The edition · Emergency & Critical Care
Reading refractory shock, and the ED's own eyes on PE
In septic shock, persistent poor perfusion marks the patients at highest risk beyond pressor dose; a bedside PE score and emergency-physician ultrasound both help triage; and rushing parenteral nutrition in critically ill children leaves a biochemical trace of harm.
The edition in brief
A secondary analysis of ANDROMEDA-SHOCK-2 (1,363 patients) tested how to define refractory septic shock. Among those on high-dose vasopressors at six hours, adding two signs of persistent tissue hypoperfusion — a capillary refill time over three seconds and non-falling lactate — identified a small group (3.9%) with 73.6% mortality versus 23.7% in the rest (adjusted hazard ratio 4.68), and stratified risk far better than vasopressor dose alone. The markers are bedside and free, though the analysis is exploratory. A secondary analysis of the PEPaNIC trial in critically ill children found that early parenteral nutrition raised urea and the urea-to-creatinine ratio, and that this rise independently tracked with more infections (adjusted odds ratio 1.75), slower recovery and higher 90-day mortality — a biochemical signature of metabolic intolerance that supports not rushing parenteral feeding. In 1,731 ED patients with pulmonary embolism, the Composite PE Shock score performed much like sPESI and the ESC classification overall but separated patients needing advanced intervention better (area under the curve 0.78). And in 194 ED patients, emergency-physician point-of-care ultrasound was 76.8% sensitive and 85.9% specific for right-ventricular dysfunction against consultative echocardiography, best when dysfunction was moderate to severe. A clinic pearl: in undifferentiated shock, use a focused bedside ultrasound to separate the treatable causes — tamponade, tension pneumothorax, massive PE and hypovolaemia — before committing to a diagnosis. Together the edition favours cheap, bedside tools — perfusion signs, ultrasound and simple scores — for the decisions that matter most in the first hours.
Persistent poor perfusion, not pressor dose, marks the deadliest septic shock
In high-dose-vasopressor septic shock, use persistent poor capillary refill and a non-falling lactate to identify the patients at highest risk of dying.
Rushing parenteral nutrition in critically ill children leaves a biochemical trace
Do not rush parenteral nutrition in the first week of paediatric critical illness, and treat a rising urea as a possible sign of metabolic intolerance.
A PE shock score adds most when deciding on advanced intervention
Use a validated PE score for risk stratification, and reach for the CPES score when the question is whether advanced intervention is likely.
Use focused ultrasound to triage undifferentiated shock
In undifferentiated shock, use a focused bedside ultrasound to separate tamponade, PE, pneumothorax and hypovolaemia before committing to one cause.
Emergency-physician ultrasound is good enough to screen for RV strain in PE
Use emergency-physician POCUS to screen for right-ventricular strain in PE at the bedside, confirming with formal echo when a normal scan would not reassure.
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