Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients.
OBJECTIVE
We examined a physician-performed, goal-directed ultrasound protocol for the emergency department management of nontraumatic, symptomatic, undifferentiated hypotension.


METHODS
Randomized, controlled trial of immediate vs. delayed ultrasound.


METHODS
Urban, tertiary emergency department, census >100,000.


METHODS
Nontrauma emergency department patients, aged >17 yrs, and initial emergency department vital signs consistent with shock (systolic blood pressure <100 mm Hg or shock index >1.0), and agreement of two independent observers for at least one sign and symptom of inadequate tissue perfusion.


METHODS
Group 1 (immediate ultrasound) received standard care plus goal-directed ultrasound at time 0. Group 2 (delayed ultrasound) received standard care for 15 mins and goal-directed ultrasound with standard care between 15 and 30 mins after time 0.


RESULTS
Outcomes included the number of viable physician diagnoses at 15 mins and the rank of their likelihood of occurrence at both 15 and 30 mins. One hundred eighty-four patients were included. Group 1 (n = 88) had a smaller median number of viable diagnoses at 15 mins (median = 4) than did group 2 (n = 96, median = 9, Mann-Whitney U test, p <.0001). Physicians indicated the correct final diagnosis as most likely among their viable diagnosis list at 15 mins in 80% (95% confidence interval, 70-87%) of group 1 subjects vs. 50% (95% confidence interval, 40-60%) in group 2, difference of 30% (95% confidence interval, 16-42%).


CONCLUSIONS
Incorporation of a goal-directed ultrasound protocol in the evaluation of nontraumatic, symptomatic, undifferentiated hypotension in adult patients results in fewer viable diagnostic etiologies and a more accurate physician impression of final diagnosis.
Department of Emergency Medicine, Carolinas Medical Center, 1000 Blythe Boulevard, Charlotte, NC 28203, USA.
Alan E
AE
Jones
Vivek S
VS
Tayal
D Matthew
DM
Sullivan
Jeffrey A
JA
Kline
D000328:Adult; D002985:Clinical Protocols; D016001:Confidence Intervals; D018592:Cross-Over Studies; D003681:Dehydration / Q000150:complications / Q000175:diagnosis; D003937:Diagnosis, Differential; D004632:Emergency Medical Services / Q000379:methods*; D006801:Humans; D007022:Hypotension / Q000000981:diagnostic imaging* / Q000209:etiology; D011237:Predictive Value of Tests; D012772:Shock, Septic / Q000150:complications / Q000175:diagnosis; D016019:Survival Analysis; D014463:Ultrasonography / Q000592:standards*