Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of non traumatic 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.

Design: Randomized, controlled trial of immediate vs. delayed ultrasound.

Setting: Urban, tertiary emergency department, census >100,000.

Patients: 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.

Interventions: 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.

Measurements and Main 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. (Crit Care Med 2004; 32:1703–1708)

KEY WORDS: hypotension; shock; ultrasound; diagnosis; mortality; clinical trial

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