Citation Information :
Javali RH, Loganathan A, Patil A, Siddappa GB, Satyanarayana N, Bheemanna AS, Jagadeesh S, Betkerur S. Reliability of Emergency Department Diagnosis in Identifying the Etiology of Nontraumatic Undifferentiated Hypotension. Indian J Crit Care Med 2020; 24 (5):313-320.
Introduction: Nontraumatic undifferentiated hypotension is one of the common and challenging critical presentations in the emergency department (ED) due to the difficulty in diagnosing the etiology of shock. In the present study, an attempt was made to test point-of-care ultrasound (PoCUS) as an early approach to improve the accuracy of diagnosis and to narrow the differentials in cases of nontraumatic undifferentiated hypotension. Materials and methods: This is a prospective explorative study conducted in the ED of a tertiary care hospital over a period of 18 months. A total of 100 patients were included in the study. All patients >18 years of age with systolic blood pressure <90 mm Hg with at least one sign or symptom of hypoperfusion were included in the study. Patients referred from another hospital as shock, history of trauma, and history suggestive of orthostatic hypotension and presented with symptomatic postural hypotension as the only chief complaint were excluded. All the patients who met the inclusion/exclusion criteria underwent detailed clinical and multi-organ PoCUS evaluation by two different observers. Assessment of the lungs, cardia, abdomen, aorta, inferior vena cava (IVC), and leg veins during the PoCUS examination was done. A third observer combined the clinical evaluation and the PoCUS findings. All patients were followed through for their final diagnosis at the time of discharge. First, the diagnosis after clinical evaluation alone was compared to the final diagnosis. Then the diagnoses based on the findings of PoCUS alone were compared with the final diagnosis. Last, the diagnosis obtained on combining the data of clinical evaluation with that of PoCUS was compared to the final diagnosis. The data were analyzed based on their reliability indices, accuracy, and the Cohen's kappa coefficient. Results: Diagnoses based on clinical evaluation alone and POCUS alone were found to be accurate in 45% and 47% of patients, respectively. But on combining the findings of clinical evaluation with PoCUS, the accuracy increased to 89%. The most common etiology of shock was found to be distributive shock present in 38% of patients with sepsis being the most common subtype. In patients with obstructive shock, combined clinical evaluation with PoCUS was in perfect agreement with Cohen's kappa coefficient (κ) = 1 and those with distributive shock were in substantial agreement with Cohen's kappa coefficient (κ) = 0717. The overall kappa correlation of the combined evaluation with PoCUS was 0.89, which shows an almost perfect agreement with the final diagnosis. Conclusion: This study demonstrates the accuracy and reliability of PoCUS as an easy and valuable bedside tool when added to the clinical evaluation. It helps in narrowing the differentials and thereby guiding early goal-directed therapy in nontraumatic, undifferentiated hypotension patients presenting to the ED.
Mosier JM, Stolz U, Milligan R, Roy-Chaudhury A, Lutrick K, Hypes CD, et al. Impact of point-of-care ultrasound in the emergency department on care processes and outcomes in critically ill nontraumatic patients. Crit Care Explor 2019;1(6):e0019. DOI: 10.1097/CCE.0000000000000019.
Jones AE, Aborn LS, Kline JA. Severity of emergency department hypotension predicts adverse hospital outcome. Shock 2004;22(5):410–414. DOI: 10.1097/01.shk.0000142186.95718.82.
Jones AE, Tayal VS, Sullivan DM, Kline JA. Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients. Crit Care Med 2004;32(8):1703–1708. DOI: 10.1097/01.ccm.0000133017.34137.82.
Moore CL. Determination of left Ventricular function by emergency physician echocardiography of hypotensive patients. Acad Emerg Med 2002;9(3):186–193. DOI: 10.1197/aemj.9.3.186.
Holler JG, Bech CN, Henriksen DP, Mikkelsen S, Pedersen C, Lassen AT. Nontraumatic hypotension and shock in the emergency department and the prehospital setting, prevalence, etiology, and mortality: a systematic review. Calvert J, ed. PLOS ONE 2015;10(3):e0119331. DOI: 10.1371/journal.pone.0119331.
Ahn JH, Jeon J, Toh H-C, Noble VE, Kim JS, Kim YS, et al. Search 8Es: a novel point of care ultrasound protocol for patients with chest pain, dyspnea or symptomatic hypotension in the emergency department. Brakenridge S, ed. PLOS ONE 2017;12(3):e0174581. DOI: 10.1371/journal.pone.0174581.
Atkinson PRT, McAuley DJ, Kendall RJ, Abeyakoon O, Reid CG, Connolly J, et al. Abdominal and cardiac evaluation with sonography in shock (ACES): an approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension. Emerg Med J 2009;26(2):87–91. DOI: 10.1136/emj.2007.056242.
Rose JS, Bair AE, Mandavia D, Kinser DJ. The UHP ultrasound protocol: a novel ultrasound approach to the empiric evaluation of the undifferentiated hypotensive patient. Am J Emerg Med 2001;19(4):299–302. DOI: 10.1053/ajem.2001.24481.
Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure*: the BLUE protocol. Chest 2008;134(1):117–125. DOI: 10.1378/chest.07-2800.
Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: rapid ultrasound in shock in the evaluation of the critically ill. Emerg Med Clin North Am 2010;28(1):29–56. DOI: 10.1016/j.emc.2009.09.010.
Rosen's Emergency Medicine: Concepts and Clinical Practice - 9th Edition [Internet]. [cited 2019 Dec 28]. Available from: https://www.elsevier.com/books/rosens-emergency-medicine-concepts-and-clinical-practice/walls/978-0-323-35479-0.
Sasmaz MI, Gungor F, Guven R, Akyol KC, Kozaci N, Kesapli M. Effect of focused bedside ultrasonography in hypotensive patients on the clinical decision of emergency physicians. Emerg Med Int 2017;2017:1–8. DOI: 10.1155/2017/6248687.
Shokoohi H, Boniface KS, Pourmand A, Liu YT, Davison DL, Hawkins KD, et al. Bedside ultrasound reduces diagnostic uncertainty and guides resuscitation in patients with undifferentiated hypotension. Crit Care Med 2015;43(12):2562–2569. DOI: 10.1097/CCM.0000000000001285.
Haydar SA, Moore ET, Higgins GL, Irish CB, Owens WB, Strout TD. Effect of bedside ultrasonography on the certainty of physician clinical decision making for septic patients in the emergency department. Ann Emerg Med 2012;60(3):346–358. DOI: 10.1016/j.annemergmed.2012.01.006.e4.
Bagheri-Hariri S, Yekesadat M, Farahmand S, Arbab M, Sedaghat M, Shahlafar N, et al. The impact of using RUSH protocol for diagnosing the type of unknown shock in the emergency department. Emerg Radiol 2015;22(5):517–520. DOI: 10.1007/s10140-015-1311-z.
Jones AE, Craddock PA, Tayal VS. Diagnostic accuracy of left ventricular function for identifying sepsis among emergency department patients with nontraumatic symptomatic undifferentiated hypotension. Shock 2005;24(6):513–517. DOI: 10.1097/01.shk.0000186931.02852.5f.
Ghane MR, Gharib M, Ebrahimi A, Saeedi M, Akbari-Kamrani M, Rezaee M, et al. Accuracy of early rapid ultrasound in shock (RUSH) examination performed by emergency physician for diagnosis of shock etiology in critically ill patients. J Emerg Trauma Shock 2015;8(1):5. DOI: 10.4103/0974-2700.145406.
Mueller X, Stauffer JC, Jaussi A, Goy JJ, Kappenberger L. Subjective visual echocardiographic estimate of left ventricular ejection fraction as an alternative to conventional echocardiographic methods: comparison with contrast angiography. Clin Cardiol 1991;14(11): 898–902. DOI: 10.1002/clc.4960141108.
Shokoohi H, Boniface KS, Zaragoza M, Pourmand A, Earls JP. Point-of-care ultrasound leads to diagnostic shifts in patients with undifferentiated hypotension. Am J Emerg Med 2017;35(12):1984.e3–1984.e7. DOI: 10.1016/j.ajem.2017.08.054.
Volpicelli G, Lamorte A, Tullio M, Cardinale L, Giraudo M, Stefanone V, et al. Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department. Intensive Care Med 2013;39(7):1290–1298. DOI: 10.1007/s00134-013-2919-7.