SHoC-IVC: Does assessment of the inferior vena cava by point-of-care ultrasound independently predict fluid status in spontaneously breathing patients with undifferentiated hypotension?

BACKGROUND: Accurately determining the fluid status of a patient during resuscitation in the emergency department (ED) helps guide appropriate fluid administration in the setting of undifferentiated hypotension. Our goal was to determine the diagnostic utility of point-of-care ultrasound (PoCUS) for inferior vena cava (IVC) size and collapsibility in predicting a volume overload fluid status in spontaneously breathing hypotensive ED patients. METHODS: This was a post hoc secondary analysis of the SHOC-ED data, a prospective randomized controlled trial investigating PoCUS in patients with undifferentiated hypotension. We prospectively collected data on IVC size and collapsibility for 138 patients in the PoCUS group using a standard data collection form, and independently assigned a fluid status (volume overloaded, normal, volume deplete) from a composite clinical chart review blinded to PoCUS findings. The primary outcome was the diagnostic performance of IVC characteristics on PoCUS in the detection of a volume overloaded fluid status. RESULTS: One hundred twenty-nine patients had completed determinant IVC assessment by PoCUS, with one hundred twenty-five receiving successful final fluid status determination, of which one hundred and seven were classified as volume deplete, thirteen normal, and seven volume overloaded. A receiver operating characteristic (ROC) curve was plotted using several IVC size and collapsibility categories. The best overall performance utilized the combined parameters of a dilated IVC (> 2.5 cm) with minimal collapsibility (less than 50%) which had a sensitivity of 85.7% and specificity of 86.4% with an area under the curve (AOC) of 0.92 for predicting an volume overloaded fluid status. CONCLUSION: IVC PoCUS is feasible in spontaneously breathing hypotensive adult ED patients, and demonstrates potential value as a predictor of a volume overloaded fluid status in patients with undifferentiated hypotension. IVC size may be the preferred measure.

RéSUMé: CONTEXTE: La détermination précise de l'état du liquide d'un patient pendant la réanimation au service des urgences (SU) aide à guider l'administration appropriée du liquide dans le cadre d'une hypotension indifférenciée. Notre objectif était de déterminer l'utilité diagnostique de l'échographie au point de soins (PoCUS) pour la taille de la veine cave inférieure (IVC) et l'collapsibilité dans la prédiction d'un état de liquide de surcharge volumique chez les patients souffrant d'une hypotension respiratoire spontanée. MéTHODES: Il s'agissait d'une analyse secondaire post-hoc des données SHOC-ED, un essai contrôlé randomisé prospectif examinant PoCUS chez des patients atteints d'hypotension indifférenciée. Nous avons collecté prospectivement des données sur la taille et la collapsibilité des IVC pour 138 patients du groupe PoCUS à l'aide d'un formulaire de collecte de données standard, et attribué indépendamment un état de fluide (volume surchargé, normal, épuisement du volume) à partir d'une revue de dossier clinique composite mise en aveugle aux résultats PoCUS. Le résultat principal était la performance diagnostique des caractéristiques IVC sur PoCUS dans la détection d'un état de fluide surchargé en volume. RéSULTATS: 129 patients avaient terminé l'évaluation IVC des déterminants par PoCUS, dont 125 ont reçu une détermination finale du statut hydrique, dont 107 ont été classés comme étant une diminution du volume, 13 normaux et 7 surchargés. Une courbe des caractéristiques de fonctionnement du récepteur (ROC) a été tracée en utilisant plusieurs catégories de taille et d'affaissement IVC. La meilleure performance globale a utilisé les paramètres combinés d'une IVC dilatée (> 2,5 cm) avec une collapsibilité minimale (moins de 50%) qui avait une sensibilité de 85,7% et une spécificité de 86,4% avec une zone sous la courbe (AOC) de 0,92 pour prédire un état de fluide surchargé en volume. CONCLUSION: IVC PoCUS est faisable chez les patients adultes souffrant d'une hypotension respiratoire spontanée et démontre une valeur potentielle en tant que prédicteur d'un état de liquide surchargé en volume chez les patients atteints d'hypotension indifférenciée. La taille IVC peut être la mesure préférée.

Sonographic Findings of Left Ventricular Dysfunction to Predict Shock Type in Undifferentiated Hypotensive Patients: An Analysis From the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Study.

Introduction Patients that present to the emergency department (ED) with undifferentiated hypotension have a high mortality rate. Hypotension can be divided into four categories: obstructive, hypovolemic, distributive, and cardiogenic. While it is possible to have overlapping or concomitant shock states, being able to differentiate between cardiogenic shock and the other categories is important as it entails a different treatment regime and extra cautions. In this secondary analysis, we investigate if using focused cardiac ultrasonography (FOCUS) to determine left ventricular dysfunction (LVD) can serve as a reliable test for cardiogenic shock. Methods We prospectively collected FOCUS findings performed in 135 ED patients with undifferentiated hypotension as part of an international study. Patients with clearly identified etiologies for hypotension were excluded, along with other specific presumptive diagnoses. LVD was defined as the identification of a generally hypodynamic left ventricle in the setting of shock. FOCUS findings were collected using a standardized protocol and data collection form. All scans were performed by emergency physicians trained in ultrasound. Final shock type was defined as cardiogenic or noncardiogenic by independent specialist blinded chart review. Results In our findings, 135 patients had complete records for assessment of left ventricular function and additional follow-up data and so were included in this secondary analysis. The median age was 56 years and 53% of patients were male. Disease prevalence for cardiogenic shock was 12% and the mortality rate was 24%. The presence of LVD on FOCUS had a sensitivity of 62.50% (95% confidence interval 35.43% to 84.80%), specificity of 94.12% (88.26% to 97.60%), positive likelihood ratio (LR) 10.62 (4.71 to 23.95), negative LR 0.40 (0.21 to 0.75) and accuracy of 90.37% (84.10% to 94.77%) for detecting cardiogenic shock. Conclusion Detecting left ventricular dysfunction on FOCUS may be useful in the early identification of cardiogenic shock in otherwise undifferentiated hypotensive adult patients in the emergency department.

Does Point of Care Ultrasound Improve Resuscitation Markers in Undifferentiated Hypotension? An International Randomized Controlled Trial From The Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Series.

Introduction Point of Care Ultrasound (PoCUS) protocols are commonly used to guide resuscitation for patients with undifferentiated hypotension, yet there is a paucity of evidence for any outcome benefit. We undertook an international multicenter randomized controlled trial (RCT) to assess the impact of a PoCUS protocol on key clinical outcomes. Here we report on resuscitation markers.  Methods Adult patients presenting to six emergency departments (ED) in Canada and South Africa with undifferentiated hypotension (systolic blood pressure (SBP) <100mmHg or a Shock Index >1.0) were randomized to receive a PoCUS protocol or standard care (control). Reported physiological markers include shock index (SI), and modified early warning score (MEWS), with biochemical markers including venous bicarbonate and lactate, at baseline and four hours.  Results A total of 273 patients were enrolled, with data collected for 270. Baseline characteristics were similar for each group. Improvements in mean values for each marker during initial treatment were similar between groups: Shock Index; mean reduction in Control 0.39, 95% CI 0.34 to 0.44 vs. PoCUS 0.33, 0.29 to 0.38; MEWS, mean reduction in Control 2.56, 2.22 to 2.89 vs. PoCUS 2.91, 2.49 to 3.32; Bicarbonate, mean reduction in Control 2.71 mmol/L, 2.12 to 3.30 mmol/L vs. PoCUS 2.30 mmol/L, 1.75 to 2.84 mmol/L, and venous lactate, mean reduction in Control 1.39 mmol/L, 0.93 to 1.85 mmol/L vs. PoCUS 1.31 mmol/L, 0.88 to 1.74 mmol/L. Conclusion We found no meaningful difference in physiological and biochemical resuscitation markers with or without the use of a PoCUS protocol in the resuscitation of undifferentiated hypotensive ED patients. We are unable to exclude improvements in individual patients or in specific shock types.

Does Point-of-care Ultrasonography Change Emergency Department Care Delivered to Hypotensive Patients When Categorized by Shock Type? A Post-Hoc Analysis of an International Randomized Controlled Trial from the SHoC-ED Investigators.

Introduction Our previously reported randomized-controlled-trial of point-of-care ultrasound (PoCUS) for patients with undifferentiated hypotension in the emergency department (ED) showed no survival benefit with PoCUS. Here, we examine the data to see if PoCUS led to changes in the care delivered to patients with cardiogenic and non-cardiogenic shock. Methods A post-hoc analysis was completed on a database of 273 hypotensive ED patients randomized to standard care or PoCUS in six centres in Canada and South Africa. Shock categories recorded one hour after the ED presentation were used to define subcategories of shock. We analyzed initial intravenous fluid volumes, as well as rates of inotrope use and procedures. Results  261 patients could be classified as cardiogenic or non-cardiogenic shock types. Although there were expected differences in the mean fluid volume administered between patients with non-cardiogenic and cardiogenic shock (p-value<0.001), there was no difference between the control and PoCUS groups (mean non-cardiogenic control 1881mL (95% CI 1567-2195mL) vs non-cardiogenic PoCUS 1763mL (1525-2001mL); and cardiogenic control 680mL (28.4-1332mL) vs. cardiogenic PoCUS 744mL (370-1117mL; p= 0.67). Likewise, there were no differences in rates of inotrope administration nor procedures for any of the subcategories of shock between the control group and PoCUS group patients. Conclusion Despite differences in care delivered by subcategory of shock, we did not find any difference in key elements of emergency department care delivered between patients receiving PoCUS and those who did not. This may help explain the previously reported lack of outcome differences between groups.

Utilisation of emergency blood in a cohort of South African emergency centres with no direct access to a blood bank.

INTRODUCTION: The transfusion of emergency blood is an essential part of haemostatic resuscitation. Locally, where direct access to a blood bank is limited, emergency blood is stored within emergency centres. It was previously suggested that stored blood provides inadequate volumes compared to what is needed. Minimal data are available regarding indications for emergency blood usage. We aimed to describe the utilisation of emergency blood in selected Cape Town emergency centres. MATERIALS AND METHODS: A cross-sectional study was carried out at three secondary level emergency centres (no blood bank), and one tertiary centre (with a blood bank). Data from emergency blood recipients were recorded over a three-month study period. Indications for transfusion, number of units and location of transfusion were recorded. Indications and usage location were described in numbers and proportions. RESULTS: A total of 329 emergency blood units were transfused to 210 patients. Trauma accounted for 39% (n = 81) of cases and other surgical conditions for 22% (n = 47), particularly upper gastrointestinal 11% (n = 24) and perioperative bleeding 8% (n = 16). Medical conditions accounted for 15% (n = 31), with anaemia 13% (n = 27), the most prevalent indication. Gynaecological conditions accounted for 15% (n = 32), mostly ectopic pregnancy 8% (n = 17). The majority of emergency blood, 77% (n = 253) were used in the emergency centres or operating theatres, 6% (n = 21). CONCLUSION: Trauma remains a major indication for emergency blood transfusion in this setting. This study questions the use of emergency blood for certain non-urgent diagnoses (i.e. anaemia). Given the scarcity of this resource and limitations to access, appropriate use of emergency blood needs to be better defined locally. Ongoing monitoring of the indications for which emergency blood is used, improved transfusion stewardship and better systems to access emergency blood should be a priority in this setting.

Utilisation of emergency blood in a cohort of South African emergency centres with no direct access to a blood bank

Introduction: The transfusion of emergency blood is an essential part of haemostatic resuscitation. Locally, where direct access to a blood bank is limited, emergency blood is stored within emergency centres. It was previously suggested that stored blood provides inadequate volumes compared to what is needed. Minimal data are available regarding indications for emergency blood usage. We aimed to describe the utilisation of emergency blood in selected Cape Town emergency centres. Materials and methods :A cross-sectional study was carried out at three secondary level emergency centres (no blood bank), and one tertiary centre (with a blood bank). Data from emergency blood recipients were recorded over a three-month study period. Indications for transfusion, number of units and location of transfusion were recorded. Indications and usage location were described in numbers and proportions. Results : A total of 329 emergency blood units were transfused to 210 patients. Trauma accounted for 39% (n = 81) of cases and other surgical conditions for 22% (n = 47), particularly upper gastrointestinal 11% (n = 24) and perioperative bleeding 8% (n = 16). Medical conditions accounted for 15% (n = 31), with anaemia 13% (n = 27), the most prevalent indication. Gynaecological conditions accounted for 15% (n = 32), mostly ectopic pregnancy 8% (n = 17). The majority of emergency blood, 77% (n = 253) were used in the emergency centres or operating theatres, 6% (n = 21).Conclusion :Trauma remains a major indication for emergency blood transfusion in this setting. This study questions the use of emergency blood for certain non-urgent diagnoses (i.e. anaemia). Given the scarcity of this resource and limitations to access, appropriate use of emergency blood needs to be better defined locally. Ongoing monitoring of the indications for which emergency blood is used, improved transfusion stewardship and better systems to access emergency blood should be a priority in this setting

Does Point-of-Care Ultrasonography Improve Clinical Outcomes in Emergency Department Patients With Undifferentiated Hypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators.

STUDY OBJECTIVE: Point-of-care ultrasonography protocols are commonly used in the initial management of patients with undifferentiated hypotension in the emergency department (ED). There is little published evidence for any mortality benefit. We compare the effect of a point-of-care ultrasonography protocol versus standard care without point-of-care ultrasonography for survival and clinical outcomes. METHODS: This international, multicenter, randomized controlled trial recruited from 6 centers in North America and South Africa and included selected hypotensive patients (systolic blood pressure <100 mm Hg or shock index >1) randomized to early point-of-care ultrasonography plus standard care versus standard care without point-of-care ultrasonography. Diagnoses were recorded at 0 and 60 minutes. The primary outcome measure was survival to 30 days or hospital discharge. Secondary outcome measures included initial treatment and investigations, admissions, and length of stay. RESULTS: Follow-up was completed for 270 of 273 patients. The most common diagnosis in more than half the patients was occult sepsis. We found no important differences between groups for the primary outcome of survival (point-of-care ultrasonography group 104 of 136 patients versus standard care 102 of 134 patients; difference 0.35%; 95% binomial confidence interval [CI] -10.2% to 11.0%), survival in North America (point-of-care ultrasonography group 76 of 89 patients versus standard care 72 of 88 patients; difference 3.6%; CI -8.1% to 15.3%), and survival in South Africa (point-of-care ultrasonography group 28 of 47 patients versus standard care 30 of 46 patients; difference 5.6%; CI -15.2% to 26.0%). There were no important differences in rates of computed tomography (CT) scanning, inotrope or intravenous fluid use, and ICU or total length of stay. CONCLUSION: To our knowledge, this is the first randomized controlled trial to compare point-of-care ultrasonography to standard care without point-of-care ultrasonography in undifferentiated hypotensive ED patients. We did not find any benefits for survival, length of stay, rates of CT scanning, inotrope use, or fluid administration. The addition of a point-of-care ultrasonography protocol to standard care may not translate into a survival benefit in this group.

Sonography in Hypotension and Cardiac Arrest (SHoC): Rates of Abnormal Findings in Undifferentiated Hypotension and During Cardiac Arrest as a Basis for Consensus on a Hierarchical Point of Care Ultrasound Protocol.

INTRODUCTION: Point of care ultrasound (PoCUS) has become an established tool in the initial management of patients with undifferentiated hypotension. Current established protocols (RUSH and ACES) were developed by expert user opinion, rather than objective, prospective data. PoCUS also provides invaluable information during resuscitation efforts in cardiac arrest by determining presence/absence of cardiac activity and identifying reversible causes such as pericardial tamponade. There is no agreed guideline on how to safely and effectively incorporate PoCUS into the advanced cardiac life support (ACLS) algorithm. We wished to report disease incidence as a basis to develop a hierarchical approach to PoCUS in hypotension and during cardiac arrest. METHODS: We summarized the recorded incidence of PoCUS findings from the initial cohort during the interim analysis of two prospective studies. We propose that this will form the basis for developing a modified Delphi approach incorporating this data to obtain the input of a panel of international experts associated with five professional organizations led by the International Federation of Emergency Medicine (IFEM). The modified Delphi tool will be developed to reach an international consensus on how to integrate PoCUS for hypotensive emergency department patients as well as into cardiac arrest algorithms. RESULTS: Rates of abnormal PoCUS findings from 151 patients with undifferentiated hypotension included left ventricular dynamic changes (43%), IVC abnormalities (27%), pericardial effusion (16%), and pleural fluid (8%). Abdominal pathology was rare (fluid 5%, AAA 2%). During cardiac arrest there were no pericardial effusions, however abnormalities of ventricular contraction (45%) and valvular motion (39%) were common among the 43 patients included. CONCLUSIONS: A prospectively collected disease incidence-based hierarchy of scanning can be developed based on the reported findings. This will inform an international consensus process towards the development of proposed SHoC protocols for hypotension and cardiac arrest, comprised of the stepwise clinical-indication based approach of Core, Supplementary, and Additional PoCUS views. We hope that such a protocol would be structured in a way that enables the clinician to only perform views that are clinically indicated, which limits exposure to the frequent incidental positive findings that accompany the current "one size fits all" standard protocols.

External patient temperature control in emergency centres, trauma centres, intensive care units and operating theatres: a multi-society literature review.

Here we review the available literature supporting the routine and timely use of external patient warming devices of all possible types during emergency department and peri-operative situations, including the role of best ambient temperature, and provides a best-practice statement on the need for such devices. It aims to present a guideline document endorsed by the major South African professional societies in the field of emergency and peri-operative care.

Adrenaline and amiodarone dosages in resuscitation: rectifying misinformation.

Despite the recognition of specialists in emergency medicine and the professionalisation of prehospital emergency care, international guidelines and consensus are often ignored, and the lag between guideline publication and translation into clinical practice is protracted. South African literature should reflect the latest evidence to guide resuscitation and safe patient care. This article addresses erroneous details regarding life-saving interventions in the South African Medicines Formulary, 10th edition. 

Adequacy of the emergency point-of-care ultrasound core curriculum for the local burden of disease in South Africa.

OBJECTIVE: This prospective cross-sectional study assesses the adequacy of the current South African emergency point-of-care ultrasound (EPCUS) core curriculum against the local burden of disease. METHOD: Patients presenting to five Emergency Centres during July 2011 were eligible for inclusion. Patients under the age of 12, after-hour presentations, missing folders and folders with incomplete notes were excluded. Emergency physicians with EPCUS exposure were responsible for data collection. They were all blinded to the study's aim. Summary statistics describe the proportion of clinical cases and procedures for which EPCUS was used. One investigator assessed the adequacy of the curriculum by matching the clinical indications of each module with the presenting complaint and final diagnosis of each patient. The ultrasound modules were ranked according to the frequency of their clinical indications. κ-Statistics are reported on 10% randomly selected cases to quantify interobserver agreement. RESULTS: The study included 2971 patients. Ultrasound assisted with diagnosis in 384 (12.92%) patients and in 34 (1.14%) procedures. A total of 1933 EPCUS procedures were indicated in 1844 (66.07%) patients. The five most frequently indicated modules were pulmonary, musculoskeletal, cardiac, focused assessment with sonography of HIV/tuberculosis co-infection and renal. The interobserver agreement (κ) was 0.602 (95% CI 0.559 to 0.645). CONCLUSIONS: This study was an attempt to ensure an evidence-based approach to assess the adequacy of the EPCUS core curriculum in South Africa. The results illustrate that our local burden of disease may require a change of the current core curriculum.

The emergency management and treatment of severe burns.

Burn injuries continue to cause morbidity and mortality internationally. Despite international collaborations and preventative measures, there are still many cases reported in high- and low-income countries. The treatment of these patients is often protracted and requires extensive resources. The adequate resuscitation of these patients coupled with meticulous wound care can have a huge impact on their outcome. The authors present a simple guideline for the initial management of severe burns which is utilised by the South African Burn Society and is based on the guidelines of the American Burn Association and the Australian and New Zealand Burn Association.

Hospital disaster planning in the Western cape, South Africa.

INTRODUCTION: The aim of this study was to describe the current state of disaster preparedness in hospitals in the public sector in the Western Cape, South Africa with the advent of the FIFA 2010 Soccer World Cup. The objectives included the completion of a self-reported assessment of readiness at all Western Cape public sector hospitals, to identify best practice and shortfalls in these facilities, as well as putting forward recommendations for improving disaster preparedness at these hospitals. METHODS: The National Department of Health, as part of the planning for the FIFA 2010 World Cup, appointed an expert committee to coordinate improvements in disaster medicine throughout the country. This workgroup developed a Self Reported Hospital Assessment Questionnaire, which was sent to all hospitals across the country. Data only were collected from public hospitals in the Western Cape and entered onto a purpose-built database. Basic descriptive statistics were calculated. Ethical approval was obtained from the Health Sciences Faculty Research Committee of the University of Cape Town. RESULTS: Twenty-seven of the 41 (68%) public hospitals provided completed data on disaster planning. The study was able to ascertain what infrastructure is available and what planning already has been implemented at these institutions. RECOMMENDATIONS: Most hospitals in the Western Cape have a disaster plan for their facility. Certain areas need more focus and attention; these include: (1) increasing collaborative partnerships; (2) improving HAZMAT response resources; (3) specific plans for vulnerable populations; (4) contingency plans for communication failure; (5) visitor, media and VIP dedicated areas and personnel; (6) evacuation and surge capacity plans; and (7) increased attention to training and disaster plan exercises.