Accuracy of echocardiography and ultrasound protocol to identify shock etiology in emergency department

Abstract

Background Early diagnosis and appropriate management of shock aimed at prevention of prolonged hypoperfusion has shown to decrease morbidity and mortality in patients with undifferentiated shock. However, there is often a challenge in emergency department (ED) – where diagnosis is mainly based on clinical signs and standard monitoring parameters. Early use of point of care ultrasound could reduce the diagnostic time and improve diagnostic accuracy. Purpose The aim of this study is to investigate the accuracy of echocardiography - ultrasound protocol to identify the cause of shock in ED. Method The study was conducted on 150 shocked patients admitted to emergency department of Alexandria Main University Hospital from December 2018 to December 2020. The study was conducted to reach initial impression about shock etiology which was then compared to final diagnosis to determine accuracy, agreement, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Results One hundred forty patients were included in the study (10 patients were excluded). The protocol was 100% accurate for diagnosing cases with obstructive and mixed obstructive distributive shock. It showed excellent rule- out characteristics for cardiogenic shock (sensitivity and NPV = 100%). There was almost perfect agreement between provisional and final shock type for mixed distributive cardiogenic shock (kappa 0.915). Echo- US protocol had lowest agreement and PPV for patients with hypovolemic shock Kappa 0.48 and 35% respectively. Conclusion The Echo- US protocol showed a high accuracy in identifying shock etiology in ED and is likely a promising diagnostic tool in emergency care.

Point-of-Care Ultrasound: A Multimodal Tool for the Management of Sepsis in the Emergency Department

“…The main downside with regard to the differential diagnostic value of POCUS for distributive/septic shock lies in the complex pathophysiology of sepsis and the lack of distinct pathognomonic sonographic findings. However, studies have shown that the integration of POCUS into the initial evaluation of undifferentiated shock can effectively narrow down the spectrum of initial differential diagnosis and thus accelerate the recognition of the type of shock [ 13 , 14 , 18 , 19 ]. In the event that sepsis is being suspected, multi-organ POCUS may further help the clinician reach a certain diagnosis and identify the septic cause.…”

Inferior vena cava ultrasound and other techniques for assessment of intravascular and extravascular volume: an update

“…The Rapid Ultrasound in SHock (RUSH) protocol enables rapid assessment and therapy of undifferentiated hypotension (Table 9 ) [ 88–90 ]. The RUSH examination has a sensitivity of 85% and specificity of 95% for identifying the cause of undifferentiated hypotension [ 88 , 89 , 91 ].…”

“…The Rapid Ultrasound in SHock (RUSH) protocol enables rapid assessment and therapy of undifferentiated hypotension (Table 9 ) [ 88–90 ]. The RUSH examination has a sensitivity of 85% and specificity of 95% for identifying the cause of undifferentiated hypotension [ 88 , 89 , 91 ]. Clinical application of the RUSH protocol resulted in improved 28-day patient survival, a reduction in stage 3 AKI, and more days alive and free of renal support [ 92 ].…”

Role of point-of-care ultrasound in critical care and emergency medicine: update and future perspective

“…POCUS using established protocols, can provide crucial information for swift diagnosis and appropriate management in critical situations that demand immediate attention and intervention to prevent death or serious harm. Such critical situations include cardiac arrest [ 86 , 87 , 121 ], major torso trauma [ 99 , 122 ], shock [ 95 , 97 , 123 , 124 ], respiratory difficulty [ 29 , 125 , 126 ], chest pain [ 127 – 129 ], and life-threatening abdominal pain. Noncritical situations such as scrotal pain, ocular symptoms, soft tissue or musculoskeletal problems, and noncritical abdominal pain also fall within the scope of EM POCUS ( Figs.…”

“…Substantial evidence supports the use of multiorgan POCUS for evaluating and managing patients with cardiopulmonary or hemodynamic failure. POCUS using established protocols, can pro- [86,87,121], major torso trauma [99,122], shock [95,97,123,124], respiratory difficulty [29,125,126], chest pain [127][128][129], and life-threatening abdominal pain. Noncritical situations such as scrotal pain, ocular symptoms, soft tissue or musculoskeletal problems, and noncritical abdominal pain also fall within the scope of EM POCUS (Figs.…”