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Moradkhani A, Zangi M, Azami M, Ghasemi-Rad M, Pakniyat A. The role of point-of-care ultrasound in the assessment of pelvic urine leakage and diagnosis of urinoma. Int J Emerg Med 2023; 16:91. [PMID: 38110890 PMCID: PMC10726508 DOI: 10.1186/s12245-023-00571-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 12/11/2023] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND Urinoma, a rare condition resulting from urine leakage due to trauma to the kidney, bladder, or urethra, is typically diagnosed using enhanced computed tomography urogram with delayed imaging. This report presents two cases of urinoma likely caused by overdistention of the renal pelvis following excessive fluid intake and the presence of a ureteral stone. CASE PRESENTATION We present two cases of 36-year-old and 38-year-old patients who presented with flank pain. point-of-care ultrasound (POCUS) played a pivotal role in identifying perinephric fluid in Morrison's space and the splenorenal space, respectively. These ultrasound findings guided further investigations, leading to definitive diagnoses via abdominal pelvic CT scans. Treatment involved prophylactic antibiotics and the successful placement of a double J stent into the renal pelvis over the wire under fluoroscopic guidance, which resulted in significant clinical improvement for both patients. CONCLUSIONS This study demonstrates the rare occurrence of urinoma from urolithiasis, the use of POCUS in expediting diagnosis and treatment, and the importance of interpreting sonographic images in the correct clinical setting.
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Affiliation(s)
- Asra Moradkhani
- Student Research Committee, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Mona Zangi
- Disaster and Emergency Management Center of Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Mobin Azami
- Student Research Committee, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Mohammad Ghasemi-Rad
- Department of Interventional Radiology, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, USA
| | - Abdolghader Pakniyat
- Department of Emergency Medicine, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran.
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2
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Chun Chau T, Nik Muhamad NA. Internal jugular vein measurements: an alternative ultrasonic approach in estimating volume status of emergency department patients. Eur J Emerg Med 2023; 30:374-375. [PMID: 37650741 DOI: 10.1097/mej.0000000000001056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- Tan Chun Chau
- Department of Emergency Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC) Jalan Yaacob Latif, Kuala Lumpur, Wilayah Persekutuan, Malaysia
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3
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Polyzogopoulou E, Velliou M, Verras C, Ventoulis I, Parissis J, Osterwalder J, Hoffmann B. Point-of-Care Ultrasound: A Multimodal Tool for the Management of Sepsis in the Emergency Department. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1180. [PMID: 37374384 DOI: 10.3390/medicina59061180] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/15/2023] [Accepted: 06/17/2023] [Indexed: 06/29/2023]
Abstract
Sepsis and septic shock are life-threatening emergencies associated with increased morbidity and mortality. Hence, early diagnosis and management of both conditions is of paramount importance. Point-of-care ultrasound (POCUS) is a cost-effective and safe imaging modality performed at the bedside, which has rapidly emerged as an excellent multimodal tool and has been gradually incorporated as an adjunct to physical examination in order to facilitate evaluation, diagnosis and management. In sepsis, POCUS can assist in the evaluation of undifferentiated sepsis, while, in cases of shock, it can contribute to the differential diagnosis of other types of shock, thus facilitating the decision-making process. Other potential benefits of POCUS include prompt identification and control of the source of infection, as well as close haemodynamic and treatment monitoring. The aim of this review is to determine and highlight the role of POCUS in the evaluation, diagnosis, treatment and monitoring of the septic patient. Future research should focus on developing and implementing a well-defined algorithmic approach for the POCUS-guided management of sepsis in the emergency department setting given its unequivocal utility as a multimodal tool for the overall evaluation and management of the septic patient.
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Affiliation(s)
- Effie Polyzogopoulou
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece
| | - Maria Velliou
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece
| | - Christos Verras
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece
- National Centre of Emergency Care (EKAB), 11527 Athens, Greece
| | - Ioannis Ventoulis
- Department of Occupational Therapy, University of Western Macedonia, 50200 Ptolemaida, Greece
| | - John Parissis
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece
| | | | - Beatrice Hoffmann
- Department of Emergency Medicine BIDMC, One Deaconess Rd, WCC2, Boston, MA 02215, USA
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4
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Verras C, Ventoulis I, Bezati S, Matsiras D, Parissis J, Polyzogopoulou E. Point of Care Ultrasonography for the Septic Patient in the Emergency Department: A Literature Review. J Clin Med 2023; 12:jcm12031105. [PMID: 36769753 PMCID: PMC9917776 DOI: 10.3390/jcm12031105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/17/2023] [Accepted: 01/28/2023] [Indexed: 02/04/2023] Open
Abstract
The point-of-care ultrasound (POCUS) has been effectively used in intensive care units for the management of septic patients. Since it is a time- and cost-effective non-invasive imaging modality, its use in the emergency department (ED) has been advocated for by medical experts. This review summarizes the existing literature regarding the breadth of POCUS as a supplementary tool to the holistic approach of septic patients in the ED setting. A literature search was conducted via PubMed (MEDLINE), Cochrane Library, and Scopus databases, analyzing studies which examined the use of POCUS in the ED for non-traumatic, septic, and/or undifferentiated hypotensive patients, resulting in 26 studies. The first cluster of studies investigates the efficiency of POCUS protocols in the differential diagnosis and its reliability for distributive/septic shock and sepsis management. In the second cluster, POCUS use results in faster sepsis cause identification and improves therapeutic management. The third cluster confirms that POCUS aids in the accurate diagnosis and management, even in rare and complicated cases. The results of the present review support the well-documented utility of POCUS and highlight the importance of POCUS incorporation in the comprehensive management of the septic patient in the ED setting.
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Affiliation(s)
- Christos Verras
- Emergency Department, National and Kapodistrian University of Athens, Attikon University Hospital, 12462 Athens, Greece
- Correspondence: ; Tel.: +30-6936585677
| | - Ioannis Ventoulis
- Department of Occupational Therapy, University of Western Macedonia, 50100 Kozani, Greece
| | - Sofia Bezati
- Emergency Department, National and Kapodistrian University of Athens, Attikon University Hospital, 12462 Athens, Greece
| | - Dionysis Matsiras
- Emergency Department, National and Kapodistrian University of Athens, Attikon University Hospital, 12462 Athens, Greece
| | - John Parissis
- Emergency Department, National and Kapodistrian University of Athens, Attikon University Hospital, 12462 Athens, Greece
| | - Effie Polyzogopoulou
- Emergency Department, National and Kapodistrian University of Athens, Attikon University Hospital, 12462 Athens, Greece
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5
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Ruben M, Molinas MS, Paladini H, Khalife W, Barbagelata A, Perrone S, Kaplinsky E. Emerging concepts in heart failure management and treatment: focus on point-of-care ultrasound in cardiogenic shock. Drugs Context 2023; 12:dic-2022-5-8. [PMID: 36660015 PMCID: PMC9828879 DOI: 10.7573/dic.2022-5-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/26/2022] [Indexed: 01/04/2023] Open
Abstract
Point-of-care ultrasound (POCUS) plays a strategic role in the diagnostic and therapeutic evaluation of critically ill patients and, especially, in those who are haemodynamically unstable. In this context, POCUS allows a more precise identification of the cause, its differential diagnosis, the eventual coexistence with another entity and, finally, guiding of the therapeutic approach. It implies a portable use of ultrasound in acute settings covering different specified protocols, such as echocardiography, vascular, lung or abdominal ultrasound. This article reviews POCUS application in the emergency department or the intensive care unit, focused on severely compromised patients with cardiogenic shock with an emergent bedside assessment. Considering the high mortality rate of this entity, POCUS provides the intensivist/clinician with an appropriate tool for accurate diagnoses and a timely management plan. The authors propose practical algorithms for the diagnosis of patients using POCUS in these settings. This article is part of the Emerging concepts in heart failure management and treatment Special Issue: https://www.drugsincontext.com/special_issues/emerging-concepts-in-heart-failure-management-and-treatment.
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Affiliation(s)
- Mariela Ruben
- Catholic University Argentina, Buenos Aires, Argentina,Cardiology Service, MIT Group, Santa Fe, Argentina
| | - María Sol Molinas
- Catholic University Argentina, Buenos Aires, Argentina,Cardiology Service, MIT Group, Santa Fe, Argentina
| | - Hugo Paladini
- Medical Images Service, MIT Group, Santa Fe, Argentina
| | - Wissam Khalife
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Alejandro Barbagelata
- Catholic University Argentina, Buenos Aires, Argentina,Duke University School of Medicine, Durham, NC, USA
| | - Sergio Perrone
- Catholic University Argentina, Buenos Aires, Argentina,Fleni Institute, Buenos Aires, Argentina
| | - Edgardo Kaplinsky
- Cardiology Unit, Medicine Department, Hospital Municipal de Badalona, Spain
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6
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Peach M, Milne J, Diegelmann L, Lamprecht H, Stander M, Lussier D, Pham C, Henneberry R, Fraser J, Chandra K, Howlett M, Mekwan J, Ramrattan B, Middleton J, van Hoving N, Taylor L, Dahn T, Hurley S, MacSween K, Richardson L, Stoica G, Hunter S, Olszynski P, Chandra K, Lewis D, Atkinson P. Does point-of-care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? An international randomized controlled trial from the SHOC-ED investigators. CAN J EMERG MED 2023; 25:48-56. [PMID: 36577931 DOI: 10.1007/s43678-022-00431-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 11/30/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE Point-of-care ultrasonography (POCUS) is an established tool in the management of hypotensive patients in the emergency department (ED). We compared the diagnostic accuracy of a POCUS protocol versus standard assessment without POCUS in patients with undifferentiated hypotension. METHODS This was an international, multicenter randomized controlled trial included three EDs in North America and three in South Africa from September 2012 to December 2016. Hypotensive patients were randomized to early POCUS protocol plus standard care (POCUS group) or standard care without POCUS (control group). Initial and secondary diagnoses were recorded at 0 and 60 min. The main outcome was measures of diagnostic accuracy of a POCUS protocol in differentiating between cardiogenic and non-cardiogenic shock. Secondary outcomes were diagnostic performance for shock sub-types, as well as changes in perceived category of shock and overall diagnosis. RESULTS Follow-up was completed for 270 of 273 patients. For cardiogenic shock, the POCUS-based diagnostic approach (POCUS) performed similarly to the non-POCUS approach (control) for specificity [95.5% (89.9-98.5) vs.93.8% (87.7-97.5)]; positive likelihood ratio (17.92 vs 14.80); negative likelihood ratio (0.21 vs 0.09) and diagnostic odds ratio (85.6 vs 166.57), with a similar overall diagnostic accuracy between the two approaches [93.7% (88-97.2) vs 93.6% (87.8-97.2)]. Diagnostic performance measures were similar across sub-categories of shock. CONCLUSION This is the first randomized controlled trial to compare diagnostic performance of a POCUS protocol to standard care without POCUS in undifferentiated hypotensive ED patients. POCUS performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test; however, performance did not differ meaningfully from standard assessment.
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Affiliation(s)
- M Peach
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
| | - J Milne
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Fraser Health Authority, Vancouver, BC, Canada
| | - L Diegelmann
- Division of Emergency Medicine, University of Stellenbosch, Cape Town, South Africa
- Department of Emergency Medicine, University of Maryland Medical Center, Baltimore, USA
| | - H Lamprecht
- Division of Emergency Medicine, University of Stellenbosch, Cape Town, South Africa
| | - M Stander
- Division of Emergency Medicine, University of Stellenbosch, Cape Town, South Africa
| | - D Lussier
- Department of Emergency Medicine, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - C Pham
- Department of Emergency Medicine, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - R Henneberry
- Department of Emergency Medicine, Dalhousie University, QEII, Halifax, NS, Canada
| | - J Fraser
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
| | - K Chandra
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - M Howlett
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - J Mekwan
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - B Ramrattan
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - J Middleton
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - N van Hoving
- Division of Emergency Medicine, University of Stellenbosch, Cape Town, South Africa
| | - L Taylor
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
| | - T Dahn
- Department of Emergency Medicine, Dalhousie University, QEII, Halifax, NS, Canada
| | - S Hurley
- Department of Emergency Medicine, Dalhousie University, QEII, Halifax, NS, Canada
| | - K MacSween
- Department of Emergency Medicine, Dalhousie University, QEII, Halifax, NS, Canada
| | - L Richardson
- Department of Emergency Medicine, Dalhousie University, QEII, Halifax, NS, Canada
| | - G Stoica
- Research Services, Horizon Health Network, Saint John, NB, Canada
| | - Samuel Hunter
- Faculty of Science, University of Ottawa, Ottawa, ON, Canada
| | - P Olszynski
- Department of Emergency Medicine, University of Saskatchewan, Royal University Hospital, Saskatoon, SK, Canada
| | - K Chandra
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - D Lewis
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - P Atkinson
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada.
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada.
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada.
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7
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Muacevic A, Adler JR. RUSHing to the Diagnosis: Aortic Abdominal Aneurysm Detected Using the Rapid Ultrasound for Shock and Hypotension (RUSH) Protocol in the Wards. Cureus 2022; 14:e32565. [PMID: 36540318 PMCID: PMC9754670 DOI: 10.7759/cureus.32565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
The rapid ultrasound for shock and hypotension (RUSH) protocol is a useful tool used in the emergency department (ED) when addressing the severity and etiology of shock. It was designed to be performed in under two minutes with evaluation of the pump (heart), tank (inferior vena cava, thoracic and abdominal compartments) and the pipes (large arteries and veins). However, its application or one similar should extend beyond the ED and into the hospital floor. Here we present an 80-year-old gentleman with a history of atrial fibrillation (A-Fib) on anticoagulation who arrived at the ED due to an episode of pre-syncope just prior to arrival. Initial EKG is concerning for A-Fib with rapid ventricular response (RVR) with a rate in the 130s. After fluid resuscitation patient improved and he was admitted to the telemetry floor for further cardiac workup and cardiology consultation. While waiting for a room in the ED, patient became hypotensive, diaphoretic and pale. After complaining of lower abdominal pain, the ED physician performed a RUSH which showed an abdominal aorta of 8 cm concerning for dissection. Diagnosis was confirmed with CT angiography of the abdomen and he was taken to the OR with successful repair of the abdominal aortic aneurysm (AAA). Patient made meaningful recovery and was discharged to in-patient rehab. The patient described in this vignette was delayed in the ED due to lack of beds on the floor. This allowed for quick ultrasound work-up by the ED physician which led to immediate recognition of the AAA and immediate response by the vascular surgery team. Should this patient have been on the hospital floor, it is unclear if such prompt steps would have occurred prior to patient's further hemodynamic demise.
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8
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Morales G, Adedipe A, Morse S, McCabe J, Mahr C, Nichol G. Feasibility of Very Early Identification of Cardiogenic Shock by Semi-automated Ultrasound Exam in the Emergency Department. Cureus 2022; 14:e30927. [DOI: 10.7759/cureus.30927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
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9
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Huang D, Al-Bassam M, Leon LN, Ganti L. Emergency Department Point-of-Care Ultrasound Diagnosis of a Large Bowel Obstruction Due to Metastatic Rectal Cancer: A Case Report. Cureus 2022; 14:e28817. [PMID: 36225420 PMCID: PMC9535202 DOI: 10.7759/cureus.28817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
Large bowel obstruction (LBO) is a life-threatening condition seen most often in the geriatric population. LBO can present with nonspecific abdominal pain that can overlap with other pathologies, such as abdominal infection, acute aortic disease, intestinal perforation, and atypical acute coronary syndrome in the geriatric population. Delays in diagnosis of colonic obstruction result in significant mortality due to complications involving bowel necrosis, perforation, and sepsis. In the emergency department (ED), abdominal point-of-care ultrasound (POCUS) can diagnose LBO and facilitate the assessment of the wide differential inherent to elderly abdominal pain. The authors report a rare ED application of abdominal POCUS to facilitate rapid diagnosis of an LBO secondary to rectal cancer.
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10
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Adi O, Fong CP, Ahmad AH, Panebianco N. Worsening cardiac tamponade after pericardiocentesis in a patient with anterior mediastinum mass: a case report. Eur Heart J Case Rep 2022; 6:ytac329. [PMID: 36004046 PMCID: PMC9395134 DOI: 10.1093/ehjcr/ytac329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/25/2022] [Accepted: 08/04/2022] [Indexed: 11/13/2022]
Abstract
Background Mediastinal mass is an entity with variable pathology and clinical spectrum. Anterior mediastinal mass can result in severe symptoms due to involvement of surrounding vital structures such as the great vessels, trachea-bronchial tree, and heart. We highlight a case of cardiac tamponade in a patient with an anterior mediastinal mass that was paradoxically worsened after decompressive pericardiocentesis. Case summary A 21-year-old male presented to the emergency department (ED) with breathlessness and hypotension. Bedside focused cardiac ultrasound revealed cardiac tamponade which was made worse with an anterior mediastinal mass compressing the right heart chambers. The patient was intubated for respiratory failure, following which an ultrasound-guided pericardiocentesis was performed. Unexpectedly, his hemodynamic status worsened after aspiration of 1000 mL of pericardial fluid. A repeat focused cardiac ultrasound showed reduced pericardial effusion, but worsening of right heart chambers compression by the mediastinal mass. Re-expansion of the pericardium space with 600 mL of normal saline improved the patient’s vital signs, and reduced the right heart compression. Computed tomography was deferred due to the patient’s hemodynamic instability. Despite resuscitation with fluids and initiation of vasopressor, the patient’s condition deteriorated. He succumbed to his illness due to obstructive shock causing multi-organ failure. The autopsy showed a large anterior mediastinal mass, and histopathological examination confirmed the diagnosis of lymphoma. Discussion This case demonstrated the therapeutic challenges of managing a shock patient with anterior mediastinal mass, and massive pericardial effusion causing cardiac tamponade.
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Affiliation(s)
- Osman Adi
- Department, Hospital Raja Permaisuri Bainun , Ipoh, PRK , Malaysia
| | - Chan Pei Fong
- Department, Hospital Raja Permaisuri Bainun , Ipoh, PRK , Malaysia
| | | | - Nova Panebianco
- Department of Emergency Medicine, Hospital of the University of Pennsylvania , Philadelphia, PA , USA
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11
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Huang D, Huttleston A, Fraunfelter F, Leon LN, Ganti L. Penetrating Aortic Ulceration With Pseudoaneurysm and Intramural Hematoma: Emergency Department Management and Point-of-Care Ultrasound Diagnosis. Cureus 2022; 14:e27536. [PMID: 36060360 PMCID: PMC9427664 DOI: 10.7759/cureus.27536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2022] [Indexed: 11/14/2022] Open
Abstract
Penetrating aortic ulcer (PAU) complicated by an intramural hematoma is a rare and potentially life-threatening emergency department (ED) presentation that is defined by progressive ulceration through the intima layer into the media layer of the aorta. Symptomatic PAUs can be clinically indistinguishable from other life-threatening pathologies such as aortic dissection, acute coronary syndrome (ACS), intrabdominal catastrophes as well as less lethal processes such as musculoskeletal back pain. Given the potential of PAUs to result in lethal aortic
rupture and dissection, the emergency provider should maintain a high index of suspicion in patients with risk factors for aortic pathologies and utilize diagnostic modalities such as point-of-care ultrasound (POCUS) to expedite diagnosis.
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12
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Ramadan A, Abdallah T, Abdelsalam H, Mokhtar A, Razek AA. Accuracy of echocardiography and ultrasound protocol to identify shock etiology in emergency department. BMC Emerg Med 2022; 22:117. [PMID: 35768775 PMCID: PMC9245270 DOI: 10.1186/s12873-022-00678-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 06/17/2022] [Indexed: 11/27/2022] Open
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.
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Affiliation(s)
- Asmaa Ramadan
- Department of Emergency Medicine, Alexandria University, Alexandria, Egypt.
| | - Tamer Abdallah
- Department of Critical Care Medicine, Alexandria University, Alexandria, Egypt
| | | | - Ahmed Mokhtar
- Department of Cardiology and angiology, Alexandria University, Alexandria, Egypt
| | - Assem Abdel Razek
- Department of Anesthesia and Surgical Intensive Care Unit, Alexandria University, Alexandria, Egypt
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13
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Spiliotaki E, Saranteas T, Moschovaki N, Panagouli K, Pistioli E, Kitsinelis V, Briasoulis P, Papadimos T. Inferior vena cava ultrasonography in the assessment of intravascular volume status and fluid responsiveness in the emergency department and intensive care unit: A critical analysis review. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:733-744. [PMID: 35302241 DOI: 10.1002/jcu.23194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/23/2022] [Accepted: 03/09/2022] [Indexed: 06/14/2023]
Abstract
Rapid evaluation of intravascular volume status is vital; either excessive or limited fluid administration may result in adverse patient outcomes. In this narrative review, critical analysis of pertinent diagnostic accuracy studies is developed to delineate the role of inferior vena cava ultrasound measurements in the assessment of both intravascular volume status and fluid responsiveness in the emergency department and intensive care unit. In addition, limitations, and technical considerations of inferior vena cava ultrasound measurements as well as directions for future research are thoroughly discussed.
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Affiliation(s)
- Eleni Spiliotaki
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodosios Saranteas
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
- Department of Anesthesia, Division of critical care, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Nefeli Moschovaki
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantina Panagouli
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathia Pistioli
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilios Kitsinelis
- Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Briasoulis
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Thomas Papadimos
- Department of Anesthesia, Division of critical care, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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14
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Abstract
The efficacy of ultrasound (US) in real-time differential diagnosis and guiding further treatment decisions has been well demonstrated in prearrest conditions and during resuscitation. Evidence is limited regarding the application of US in postresuscitation care. Most of the patients following resuscitation remain comatose, and the requirement for transportation to other examination rooms increases their risk of injury. US can be performed at the bedside with high accessibility and timeliness without radiation. This narrative review provides an overview of current evidence regarding the application of US in identifying the cause of cardiac arrest (CA), hemodynamic monitoring, and prognostication in postresuscitation care. For identifying the cause of CA, cardiac US is mainly used to detect regional wall motion abnormality. However, postarrest myocardial dysfunction would confound the sonographic findings that a combination of electrocardiograms and biomarkers besides the cardiac US could improve the positive predictive value of coronary artery disease. For hemodynamic monitoring, left ventricular outlet tract velocity time integral has the best performance in predicting fluid responsiveness in conjunction with the passive leg raising test. The RUSH protocol assists in determining the subtypes of shock with high sensitivity and specificity in hypovolemic, cardiogenic, or obstructive shock. Evidence regarding the application of US for prognostication is still limited, and further evaluation should be needed.
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Im KM, Kim EY. Focused Bedside Ultrasound Training Program for Surgical Residents in the Intensive Care Unit of Tertiary hospital. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03305-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
AbstractBedside ultrasound has become one of the most important noninvasive and readily available diagnostic tools for critically ill patients. However, the current ultrasound training program for surgical residents is not standardized and is mostly unavailable to all surgical residents equally. Herein, we evaluated the effectiveness of the new training program in bedside ultrasound for surgical residents. Postgraduate residents (years 1 to 4) from the department of general surgery in a tertiary hospital attended the newly designed, 8-week ultrasound training course at the surgical intensive care unit. Didactic and experimental lectures about basic ultrasound physics and machine usage were delivered, followed by daily hands-on training to actual patients. Each participant documented their ultrasound findings and completed a self-assessment survey of ultrasound skills using the Likert scale. A total of 44 residents were enrolled, and only 36.4% of them were previously exposed to bedside ultrasound experience. Following the completion of the training course, the proficiency levels and the objective structured assessment of ultrasound skill scores showed significant improvement in every element (P < 0.001). The mean differences in pre- and post-course scores between post-graduate years and post hoc analysis revealed that the post-graduate year 2 group showed a higher improvement in most elements. Whether or not residents had previous experience with ultrasound, the significant improvement was seen in post-course scores. The knowledge and confidence of surgical residents in bedside ultrasound could be improved after our short training curriculum. Such education should be encouraged for all surgical residents to enhance their competency in performing bedside ultrasounds and use in managing critically ill patients.
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Ávila-Reyes D, Acevedo-Cardona AO, Gómez-González JF, Echeverry-Piedrahita DR, Aguirre-Flórez M, Giraldo-Diaconeasa A. Point-of-care ultrasound in cardiorespiratory arrest (POCUS-CA): narrative review article. Ultrasound J 2021; 13:46. [PMID: 34855015 PMCID: PMC8639882 DOI: 10.1186/s13089-021-00248-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 11/12/2021] [Indexed: 12/28/2022] Open
Abstract
The POCUS-CA (Point-of-care ultrasound in cardiac arrest) is a diagnostic tool in the Intensive Care Unit and Emergency Department setting. The literature indicates that in the patient in a cardiorespiratory arrest it can provide information of the etiology of the arrest in patients with non-defibrillable rhythms, assess the quality of compressions during cardiopulmonary resuscitation (CPR), and define prognosis of survival according to specific findings and, thus, assist the clinician in decision-making during resuscitation. This narrative review of the literature aims to expose the usefulness of ultrasound in the setting of cardiorespiratory arrest as a tool that allows making a rapid diagnosis and making decisions about reversible causes of this entity. More studies are needed to support the evidence to make ultrasound part of the resuscitation algorithms. Teamwork during cardiopulmonary resuscitation and the inclusion of ultrasound in a multidisciplinary approach is important to achieve a favorable clinical outcome.
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Affiliation(s)
- Diana Ávila-Reyes
- Department of Critical Care Medicine, Universidad Tecnológica de Pereira, Grupo de Investigación Medicina Crítica Y Cuidados Intensivos (GIMCCI), Pereira, Colombia.
| | - Andrés O Acevedo-Cardona
- Department of Critical Care Medicine, Universidad Tecnológica de Pereira,, Pereira, Colombia
- Master en Ecocardiografía en Cuidados Intensivos, Sociedad Española de Imagen Cardíaca/Universidad Francisco de Vitoria, España, Pereira, Spain
| | - José F Gómez-González
- Department of Critical Care Medicine, Universidad Tecnológica de Pereira, Pereira, Colombia
- Grupo Investigación de Medicina Crítica Y Cuidados Intensivos (GIMCCI), Pereira, Colombia
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Rice JA, Brewer J, Speaks T, Choi C, Lahsaei P, Romito BT. The POCUS Consult: How Point of Care Ultrasound Helps Guide Medical Decision Making. Int J Gen Med 2021; 14:9789-9806. [PMID: 34938102 PMCID: PMC8685447 DOI: 10.2147/ijgm.s339476] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/01/2021] [Indexed: 12/30/2022] Open
Affiliation(s)
- Jake A Rice
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jonathan Brewer
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tyler Speaks
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Christopher Choi
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Peiman Lahsaei
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bryan T Romito
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Correspondence: Bryan T Romito Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390-9068, USATel +1 214 648 7674Fax +1 214 648 5461 Email
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18
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Hu KM, Brown RM. Resuscitation of the Critically Ill Older Adult. Emerg Med Clin North Am 2021; 39:273-286. [PMID: 33863459 DOI: 10.1016/j.emc.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In 30 years, adults 65 and older will represent 20% of the US population, with increased medical comorbidities leading to higher rates of critical illness and mortality. Despite significant acute illness, presenting symptoms and vital sign abnormalities may be subtle. Resuscitative guidelines are a helpful starting point but appropriate diagnostics, bedside ultrasound, and frequent reassessments are needed to avoid procrustean care that may worsen outcomes. Baseline functional status is as important as underlying comorbid conditions when prognosticating, and the patient's personal wishes should be sought early and throughout care with clear communication regarding prospects for immediate survival and overall recovery.
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Affiliation(s)
- Kami M Hu
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA; Department of Internal Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Robert M Brown
- Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Carilion Roanoke Memorial Hospital, 1906 Belleview Ave SE, Roanoke, VA 24014, USA
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19
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Pyo SY, Park GJ, Kim SC, Kim H, Lee SW, Lee JH. Impact of the modified SESAME ultrasound protocol implementation on patients with cardiac arrest in the emergency department. Am J Emerg Med 2021; 43:62-68. [PMID: 33529851 DOI: 10.1016/j.ajem.2021.01.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 01/07/2021] [Accepted: 01/09/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Point-of-care (POC) ultrasound protocols are commonly used for the initial management of patients with cardiac arrest in the emergency department (ED). However, there is little published evidence regarding any mortality benefit. We compared and studied the effect of implementation of the modified SESAME protocol in terms of clinical outcomes and resuscitation management. METHODS This was a single-center retrospective observational study. We conducted a pre- and post-intervention study to evaluate changes in patient outcomes and management after educating emergency medicine residents and the faculty about the modified SESAME protocol. The pre-intervention period lasted from March 2018 to February 2019, and the post-intervention period lasted from May 2019 to April 2020. The modified SESAME protocol education was initiated in March 2019. Multivariate logistic regression analyses were performed to examine the associations between independent variables and outcomes. RESULTS A total of 334 patients were included in this study during a 24-month period. We found no significant differences between the two groups for the primary outcome of survival to hospital admission (pre-intervention group 28.9% versus post-intervention group 28.6%; P = 0.751), survival to hospital discharge (12.1% vs. 12.4%; P = 0.806), and good neurologic outcome at discharge (6.0% vs. 8.1%; P = 0.509). The proportion of resuscitation procedures of thrombolysis, emergency transfusion, tube thoracotomy, and pericardiocentesis during resuscitation increased from 0.6% in the pre-intervention period to 4.9% in the post-intervention period (P = 0.016). CONCLUSION We did not discover any significant survival benefits associated with the implementation of the modified SESAME protocol; however, early diagnosis of specific pathologies (pericardial effusion, possible pulmonary embolism, tension pneumothorax, and hypovolemia) and accordingly a direct increase in the resuscitation management were seen in this study. Future studies with larger sample sizes are required to examine the clinical outcomes as well as to identify the most effective POC ultrasonography protocols for non-traumatic cardiac arrests.
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Affiliation(s)
- Su Yeong Pyo
- Department of Emergency Medicine, Chungbuk National University Hospital, 776, Sunhwan-ro, Seowon-gu, Cheongju, Republic of Korea
| | - Gwan Jin Park
- Department of Emergency Medicine, Chungbuk National University Hospital, 776, Sunhwan-ro, Seowon-gu, Cheongju, Republic of Korea
| | - Sang Chul Kim
- Department of Emergency Medicine, Chungbuk National University Hospital, 776, Sunhwan-ro, Seowon-gu, Cheongju, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungbuk National University, 1, Chungdae-ro, Seowon-gu, Cheongju, Republic of Korea
| | - Hoon Kim
- Department of Emergency Medicine, Chungbuk National University Hospital, 776, Sunhwan-ro, Seowon-gu, Cheongju, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungbuk National University, 1, Chungdae-ro, Seowon-gu, Cheongju, Republic of Korea
| | - Suk Woo Lee
- Department of Emergency Medicine, Chungbuk National University Hospital, 776, Sunhwan-ro, Seowon-gu, Cheongju, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungbuk National University, 1, Chungdae-ro, Seowon-gu, Cheongju, Republic of Korea
| | - Ji Han Lee
- Department of Emergency Medicine, Chungbuk National University Hospital, 776, Sunhwan-ro, Seowon-gu, Cheongju, Republic of Korea.
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20
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Adi O, Fong CP, Ahmad AH, Azil A, Ranga A, Panebianco N. Pericardial decompression syndrome: A complication of pericardiocentesis. Am J Emerg Med 2021; 45:688.e3-688.e7. [PMID: 33514476 DOI: 10.1016/j.ajem.2021.01.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/09/2021] [Accepted: 01/10/2021] [Indexed: 11/28/2022] Open
Abstract
Pericardial Decompression Syndrome (PDS) is an uncommon but life-threatening complication following pericardiocentesis for cardiac tamponade. We report PDS after pericardiocentesis in two patients that presented to the emergency department with cardiac tamponade. In both cases, pericardiocentesis was performed under ultrasound guidance using the left parasternal approach and approximately 1200-1500 mL of pericardial fluid was removed. Immediately after pericardiocentesis, the haemodynamic status of the patients improved. However, 2-3 h post decompression, both patients developed hypotension and pulmonary edema with reduced left ventricular function, suggestive of PDS. PDS is a condition that is described as paradoxical worsening of vital signs after successful decompression of the pericardium in the setting of acute tamponade. Three possible mechanisms explaining PDS are ischaemic, hemodynamic and autonomic processes. If PDS is unrecognized and untreated, it is associated with a high mortality rate secondary to pulmonary edema and cardiogenic shock. If managed urgently, the cardiopulmonary dysfunction in PDS is usually transient and largely reversible with supportive care.
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Affiliation(s)
- Osman Adi
- Consultant Emergency Physician & ED Critical Care, Trauma & Emergency Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia.
| | - Chan Pei Fong
- Consultant Emergency Physician & ED Critical Care, Trauma & Emergency Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
| | - Azma Haryaty Ahmad
- Consultant Emergency Physician & ED Critical Care, Trauma & Emergency Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
| | - Azlizawati Azil
- Consultant Emergency Physician & ED Critical Care, Trauma & Emergency Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
| | - Asri Ranga
- Department of Cardiology, Hospital Serdang, 43400 Serdang, Selangor, Malaysia
| | - Nova Panebianco
- Division of Emergency Ultrasound, Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, United States of America.
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21
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Nagre AS. Focus-assessed transthoracic echocardiography: Implications in perioperative and intensive care. Ann Card Anaesth 2020; 22:302-308. [PMID: 31274494 PMCID: PMC6639886 DOI: 10.4103/aca.aca_88_18] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Transthoracic echocardiography is a potent and appealing diagnostic tool by virtue of rapidity, noninvasiveness, and repeatability. Focus-assessed transthoracic echocardiography (FATE) forms quick guidance to interpret the echocardiographic information and relates it to the clinical context. It can be applied in the perioperative period, intensive care units (ICUs), and emergency situations, in trauma and as resuscitation aids. FATE intents to assess cardiac function including contractility, chamber size and hypertrophy, valvular dysfunction, cardiac tamponade, and pericardial and pleural effusions. Thence, FATE has become a quintessential scanning tool perioperatively and in ICUs.
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Affiliation(s)
- Amarja Sachin Nagre
- Department of Anaesthesia, Kamalnayan Bajaj Hospital, Aurangabad,Maharashtra, India
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22
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Diederich H, Burkhardt H. Diagnostic efficacy of bedside ultrasound to detect dehydration in older patients attending an emergency care unit. Z Gerontol Geriatr 2020; 54:130-135. [PMID: 32108241 DOI: 10.1007/s00391-020-01711-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 02/06/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND The diagnosis of dehydration in older patients remains a challenge because clinical and laboratory signs are unspecific. The use of B‑Mode ultrasound of the inferior vena cava is proposed to aid in the diagnosis but data concerning diagnostic efficacy of bedside ultrasound are lacking. METHODS In this study 78 patients ≥65 years old referred to the emergency unit of a university hospital and identified as being dehydrated by applying clinical signs were compared with a reference of 121 patients. The diameter of the inferior vena cava (IVC) was assessed by ultrasound while compressing the IVC during an inspiratory maneuver and the minimum and maximum diameter in M‑Mode. RESULTS Significant differences were found concerning compressibility, variability of the diameter assessed by M‑Mode and the diameter during an inspiratory maneuver of the IVC (<0.001); however, a receiver operator characteristics (ROC) showed only moderate values for diagnostic efficacy for all these parameters where the best result was found for the inspiratory maneuver (Area under the curve [AUC] = 0.73). To reach a specificity of 0.8 to diagnose dehydration, a cut-off value of ≤0.4 cm for IVC diameter was suitable. CONCLUSION Ultrasound of the IVC can easily be applied in a bedside setting and may be helpful in identifying dehydration in older patients; however, this remains challenging and a synopsis covering clinical and technical data is indispensable.
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Affiliation(s)
- H Diederich
- IV. Medizinische Universitätsklinik, Geriatrisches Zentrum, Universitätsklinikum Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - H Burkhardt
- IV. Medizinische Universitätsklinik, Geriatrisches Zentrum, Universitätsklinikum Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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23
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Javali RH, Loganathan A, Srinivasarangan M, 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; 24:313-320. [PMID: 32728321 PMCID: PMC7358855 DOI: 10.5005/jp-journals-10071-23429] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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. How to cite this article Javali RH, Loganathan A, Srinivasarangan M, Akkamahadevi P, Ganesha BS, Nisarg S, et al. Reliability of Emergency Department Diagnosis in Identifying the Etiology of Nontraumatic Undifferentiated Hypotension. Indian J Crit Care Med 2020;24(5):313–320.
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Affiliation(s)
- Rameshbabu H Javali
- Department of Emergency Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
| | - Arpitha Loganathan
- Department of Emergency Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
| | - Madhu Srinivasarangan
- Department of Emergency Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
| | - Akkamahadevi Patil
- Department of Anesthesia, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
| | | | - Nisarg Satyanarayana
- Department of Emergency Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
| | - Adarsh S Bheemanna
- Department of Emergency Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
| | - Sriharsha Jagadeesh
- Department of Emergency Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
| | - Sagarika Betkerur
- Department of Emergency Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
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SIRS Triggered by Acute Right Ventricular Function, Mimicked Septic Shock. ACTA ACUST UNITED AC 2019; 5:149-156. [PMID: 31915722 PMCID: PMC6942449 DOI: 10.2478/jccm-2019-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/23/2019] [Indexed: 11/20/2022]
Abstract
Background The systemic inflammatory response syndrome (SIRS) is a complex immune response which can be precipitated by non-infectious aetiologies such as trauma, burns or pancreatitis. Addressing the underlying cause is crucial because it can be associated with increased mortality. Although the current literature associates chronic heart failure with SIRS, acute right ventricular dysfunction has not previously been reported to trigger SIRS. This case report describes the presentation of acute right ventricular dysfunction that triggered SIRS and mimicked septic shock. Case presentation A 70-year-old male presented to the Intensive Care Unit (ICU) with elevated inflammatory markers and refractory hypotension after a robotic-assisted laparoscopic radical choledochectomy with pancreaticoduodenectomy. Septic shock was misdiagnosed, and he was later found to have a pulmonary embolus. Thrombectomy and antimicrobials had no significant efect on lowering the elevated inflammatory markers or improving the persistent hypotension. Through Point of Care Ultrasound (POCUS), right ventricular dysfunction was diagnosed. Treatment with intravenous milrinone improved blood pressure, normalised inflammatory markers and led to a prompt discharge from the ICU. Conclusion Acute right ventricular dysfunction can trigger SIRS, which may mimic septic shock and delay appropriate treatment.
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Abstract
The differential diagnosis for patients presenting in shock can be broad, making rapid diagnosis and management challenging. We present a case of a medically complex patient with presumed septic shock, diagnosed with a large pericardial effusion with evidence of tamponade using the rapid ultrasound in shock and hypotension protocol. The point-of-care ultrasound examination allowed for more timely and definitive management.
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Tarrazo Suárez JA, Morales Cano JM, Pujol Salud J, Sánchez Barrancos IM, Diaz Sánchez S, Conangla Ferrín L. [Usefulness and reliability of point of care ultrasound in Family Medicine: Focused ultrasound in neck and emergency]. Aten Primaria 2019; 51:367-379. [PMID: 31101376 PMCID: PMC6836943 DOI: 10.1016/j.aprim.2019.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 03/13/2019] [Indexed: 11/17/2022] Open
Abstract
La ecografía clínica es una herramienta que complementa a la anamnesis y a la exploración física, lo que facilita y agiliza la toma de decisiones en cualquier entorno de atención médica El médico de familia es el especialista que más se puede beneficiar del empleo de la ecografía porque debe ser competente en todos los terrenos de la enfermedad El estudio mediante ecografía, por su fiabilidad, seguridad, reproducibilidad y bajo coste debe estar accesible para su empleo en atención primaria, tanto en el ámbito de la atención normal como la urgente Esta técnica, aplicada en escenarios concretos y con una sistemática de estudio definida, confirma o descarta enfermedades, lo que orienta el diagnóstico con elevada fiabilidad, así como sustenta de modo eficaz la conducta del profesional Este artículo revisa la fiabilidad y la utilidad de la ecografía clínica en escenarios como la enfermedad cervical, y en diferentes situaciones de urgencia, como sospecha de trombosis venosa profunda en la extremidad inferior, traumatismo toracoabdominal, inestabilidad hemodinámica o parada cardiaca
La ecografía es una herramienta de gran valor para el diagnóstico y el manejo de una gran variedad de situaciones clínicas cotidianas. El médico de familia como especialista generalista debe ser competente para el abordaje de prácticamente cualquier problema de salud que afecte a su población, por lo que, en sus manos, esta herramienta puede proporcionar un elevado impacto sobre la calidad y la eficacia del proceso asistencial. Este es el último artículo de una serie dedicada a mostrar la aplicabilidad de la ecografía clínica en nuestras manos, en la que hemos revisado la mayoría de sus aplicaciones, como la ecografía clínica abdominal, la nefrourológica, la musculoesquelética, la cardiaca o la pulmonar. Queremos terminar con escenarios como la afección del cuello o su uso en situaciones de urgencia, en las que proporciona datos definitivos para la orientación diagnóstica, el manejo clínico e incluso la supervivencia del paciente, tales como el paciente con sospecha de trombosis venosa profunda en miembros inferiores, traumatismo toracoabdominal, compromiso hemodinámico o parada cardiaca.
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Affiliation(s)
- José Antonio Tarrazo Suárez
- Medicina Familiar y Comunitaria; Grupo de Trabajo de Ecografía, Sociedad Española de Medicina Familiar y Comunitaria; Centro de Salud Siero-Sariego, Servicio Asturiano de Salud, Pola de Siero, Asturias, España
| | - José Manuel Morales Cano
- Medicina Familiar y Comunitaria; Grupo de Trabajo de Ecografía, Sociedad Española de Medicina Familiar y Comunitaria; Centro de Salud Ciudad Real 2, Servicio de Salud de Castilla-La Mancha, Ciudad Real, España
| | - Jesús Pujol Salud
- Medicina Familiar y Comunitaria; Grupo de Trabajo de Ecografía, Sociedad Española de Medicina Familiar y Comunitaria; Centro de Atención Primaria Balaguer, Instituto Catalán de Salud, Balaguer, Lleida, España
| | - Ignacio Manuel Sánchez Barrancos
- Medicina Familiar y Comunitaria; Grupo de Trabajo de Ecografía, Sociedad Española de Medicina Familiar y Comunitaria; Consultorio de Membrilla, Centro de Salud Manzanares 2, Servicio de Salud de Castilla-La Mancha, Membrilla, Ciudad Real, España.
| | - Santiago Diaz Sánchez
- Medicina Familiar y Comunitaria; Grupo de Trabajo de Ecografía, Sociedad Española de Medicina Familiar y Comunitaria; Centro de Salud Pintores de Parla, Servicio Madrileño de Salud, Parla, Madrid. España
| | - Laura Conangla Ferrín
- Medicina Familiar y Comunitaria; Grupo de Trabajo de Ecografía, Sociedad Española de Medicina Familiar y Comunitaria; Centro de Atención Primaria Badalona-2, Centre Dalt la Vila, Instituto Catalán de Salud, Badalona, Barcelona, España
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The diagnostic accuracy of a point-of-care ultrasound protocol for shock etiology: A systematic review and meta-analysis. CAN J EMERG MED 2019; 21:406-417. [PMID: 30696496 DOI: 10.1017/cem.2018.498] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The aim of this study was to perform a systematic review and meta-analysis of the diagnostic accuracy of a point-of-care ultrasound exam for undifferentiated shock in patients presenting to the emergency department. METHODS Ovid MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, and research meeting abstracts were searched from 1966 to June 2018 for relevant studies. QUADAS-2 was used to assess study quality, and meta-analysis was conducted to pool performance data of individual categories of shock. RESULTS A total of 5,097 non-duplicated studies were identified, of which 58 underwent full-text review; 4 were included for analysis. Study quality by QUADAS-2 was considered overall a low risk of bias. Pooled positive likelihood ratio values ranged from 8.25 (95% CI 3.29 to 20.69) for hypovolemic shock to 40.54 (95% CI 12.06 to 136.28) for obstructive shock. Pooled negative likelihood ratio values ranged from 0.13 (95% CI 0.04 to 0.48) for obstructive shock to 0.32 (95% CI 0.16 to 0.62) for mixed-etiology shock. CONCLUSION The rapid ultrasound for shock and hypotension (RUSH) exam performs better when used to rule in causes of shock, rather than to definitively exclude specific etiologies. The negative likelihood ratios of the exam by subtype suggest that it most accurately rules out obstructive shock.
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Does Point-of-Care Ultrasonography Improve Clinical Outcomes in Emergency Department Patients With Undifferentiated Hypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators. Ann Emerg Med 2018; 72:478-489. [DOI: 10.1016/j.annemergmed.2018.04.002] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 03/21/2018] [Accepted: 04/04/2018] [Indexed: 11/22/2022]
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Integrated Cardiac and Lung Ultrasound (ICLUS) in the Cardiac Intensive Care Unit. CURRENT CARDIOVASCULAR IMAGING REPORTS 2018. [DOI: 10.1007/s12410-018-9463-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Mongodi S, Roldi EM, Orlando A, Civardi L, Iotti GA, Mojoli F. A 70-Year-Old Develops Refractory Hypotension in the ICU. Chest 2017; 152:e61-e63. [DOI: 10.1016/j.chest.2017.03.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 02/05/2017] [Accepted: 03/16/2017] [Indexed: 11/28/2022] Open
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Effect of Focused Bedside Ultrasonography in Hypotensive Patients on the Clinical Decision of Emergency Physicians. Emerg Med Int 2017; 2017:6248687. [PMID: 28357139 PMCID: PMC5357513 DOI: 10.1155/2017/6248687] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 01/15/2017] [Accepted: 02/01/2017] [Indexed: 01/05/2023] Open
Abstract
We assessed the effect of focused point of care ultrasound (POCUS) used for critical nontraumatic hypotensive patients presenting to the emergency department of our hospital on the clinical decisions of the physicians and whether it led to the modification of the treatment modality. This prospective clinical study was conducted at the Emergency Department of Antalya Training and Research Hospital. Nontraumatic patients aged 18 and older who presented to our emergency department and whose systolic blood pressure was <100 mmHg or shock index (heart rate/systolic blood pressure) was >1 were included in the study. While the most probable preliminary diagnosis established by the physician before POCUS was consistent with the definitive diagnosis in 60.6% (n = 109) of 180 patients included in the study, it was consistent with the definitive diagnosis in 85.0% (n = 153) of the patients after POCUS (p < 0.001). POCUS performed for critical hypotensive patients presenting to the emergency department is an appropriate diagnostic tool that can be used to enable the physicians to make the accurate preliminary diagnosis and start the appropriate treatment in a short time.
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Mok KL. Make it SIMPLE: enhanced shock management by focused cardiac ultrasound. J Intensive Care 2016; 4:51. [PMID: 27529027 PMCID: PMC4983798 DOI: 10.1186/s40560-016-0176-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 07/12/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Shock is a spectrum of circulatory failure that, if not properly managed, would lead to high mortality. Special diagnostic and treatment strategies are essential to save lives. However, clinical and laboratory findings are always non-specific, resulting in clinical dilemmas. MAIN CONTENT Focused cardiac ultrasound (FoCUS) has emerged as one of the power tools for clinicians to answer simple clinical questions and guide subsequent management in hypotensive patients. This article will review the development and utility of FoCUS in different types of shock. The sonographic features and ultrasound enhanced management of hypotensive patients by a de novo "SIMPLE" approach will be described. Current evidence on FoCUS will also be reviewed. CONCLUSION Focused cardiac ultrasound provides timely and valuable information for the evaluation of shock. It helps to improve the diagnostic accuracy, narrow the possible differential diagnoses, and guide specific management. SIMPLE is an easy-to-remember mnemonic for non-cardiologists or novice clinical sonographers to apply FoCUS and interpret the specific sonographic findings when evaluating patients in shock.
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Affiliation(s)
- Ka Leung Mok
- Accident and Emergency Department, Ruttonjee Hospital, 266 Queen’s Road East, Wanchai, Hong Kong SAR
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Mojoli F, Orlando A, Mongodi S, Braschi A. A 44-Year-Old Woman Presents to the ED With Agitation, Dyspnea, and Hypotension. Chest 2016; 149:e137-9. [DOI: 10.1016/j.chest.2015.11.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 11/19/2015] [Accepted: 11/25/2015] [Indexed: 11/29/2022] Open
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Jammal M, Milano P, Cardenas R, Mailhot T, Mandavia D, Perera P. The diagnosis of right heart thrombus by focused cardiac ultrasound in a critically ill patient in compensated shock. Crit Ultrasound J 2015; 7:6. [PMID: 25995832 PMCID: PMC4437995 DOI: 10.1186/s13089-015-0023-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 04/19/2015] [Indexed: 02/06/2023] Open
Abstract
Right heart thrombus (RHT) is a life-threatening diagnosis that is rarely made in the emergency department (ED), but with the increasing use of focused cardiac ultrasound (FocUS), more of these cases may be identified in a timely fashion. We present a case of an ill-appearing patient who had an immediate change in management due to the visualization of RHT soon after arrival to the ED. The diagnosis was confirmed after a cardiology-performed ultrasound (US). This case illustrates the value of the recognition of RHT on FocUS and how US protocols designed for the evaluation of shock and shortness of breath may potentially be expanded to patients in a 'compensated' or 'pre-shock' state to expedite the correct diagnosis and to facilitate more timely management.
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Affiliation(s)
- Mansour Jammal
- />Division of Emergency Medicine, 300 Pasteur Drive, Alway Building, M121, Stanford, CA 94305 USA
| | - Peter Milano
- />Department of Emergency Medicine, Los Angeles County + USC Medical Center, 1200 N. State St # 1011, , Los Angeles, CA 90033 USA
| | - Renzo Cardenas
- />Department of Emergency Medicine, Los Angeles County + USC Medical Center, 1200 N. State St # 1011, , Los Angeles, CA 90033 USA
| | - Thomas Mailhot
- />Department of Emergency Medicine, Los Angeles County + USC Medical Center, 1200 N. State St # 1011, , Los Angeles, CA 90033 USA
| | - Diku Mandavia
- />Department of Emergency Medicine, Los Angeles County + USC Medical Center, 1200 N. State St # 1011, , Los Angeles, CA 90033 USA
| | - Phillips Perera
- />Division of Emergency Medicine, 300 Pasteur Drive, Alway Building, M121, Stanford, CA 94305 USA
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