Abstract
IntroductionPatients that present to the emergency department (ED) with undifferentiated hypotension have a high mortality rate. Hypotension can be divided into four categories: obstructive, hypovolemic, distributive, and cardiogenic. While it is possible to have overlapping or concomitant shock states, being able to differentiate between cardiogenic shock and the other categories is important as it entails a different treatment regime and extra cautions. In this secondary analysis, we investigate if using focused cardiac ultrasonography (FOCUS) to determine left ventricular dysfunction (LVD) can serve as a reliable test for cardiogenic shock.MethodsWe prospectively collected FOCUS findings performed in 135 ED patients with undifferentiated hypotension as part of an international study. Patients with clearly identified etiologies for hypotension were excluded, along with other specific presumptive diagnoses. LVD was defined as the identification of a generally hypodynamic left ventricle in the setting of shock. FOCUS findings were collected using a standardized protocol and data collection form. All scans were performed by emergency physicians trained in ultrasound. Final shock type was defined as cardiogenic or noncardiogenic by independent specialist blinded chart review.ResultsIn our findings, 135 patients had complete records for assessment of left ventricular function and additional follow-up data and so were included in this secondary analysis. The median age was 56 years and 53% of patients were male. Disease prevalence for cardiogenic shock was 12% and the mortality rate was 24%. The presence of LVD on FOCUS had a sensitivity of 62.50% (95% confidence interval 35.43% to 84.80%), specificity of 94.12% (88.26% to 97.60%), positive likelihood ratio (LR) 10.62 (4.71 to 23.95), negative LR 0.40 (0.21 to 0.75) and accuracy of 90.37% (84.10% to 94.77%) for detecting cardiogenic shock.ConclusionDetecting left ventricular dysfunction on FOCUS may be useful in the early identification of cardiogenic shock in otherwise undifferentiated hypotensive adult patients in the emergency department.
Highlights
Patients that present to the emergency department (ED) with undifferentiated hypotension have a high mortality rate
The presence of left ventricular dysfunction (LVD) on focused cardiac ultrasonography (FOCUS) had a sensitivity of 62.50% (95% confidence interval 35.43% to 84.80%), specificity of 94.12% (88.26% to 97.60%), positive likelihood ratio (LR) 10.62 (4.71 to 23.95), negative LR 0.40 (0.21 to 0.75) and accuracy of 90.37% (84.10% to 94.77%) for detecting cardiogenic shock
Patients with clearly identified etiologies for hypotension were excluded from the study, along with other specific presumptive diagnoses including patients with ectopic pregnancy or aortic aneurysm, evidence of differentiated hypotension as indicated by cardiopulmonary resuscitation (CPR) or other advanced cardiac life support interventions; a history of significant recent trauma; acute myocardial infarction (AMI); another clear mechanism or etiology for the hypotension or shock such as gastrointestinal bleeding
Summary
Patients that present to the emergency department (ED) with undifferentiated hypotension have a high mortality rate. Hypotension can be divided into four categories: obstructive, hypovolemic, distributive, and cardiogenic. While it is possible to have overlapping or concomitant shock states, being able to differentiate between cardiogenic shock and the other categories is important as it entails a different treatment regime and extra cautions. In this secondary analysis, we investigate if using focused cardiac ultrasonography (FOCUS) to determine left ventricular dysfunction (LVD) can serve as a reliable test for cardiogenic shock. Received 06/14/2021 Review began 06/14/2021 Review ended 06/22/2021 Published 07/13/2021
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