Point-of-care Ultrasound Leads to Diagnostic Shifts in Patients With Undifferentiated Hypotension

Am J Emerg Med. 2017 Dec;35(12):1984.e3-1984.e7. doi: 10.1016/j.ajem.2017.08.054. Epub 2017 Aug 26.

Abstract

Objective: To assess the impact of an ultrasound hypotension protocol in identifying life-threatening diagnoses that were missed in the initial evaluation of patients with hypotension and shock.

Methods: A subset of cases from a previously published prospective study of hypotensive patients who presented at the Emergency Department in a single, academic tertiary care hospital is described. An ultrasound-trained emergency physician performed an ultrasound on each patient using a standardized hypotension protocol. In each case, the differential diagnosis and management plan was solicited from the treating physician immediately before and after the ultrasound. This is a case series of patients with missed diagnoses in whom ultrasound led to a dramatic shift in diagnosis and management by detecting life threatening pathologies.

Results: Following a published prospective study of the effect on an ultrasound protocol in 118 hypotensive patients, we identified a series of cases that ultrasound protocol unexpectedly determined serious life threatening diagnoses such as Takotsubo cardiomyopathy, pulmonary embolism, pericardial effusion with tamponade physiology, abdominal aortic aneurysm and perforated viscus resulting in proper diagnoses and management. These hypotensive patients had completely unsuspected but critical diagnoses explaining their hypotension, who in every case had their management altered to target the newly identified life-threatening condition.

Conclusions: A hypotension protocol is an optimal use of ultrasound that exemplifies "right time, right place", and impacts decision-making at the bedside. In cases with undifferentiated hypotension, ultrasound is often the most readily available option to ensure that the most immediate life-threatening conditions are quickly identified and addressed in the order of their risk potential.

Keywords: Emergency treatment (E02.365); Hypotension (C14.907.514); Resuscitation (E02.365.647); Shock (C23.550.835); Ultrasonography (E01.370.350.850).

Publication types

  • Case Reports

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Critical Care*
  • Diagnosis, Differential
  • Emergency Service, Hospital*
  • Female
  • Humans
  • Hypotension / diagnosis*
  • Hypotension / diagnostic imaging*
  • Hypotension / therapy
  • Male
  • Middle Aged
  • Point-of-Care Systems* / statistics & numerical data
  • Prospective Studies
  • Ultrasonography*