Gastric ultrasound-assisted diagnosis of undifferentiated shock:A case report

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.

Xuebijing Injection(血必净注射液)Increases Early Survival Rate by Alleviating Pulmonary Vasopermeability in Rats Subjected to Severe Burns

Objective： To investigate the effects of Xuebijing Injection（血必净注射液, XBJ） on survival rate and pulmonary vasopermeability in a rat model of severe scald injury. Methods： Rats were divided into two experiments： experiment 1 was monitored for 12 h post-injury for survival analysis after severe burns; in experiment 2, rats were killed for determination of pulmonary vascular permeability and pro-inflammatory mediators. In both experiments, rats were subject to third-degree 50% total body surface area（TBSA） burns or sham injury followed by XBJ or normal saline（NS） treatment. In addition, rat pulmonary microvascular endothelium cells（PMECs） were pretreated with either XBJ or phosphate buffer saline（PBS）, and then subjected to sham serum or scald serum stimulation for 2 or 6 h, followed by transwell examination for the permeability of PMECs. Meanwhile, pro-inflammatory mediators in PMECs culture supernatant were also investigated. Results： The average survival time in the scald＋XBJ group was 582.1±21.2 min, which was significantly longer than that in the scald ＋ NS group（345.8±25.4 min, P〈0.01）. Plasma levels of tumor necrosis factor-alpha（TNF-α）, E-selectin, interleukin-6（IL-6）, vascular permeability and water content of lung tissues were significantly increased in animals after severe burns（P〈0.01）. However, administration of XBJ significantly decreased these levels in plasma and lung tissue. In in vitro cell experiments, XBJ markedly attenuated permeability in PMECs monolayer and reduced the levels of TNF-α, IL-6 and soluble E-selectin after stimulation with scald serum（P〈0.01）. Conclusions： XBJ increases early survival rate by alleviating pulmonary vasopermeability and inhibiting pro-inflammatory mediators in rats subjected to lethal scald injury. XBJ may be a potent drug in treatment of severe burns.