title: A, B, C, D, echo: limited transthoracic echocardiogram is a useful tool to guide therapy for hypotension in the trauma bay--a pilot study.
abstract: BACKGROUND
  Limited transthoracic echocardiogram (LTTE) has been introduced as a technique to direct resuscitation in intensive care unit (ICU) patients. Our hypothesis is that LTTE can provide meaningful information to guide therapy for hypotension in the trauma bay.
  
  
  METHODS
  LTTE was performed on hypotensive patients in the trauma bay. Views obtained included parasternal long and short, apical, and subxyphoid. Results were reported regarding contractility (good vs. poor), fluid status (flat inferior vena cava [hypovolemia] vs. fat inferior vena cava [euvolemia]), and pericardial effusion (present vs. absent). Need for surgery, ICU admission, Focused Assessment with Sonography for Trauma examination results, and change in therapy as a consequence of LTTE findings were examined. Data were collected prospectively to evaluate the utility of this test.
  
  
  RESULTS
  A total of 148 LTTEs were performed in consecutive patients from January to December 2011. Mean age was 46 years. Admission diagnosis was 80% blunt trauma, 16% penetrating trauma, and 4% burn. Subxyphoid window was obtained in all patients. Parasternal and apical windows were obtained in 96.5% and 11%, respectively. Flat inferior vena cava was associated with an increased incidence of ICU admission (p < 0.0076) and therapeutic operation (p < 0.0001). Of the 148 patients, 27 (18%) had LTTE results indicating euvolemia. The diagnosis in these cases was head injury (n = 14), heart dysfunction (n = 5), spinal shock (n = 4), pulmonary embolism (n = 3), and stroke (n = 1). Of the patients, 121 had LTTE results indicating hypovolemia. Twenty-eight hypovolemic patients had a negative or inconclusive Focused Assessment with Sonography for Trauma examination finding (n = 18 penetrating, n = 10 blunt), with 60% having blood in the abdomen confirmed by surgical exploration or computed tomographic scan. Therapy was modified as a result of LTTE in 41% of cases. Strikingly, in patients older than 65 years, LTTE changed therapy in 96% of cases.
  
  
  CONCLUSIONS
  LTTE is a useful tool to guide therapy in hypotensive patients in the trauma bay.
  
  
  METHODS
  Diagnostic study, level III.
authors.affiliation: Critical Care and Emergency Surgery, Virginia Commonwealth University, West Hospital, Richmond, Virginia 23298, USA.
authors.forename: Paula
authors.initials: P
authors.lastname: Ferrada
authors.forename: Poornima
authors.initials: P
authors.lastname: Vanguri
authors.forename: Rahul J
authors.initials: RJ
authors.lastname: Anand
authors.forename: James
authors.initials: J
authors.lastname: Whelan
authors.forename: Therese
authors.initials: T
authors.lastname: Duane
authors.forename: Michel
authors.initials: M
authors.lastname: Aboutanos
authors.forename: Ajai
authors.initials: A
authors.lastname: Malhotra
authors.forename: Rao
authors.initials: R
authors.lastname: Ivatury
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004452:Echocardiography; D006801:Humans; D007022:Hypotension / Q000000981:diagnostic imaging* / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D008875:Middle Aged; D012151:Resuscitation; D014947:Wounds and Injuries / Q000150:complications*; D055815:Young Adult