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Sonography in Hypotension and Cardiac Arrest (SHoC): Rates of Abnormal Findings in Undifferentiated Hypotension and During Cardiac Arrest as a Basis for Consensus on a Hierarchical Point of Care Ultrasound Protocol

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      Abstract

      Introduction

      Point of care ultrasound (PoCUS) has become an established tool in the initial management of patients with undifferentiated hypotension. Current established protocols (RUSH and ACES) were developed by expert user opinion, rather than objective, prospective data. PoCUS also provides invaluable information during resuscitation efforts in cardiac arrest by determining presence/absence of cardiac activity and identifying reversible causes such as pericardial tamponade. There is no agreed guideline on how to safely and effectively incorporate PoCUS into the advanced cardiac life support (ACLS) algorithm. We wished to report disease incidence as a basis to develop a hierarchical approach to PoCUS in hypotension and during cardiac arrest.

      Methods

      We summarized the recorded incidence of PoCUS findings from the initial cohort during the interim analysis of two prospective studies. We propose that this will form the basis for developing a modified Delphi approach incorporating this data to obtain the input of a panel of international experts associated with five professional organizations led by the International Federation of Emergency Medicine (IFEM). The modified Delphi tool will be developed to reach an international consensus on how to integrate PoCUS for hypotensive emergency department patients as well as into cardiac arrest algorithms.

      Results

      Rates of abnormal PoCUS findings from 151 patients with undifferentiated hypotension included left ventricular dynamic changes (43%), IVC abnormalities (27%), pericardial effusion (16%), and pleural fluid (8%). Abdominal pathology was rare (fluid 5%, AAA 2%). During cardiac arrest there were no pericardial effusions, however abnormalities of ventricular contraction (45%) and valvular motion (39%) were common among the 43 patients included.

      Conclusions

      A prospectively collected disease incidence-based hierarchy of scanning can be developed based on the reported findings. This will inform an international consensus process towards the development of proposed SHoC protocols for hypotension and cardiac arrest, comprised of the stepwise clinical-indication based approach of Core, Supplementary, and Additional PoCUS views. We hope that such a protocol would be structured in a way that enables the clinician to only perform views that are clinically indicated, which limits exposure to the frequent incidental positive findings that accompany the current “one size fits all” standard protocols.

      Related collections

      Most cited references 5

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      The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll.

      The RUSH exam (Rapid Ultrasound in SHock examination), presented in this article, represents a comprehensive algorithm for the integration of bedside ultrasound into the care of the patient in shock. By focusing on a stepwise evaluation of the shock patient defined here as "Pump, Tank, and Pipes," clinicians will gain crucial anatomic and physiologic data to better care for these patients.
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        Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients.

        We examined a physician-performed, goal-directed ultrasound protocol for the emergency department management of nontraumatic, symptomatic, undifferentiated hypotension. Randomized, controlled trial of immediate vs. delayed ultrasound. Urban, tertiary emergency department, census >100,000. Nontrauma emergency department patients, aged >17 yrs, and initial emergency department vital signs consistent with shock (systolic blood pressure 1.0), and agreement of two independent observers for at least one sign and symptom of inadequate tissue perfusion. Group 1 (immediate ultrasound) received standard care plus goal-directed ultrasound at time 0. Group 2 (delayed ultrasound) received standard care for 15 mins and goal-directed ultrasound with standard care between 15 and 30 mins after time 0. Outcomes included the number of viable physician diagnoses at 15 mins and the rank of their likelihood of occurrence at both 15 and 30 mins. One hundred eighty-four patients were included. Group 1 (n = 88) had a smaller median number of viable diagnoses at 15 mins (median = 4) than did group 2 (n = 96, median = 9, Mann-Whitney U test, p <.0001). Physicians indicated the correct final diagnosis as most likely among their viable diagnosis list at 15 mins in 80% (95% confidence interval, 70-87%) of group 1 subjects vs. 50% (95% confidence interval, 40-60%) in group 2, difference of 30% (95% confidence interval, 16-42%). Incorporation of a goal-directed ultrasound protocol in the evaluation of nontraumatic, symptomatic, undifferentiated hypotension in adult patients results in fewer viable diagnostic etiologies and a more accurate physician impression of final diagnosis.
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          Focused Assessment with Sonography for Trauma (FAST): results from an international consensus conference.

          To assemble an international panel of experts to develop consensus recommendations on selected important issues on the use of ultrasonography (US) in trauma care. R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Md. The conference was held on December 4, 1997. A committee of two co-directors and eight faculty members, in the disciplines of surgery and emergency medicine, representing four nations. Each faculty member had made significant contributions to the current understanding of US in trauma. Six broad topics felt to be controversial or to have wide variation in practice were discussed using the ad hoc process: (1) US nomenclature and technique; (2) US for organ-specific injury; (3) US scoring systems; (4) the meaning of positive and negative US studies; (5) US credentialing issues; and (6) future applications of US. Consensus recommendations were made when unanimous agreement was reached. Majority viewpoints and minority opinions are presented for unresolved issues. The consensus conference process fostered an international sharing of ideas. Continued communication is needed to advance the science and technology of US in trauma care.
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            Author and article information

            Affiliations
            [1 ] Family Medicine Residency Program, Sydney, Nova Scotia, Dalhousie
            [2 ] Emergency Medicine, Saint John Regional Hospital
            [3 ] Emergency Medicine, Dalhousie University
            [4 ] Emergency Medicine, Horizon Health Network
            [5 ] Emergency Medicine, University of Maryland
            [6 ] Emergency Medicine, Saskatoon Health Region
            [7 ] Division of Emergency Medicine, University of Cape Town
            [8 ] Emergency Medicine, Stellenbosch University
            Author notes
            Journal
            Cureus
            Cureus
            2168-8184
            Cureus
            Cureus (Palo Alto (CA) )
            2168-8184
            8 April 2016
            April 2016
            : 8
            : 4
            27190729 4859814 10.7759/cureus.564
            Copyright © 2016, Milne et al.

            This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

            Funding
            Horizon Health Network Health Promotion Research Fund local grant for $10,000 CAD.
            Categories
            Emergency Medicine
            Anesthesiology
            Cardiology

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