Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients

Crit Care Med. 2004 Aug;32(8):1703-8. doi: 10.1097/01.ccm.0000133017.34137.82.


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.

Publication types

  • Clinical Trial
  • Comparative Study
  • Randomized Controlled Trial

MeSH terms

  • Adult
  • Clinical Protocols*
  • Confidence Intervals
  • Cross-Over Studies
  • Dehydration / complications
  • Dehydration / diagnosis
  • Diagnosis, Differential
  • Emergency Medical Services / methods*
  • Humans
  • Hypotension / diagnostic imaging*
  • Hypotension / etiology
  • Predictive Value of Tests
  • Shock, Septic / complications
  • Shock, Septic / diagnosis
  • Survival Analysis
  • Ultrasonography / standards*