Ultrasound in Undifferentiated Hypotension

Focused Multiorgan Ultrasound in the Emergency Evaluation of Undifferentiated Hypotension

Background

• Symptomatic undifferentiated hypotension represents a negative prognostic factor and the strongest predictor of in-hospital mortality.
• Misdiagnosis may lead to delayed or incorrect treatment of some life-threatening conditions.

Aim

- The aim of the study is to evaluate the feasibility and accuracy of a new bedside ultrasound method that consists in the focused imaging of the thorax, abdomen and leg veins, in emergency.

Methods

• Hypotensive (<100 mm/Hg) patients presenting to our emergency department, complaining of at least one of the neurologic, respiratory and cutaneous signs and symptoms of inadequate tissue perfusion, are prospectively studied by ultrasound-focused assessment of the heart, lungs, inferior vena cava, peritoneum, aorta and leg deep veins.
• On the basis of physical examination and ultrasound results, the operator declares the diagnostic hypothesis without influencing the attending physician and the following diagnostic procedure (which includes ultrasound, when needed).
• The diagnostic hypothesis is compared with the final diagnosis, obtained after the hospital route and discussed by a panel of three blinded experts (one radiologist, one cardiologist and one emergency physician).
• The statistical agreement is calculated by the k of Cohen with p-value, confidence intervals and raw agreement (Ra).

Inclusion Criteria:

• Arterial pressure <100 mm/Hg at presentation
• At least one of the following symptoms:
• Unresponsive
• Syncope
• Impaired mental status
• Respiratory distress
• Severe malaise and fatigue

Exclusion Criteria:

• Patients undergoing cardiopulmonary resuscitation
• Trauma patients
• Electrocardiographic and clinical diagnosis of STEMI or NSTEMI
• Clear cause of shock that needs immediate intervention (hemorrhage, gastrointestinal bleeding, drugs overdose)
• Late evolution of shock state in a patient already treated with known diagnostic tests