico , Biomarcadores/sangreRESUMEN
PURPOSE: The aim of this study is to evaluate the role of shock index (SI), modified shock index (MSI), and delta shock index (ΔSI) in predicting postpartum hemorrhage (PPH) and adverse maternal outcomes. MATERIAL AND METHODS: In this cross-sectional cohort study, a study group consisting of 416 pregnant women who delivered at our hospital and had postpartum hemorrhage was compared with 467 control patients with normal follow-up. SI (pulse/systolic blood pressure), MSI (pulse/mean arterial pressure), ΔSI (input SI - 2nd- or 6th-hour SI) values were calculated. RESULTS: A total of 883 postpartum women were included in the study. The study group had higher peripartum, 2nd-hour, and 6th-hour SI values (p=0.011, p=0.001, p<0.001, respectively). Peripartum MSI values (p=0.004), 2nd-hour MSI values (p<0.001), and 6th-hour MSI values (p<0.001) were significantly lower in the control group than in the PPH group. When the groups were evaluated, the cut-off value of the 2nd-hour SI parameter was>0.8909 (sensitivity 30%, specificity 84%), and the 6th-hour SI parameter was>0.8909 (sensitivity 40%, specificity 80%) for predicting postpartum hemorrhage requiring blood transfusion and surgical intervention. The cut-off value of the 2nd-hour MSI parameter was>1.2 (sensitivity 34%, specificity 82%), and the cut-off value of the 6th-hour MSI parameter was>1.2652 (sensitivity 32%, specificity 90%). CONCLUSION: The 2nd- and 6th-hour SI and 2nd- and 6th-hour MSI values were significantly higher in patients with postpartum hemorrhage. Values greater than 0.89 for SI and 1.2 for MSI were considered significant for predicting postpartum hemorrhage with maternal impairment.
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Hemorragia Posparto , Sensibilidad y Especificidad , Humanos , Hemorragia Posparto/diagnóstico , Femenino , Adulto , Embarazo , Reproducibilidad de los Resultados , Estudios Transversales , Choque/diagnóstico , Estudios de Cohortes , Adulto Joven , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: The Shock Index (SI) is emerging as a potentially useful measure among children with injury or suspected sepsis. OBJECTIVE: The aim of this study was to evaluate the distribution of the SI and evaluate its association with clinical outcomes among all children presenting to the emergency department (ED). METHODS: A complex survey of nonfederal U.S. ED encounters from 2016 through 2021 was analyzed. Among children, the Pediatric Age-Adjusted Shock Index (SIPA), Pediatric Shock Index (PSI), and the Temperature- and Age-Adjusted Shock Index (TAMSI) were analyzed. The association of these criteria with disposition, acuity, medication administration, diagnoses and procedures was analyzed. RESULTS: A survey-weighted 81.5 million ED visits were included for children aged 4-16 years and 117.2 million visits were included for children aged 1-12 years. SI could be calculated for 78.6% of patients aged 4-16 years and 57.9% of patients aged 1-12 years. An abnormal SI was present in 15.9%, 11.1%, and 31.7% when using the SIPA, PSI, and TAMSI, respectively. With all criteria, an elevated SI was associated with greater hospitalization. The SIPA and PSI were associated with triage acuity. All criteria were associated with medical interventions, including provision of IV fluids and acquisition of blood cultures. CONCLUSIONS: An elevated SI is indicative of greater resource utilization needs among children in the ED. When using any criteria, an elevated SI was associated with clinically important outcomes. Further research is required to evaluate the distribution of the SI in children and to investigate its potential role within existing triage algorithms for children in the ED.
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Servicio de Urgencia en Hospital , Choque , Humanos , Niño , Servicio de Urgencia en Hospital/estadística & datos numéricos , Servicio de Urgencia en Hospital/organización & administración , Preescolar , Adolescente , Femenino , Masculino , Choque/diagnóstico , Lactante , Triaje/métodos , Triaje/estadística & datos numéricos , Índice de Severidad de la Enfermedad , Estados Unidos , Encuestas y Cuestionarios , Sepsis/diagnósticoRESUMEN
OBJECTIVES: Early shock reversal is crucial to improve patient outcomes. Capillary refill time (CRT) is clinically important to identify and monitor shock in children but has issues with inconsistency. To minimize inconsistency, we evaluated a CRT monitoring system using an automated compression device. Our objective was to determine proper compression pressure in children. METHODS: Clinician force for CRT was collected during manual CRT measurement as a reference for automated compression in a previous study (12.9 N, 95% confidence interval, 12.5-13.4; n = 454). An automated compression device with a soft inflation bladder was fitted with a force sensor. We evaluated the effectiveness of the automated pressure to eliminate pulsatile blood flow from the distal phalange. Median and variance of CRT analysis at each pressure was compared. RESULTS: A comparison of pressures at 300 to 500 mm Hg on a simulated finger yielded a force of 5 to 10 N, and these pressures were subsequently used for automated compression for CRT. Automated compression was tested in 44 subjects (median age, 33 months; interquartile range [IQR], 14-56 months). At interim analysis of 17 subjects, there was significant difference in the waveform with residual pulsatile blood flow (9/50: 18% at 300 mm Hg, 5/50:10% at 400 mm Hg, 0/51: 0% at 500 mm Hg, P = 0.008). With subsequent enrollment of 27 subjects at 400 and 500 mm Hg, none had residual pulsatile blood flow. There was no difference in the CRT: median 1.8 (IQR, 1.06-2.875) in 400 mm Hg vs median 1.87 (IQR, 1.25-2.8325) in 500 mm Hg, P = 0.81. The variance of CRT was significantly larger in 400 mm Hg: 2.99 in 400 mm Hg vs. 1.35 in 500 mm Hg, P = 0.02, Levene's test. Intraclass correlation coefficient for automated CRT was 0.56 at 400 mm Hg and 0.78 at 500 mm Hg. CONCLUSIONS: Using clinician CRT measurement data, we determined either 400 or 500 mm Hg is an appropriate pressure for automated CRT, although 500 mm Hg demonstrates superior consistency.
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Capilares , Dedos , Humanos , Dedos/irrigación sanguínea , Masculino , Femenino , Preescolar , Lactante , Capilares/fisiología , Flujo Pulsátil/fisiología , Choque/fisiopatología , Choque/diagnóstico , Choque/terapia , Niño , Presión , Monitoreo Fisiológico/métodos , Monitoreo Fisiológico/instrumentación , AutomatizaciónRESUMEN
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.
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Transfusión Sanguínea , Traumatismos Torácicos , Humanos , Masculino , Femenino , Transfusión Sanguínea/métodos , Adulto , Estudios Retrospectivos , Traumatismos Torácicos/terapia , Persona de Mediana Edad , Pronóstico , Puntaje de Gravedad del Traumatismo , Heridas Penetrantes/terapia , Hemorragia/terapia , Hemorragia/etiología , Hemorragia/diagnóstico , Choque/terapia , Choque/etiología , Choque/diagnósticoRESUMEN
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.
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Anafilaxia , Hipersensibilidad a los Alimentos , Choque , Humanos , Anafilaxia/diagnóstico , Anafilaxia/terapia , Anafilaxia/etiología , Hipersensibilidad a los Alimentos/diagnóstico , Hipersensibilidad a los Alimentos/complicaciones , Hipersensibilidad a los Alimentos/inmunología , Choque/etiología , Choque/diagnóstico , Hipersensibilidad a las Drogas/diagnóstico , Hipersensibilidad a las Drogas/terapia , Masculino , Animales , Inmunoglobulina E/inmunología , Excipientes/efectos adversos , Disacáridos/inmunología , Disacáridos/efectos adversos , Femenino , Trisacáridos/inmunología , Gelatina/efectos adversos , SíndromeRESUMEN
INTRODUCTION: The shock index (SI) is a known predictor of unfavorable outcomes in trauma. This study seeks to examine and compare the SI values between geriatric patients and younger adults. METHODS: We conducted a retrospective study of the Trauma Quality Improvement Program database from 2017 to 2019. All patients≥ 25 y with injury severity score ≥ 16 were included. Age groups were defined as 25-44 y (group A), 45-64 y (group B), and ≥65 y (group C). SI was calculated for all patients. The primary outcome was mortality and secondary outcomes were need for blood transfusion and need for major surgical intervention (consisting angiography, exploratory laparotomy, and thoracotomy). RESULTS: A total of 244,943 patients were studied. The SI was highest in group A (0.82 ± 0.33) and lowest in group C (0.62 ± 0.30) (P < 0.001). Mortality rate of group C (17%) was significantly higher than group A (9.7%) and B (11.3%) (P < 0.001). In group A, each 0.1 increase in SI was associated with mortality (odds ratio [OR] = 1.079), need for blood transfusion (OR = 1.225) and need for major surgical intervention (OR = 1.347) (P < 0.001 for all). In group C, each 0.1 increase in SI was associated with mortality (OR = 1.126), need for blood transfusion (OR = 1.318), and need for major surgical intervention (OR = 1.648) (P < 0.001 for all). The area under the curve of SI was significantly higher in group C compared to other groups for needing a major surgical intervention and need for blood transfusion (P < 0.05 for both). CONCLUSIONS: These results highlight the significance of the SI as a valuable indicator in geriatric patients with severe trauma. The findings show that SI predicts outcomes in geriatrics more strongly than in younger counterparts.
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Choque , Humanos , Estudios Retrospectivos , Persona de Mediana Edad , Masculino , Femenino , Anciano , Adulto , Factores de Edad , Choque/mortalidad , Choque/diagnóstico , Choque/terapia , Transfusión Sanguínea/estadística & datos numéricos , Heridas y Lesiones/mortalidad , Heridas y Lesiones/terapia , Heridas y Lesiones/diagnóstico , Puntaje de Gravedad del Traumatismo , PronósticoRESUMEN
In this study, we found that a low LVOT VTI (<15 cm), a simple bedside point-of-care measurement, predicts normotensive shock in patients with acute intermediate-risk PE.
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Embolia Pulmonar , Humanos , Embolia Pulmonar/fisiopatología , Embolia Pulmonar/complicaciones , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/diagnóstico por imagen , Masculino , Femenino , Enfermedad Aguda , Choque/fisiopatología , Choque/etiología , Choque/diagnóstico , Persona de Mediana Edad , Anciano , Presión Sanguínea/fisiología , Pronóstico , Valor Predictivo de las PruebasRESUMEN
Background and Objectives: The Taiwan Triage and Acuity Scale (TTAS) is reliable for triaging patients in emergency departments in Taiwan; however, most triage decisions are still based on chief complaints. The reverse-shock index (SI) multiplied by the simplified motor score (rSI-sMS) is a more comprehensive approach to triage that combines the SI and a modified consciousness assessment. We investigated the combination of the TTAS and rSI-sMS for triage compared with either parameter alone as well as the SI and modified SI. Materials and Methods: We analyzed 13,144 patients with trauma from the Taipei Tzu Chi Trauma Database. We investigated the prioritization performance of the TTAS, rSI-sMS, and their combination. A subgroup analysis was performed to evaluate the trends in all clinical outcomes for different rSI-sMS values. The sensitivity and specificity of rSI-sMS were investigated at a cutoff value of 4 (based on previous study and the highest score of the Youden Index) in predicting injury severity clinical outcomes under the TTAS system were also investigated. Results: Compared with patients in triage level III, those in triage levels I and II had higher odds ratios for major injury (as indicated by revised trauma score < 7 and injury severity score [ISS] ≥ 16), intensive care unit (ICU) admission, prolonged ICU stay (≥14 days), prolonged hospital stay (≥30 days), and mortality. In all three triage levels, the rSI-sMS < 4 group had severe injury and worse outcomes than the rSI-sMS ≥ 4 group. The TTAS and rSI-sMS had higher area under the receiver operating characteristic curves (AUROCs) for mortality, ICU admission, prolonged ICU stay, and prolonged hospital stay than the SI and modified SI. The combination of the TTAS and rSI-sMS had the highest AUROC for all clinical outcomes. The prediction performance of rSI-sMS < 4 for major injury (ISS ≥ 16) exhibited 81.49% specificity in triage levels I and II and 87.6% specificity in triage level III. The specificity for mortality was 79.2% in triage levels I and II and 87.4% in triage level III. Conclusions: The combination of rSI-sMS and the TTAS yielded superior prioritization performance to TTAS alone. The integration of rSI-sMS and TTAS effectively enhances the efficiency and accuracy of identifying trauma patients at a high risk of mortality.
Asunto(s)
Triaje , Heridas y Lesiones , Humanos , Triaje/métodos , Triaje/normas , Masculino , Femenino , Taiwán/epidemiología , Persona de Mediana Edad , Adulto , Heridas y Lesiones/mortalidad , Anciano , Servicio de Urgencia en Hospital/organización & administración , Servicio de Urgencia en Hospital/estadística & datos numéricos , Puntaje de Gravedad del Traumatismo , Sensibilidad y Especificidad , Índices de Gravedad del Trauma , Choque/mortalidad , Choque/diagnóstico , Tiempo de Internación/estadística & datos numéricosRESUMEN
Adrenal insufficiency (AI) is one of the most life-threatening disorders resulting from adrenal cortex dysfunction. Symptoms and signs of AI are often nonspecific, and the diagnosis can be missed and lead to the development of AI with severe hypotension and hypovolemic shock. We report the case of a 13-year-old child admitted for cardiac arrest following severe hypovolemic shock. The patient initially presented with isolated mild abdominal pain and vomiting together with unexplained hyponatremia. He was discharged after an initial short hospitalization with rehydration but with persistent hyponatremia. After discharge, he had persistent refractory vomiting, finally leading to severe dehydration and extreme asthenia. He was admitted to pediatric intensive care after prolonged hypovolemic cardiac arrest with severe anoxic encephalopathy leading to brain death. After re-interviewing, the child's parents reported that he had experienced polydipsia, a pronounced taste for salt with excessive consumption of pickles lasting for months, and a darkened skin since their last vacation 6 months earlier. A diagnosis of autoimmune Addison's disease was made. Primary AI is a rare life-threatening disease that can lead to hypovolemic shock. The clinical symptoms and laboratory findings are nonspecific, and the diagnosis should be suspected in the presence of unexplained collapse, hypotension, vomiting, or diarrhea, especially in the case of hyponatremia.
Asunto(s)
Enfermedad de Addison , Humanos , Adolescente , Masculino , Enfermedad de Addison/diagnóstico , Enfermedad de Addison/complicaciones , Enfermedad de Addison/etiología , Choque/etiología , Choque/diagnóstico , Hiponatremia/etiología , Hiponatremia/diagnóstico , Hiponatremia/terapia , Insuficiencia Suprarrenal/diagnóstico , Insuficiencia Suprarrenal/etiología , Paro Cardíaco/etiología , Paro Cardíaco/diagnósticoRESUMEN
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.