Goal-directed ultrasound protocol in patients with nontraumatic undifferentiated shock in the emergency department: prospective dual centre study.
Journal
European journal of emergency medicine : official journal of the European Society for Emergency Medicine
ISSN: 1473-5695
Titre abrégé: Eur J Emerg Med
Pays: England
ID NLM: 9442482
Informations de publication
Date de publication:
01 Aug 2021
01 Aug 2021
Historique:
pubmed:
13
3
2021
medline:
2
7
2021
entrez:
12
3
2021
Statut:
ppublish
Résumé
Early identification of the cause of shock is associated with better prognosis. The aim of this study was to explore the performances of an ultrasound protocol (echoSHOCK) to diagnose the cause of shock in the emergency department (ED). This was a prospective study performed in two EDs. Included patients were older than 18 years admitted with shock. After routine workup strategy, the suspected cause of shock and the planned treatment were reported. The echoSHOCK protocol, using only B mode, was then performed. After performing echoSHOCK, the investigator reported the same two items. echoSHOCK protocol that assessed: compressive pericardial effusion (tamponade), right ventricle dilatation and flattening of the septum, left ventricle dimension and systolic function, indices of hypovolemia. We defined four different causes for shock (tamponade, acute cor pulmonale, cardiogenic and hypovolemia). The primary endpoint was the degree of agreement of the routine workup and echoSHOCK with an expert panel. 85 patients [mean age of 73 (14) years] were included. Kappa coefficients between routine strategy and echoSHOCK for the cause of shock, with the expert panel were 0.33 (95% CI, 0.26-0.4) and 0.88 (95% CI, 0.83-0.93), respectively. Likewise, for the planned treatment, kappa were 0.21 (95% CI, 0.14-0.28) and 0.9 (95% CI, 0.85-0.94), respectively. The physician's confidence increased from 3.9 (2.1) before echoSHOCK to 9.3 (1.1) after, (P < 0.001). This study suggested that echoSHOCK significantly increased the ability to determine the cause of undifferentiated shock in the ED.
Sections du résumé
BACKGROUND AND IMPORTANCE
BACKGROUND
Early identification of the cause of shock is associated with better prognosis.
OBJECTIVE
OBJECTIVE
The aim of this study was to explore the performances of an ultrasound protocol (echoSHOCK) to diagnose the cause of shock in the emergency department (ED).
DESIGN, SETTINGS AND PARTICIPANTS
METHODS
This was a prospective study performed in two EDs. Included patients were older than 18 years admitted with shock. After routine workup strategy, the suspected cause of shock and the planned treatment were reported. The echoSHOCK protocol, using only B mode, was then performed. After performing echoSHOCK, the investigator reported the same two items.
INTERVENTION
METHODS
echoSHOCK protocol that assessed: compressive pericardial effusion (tamponade), right ventricle dilatation and flattening of the septum, left ventricle dimension and systolic function, indices of hypovolemia.
OUTCOMES MEASURE AND ANALYSIS
METHODS
We defined four different causes for shock (tamponade, acute cor pulmonale, cardiogenic and hypovolemia). The primary endpoint was the degree of agreement of the routine workup and echoSHOCK with an expert panel.
MAIN RESULTS
RESULTS
85 patients [mean age of 73 (14) years] were included. Kappa coefficients between routine strategy and echoSHOCK for the cause of shock, with the expert panel were 0.33 (95% CI, 0.26-0.4) and 0.88 (95% CI, 0.83-0.93), respectively. Likewise, for the planned treatment, kappa were 0.21 (95% CI, 0.14-0.28) and 0.9 (95% CI, 0.85-0.94), respectively. The physician's confidence increased from 3.9 (2.1) before echoSHOCK to 9.3 (1.1) after, (P < 0.001).
CONCLUSION
CONCLUSIONS
This study suggested that echoSHOCK significantly increased the ability to determine the cause of undifferentiated shock in the ED.
Identifiants
pubmed: 33709995
doi: 10.1097/MEJ.0000000000000801
pii: 00063110-202108000-00014
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
306-311Informations de copyright
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
Références
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. PLoS One. 2015; 10:e0119331
Holler JG, Henriksen DP, Mikkelsen S, Rasmussen LM, Pedersen C, Lassen AT. Shock in the emergency department; a 12 year population based cohort study. Scand J Trauma Resusc Emerg Med. 2016; 24:87
Jones AE, Puskarich MA. The Surviving Sepsis Campaign guidelines 2012: update for emergency physicians. Ann Emerg Med. 2014; 63:35–47
Vahdatpour C, Collins D, Goldberg S. Cardiogenic shock. J Am Heart Assoc. 2019; 8:e011991
Atkinson P, Hunter S, Banerjee A, Lewis D, Fraser J, Milne J, et al. Does point-of-care ultrasonography change emergency department care delivered to hypotensive patients when categorized by shock type? A post-hoc analysis of an international randomized controlled trial from the SHoC-ED Investigators. Cureus. 2019; 11:e6058
Öhman J, Harjola VP, Karjalainen P, Lassus J. Rapid cardiothoracic ultrasound protocol for diagnosis of acute heart failure in the emergency department. Eur J Emerg Med. 2019; 26:112–117
Le Bastard Q, Javaudin F, Montassier E, Pes P, Arnaudet I, Le Conte P. Fluid loading guided by cardiac and lung ultrasound for patients with sepsis in the emergency department: proof-of-concept study. Eur J Emerg Med. 2020; 27:228–229
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; 32:1703–1708
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; 39:1290–1298
Via G, Hussain A, Wells M, Reardon R, ElBarbary M, Noble VE, et al.; International Liaison Committee on Focused Cardiac UltraSound (ILC-FoCUS); International Conference on Focused Cardiac UltraSound (IC-FoCUS). International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr. 2014; 27:683.e1–683.e33
Peterson D, Arntfield RT. Critical care ultrasonography. Emerg Med Clin North Am. 2014; 32:907–926
Moore CL, Rose GA, Tayal VS, Sullivan DM, Arrowood JA, Kline JA. Determination of left ventricular function by emergency physician echocardiography of hypotensive patients. Acad Emerg Med. 2002; 9:186–193
Brennan JM, Ronan A, Goonewardena S, Blair JE, Hammes M, Shah D, et al. Handcarried ultrasound measurement of the inferior vena cava for assessment of intravascular volume status in the outpatient hemodialysis clinic. Clin J Am Soc Nephrol. 2006; 1:749–753
Leung JM, Levine EH. Left ventricular end-systolic cavity obliteration as an estimate of intraoperative hypovolemia. Anesthesiology. 1994; 81:1102–1109
Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: rapid ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am. 2010; 28:29–56, vii
Keikha M, Salehi-Marzijarani M, Soldoozi Nejat R, Sheikh Motahar Vahedi H, Mirrezaie SM. Diagnostic accuracy of rapid ultrasound in shock (RUSH) exam; a systematic review and meta-analysis. Bull Emerg Trauma. 2018; 6:271–278
Stickles SP, Carpenter CR, Gekle R, Kraus CK, Scoville C, Theodoro D, et al. The diagnostic accuracy of a point-of-care ultrasound protocol for shock etiology: a systematic review and meta-analysis. CJEM. 2019; 21:406–417
Lafon T, Appert A, Hadj M, Bigrat V, Legarcon V, Claveries P, et al. Comparative early hemodynamic profiles in patients presenting to the emergency department with septic and nonseptic acute circulatory failure using focused echocardiography. Shock. 2020; 53:695–700
Airapetian N, Maizel J, Alyamani O, Mahjoub Y, Lorne E, Levrard M, et al. Does inferior vena cava respiratory variability predict fluid responsiveness in spontaneously breathing patients?. Crit Care. 2015; 19:400
Nagre AS. Focus-assessed transthoracic echocardiography: Implications in perioperative and intensive care. Ann Card Anaesth. 2019; 22:302–308
IFEM. Sonography in Hypotension and Cardiac Arrest (SHoC) Protocol Consensus Statement. https://www.ifem.cc/resources/sonography-in-hypotension-and-cardiac-arrest-shoc-protocol-consensus-statement/ . [Accessed October 20, 2020]
Gitz Holler J, Jensen HK, Henriksen DP, Rasmussen LM, Mikkelsen S, Pedersen C, Lassen AT. Etiology of shock in the emergency department: a 12-year population-based cohort study. Shock. 2019; 51:60–67