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Ultrasonic Evaluation of Shock in Emergency Department

Editorial | Open Access

  • 1. Physician Emergency Department, Policlinico Modena, Italy
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Corresponding Authors
Nicola Parenti , Physician Emergency Department, Policlinico Modena, Via San Vitale 96 Bologna Zip Code 40125 BO Italy
Citation

Parenti N, Luciani A (2016) Ultrasonic Evaluation of Shock in Emergency Department. Arch Emerg Med Crit Care 1(1): 1001.

EDITORIAL

A prompt and accurate diagnosis of shock in the Emergency Department (ED) could improve the outcome of patients. Ultrasound is fundamental to guide an early diagnosis and therapy [1] for several reasons: ultrasound equipment has become more available because more compact, higher quality and less expensive; it allows a very rapid assessment of the hemodynamic state of the patient, giving a rapid help to found the main causes of shock; it guides therapeutic interventions (eg fluid therapy, pericardiocentesis) and can be used serially to assess response to interventions in a “real-time” manner . For these reasons many Emergency and Intensive scientific societies have suggested to spread an early use of Ultrasound exam for the evaluation of critical patients in the ED [2-4] and have defined the competence and training standards for critical care ultrasonography [2,4-6].

However the Ultrasonography is a user-dependent technology and this could be a great limit in the management of the patient in shock .

For this reason, in the last years several authors proposed ultrasound protocols to improve the standardization of the methodology in patients with undifferentiated hypotension and shock in ED [1,4-5,7-12] .

All the ultrasound protocols actually in use are complex because they include the evaluation of many organs: heart, thorax, vessels, abdomen. However they have common characteristics : the evaluation of heart with cardiac function, pericardial, chamber size (although the valvular assessment remains absent from most protocols); the volume assessment.

The mayor ultrasound protocols for medical shock assessment in Emergency Department are shown in the Table 1.

Table 1: Comparison of major Ultrasound protocols for shock.

  Views Goal
? FOCUS Not specify Pericardial effusion
Global cardiac function
Enlargement of right and left 
ventricular chamber
Intravascular volume assessment
? RACE Parasternal long and short axis Apical four and two chamber Subcostal Left Ventricular function
Right Ventricular function
Pericardial effusion
Fluid status
¹ GDE Parasternal long and 
short axis
Apical four and two 
chamber
Subcostal
Color Doppler
Left and Right Ventricular 
function
Pericardial effusion
Septal dynamics
Valvular morphology
Fluid responsiveness
? ACES Parasternal long
Apical four chamber
Subcostal
FAST
Left and Right Ventricular size and 
contractility
Pericardial
Inferior Vena Cava max. diameter 
and caval index
Abdominal aorta
Free peritoneal, pleural and pelvic 
fluid
¹? RUSH Parasternal long and 
short
Apical four chamber
Subcostal
FAST and Thoracic US
PUMP
Pericardial effusion and Cardiac 
Tamponade
Left ventricular contractility
Right ventricular size
TANK : Volume status
Inferior vena cava and 
InternalJugularvein
FAST and Thoracic US
PIPES : Aorta and Femoral Popliteal veins
¹¹ EGLS Thoracic
Subcostal
Parasternal long and 
short
Apical
Pneumothorax ?
Tamponade ?
Hypovolemic ?
Hypotension for poor Left 
ventricular function ?
Signs of Right Ventricular strain ?
¹² FAST 
and 
RELIABLE
Parasternal long and 
short
Apical four chamber
Subcostal
FAST and Thoracic US
FAST
Right ventricular strain
Pericardial effusion
Left Ventricular function
Inferior Vena Cava, aorta, Venous 
for deep venous thrombosis
Pneumothorax
Ectopic pregnancy

The ultrasound (US) management of critical patients based on a US protocol has many advantages : it is rapid, objective and complete

Ideally before using an US protocol it should be tested for the major quality indexes: validity , reliability and feasibility.

But to our knowledge there are not reports on this topic and few studies tested the impact of this protocols on clinical practice [13,14].

In particular Jones et al in 2004 looked at the effect of a goal-direct US protocol in the management of patients with undifferentiated hypotension in ED. The authors concluded that the incorporation of a US protocol results in a more accurate physician impression of final diagnosis.

Manno et al in 2012 determined whether a US protocol can change therapy , induce further testing or interventions and confirm or modify diagnosis in one Intensive Care Unit (ICU). The researchers concluded that the US exam revealed unsuspected clinical abnormalities , modified many admitting diagnosis (26%) and confirmed it in a lot of patients (58,4%); it prompted further testing in 18% of patients, led to changes in medical therapy in 18% of cases. For these reasons it could be included as a tool of rapid global assessment of the patient on admission to improve healthcare quality. But this study has been conducted in an ICU so it could be difficult to apply its conclusions at the ED.

In fact there are not randomized controlled trials which investigate the US protocols validity in improving management of hypotensive or shock patient in ED.

Moreover there are not studies on the impact of US protocols on outcomes neither reports on the reliability among users. In our opinion this gap in the research could influence the clinical use of the previous protocols.

In particular the reliability should be test in further research because the user-dependent feature of ultrasonography. It could be interesting to check the inter-rater reliability in the centers who apply the international statements on the US training in critical care setting [2, 4-6]

Finally are the US protocols feasible in the setting of crowded ED when the Emergency Physician should visit a very large number of critical patients very rapidly ? Further research should answer this question. Although there is a study on the time needed to perform FOCUS by ultrasonographers of variable expertise [15] to our knowledge other US protocols have not been tested for this outcome.

In conclusion, in our opinion, it is the time to stop developing US protocols and to plan research on those which actually in use .

Point-of-care echocardiography using portable machines is an exciting development in emergency medicine and recent improvements in ultrasound quality mean that emergency physicians are finding echocardiography useful in a variety of clinical settings but further research should be published on the validation of the main US protocols proposed for the shock and hypotensive patient.

REFERENCES

1. Schmidt GA, Koenig S, Mayo PH. Shock: ultrasound to guide diagnosis and therapy. Chest. 2012; 142: 1042-1048.

2. American College of Emergency Physicians. Emergency ultrasound guidelines 2009.

3. Society for Academic Emergency Medicine. Ultrasound position statement. 1991.

4. Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, et al. Focused Cardiac Ultrasound in the emergent setting: a consensus statement of the American society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010; 23: 1225-1230.

5. Mayo PH, Beaulieu Y, Doelken P, Feller-Kopman D, Harrod C, Kaplan A, et al. American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest. 2009; 135: 1050-1060.

6. Cholley BP, Mayo PH, Poelaert J, Vieillard-Baron A, Vigno P, Alhamid S, et al.International expert statement on training standards for critical care ultrasonography. Intensive Care Med. 2011; 37: 1077-1083

7. McLean A, Huang S. Critical care ultrasound manual. Chatswood, Australia: Churchill Livingstone, Elsevier; 2012.

8. Repessé X, Charron C, Vieillard-Baron A. Intensive care ultrasound: V. Goal-directed echocardiography. Ann Am Thorac Soc. 2014; 11: 122- 128.

9. Atkinson PRT, Mc Auley DJ, Kendall RJ, Abeyakoon O, Reid CG, Connolly J, et al. 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 2009; 26: 87-91.

10. Perera P , Mailhot T, Riley D, Mandavia D. The RUSH exam: rapid ultrasound in Shock in the evaluation of the critically III. Emerg Med Clin North Am. 2010; 28: 29-56.

11. L anctot YF, Valois M, Bealieu Y. EGLS: Echo-guided life support. Crit Ultrasound J. 2011;3: 123-129.

12. Liteplo A, Noble V, Atkinson P. My patient has no blood pressure: point-of-care ultrasouns in the hypotensive patient – FAST and RELIABLE. Ultrasound. 2012; 20: 64-68.

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

14. Manno E, Navarra M, Faccio L, Motevallian M, Bertolaccini L, Mfochivè A, et al. Deep impact of ultrasound in the intensive care unit: the “ICUsound” protocol. Anesthesiology. 2012; 117: 801-809.

15. Beraud AS, Rizk NW, Pearl RG, Liang DH, Patterson AJ. Focused transthoracic echocardiography during critical care medicine training: curriculum implementation and evaluation of proficiency. Crit Care Med 2013; 41 : e179-e181

Parenti N, Luciani A (2016) Ultrasonic Evaluation of Shock in Emergency Department. Arch Emerg Med Crit Care 1(1): 1001.

Received : 11 May 2016
Accepted : 12 May 2016
Published : 12 May 2016
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