Abstract
Early identification of the shock type and correct diagnosis is associated with better outcomes. Previous studies have suggested that point-of-care ultrasound (POCUS) increases the diagnostic accuracy of patients in undifferentiated shock. However, a complete overview of the diagnostic accuracy of POCUS and the related treatment changes when compared to standard care is still limited. Our objective was to compare POCUS against standard practice regarding the diagnostic accuracy and specific therapeutic management changes (fluid volume administration and vasopressor use) in patients with undifferentiated shock in the emergency department (ED).We conducted a systematic review in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. A systematic search was performed using Embase, PubMed, Cochrane Central Register for Controlled Trials, and clinicaltrials.gov. Two physicians independently selected the articles and assessed the quality of the studies independently with the Quadas-2 tool. All included studies used POCUS in adult patients in undifferentiated shock and described diagnostic accuracy or specific therapeutic management changes (fluid volume administration or vasopressor use) and compared this to standard care. The primary outcome was diagnostic accuracy. Secondary outcomes were the amount of fluid administered and vasopressor use in the ED. Only articles published after 1996 were included.There were 10,805 articles found of which 6 articles were included. Four out of six studies reported diagnostic accuracy, three reported on fluid administration and vasopressors. We found that the diagnostic accuracy improved through the use of POCUS when compared to the standard care group, increasing overall diagnostic accuracy from 45-60% to 80-89% when combined with clinical information. There was no significant difference in fluid administration or vasopressor use between the groups.In our systematic review, we found that the use of POCUS in patients that presented with undifferentiated shock in the ED improved the diagnostic accuracy of the shock type and final diagnosis. POCUS resulted in no changes in fluid administration or vasopressor use when compared to standard care. However, the results should be interpreted within the limitations of some of the studies that were included in the review.
Highlights
BackgroundShock represents 0.4% to 1.3% of all emergency department (ED) presentations and up to one-third of all intensive care unit (ICU) admissions [1-3]
We found that the use of point-of-care ultrasound (POCUS) in patients that presented with undifferentiated shock in the ED improved the diagnostic accuracy of the shock type and final diagnosis
This systematic review demonstrates that POCUS improved the diagnostic accuracy of the underlying shock type in patients presenting with undifferentiated shock in the ED, compared to when clinical assessment without POCUS was used
Summary
Shock represents 0.4% to 1.3% of all emergency department (ED) presentations and up to one-third of all intensive care unit (ICU) admissions [1-3]. It is associated with high morbidity and in-hospital mortality of up to 48% [1,4-6]. Recognition by the use of shock alerting systems has been shown to decrease mortality. It seems reasonable to assume that rapid and accurate detection of the cause of shock has the potential to improve patient outcomes further [7]. While physical examination alone is unreliable to accurately determine the correct cause of hypotension [8,9], evidence suggests that point-of-care ultrasound (POCUS) has the potential to obtain good diagnostic accuracy in patients with hypotension in the ED [10,11].
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