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LO07: Does point of care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? The first Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED1) Study; an international randomized controlled trial

Published online by Cambridge University Press:  15 May 2017

M. Peach*
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
J. Milne
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
D. Lewis
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
L. Diegelmann
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
H. Lamprecht
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
M. Stander
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
D. Lussier
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
C. Pham
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
R. Henneberry
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
J. Fraser
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
M. Howlett
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
J. Mekwan
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
B. Ramrattan
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
J. Middleton
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
D.J. van Hoving
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
D. Fredericks
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
L. Taylor
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
T. Dahn
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
S.T. Hurley
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
K. MacSween
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
C. Cox
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
L. Richardson
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
O. Loubani
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
G. Stoica
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
S. Hunter
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
P. Olszynski
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
P.R. Atkinson
Affiliation:
Dalhousie University, Integrated Family/Emergency Residency Program, Saint John, NB
*
*Corresponding authors

Abstract

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Introduction: Point of care ultrasonography (PoCUS) is an established tool in the initial management of hypotensive patients in the emergency department (ED). It has been shown rule out certain shock etiologies, and improve diagnostic certainty, however evidence on benefit in the management of hypotensive patients is limited. We report the findings from our international multicenter RCT assessing the impact of a PoCUS protocol on diagnostic accuracy, as well as other key outcomes including mortality, which are reported elsewhere. Methods: Recruitment occurred at 4 North American and 3 Southern African sites. Screening at triage identified patients (SBP<100 mmHg or shock index >1) who were randomized to either PoCUS or control groups. Scans were performed by PoCUS-trained physicians. Demographics, clinical details and findings were collected prospectively. Initial and secondary diagnoses were recorded at 0 and 60 minutes, with ultrasound performed in the PoCUS group prior to secondary assessment. Final chart review was blinded to initial impressions and PoCUS findings. Categorical data was analyzed using Fishers two-tailed test. Our sample size was powered at 0.80 (α:0.05) for a moderate effect size. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. The perceived shock category changed more frequently in the PoCUS group 20/127 (15.7%) vs. control 7/125 (5.6%); RR 2.81 (95% CI 1.23 to 6.42; p=0.0134). There was no significant difference in change of diagnostic impression between groups PoCUS 39/123 (31.7%) vs control 34/124 (27.4%); RR 1.16 (95% CI 0.786 to 1.70; p=0.4879). There was no significant difference in the rate of correct category of shock between PoCUS (118/127; 93%) and control (113/122; 93%); RR 1.00 (95% CI 0.936 to 1.08; p=1.00), or for correct diagnosis; PoCUS 90/127 (70%) vs control 86/122 (70%); RR 0.987 (95% CI 0.671 to 1.45; p=1.00). Conclusion: This is the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients. We found that the use of PoCUS did change physicians’ perceived shock category. PoCUS did not improve diagnostic accuracy for category of shock or diagnosis.

Type
Oral Presentations
Copyright
Copyright © Canadian Association of Emergency Physicians 2017