New cockpit mode A second interface styled like a flight deck: six analogue needle gauges, a multi-page multifunction display, an annunciator light panel and continuous-dose infusion levers instead of fixed-dose buttons. The classic interface remains available, and the game starts as it always has. The cockpit is optional and can be activated using the button in the bottom-left corner, from the Options menu or with ⇧⌘I. Tests that must be ordered Blood gas, lactate, blood count, echocardiogram and a Swan-Ganz catheter. Each test takes a different amount of time to return its results. The catheter unlocks the pulmonary capillary wedge pressure, cardiac output and systemic vascular resistance readings, which remain dark until it has been inserted. The catheter can only be ordered while a case is running. Lactate with inertia Lactate rises quickly when things are going badly and falls slowly once they are corrected. Menus and keyboard shortcuts Restart, pause, defibrillate, select a case and change the difficulty or language — all from the keyboard. The window opens at a comfortable size, and Preferences follow the language selected in the game. Session scoreboard Accumulated points, games played and average score are visible in both interfaces and are kept separate from the examination score. Venous pressure is displayed with one decimal place because its range is narrow. Adjustments to patient behaviour Dobutamine reduces pulmonary capillary wedge pressure and no longer causes an abrupt heart-rate adjustment when the infusion is started. Stopping noradrenaline now has a noticeable effect on blood pressure. Furosemide acts for thirty seconds, with a countdown displayed on the button, and causes a smaller increase in heart rate as the patient improves. Amiodarone and propranolol retain their effects for several seconds instead of wearing off immediately by themselves.

Japanese language support has been added for both voice and text. The interface for the variable bars and the ECG monitor has also been updated, especially in dark mode, to improve visibility. 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 in SimShockDesktop - Expanded multilingual support: now with text and voice in Spanish, English, German, and Mainland Chinese, so you can enjoy the experience in your own language - New low-MAP heart failure mode. Previously only hypertensive emergency heart failure was available. Now there is a 50% chance of either mode appearing - More realistic experience: refined shock pathophysiology and treatments, with more accurate hemodynamic responses including the correction of an issue that caused sudden CVP drops when applying Nitroglycerin/Diuretics; now the variation is progressive according to dose and time - More therapeutic options: new drug added such as Norepinephrine and ventilatory support with BIPAP

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.

Automatic System 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 using it smoothly. We hope you enjoy this improvement! No other changes have been made.

We have fixed a bug that was preventing keyboard shortcuts from working properly in SimShock. The issue was caused by an error in event handling within the main game view. With this update, all keyboard shortcuts (for treatments and quick actions) are now fully operational and respond as expected. This improvement enhances the overall user experience and ensures smoother, faster gameplay for users who rely on keyboard commands.