Skip to main content
SpringerLink
Log in

Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department

  • Original
  • Published:
Intensive Care Medicine Aims and scope Submit manuscript

Abstract

Purpose

We analyzed the efficacy of a point-of-care ultrasonographic protocol, based on a focused multiorgan examination, for the diagnostic process of symptomatic, non-traumatic hypotensive patients in the emergency department.

Methods

We prospectively enrolled 108 adult patients complaining of non-traumatic symptomatic hypotension of uncertain etiology. Patients received immediate point-of-care ultrasonography to determine cardiac function and right/left ventricle diameter rate, inferior vena cava diameter and collapsibility, pulmonary congestion, consolidations and sliding, abdominal free fluid and aortic aneurysm, and leg vein thrombosis. The organ-oriented diagnoses were combined to formulate an ultrasonographic hypothesis of the cause of hemodynamic instability. The ultrasonographic diagnosis was then compared with a final clinical diagnosis obtained by agreement of three independent expert physicians who performed a retrospective hospital chart review of each case.

Results

Considering the whole population, concordance between the point-of-care ultrasonography diagnosis and the final clinical diagnosis was interpreted as good, with Cohen’s k = 0.710 (95 % CI, 0.614–0.806), p < 0.0001 and raw agreement (Ra) = 0.768. By eliminating the 13 cases where the final clinical diagnosis was not agreed upon (indefinite), the concordance increased to almost perfect, with k = 0.971 (95 % CI, 0.932–1.000), p < 0.0001 and Ra = 0.978.

Conclusions

Emergency diagnostic judgments guided by point-of-care multiorgan ultrasonography in patients presenting with undifferentiated hypotension significantly agreed with a final clinical diagnosis obtained by retrospective chart review. The integration of an ultrasonographic multiorgan protocol in the diagnostic process of undifferentiated hypotension has great potential in guiding the first-line therapeutic approach.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Moore CL, Copel JA (2011) Point-of-care ultrasonography. N Engl J Med 364:749–757

    Article  CAS  PubMed  Google Scholar 

  2. Volpicelli G (2011) Usefulness of emergency ultrasound in nontraumatic cardiac arrest. Am J Emerg Med 29:216–223

    Article  PubMed  Google Scholar 

  3. Volpicelli G (2013) Lung sonography. J Ultrasound Med 32:165–171

    PubMed  Google Scholar 

  4. Lichtenstein DA (2007) Ultrasound in the management of thoracic disease. Crit Care Med 35:S250–S261

    Article  PubMed  Google Scholar 

  5. Jones AE, Aborn LS, Kline JA (2004) Severity of emergency department hypotension predicts adverse hospital outcome. Shock 22:410–414

    Article  PubMed  Google Scholar 

  6. Jones AE, Yiannibas V, Johnson C, Kline JA (2006) Emergency department hypotension predicts sudden unexpected in-hospital mortality: a prospective cohort study. Chest 130:941–946

    Article  PubMed  Google Scholar 

  7. Jones AE, Tayal VS, Sullivan DM, Kline JA (2004) Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients. Crit Care Med 32:1703–1708

    Article  PubMed  Google Scholar 

  8. Atkinson PR, McAuley DJ, Kendall RJ, Abeyakoon O, Reid CG, Connolly J, Lewis D (2009) Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): an approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension. Emerg Med J 26:87–91

    Article  CAS  PubMed  Google Scholar 

  9. Rose JS, Bair AE, Mandavia D, Kinser DJ (2001) The UHP ultrasound protocol: a novel ultrasound approach to the empiric evaluation of the undifferentiated hypotensive patient. Am J Emerg Med 19:299–302

    Article  CAS  PubMed  Google Scholar 

  10. Perera P, Mailhot T, Riley D, Mandavia D (2010) The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am 28:29–56

    Article  PubMed  Google Scholar 

  11. Lanctot J, Valois M, Beaulieu Y (2011) EGLS: Echo-guided life support. An algorithmic approach to undifferentiated shock. Crit Ultrasound J 3:123–129

    Article  Google Scholar 

  12. Copetti R, Copetti P, Reissig A (2012) Clinical integrated ultrasound of the thorax including causes of shock in nontraumatic critically ill patients. A practical approach. Ultrasound Med Biol 38:349–359

    Article  PubMed  Google Scholar 

  13. Lichtenstein D, Karakitsos D (2012) Integrating lung ultrasound in the hemodynamic evaluation of acute circulatory failure (the fluid administration limited by lung sonography protocol). J Crit Care 27(533):e511–e519

    Google Scholar 

  14. Seif D, Perera P, Mailhot T, Riley D, Mandavia D (2012) Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol. Crit Care Res Pract 2012:503254

    PubMed  Google Scholar 

  15. Moore CL, Rose GA, Tayal VS, Sullivan DM, Arrowood JA, Kline JA (2002) Determination of left ventricular function by emergency physician echocardiography of hypotensive patients. Acad Emerg Med 9:186–193

    Article  PubMed  Google Scholar 

  16. Randazzo MR, Snoey ER, Levitt MA, Binder K (2003) Accuracy of emergency physician assessment of left ventricular ejection fraction and central venous pressure using echocardiography. Acad Emerg Med 10:973–977

    Article  PubMed  Google Scholar 

  17. Becattini C, Agnelli G, Vedovati MC, Pruszczyk P, Casazza F, Grifoni S, Salvi A, Bianchi M, Douma R, Konstantinides S, Lankeit M, Duranti M (2011) Multidetector computed tomography for acute pulmonary embolism: diagnosis and risk stratification in a single test. Eur Heart J 32:1657–1663

    Article  PubMed  Google Scholar 

  18. Steering C (2012) Single-bolus tenecteplase plus heparin compared with heparin alone for normotensive patients with acute pulmonary embolism who have evidence of right ventricular dysfunction and myocardial injury: rationale and design of the Pulmonary Embolism Thrombolysis (PEITHO) trial. Am Heart J 163(33–38):e31

    Google Scholar 

  19. Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, Jenkins JS, Kline JA, Michaels AD, Thistlethwaite P, Vedantham S, White RJ, Zierler BK (2011) Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 123:1788–1830

    Article  PubMed  Google Scholar 

  20. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, Solomon SD, Louie EK, Schiller NB (2010) Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr 23:685–713; (quiz 786–688)

    Google Scholar 

  21. Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW, Melniker L, Gargani L, Noble VE, Via G, Dean A, Tsung JW, Soldati G, Copetti R, Bouhemad B, Reissig A, Agricola E, Rouby JJ, Arbelot C, Liteplo A, Sargsyan A, Silva F, Hoppmann R, Breitkreutz R, Seibel A, Neri L, Storti E, Petrovic T, International Liaison Committee on Lung Ultrasound for International Consensus Conference on Lung Ultrasound (2012) International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 38:577–591

    Article  PubMed  Google Scholar 

  22. Volpicelli G, Mussa A, Garofalo G, Cardinale L, Casoli G, Perotto F, Fava C, Frascisco M (2006) Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome. Am J Emerg Med 24:689–696

    Article  PubMed  Google Scholar 

  23. Lichtenstein D, Meziere G, Seitz J (2009) The dynamic air bronchogram. A lung ultrasound sign of alveolar consolidation ruling out atelectasis. Chest 135:1421–1425

    Article  PubMed  Google Scholar 

  24. Lichtenstein DA, Lascols N, Meziere G, Gepner A (2004) Ultrasound diagnosis of alveolar consolidation in the critically ill. Intensive Care Med 30:276–281

    Article  PubMed  Google Scholar 

  25. Volpicelli G (2011) Sonographic diagnosis of pneumothorax. Intensive Care Med 37:224–232

    Article  PubMed  Google Scholar 

  26. Wallace DJ, Allison M, Stone MB (2010) Inferior vena cava percentage collapse during respiration is affected by the sampling location: an ultrasound study in healthy volunteers. Acad Emerg Med 17:96–99

    Article  PubMed  Google Scholar 

  27. Brennan JM, Blair JE, Goonewardena S, Ronan A, Shah D, Vasaiwala S, Kirkpatrick JN, Spencer KT (2007) Reappraisal of the use of inferior vena cava for estimating right atrial pressure. J Am Soc Echocardiogr 20:857–861

    Article  PubMed  Google Scholar 

  28. Kircher BJ, Himelman RB, Schiller NB (1990) Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. Am J Cardiol 66:493–496

    Article  CAS  PubMed  Google Scholar 

  29. Volpicelli G, Mussa A, Frascisco MF (2012) Sonographic diagnosis of pulmonary embolism with cardiac arrest without major dilation of the right ventricle or direct sign of lower limb venous thrombosis. J Clin Ultrasound 40:529–533

    Article  PubMed  Google Scholar 

  30. Scalea TM, Rodriguez A, Chiu WC, Brenneman FD, Fallon WF Jr, Kato K, McKenney MG, Nerlich ML, Ochsner MG, Yoshii H (1999) Focused Assessment with Sonography for Trauma (FAST): results from an international consensus conference. J Trauma 46:466–472

    Article  CAS  PubMed  Google Scholar 

  31. Hendrickson RG, Dean AJ, Costantino TG (2001) A novel use of ultrasound in pulseless electrical activity: the diagnosis of an acute abdominal aortic aneurysm rupture. J Emerg Med 21:141–144

    Article  CAS  PubMed  Google Scholar 

  32. Siragusa S, Anastasio R, Porta C, Falaschi F, Pirrelli S, Palmieri P, Gamba G, Granzow K, Malato A, Minardi V, Tatoni P, Bressan MA, Mariani G (2004) Deferment of objective assessment of deep vein thrombosis and pulmonary embolism without increased risk of thrombosis: a practical approach based on the pretest clinical model, D-dimer testing, and the use of low-molecular-weight heparins. Arch Intern Med 164:2477–2482

    Article  PubMed  Google Scholar 

  33. Loscalzo J, Harrison TR (2013) Harrison’s pulmonary and critical care medicine. McGraw-Hill Medical, New York

    Google Scholar 

  34. Tintinalli JE, Stapczynski JS (2011) Tintinalli’s emergency medicine: a comprehensive study guide. McGraw-Hill, New York

    Google Scholar 

  35. Berry CC (1992) The kappa statistic. JAMA 268:2513–2514

    Article  CAS  PubMed  Google Scholar 

  36. Viera AJ, Garrett JM (2005) Understanding interobserver agreement: the kappa statistic. Fam Med 37:360–363

    PubMed  Google Scholar 

  37. Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, Marshall J (2008) C.A.U.S.E.: Cardiac arrest ultra-sound exam–a better approach to managing patients in primary non-arrhythmogenic cardiac arrest. Resuscitation 76:198–206

    Article  PubMed  Google Scholar 

  38. Haydar SA, Moore ET, Higgins GL 3rd, Irish CB, Owens WB, Strout TD (2012) Effect of bedside ultrasonography on the certainty of physician clinical decision making for septic patients in the emergency department. Ann Emerg Med 60(346–358):e344

    Google Scholar 

  39. Expert Round Table on Ultrasound in ICU (2011) International expert statement on training standards for critical care ultrasonography. Intensive Care Med 37:1077–1083

    Article  Google Scholar 

Download references

Acknowledgments

The authors thank all the staff of our emergency department who worked with enthusiasm in the study.

Conflicts of interest

None.

Author information

Authors and Affiliations

  1. Department of Emergency Medicine, S.C.D.O, Medicina d’Urgenza, Ospedale Universitario San Luigi Gonzaga, Orbassano, Turin, Italy

    G. Volpicelli, A. Lamorte, M. Tullio, V. Stefanone, E. Boero & M. F. Frascisco

  2. Radiology Department, San Luigi Gonzaga University Hospital, Turin, Italy

    L. Cardinale

  3. Department of Mathematics, University of Torino, Turin, Italy

    M. Giraudo

  4. Department of Emergency Medicine, Careggi University Hospital, Florence, Italy

    P. Nazerian

  5. Cardiology Unit, San Luigi Gonzaga University Hospital, Turin, Italy

    R. Pozzi

Authors
  1. G. Volpicelli
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. A. Lamorte
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. M. Tullio
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. L. Cardinale
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. M. Giraudo
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. V. Stefanone
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. E. Boero
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. P. Nazerian
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. R. Pozzi
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. M. F. Frascisco
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to G. Volpicelli.

Additional information

Trial registry: ClinicalTrials.gov; No.: NCT01572571; URL: http://www.clinicaltrials.gov

Rights and permissions

Reprints and permissions

About this article

Cite this article

Volpicelli, G., Lamorte, A., Tullio, M. et al. Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department. Intensive Care Med 39, 1290–1298 (2013). https://doi.org/10.1007/s00134-013-2919-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00134-013-2919-7

Keywords

Search

Navigation