Undifferentiated Shock Research Articles

Gastric ultrasound-assisted diagnosis of undifferentiated shock

Rationale: Peptic ulcer disease and variceal bleeding are two of the most common causes of gastrointestinal (GI) bleeding. GI bleeding can present with symptoms of hemodynamic instability such as tachycardia and shock. Patient’s Concern: A 33-year-old man with confusion and hypotension (blood pressure: 70/40 mmHg and pulse rate: 140/min) was brought by emergency medical services from home to the emergency department without any companion. The patient was in undifferentiated shock. His hypotension was assessed with inferior vena cava (IVC) size and collapsibility, and rapid ultrasound in shock and hypotension (RUSH) protocol was used to investigate the cause of his shock. Following the RUSH protocol when scanning the IVC, parts of the stomach were seen in its vicinity and suspended heterogeneous particles were observed in the fluid. After seeing these particles, we suspected GI bleeding. Diagnosis: Endoscopy confirmed GI bleeding. Interventions: After placing an orogastric tube and suction, about 2 L of coffee-ground fluid with clots was removed. We started intravenous proton-pump inhibitors 80 mg bolus, followed by a continuous infusion of 8 mg/h. The patient received about 2 L of normal saline and 2 units of packed red blood cells to correct his hypotension. Outcomes: After being admitted to the GI ward and treated for three days, the patient was discharged from the hospital with a hemoglobin level of 11 g/dL and continued to have an outpatient follow-up at the clinic. Lessons: The use of gastric ultrasound in conjunction with the RUSH protocol can help to diagnose undifferentiated hypotensive shock. The components of the RUSH exam are the heart (H), IVC (I), Morrison’s/FAST abdominal views with the aorta (MA), and pulmonary and pipes scanning (P), and can be memorized with the mnemonic: HI-MAP. We would like to introduce a new mnemonic: Hi-MAPS, adding stomach (S) to the RUSH protocol in undifferentiated hypotension and shock to evaluate upper GI bleeding.

Point-of-care ultrasound use in emergencies: what every anaesthetist should know.

Point-of-care ultrasound has been embraced by anaesthetists as an invaluable tool for rapid diagnosis of haemodynamic instability, to ensure procedural safety and monitor response to treatments. Increasingly available, affordable and portable, with emerging evidence of improved patient outcomes, point-of-care ultrasound has become a valuable tool in the emergency setting. This state-of-the-art review describes the feasibility of point-of-care ultrasound practice, training and maintenance of competence. It also describes the many uses of point-of-care ultrasound for the anaesthetist and describes the most salient point-of-care ultrasound views for anaesthetic emergencies including: undifferentiated shock; hypoxemia; and trauma. Procedural safety is also discussed in addition to relevant important governance aspects. Cardiac function should be assessed using the parasternal long axis, parasternal short basal/mid-papillary/apical, apical four chamber and subcostal four chamber views, and should include a visual estimation of global left ventricular ejection fraction. Other cardiovascular conditions that can be identified using point-of-care ultrasound include: pericardial effusion; cardiac tamponade; and pulmonary embolism. Pulmonary emergency conditions that can be diagnosed using point-of-care ultrasound include pneumothorax; pleural effusion; and interstitial syndrome. The extended focused assessment with sonography for trauma examination may of value in patients who are hypotensive in order to identify intra-abdominal haemorrhage, pneumothoraces and haemothoraces.

Abstract 11593: The Critical Role of Transthoracic Echocardiography in the Evaluation of Cardiogenic Shock and Takotsubo Cardiomyopathy

Introduction: Cardiogenic shock occurs in 10% of patients with takotsubo cardiomyopathy (TTC) as a result of severe systolic dysfunction, or left ventricular outflow tract (LVOT) obstruction. Methods: Case report and review of the literature. Results: A 62-year-old female with a history of hypertension and diabetes mellitus presented with lightheadedness, shortness of breath, and chest discomfort. She was hemodynamically unstable, tachycardic, and hypotensive (70/40 mmHg). Her EKG showed sinus tachycardia at 101 BPM with 1 mm ST depression in leads II, III, AVF; V3-V6. Chest radiograph revealed pulmonary edema. High-sensitive troponin was 146.7. She was intubated for respiratory distress and had rapidly increasing vasopressor requirements. Emergent coronary angiography revealed nonobstructive coronary artery disease. A left ventriculogram revealed apical ballooning with an estimated ejection fraction of 25%, consistent with TTC. Transthoracic echocardiogram (TTE) showed severe mid and apical LV hypokinesis with basal hyperkinesis. Additionally, systolic anterior motion (SAM) of the mitral valve (MV) was noted, with a peak LVOT gradient of 7 mmHg. The patient improved clinically, and all support was weaned off. However, she later acutely developed recurrent respiratory distress and hypotension. Repeat TTE showed LVOT obstruction with a gradient of 40 mmHg due to increased basal hyperkinesis and SAM. The choice of vasopressor was switched from norepinephrine to phenylephrine to reduce the obstruction. She clinically improved and metoprolol succinate was added to reduce basal hypercontractility and improve left ventricular filling. Conclusions: Differentiating the mechanism of shock in TTC can easily be accomplished with TTE, and is essential to guiding treatment. The initial acute systolic dysfunction was effectively managed with norepinephrine, dopamine, and an intra-aortic balloon pump. She later developed LVOT obstruction as her systolic function improved. This was recognized with TTE and led to an appropriate change in vasopressor, as norepinephrine would have worsened the obstruction. This highlights the importance of early TTE in patients presenting with undifferentiated shock, especially when TTC is suspected.

Abstract 11476: The Clot Thickens: Massive Left Ventricular Thrombus After Sub-Acute Myocardial Infarction

Introduction: Left ventricular thrombus (LVT) following myocardial infarction (MI) can affect up to 19.2% of patients with anterior wall MI. The mechanism is thought to be due to stasis from LV regional wall akinesia, endothelial injury from prolonged ischemia, and hypercoagulability from acute coronary syndrome. In patients with LVT after MI, anticoagulation choice and duration is still a matter of debate. Case Report: A 51-year-old woman with diabetes and prior anterior wall MI with LVT presented with non-healing diabetic leg wounds. One year ago at the time of the MI, transthoracic echocardiogram (TTE) showed a 4.0 x 1.3 cm mural thrombus. She was discharged on prasugrel and apixaban. Apixaban was discontinued after five months, with follow-up TTE showing resolution of LVT, with 30% LV ejection fraction and evidence of LV remodeling. This hospitalization, while awaiting discharge, the patient developed sudden undifferentiated shock requiring norepinephrine and dobutamine. Repeat TTE revealed a 6.0 x 5.5 cm apical LVT filling more than 50% of the LV cavity, with unchanged LV ejection fraction. Heparin drip was started. Prior to evaluation by cardiothoracic surgery, patient became acutely unresponsive, had a cardiac arrest, and expired. Cause of death suspected to be due to cardioembolic events, worsened with mixed shock and low-output heart failure from LVT. Discussion: Management of LVT after MI remains unclear. Current guidelines indicate treatment with vitamin K antagonist (VKA) for at least 3 - 6 months, and consideration of prophylactic anticoagulation with VKA for patients with apical dyskinesis after MI. Retrospectively, this patient may have benefitted from a prolonged course of anticoagulation given the extent of LV remodeling five months after initial event despite resolution of LVT. Anticoagulation must be evaluated on a case-by-case basis weighing propensity of thrombotic events with risk of bleeding.

SYSTEMIC MASTOCYTOSIS PRESENTING WITH KOUNIS SYNDROME AND REFRACTORY SHOCK

<h3>Introduction</h3> Systemic mastocytosis (SM) can rarely present in the setting of refractory shock and/or coronary artery vasospasm triggered by mast cell activation, also known as Kounis Syndrome. <h3>Case Description</h3> A 30-year-old male with a history of urticaria pigmentosa (lost to follow up as an adolescent) and unexplained syncopal episodes was found unconscious at home. Upon EMS arrival, he was hypotensive and severely hypoxemic prompting intubation. The patient required epinephrine, norepinephrine, and vasopression to maintain normotension. Skin exam was notable for diffusely distributed small monomorphic brown macules sparing the face, palms, and soles. In the ED, initial EKGs showed ST segment elevations in leads II, III, aVF and reciprocal ST segment depressions in V4-V6. He underwent emergent left heart catheterization which lacked evidence of coronary artery disease. Unexpectedly, troponins were negative and abnormal EKG findings resolved without intervention. Extensive infectious workup was also negative. Allergy was then consulted given suspicion for undiagnosed SM. Workup revealed an elevated serum tryptase of 77.6 ng/mL, positive KIT D816V mutation, and a bone marrow biopsy demonstrating atypical aggregates of mast cells (≥15 mast cells). He was diagnosed with aggressive SM; undifferentiated shock resolved following treatment with cladribine followed by midostaurin. <h3>Discussion</h3> This case describes a patient who presented with an excessive burden of mast cell degranulation leading to persistent shock and a rare phenomenon known as Kounis Syndrome. Undiagnosed aggressive SM can masquerade as sepsis or cardiogenic shock as the initial presentation potentially leading to increased morbidity and mortality.

A Multifaceted Educational Design Approach to Critical Care Rotation Improves Learner Confidence and Knowledge.

Purpose: We developed a pilot elective to enhance the critical care training experience for medical students through integration of didactic, simulation, and experiential learning with the goal to increase student confidence in caring for patients with critical illness and advance knowledge and competencies within core critical care topics. Approach: We created and piloted a 4-week critical care elective for fourth-year medical students pairing clinical experience with didactic and simulation-based training. Students completed two 2-week intensive care unit (ICU) rotations in both medical and surgical ICUs. Students received 6 half-days of didactics focusing on: respiratory failure, ventilator management, shock, acid/base, and discussions at the end of life. Didactic sessions were coupled with simulation-based training to reinforce content through application and provide opportunity to build procedural skills. Medical knowledge was assessed via multiple-choice questions delivered before and after course completion. Course grades were determined through clinical evaluations by faculty/residents, written examination, and simulation assessment. Pre- and postknowledge assessment performance was compared between students enrolled in the pilot and traditional curricula. The traditional curriculum involved clinical experience without formal didactics or simulation opportunities, and course grades were determined by evaluations only. Outcomes: No students received passing scores of 70% on the precourse medical assessment in either curriculum group. The mean score on the postcourse knowledge assessment for the novel-curriculum students (N = 13) was 21.8/30 (72.8%), compared with the 17/30 (56%) for the students in the traditional curriculum (N = 6). No students in the traditional curriculum received a passing score on the postcourse assessment. Before the course, few students felt “comfortable” or “very comfortable” managing common ICU conditions (acute respiratory distress syndrome, 0%; undifferentiated shock, acute hypercarbic respiratory failure, and identifying need for mechanical ventilation, 33%; acute hypoxemic respiratory failure and cardiogenic shock, 50%; septic and hypovolemic shock, 83%). At completion, there was an improvement in the reported level of comfort; 100% of students reported feeling “comfortable” or “very comfortable” with all topics, save for cardiogenic shock at 83%. Comfortability levels remained high on subsequent evaluation 12 months post-course (6 months into trainee’s intern year). Discussion: A limitation of traditional critical care curricula is that it lacks structure designed to ensure exposure to core critical care topics. It relies on the randomness of patient’s disease states present during a given rotation. Incorporating scheduled didactics ensures consistent exposure to these topics regardless of the patient cases on service. A limitation of this study is the small sample size of both the novel-curriculum group and the percentage of traditional curriculum students undergoing written assessment. Despite the small sample size (N = 13), this pilot demonstrates feasibility of consistent delivery of core content via didactics and simulation coupled with experiential learning. Our results may suggest benefit in this multimodal approach compared with experiential learning alone; however, further research is needed. Traditional assessment relies solely on clinical impression which is biased and often fails to capture an actionable level of detail. Lack of objective measures of assessment impedes identification of areas for improvement at the trainee level as well as within a curriculum. The use of multiple methods of assessment allows for mitigation of bias and overcomes some of the limitations of a single method alone. 1 Simulation assessment allows for greater practical assessment of procedural competency than written assessment. Significance: With this novel pilot curriculum incorporating multiple educational strategies, students improved their confidence and knowledge in core critical care topics. By harnessing didactic and simulation training to complement the clinical experience, consistent delivery of core content is assured. Furthermore, evaluation is strengthened through use of knowledge assessment questions and simulation-based assessment as compared with traditional evaluations which are largely subjective. More research is needed to understand the impact when scaled to a larger group.

CT signs of hypovolemic shock complex in patients with non-traumatic shock.

To assess the frequency of hypovolemic shock complex (HSC) signs on CT in patients who presented to the emergency department (ED) with undifferentiated non-traumatic shock. Secondary aim was to assess the correlation between HSC signs and all-cause mortality. This retrospective, single-center study included 100 patients who underwent contrast-enhanced thoraco-abdominal CT in the ED to evaluate the etiology for non-traumatic undifferentiated shock. All patients were retrospectively assigned a shock subtype (i.e., distributive, cardiogenic, hypovolemic, obstructive, multifactorial, and unknown) based on medical records. Patients' demographics and time to all-cause mortality up to 90days were collected. All CT studies were re-assessed for the presence of HSC signs. Correlation between HSC signs, mortality and shock subtype was assessed. Overall, 58% (58/100) of all patients had at least one HSC sign. Flattened inferior vena cava and adrenal hyper-enhancement were the most common HSC signs (27.3%, 27/99; in both). Overall mortality was 59% (59/100). When evaluated separately, shock liver was the only HSC sign to significantly correlate with increased mortality (84.6% vs. 55.2%, p = .04). However, patients with at least two HSC signs had a significantly higher mortality rate compared to patients without any HSC signs (73.5% vs. 45.2%, p = .017). Most patients with non-traumatic shock had at least one HSC sign. Mortality rates were significantly higher in patients with two or more HSC signs compared to patients without any signs. Patients with shock liver sign had significantly higher mortality rates.

S3058 Kratom Induced Acute Liver Injury: A Case Study and Systematic Review of Liver Injury Patterns Due to Kratom

Introduction: Kratom is an herbal supplement derived from the Mitragyna speciosa tree leaves in Southeast Asia. It is currently banned in only 6 states, regulated in 8, and completely unregulated in the rest (Figure 1). Kratom is popular for its psychotropic and opioid-like activity. In addition to other side effects, it is associated with acute liver injury and in rare cases, acute liver failure. Here, we report a patient who presented with cholestatic liver injury after Kratom use. We compare this case to 53 other reports of Kratom-associated hepatotoxicity to better understand the safety of this drug. Case Description/Methods: A 47-year-old male with a history of peripheral neuropathy and hypertension presented with 15 lbs of unintentional weight loss over a month and jaundice for 5 days. For at least three weeks, he had taken Kratom for neuropathy and hip pain. Labs were notable for cholestatic injury with an R factor of 1.8 and a urine drug screen positive for tetrahydrocannabinol and benzodiazepines (Table 1). Other workups including HIV, acetaminophen, and hepatitis labs were negative. He improved with supportive care and was advised to discontinue Kratom. After discharge, the patient reported complete resolution of his symptoms. A literature search in PubMed, Cochrane, and Embase found 69 cases of Kratom-induced DILI. We excluded cases without laboratory values, leaving 53 cases. A majority of Kratom users report taking the drug for acute or chronic pain. Males were predominant (64%) and the majority had a cholestatic liver injury pattern (80%). Unfortunately, 5.6% of these cases resulted in liver transplants. Furthermore, 9.4% of these cases experienced acute renal injury, with 60% requiring hemodialysis. Some patients also experienced rhabdomyolysis (3.7%), reversible heart failure (3.7%), acute cholecystitis (3.7%), and undifferentiated shock (1.9%). One patient suffered from Salmonella-contaminated Kratom ingestion. (Figure) Discussion: Kratom is widely available throughout the United States with very minimal regulation. After a review of our patient’s case report, as well as those of 53 other patients, we have significant safety concerns for the use of Kratom in the general population. Caution is advised in patients with pre-existing liver disease. Though its chemical properties may have interesting applications worthy of investigation, we recommend further research on the risks and mechanism of liver injury of Kratom.Figure 1.: A map of the United States and locations of Kratom restrictions as of 2022. California: Kratom is legal, except in San Diego and Oceanside; Colorado: Kratom is legal, except in the towns of Monument and Parker; Florida: Kratom is legal, except in Sarasota country; Illinois: Kratom is legal for adults 18 years and older, except in Jerseyville and Alton; Mississippi: Kratom is legal, except in several counties; New Hampshire: Kratom is legal, except in Franklin city; North Carolina: Kratom is legal for adults 18 years and older; Tennesee: Kratom is legal for adults 21 and older. Table 1. - Laboratory test results Variable (normal range) Day of admission Day of discharge Bilirubin, Total mg/dL (0.0-1.2) 10.7 5.0 Bilirubin, Direct mg/dL (< = 0.5) 6.7 AST U/L (8-34) 64 53 ALT U/L (10-49) 168 87 Alk-Phos U/L (46-116) 265 279 GGT U/L (12-64) 376 INR (0.80-1.2) 1.04 Prothrombin time (9.3-12.4 seconds) 10.9 Lipase U/L (< 78) 36 CA 19-9 U/mL < 5.30 Acetaminophen ug/mL (0.0-10.0) 5.6 Ferritin ng/mL (11.0-307.0) 410.2 Iron ug/dL (65-175) 140 Ceruloplasmin mg/dL (16.0-31.0) 31.3 Copper ug/dL (72-166) 120 Antinuclear Antibody Negative Smooth Muscle Antibody U (0-19) 20 Anti-Mitochondrial Antibody units (0.0-20.0) < 20.0 Alpha-1 Antitrypsin mg/dL (90.0-200.0) 186.0 AST, aspartate transaminase; ALT, alanine transaminase; Alk-Phos, alkaline phosphatase; INR, International Normalization Ratio; aPTT, activated partial thromboplastin; GGT, Gamma-Glutamyl Transferase.

THIRD bedside ultrasound protocol for rapid diagnosis of undifferentiated shock: a prospective observational study.

It is clinically challenging to differentiate the pathophysiological types of shock in emergency situations. Here, we evaluated the ability of a novel bedside ultrasound protocol (Tamponade/tension pneumothorax, Heart, Inferior vena cava, Respiratory system, Deep venous thrombosis/aorta dissection [THIRD]) to predict types of shock in the emergency department. An emergency physician performed the THIRD protocol on all patients with shock who were admitted to the emergency department. All patients were closely followed to determine their final clinical diagnoses. The kappa index, sensitivity, specificity, positive predictive value, and negative predictive value were calculated for the initial diagnostic impression provided by the THIRD protocol, compared with each patient's final diagnosis. In total, 112 patients were enrolled in this study. The kappa index between initial impression and final diagnosis was 0.81 (95% confidence interval=0.73-0.89; P<0.001). For hypovolaemic, cardiogenic, distributive, and obstructive types of shock, the sensitivities of the THIRD protocol were 100%, 100%, 93%, and 100%, respectively; the sensitivity for a 'mixed' shock aetiology was 86%. The negative predictive value of the THIRD protocol for all five types of shock was ≥96%. Initial diagnostic judgements determined using the THIRD protocol showed favourable agreement with the final diagnosis in patients who presented with undifferentiated shock. The THIRD protocol has great potential for use as a bedside approach that can guide the rapid management of undifferentiated shock in emergency settings, particularly for patients with obstructive, hypovolaemic, or cardiogenic shock.

172 The Impact of Resuscitative Transesophageal Echocardiography Performed by Emergency Physicians on Diagnosis and Management of Critically Ill Patients

Transesophageal echocardiography (TEE) is an emerging tool that can aid emergency physicians in treating patients in cardiac arrest and undifferentiated shock. TEE can aid in diagnosis, resuscitation, identify cardiac rhythms, guide chest compression vectors, and shorten sonographic pulse checks. The objective of this study is to evaluate proportion of patients who underwent a change in their resuscitation management as a result of emergency department resuscitative TEE.

38 Resuscitative TEE Collaborative Registry: Development and Implementation of a Multicenter Registry for Focused Transesophageal Echocardiography (TEE) in the Emergency Department and Intensive Care Settings

38 Resuscitative TEE Collaborative Registry: Development and Implementation of a Multicenter Registry for Focused Transesophageal Echocardiography (TEE) in the Emergency Department and Intensive Care Settings

Perceptions and Barriers to Administering Vasopressors in the Prehospital Setting.

Introduction Vasopressor administration is a critical medical intervention for patients with hypotension in undifferentiated shock states. Over the years, prehospital care has advanced with protocols and training that allow paramedics in the field to administer a variety of vasopressors. The primary objective of this investigation was to evaluate vasopressor experience among paramedics with regardto preference as well as the barriers to its preparation and administration. Methods A cross-sectional survey of vasopressor use by nationally certified paramedics (NRPs) was performed. A 20-item questionnaire was constructed to capture the prehospital perceptions and barriers of dopamine infusion, norepinephrine infusion, and IV bolus "push-dose" epinephrine (PD-E). Data collection was carried out from June to September 2021. Results A total of 44 responses were obtained (response rate = 44%). All participants had experience using vasopressors and understood their medical indications. Overall, PD-E was the most common vasopressor used in the prehospital setting, and participants felt equally confident in "using" and "preparing" it. Participants felt less confident with "using" and "preparing" vasopressors that required channel setup and maintaining a flow rate. Younger paramedics with less than five years of experience were more eager to use norepinephrine if trucks were stocked with pre-mixed norepinephrine rather than the current formulation that required compounding. Conclusion This study provided preliminary data that evaluated perceptions of vasopressor use in the prehospital setting among paramedics in a large urban environment. Preference and barriers to its preparation and administration were surveyed. Further research is needed to identify the interventions to reduce barriers and allow paramedics to be less limited by logistical considerations when choosing vasopressors in the prehospital setting.

Assessment of volume responsiveness by ultrasound parameters of carotid blood flow in patients with cardiogenic shock

Introduction There is no noninvasive method that can reliably and accurately identify fluid responsiveness. As such, in patients with undifferentiated shock, treatment often involves empiric fluid administration, in the hope that volume expansion will increase preload, which will then serve to increase cardiac output. However, for patients on the flat portion of the Starling curve, aggressive fluid administration results in no appreciable increase in cardiac output and may be detrimental to hemodynamically unstable patients. Objective The aim of this study was to compare the sensitivity and specificity of cardiac output measurement using bedside ultrasound on carotid artery and Transthoracic Echocardiogram(TTE) while assessing volume responsiveness in cardiogenic shock patients. Patients and methods In this prospective observational study, 40 cardiogenic shock patients were enrolled. Carotid artery Doppler ultrasound was performed where carotid blood flow (CBF) was calculated and TTE where cardiac output was calculated before and after passive leg-raising test to assess volume responsiveness. Results CBF measurements in comparison with cardiac output for assessment of fluid responsiveness had a sensitivity of 83.33% and specificity of 100%. Conclusion Carotid Doppler ultrasound and calculation of CBF is a reliable predictor to fluid responsiveness in patients with cardiogenic shock where transthoracic echocardiography is the gold standard in dynamic monitoring of the change in stroke volume after a maneuver that increases venous return (preload).

Accuracy of echocardiography and ultrasound protocol to identify shock etiology in emergency department

BackgroundEarly diagnosis and appropriate management of shock aimed at prevention of prolonged hypoperfusion has shown to decrease morbidity and mortality in patients with undifferentiated shock. However, there is often a challenge in emergency department (ED) – where diagnosis is mainly based on clinical signs and standard monitoring parameters. Early use of point of care ultrasound could reduce the diagnostic time and improve diagnostic accuracy.PurposeThe aim of this study is to investigate the accuracy of echocardiography - ultrasound protocol to identify the cause of shock in ED.MethodThe study was conducted on 150 shocked patients admitted to emergency department of Alexandria Main University Hospital from December 2018 to December 2020. The study was conducted to reach initial impression about shock etiology which was then compared to final diagnosis to determine accuracy, agreement, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).ResultsOne hundred forty patients were included in the study (10 patients were excluded). The protocol was 100% accurate for diagnosing cases with obstructive and mixed obstructive distributive shock. It showed excellent rule- out characteristics for cardiogenic shock (sensitivity and NPV = 100%). There was almost perfect agreement between provisional and final shock type for mixed distributive cardiogenic shock (kappa 0.915). Echo- US protocol had lowest agreement and PPV for patients with hypovolemic shock Kappa 0.48 and 35% respectively.ConclusionThe Echo- US protocol showed a high accuracy in identifying shock etiology in ED and is likely a promising diagnostic tool in emergency care.

MASSIVE PULMONARY EMBOLISM IN COVID-19 PNEUMONIA DIAGNOSED WITH POCUS

TYPE: Case Report TOPIC: Cardiovascular Disease INTRODUCTION: COVID19 patients have been known to be prone to systemic thromboembolism, and about 25% of COVID19 cases of pulmonary embolism (PE) have been reported. PE in these patients may be just the most prominent manifestation of the thrombophillic state of COVID19. CASE PRESENTATION: A 50 y/o male transferred from another facility where he was admitted for COVID pneumonia. His course there was complicated by worsening hypoxiemia requiring intubation. Shortly after arrival to our ICU, he decompensated. Initial resuscitation attempts were successful, but he progressed to refractory shock despite three (3) vasopressors and became persistently hypoxiemic. Focused US: severely hypokinetic and dilated right ventricle (RV) with flattening and deviation of the interventricular septum (IVS) towards the left ventricle (LV)—McConnell’s sign. IV resuscitation medications were seen swirling around the RV, with no forward flow. He received thrombolytic therapy, with the interventricular septum (IVS) returning to neutral position. He had additional episodes of arrest and died. DISCUSSION: The significance and role of POCUS was not explored in the diagnosis of PE in COVID19 pneumonia patients. McConnell’s sign is a specific clinical indicator of pulmonary embolism and can be assessed with bedside ultrasonography, which is now, an increasingly available diagnostic modality that can prove to be very effective in early assessment of cardiovascular function. CONCLUSIONS: This case highlights the importance of POCUS for the diagnosis and management of undifferentiated shock and PE in COVID19 patients. DISCLOSURE: Nothing to declare. KEYWORD: covid pulmonary embolism ultrasound

The use of contrast enhanced thoraco-abdominal CT in patients with non-traumatic undifferentiated hemodynamic shock

ObjectiveTo assess the role of thoraco-abdominal computed tomography (CT) in patients with undifferentiated shock in the emergency department (ED). Secondary aim was to assess common etiologies for undifferentiated shock. MethodsThis was a single-center, retrospective study evaluating patients with undifferentiated shock who underwent a dedicated “shock protocol” CT in the ED. CT included a non-contrast thoraco-abdominal scan followed by arterial thoraco-abdominal and abdominal portal phases. Patients' clinical records, laboratory, imaging data and all-cause 90-days mortality were collected. Patients’ shock category (i.e., distributive, cardiogenic, hypovolemic, obstructive, multifactorial, and unknown) and etiology for shock were retrospectively determined based on patients’ medical records. Effect of CT on patients' diagnosis and management was assessed based on physicians' reports before and after CT. ResultsOverall, 102 patients were scanned between December 2018 and December 2020. Distributive shock was the most prevalent type with 47.1% of all patients (48/102), followed by hypovolemic shock (17/102, 16.7%). Based on clinical data and CT reports, shock etiology was diagnosed for 89.2% (91/102) patients. Sepsis was the most common etiology in 50% of patients, followed by non-traumatic hemorrhage (15/102, 14.7%). Overall, 90-day mortality was 58.8%. Shock protocol CT led to change in differential diagnosis in 49% of patients and to change in management in 42.2%. ConclusionContrast-enhanced shock protocol CT can help in shock differentiation, assessment of etiology and in management of patients presenting to the ED with undifferentiated shock.

A Systemic Review on the Diagnostic Accuracy of Point-of-Care Ultrasound in Patients With Undifferentiated Shock in the Emergency Department.

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.

Shock Management Without Formal Fluid Responsiveness Assessment: A Retrospective Analysis of Fluid Responsiveness and Its Outcomes.

In order to quantify fluid administration and evaluate the clinical consequences of conservative fluid management without hemodynamic monitoring in undifferentiated shock, we analyzed previously collected data from a study of carotid Doppler monitoring as a predictor of fluid responsiveness (FR). This study was a retrospective analysis of data collected from a single tertiary academic center from a previous study. Seventy-four patients were included for post-hoc analysis, and 52 of them were identified as fluid responsive (cardiac output increase > 10% with passive leg raise) according to NICOMTM bioreactance monitoring (Cheetah Medical, Newton Center, MA, USA). Treating teams provided standard of care conservative fluid resuscitation but were blinded to independently performed FR testing results. Outcomes were compared between fluid responsive and fluid non-responsive patients. Primary outcome measures were volume fluids administered and net fluid balance 24- and 72-hour post-FR assessment. Secondary outcome measures included change in vasopressor requirements, mean peak lactate levels, length of hospital/intensive care unit stay, acute respiratory failure, hemodialysis requirement, and durations of vasopressors and mechanical ventilation. Mean fluids administered within 72 hours were similar between fluid non-responsive and fluid responsive patients (139 mL/kg [95% confidence interval [CI]: 102.00-175.00] vs.136 mL/kg [95% CI: 113.00-158.00], p = 0.92, respectively). We observed an insignificant trend toward higher 28-day mortality among fluid non-responsive patients (36% vs.19%, p = 0.14). Volume of fluids administered significantly correlated with adverse outcomes such as increased hemodialysis requirements (32 patients, 43%), (odds ratio [OR] = 1.7200, p = 0.0018). Subgroup analysis suggested administering ≥ 30 mL/kg fluids to fluid responsive patients had a trend toward increased mortality (25% vs.0%, p = 0.09) and a significant increase in hemodialysis (55% vs.17%, p = 0.024). Without formal FR assessment, similar amounts of total fluids were administered in both fluid responsive and non-responsive patients. As greater volumes of intravenous fluids administered were associated with adverse outcomes, we suggest that dedicated FR assessment may be a beneficial utility in early shock resuscitation.

Undifferentiated shock in a cirrhotic patient: Ascites matters.

In cirrhotic patients with undifferentiated shock, early CT with emphasis in ascitic fluid density should be performed to exclude rare causes of shock such as secondary peritonitis or hemoperitoneum.

Integrated Multiorgan Bedside Ultrasound for the Diagnosis and Management of Sepsis and Septic Shock.

Despite decades of research, the mortality rate of sepsis and septic shock remains unacceptably high. Delays in diagnosis, identification of an infectious source, and the challenge of providing patient-tailored resuscitation measures routinely result in suboptimal patient outcomes. Bedside ultrasound improves a clinician's ability to both diagnose and manage the patient with sepsis. Indeed, multiple point-of-care ultrasound (POCUS) protocols have been developed to evaluate and treat various subsets of critically ill patients. These protocols mostly target patients with undifferentiated shock and have been shown to improve clinical outcomes. Other studies have shown that POCUS can improve a clinician's ability to identify a source of infection. Once a diagnosis of septic shock has been made, serial POCUS exams can be used to continuously guide resuscitative efforts. In this review, we advocate that the patient with suspected sepsis or septic shock undergo a comprehensive POCUS exam in which sonographic information across organ systems is synthesized and used in conjunction with traditional data gleaned from the patient's history, physical exam, and laboratory studies. This harmonization of information will hasten an accurate diagnosis and assist with hemodynamic management.