Refractory cardiogenic shock (CS) often requires veno-arterial extracorporeal membrane oxygenation (VA-ECMO) to sustain end-organ perfusion. Current animal models result in heterogenous cardiac injury and frequent episodes of refractory ventricular fibrillation. Thus, we aimed to develop an innovative, clinically relevant, and titratable model of severe cardiopulmonary failure. Six sheep (60 ± 6 kg) were anaesthetized and mechanically ventilated. VA-ECMO was commenced and CS was induced through intramyocardial injections of ethanol. Then, hypoxemic/hypercapnic pulmonary failure was achieved, through substantial decrease in ventilatory support. Echocardiography was used to compute left ventricular fractional area change (LVFAC) and cardiac Troponin I (cTnI) was quantified. After 5 h, the animals were euthanised and the heart was retrieved for histological evaluations. Ethanol (58 ± 23 mL) successfully induced CS in all animals. cTnI levels increased near 5000-fold. CS was confirmed by a drop in systolic blood pressure to 67 ± 14 mmHg, while lactate increased to 4.7 ± 0.9 mmol/L and LVFAC decreased to 16 ± 7%. Myocardial samples corroborated extensive cellular necrosis and inflammatory infiltrates. In conclusion, we present an innovative ovine model of severe cardiopulmonary failure in animals on VA-ECMO. This model could be essential to further characterize CS and develop future treatments.

A high index of suspicion must be employed for DI in the context of penetrating thoraco-abdominal trauma. Inpatient observation and laparoscopy/thoracoscopy should be considered when radiological findings are ambiguous. Front line physicians should also consider diaphragmatic herniation in stab victims who re-present with respiratory, circulatory, or gastrointestinal symptomology.

The 2016 Sepsis-3 consensus statement removed the Systemic Inflammatory Response Syndrome (SIRS) criteria from the definition of sepsis, in part for its poor specificity. (1, 2) In its place, Sepsis-3 recommended the Sequential Organ Failure Assessment (SOFA) be used to assist in identifying sepsis among patients with infection. SOFA was selected based on a detailed analysis of its performance in contrast to the Sepsis-2 definition derived from expert opinion. The SOFA score better identified patients at risk of sepsis, as well as its associated organ dysfunction and mortality risk. (3) Because SOFA is more time and resource intensive than SIRS and is not fully calculable pre-hospital or at initial emergency department (ED) triage, the Sepsis-3 group developed the quick SOFA (qSOFA). qSOFA has three clinical components and offers clinicians the ability to rapidly assess a patient without need of laboratory results. Pneumonia is the leading infectious cause of hospitalization among U.S. adults, and the most common cause of severe sepsis. (4, 5) Several pneumonia mortality risk scores are used in the ED to guide disposition and management. Because we anticipate calculation of qSOFA and SOFA will soon become common in the ED, we investigated whether these scores would offer any value in pneumonia triage. We sought to investigate qSOFA's association with mortality in pneumonia patients, and its potential to inform ED decision making as an alternative to traditional pneumonia severity and mortality risk scores. In a large population of ED patients with pneumonia, we aimed to determine how well SIRS, SOFA, and qSOFA correlate with 30 day all-cause mortality, ED disposition, and intensive care unit (ICU) admission.

Therapeutic study, level IV.