title: Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department.
abstract: OBJECTIVE
  We analyzed the efficacy of a point-of-care ultrasonographic protocol, based on a focused multiorgan examination, for the diagnostic process of symptomatic, non-traumatic hypotensive patients in the emergency department.
  
  
  METHODS
  We prospectively enrolled 108 adult patients complaining of non-traumatic symptomatic hypotension of uncertain etiology. Patients received immediate point-of-care ultrasonography to determine cardiac function and right/left ventricle diameter rate, inferior vena cava diameter and collapsibility, pulmonary congestion, consolidations and sliding, abdominal free fluid and aortic aneurysm, and leg vein thrombosis. The organ-oriented diagnoses were combined to formulate an ultrasonographic hypothesis of the cause of hemodynamic instability. The ultrasonographic diagnosis was then compared with a final clinical diagnosis obtained by agreement of three independent expert physicians who performed a retrospective hospital chart review of each case.
  
  
  RESULTS
  Considering the whole population, concordance between the point-of-care ultrasonography diagnosis and the final clinical diagnosis was interpreted as good, with Cohen's k = 0.710 (95 % CI, 0.614-0.806), p < 0.0001 and raw agreement (Ra) = 0.768. By eliminating the 13 cases where the final clinical diagnosis was not agreed upon (indefinite), the concordance increased to almost perfect, with k = 0.971 (95 % CI, 0.932-1.000), p < 0.0001 and Ra = 0.978.
  
  
  CONCLUSIONS
  Emergency diagnostic judgments guided by point-of-care multiorgan ultrasonography in patients presenting with undifferentiated hypotension significantly agreed with a final clinical diagnosis obtained by retrospective chart review. The integration of an ultrasonographic multiorgan protocol in the diagnostic process of undifferentiated hypotension has great potential in guiding the first-line therapeutic approach.
authors.affiliation: Department of Emergency Medicine, S.C.D.O, Medicina d'Urgenza, Ospedale Universitario San Luigi Gonzaga, Orbassano, Turin, Italy. gio.volpicelli@tin.it
authors.forename: G
authors.initials: G
authors.lastname: Volpicelli
authors.forename: A
authors.initials: A
authors.lastname: Lamorte
authors.forename: M
authors.initials: M
authors.lastname: Tullio
authors.forename: L
authors.initials: L
authors.lastname: Cardinale
authors.forename: M
authors.initials: M
authors.lastname: Giraudo
authors.forename: V
authors.initials: V
authors.lastname: Stefanone
authors.forename: E
authors.initials: E
authors.lastname: Boero
authors.forename: P
authors.initials: P
authors.lastname: Nazerian
authors.forename: R
authors.initials: R
authors.lastname: Pozzi
authors.forename: M F
authors.initials: MF
authors.lastname: Frascisco
mesh_terms: D000005:Abdomen / Q000000981:diagnostic imaging; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004452:Echocardiography; D004630:Emergencies; D005260:Female; D006801:Humans; D007022:Hypotension / Q000000981:diagnostic imaging* / Q000209:etiology*; D007558:Italy; D008168:Lung / Q000000981:diagnostic imaging; D008297:Male; D008875:Middle Aged; D019095:Point-of-Care Systems; D011446:Prospective Studies; D012189:Retrospective Studies; D012769:Shock / Q000000981:diagnostic imaging* / Q000209:etiology*; D014680:Veins / Q000000981:diagnostic imaging