New cockpit mode. A second interface styled like a flight deck: six analogue needle instruments, a multi-function display with switchable pages, a warning light panel, and infusion levers with continuous dosing instead of fixed doses. The classic interface is still there. After updating, the game starts as it always did. Cockpit mode is optional and is switched on from the pill at the bottom left, or from the selector in the cockpit itself. Your choice is remembered. Tests you have to order. Blood gas, lactate, blood count, echocardiogram and Swan-Ganz catheter. Each takes its time to come back, and the catheter unlocks the wedge pressure, cardiac output and resistance readings, which stay dark without it. Lactate with inertia. It rises fast when things go wrong and falls slowly when they are put right, so normalising the numbers is not enough. Ventricular fibrillation is now visible on the electrocardiogram trace, with an on-screen warning. Outcome panel at the end of the game, with the round score and the cumulative total. Internal adjustments to how the patient behaves and to the antibiotic options, so they respond more coherently. Five languages: Spanish, English, German, Chinese and Japanese.

Japanese language support has been added for both voice and text. This version is the same as the previous one. No other changes have been made.

The logic of diagnostic and therapeutic modes has been updated to make it more consistent with real physiology. A distinction has been added between the right and left circulations: • The right side is now separated from the left side to increase realism. Pressures are now calculated in a backward direction, from the left ventricle toward the right side, which reflects how congestion usually develops in heart failure. • New variable: PVR (Pulmonary Vascular Resistance). Similar to SVR in the systemic circuit, a simplified PVR has been introduced. • PCP (Pulmonary Capillary Pressure or Wedge) is now calculated based on blood volume and left ventricular function. • PAP (Pulmonary Arterial Pressure) has been updated. PAP is now the sum of the pressure ahead (PCP) plus the resistance of the lungs. • PVC (Central Venous Pressure) calculation has been revised. PVC now depends on total blood volume and how easily blood can enter the pulmonary artery through PAP. These changes allow the simulator to show high PCP with normal PVC, enabling the diagnosis of pure left sided failure. This requires specific vasodilator and diuretic therapy instead of treating it as global volume overload. It also allows untreated left sided failure to evolve into right sided failure, as PVC starts to rise minutes later.

A new version of SimShock has been implemented with significant technical and physiological updates: * Simultaneous Therapies: The simulation engine has been refactored to allow for simultaneous therapy administration. It is now possible to combine the effects of multiple drugs (e.g., Saline, Dopamine, Noradrenaline, Dobutamine, Nitroglycerin) at the same time, resulting in a more complex and realistic hemodynamic simulation. * Physiological Tuning (Furosemide): A hemodynamic response adjustment has been implemented. Specifically, the logic for Furosemide (Seguril) has been modified from a continuous infusion to a 30-second bolus, and its potency has been adjusted. This prevents an abrupt drop in volemia and stabilizes the heart rate response, resulting in more physiological behavior. * Quick Reset Function: A hidden reset function has been added. Tapping the heart icon on the main screen will reset the simulation to its initial state.

New Modes in SimShock This update adds two game modes designed to make training more intense: • Free Mode Play without limits by selecting the initial condition: Heart Failure, Hemorrhage, Septic Shock, or Random (starts the game with any of the previous ones). Each game is scored based on the chosen difficulty and the time used: –10 points if the patient dies +1 to +10 points if you cure the patient depending on the time invested All scores are added together to obtain an accumulated total • Exam Mode Designed to compete against yourself. It consists of 10 randomly generated games played continuously. In this mode, end screens for cure or death are disabled: when one game finishes, the next starts immediately with a beep. The ICU button is inactive and you rely only on your decisions. To end the exam early, press the Exam button again or the Reset button to return to Free Mode.

What’s New • New heart selector with symbols. • New heart failure mode with low MAP. • New BIPAP therapy (non-invasive ventilatory support). • New ECG monitor power button. Fix • Adjusted Solinitrine/Lasix response: CVP now decreases progressively according to dose and time.

New Features 1. Full German Support: Interface, instructions, voices, and end-game images are now fully localized into German for a complete immersive experience. 2. New Drug: Norepinephrine: Added as the vasopressor of choice in septic shock, for greater clinical realism. 3. Nitroglycerin (Solinitrine): Dosage is now displayed in standard clinical units (mcg/min) instead of mcg/kg/h, improving realism without altering simulation balance. 4. Bibliographic References: A new “References” button in Instructions and Antibiotics screens cites real clinical guidelines (Surviving Sepsis Campaign 2021, IDSA/ATS 2019). 5. Pause Button: You can now pause the game to carefully review vitals and decide the best therapeutic strategy. 6. Therapy Button Reorganization (Desktop): Buttons have been rearranged for a more logical and clinically intuitive workflow. 7. iPhone Max & Plus Fix: Drug dosages are now displayed directly without requiring an extra tap, consistent with other devices. Simulation & Realism Improvements 1. Septic Shock: Heart rate response to hypotension is more gradual and controlled; CVP drop is more pronounced and fluid response slower, accurately reflecting capillary leak. 2. Hemorrhage: More realistic CVP drop at onset. Blood transfusion now provides an initial “bolus” and is the key therapy to definitively stop bleeding once stabilized. Saline loading is intelligently limited to prevent unrealistic fluid overload.

Release Notes Description: Minor changes. Corrected a unit error for the Nitroglycerin (Solinitrina) dosage, which is now correctly displayed as mcg/kg/h instead of mcg/kg/min.

Interface Correction on the Monitor: A design issue on the vital signs monitor has been resolved. The "Therapeutic Modes" buttons were partially hidden at the bottom of the screen on some devices. They have been repositioned to ensure full visibility and accessibility. Improved Transfusion Simulation: A functional error where the patient's blood volume did not update during a transfusion has been corrected. Now, the volume increases realistically in real-time, improving the simulation's accuracy. Enhanced Visual Feedback: The graphical representation of the blood transfusion has been improved. The bag's tubing is now visually shown filled with blood (red color) when the transfusion is active, providing a clear indication of the process. Increased Visual Clarity: The definition and contrast of the colors and text on the main control panel have been enhanced. This change increases readability and facilitates faster and safer interaction. Complete Fix of the Pause Function: The "Pause" function has been improved. Previously, when pausing the simulation, some animations and processes continued to run. Now, pressing pause completely stops all in-game activity, ensuring a total and consistent interruption.

This update introduces significant improvements to the hemodynamic simulation engine of SimShockPad, as well as new visual features for a more immersive and educational experience. The key changes are as follows: Deep Overhaul of the Hemodynamic Simulation Engine: Realistic Fluid Response: The response to fluid infusion (saline solution) has been completely redesigned. Now, the Central Venous Pressure (CVP) responds dynamically and gradually. This prevents unrealistic behaviors (such as sudden drops or spikes) and ensures that the CVP rises naturally as the patient's volume is restored, resolving previous instabilities. Implementation of Myocardial Depression: To increase realism and clinical challenge, a new "cardiac fatigue" (myocardial depression) mechanic has been added following prolonged shock. This creates complex scenarios where fluid administration alone is not sufficient, requiring the use of inotropic drugs (such as Dobutamine) to restore heart function. Improved Pathology Models: The Heart Failure model has been refined to more accurately simulate the decrease in cardiac contractility, making it more faithful to real pathophysiology. Visual and Interface Enhancements: Defibrillator Paddle Animation: When applying an electrical shock, an animation of the defibrillator paddles on the patient is now displayed. This provides clear and immediate visual feedback for this critical action, enhancing user immersion.

Hello! In this update, we've improved the app to make it even easier for you to use. - Automatic Language Detection: The app now detects your device's language and adjusts automatically (Spanish, English, or Mandarin Chinese). - If your device is set to a language other than Spanish, English, or Chinese, the app will default to English to ensure you can continue to use it without issues. We hope you enjoy this improvement!

A bug was fixed in this version where the doctor’s image did not blink as intended when the heart rate was elevated. The animation now works correctly, alternating the doctor’s facial expression to provide visual feedback during episodes of tachycardia. No other functionality or content in the app has been changed.

Only the keyboard interface has been improved.

Fully translated into Spanish, English, and Mandarin Chinese Individualized metadata in each language Individualized exit screens The simulation has been made more fluid

PVC_LABEL has been corrected to obtain the values in Spanish, English, and Mandarin Chinese.

We have fixed a bug that caused the app to hang when pressing the therapy buttons, which occurred only on macOS but not on iOS devices. Changes since version 1.7: 1. Introduced an On/Off toggle button on the constants monitor to display a bar chart of all hemodynamic parameters. 2. Added a new drug option: Dobutamine. 3. Revamped the interface for greater dynamism—updated colors and reorganized the control panel. 4. Yellow indicator light now turns red when pulse reaches extreme low or high values. 5. Added a click sound when selecting the antibiotic for improved feedback. 6. Added a “Legal” button over the logo to open the legal notice. 7. Expanded the in-app instructions. 8. Text, visual alerts, and audio alerts have been translated into Simplified Chinese.

We have fixed a bug that caused the app to hang when pressing the therapy buttons, which occurred only on macOS but not on iOS devices. Changes since version 1.7: 1. Introduced an On/Off toggle button on the constants monitor to display a bar chart of all hemodynamic parameters. 2. Added a new drug option: Dobutamine. 3. Revamped the interface for greater dynamism—updated colors and reorganized the control panel. 4. Yellow indicator light now turns red when pulse reaches extreme low or high values. 5. Added a click sound when selecting the antibiotic for improved feedback. 6. Added a “Legal” button over the logo to open the legal notice. 7. Expanded the in-app instructions. 8. Text, visual alerts, and audio alerts have been translated into Simplified Chinese.

Changes since version 1.7: 1. Introduced an On/Off toggle button on the constants monitor to display a bar chart of all hemodynamic parameters. 2. Added a new drug option: Dobutamine. 3. Revamped the interface for greater dynamism—updated colors and reorganized the control panel. 4. Yellow indicator light now turns red when pulse reaches extreme low or high values. 5. Added a click sound when selecting the antibiotic for improved feedback. 6. Added a “Legal” button over the logo to open the legal notice. 7. Expanded the in-app instructions. 8. Text, visual alerts, and audio alerts have been translated into Simplified Chinese.

Changes since version 1.7 1) Introduced an On/Off toggle button on the constants monitor that displays a bar chart of all hemodynamic constants. 2) Added a new drug option: Dobutamine. 3) Revamped the interface for greater dynamism—updated colors and reorganized the control panel. 4) Yellow indicator light now turns red when the pulse reaches extreme low or high values. 6) Added a Legal button over the logo, opening the legal notice. 7) The instructions have been expanded. 8) Text, visual alerts, and audio alerts have been translated into Simplified Chinese.

• Now distributed as a universal arm64 build, fully compatible with iPhone, iPad, and Apple Silicon Macs. • The bars and indicator boxes for vital signs now change color (green, yellow, red) based on physiological limits, according to the selected difficulty level. • Therapeutic buttons now use interactive sheets for dosage selection, making gameplay smoother and more intuitive on iOS devices. • The App Store description and release notes have been translated into English for international users.