Accuracy and outcome of rapid ultrasound in shock and hypotension (RUSH) in Egyptian polytrauma patients

Resuscitative Ultrasound and Protocols

The management of patients in shock or arrest is a critical aspect of emergency medicine and critical care. Rapid and accurate assessment is paramount in determining the underlying causes and initiating timely interventions. This article provides a summary of essential ultrasound protocols for the critically ill patient including the extended focused assessment with sonography for trauma (EFAST), rapid ultrasound for shock and hypotension (RUSH), and sonography in hypotension and cardiac arrest in the emergency department (SHoC-ED).

Diagnostic accuracy of point-of-care ultrasound for shock: a systematic review and meta-analysis

BACKGROUND

Circulatory failure is classified into four types of shock (obstructive, cardiogenic, distributive, and hypovolemic) that must be distinguished as each requires a different treatment. Point-of-care ultrasound (POCUS) is widely used in clinical practice for acute conditions, and several diagnostic protocols using POCUS for shock have been developed. This study aimed to evaluate the diagnostic accuracy of POCUS in identifying the etiology of shock.

METHODS

We conducted a systematic literature search of MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Web of Science, Clinicaltrial.gov, European Union Clinical Trials Register, WHO International Clinical Trials Registry Platform, and University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) until June 15, 2022. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and assessed study quality using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analysis was conducted to pool the diagnostic accuracy of POCUS for each type of shock. The study protocol was prospectively registered in UMIN-CTR (UMIN 000048025).

RESULTS

Of the 1553 studies identified, 36 studies were full-text reviewed, and 12 studies with 1132 patients were included in the meta-analysis. Pooled sensitivity and specificity were 0.82 [95% confidence interval (CI) 0.68-0.91] and 0.98 [95% CI 0.92-0.99] for obstructive shock, 0.78 [95% CI 0.56-0.91] and 0.96 [95% CI 0.92-0.98] for cardiogenic shock, 0.90 [95% CI 0.84-0.94] and 0.92 [95% CI 0.88-0.95] for hypovolemic shock, and 0.79 [95% CI 0.71-0.85] and 0.96 [95% CI 0.91-0.98] for distributive shock, respectively. The area under the receiver operating characteristic curve for each type of shock was approximately 0.95. The positive likelihood ratios for each type of shock were all greater than 10, especially 40 [95% CI 11-105] for obstructive shock. The negative likelihood ratio for each type of shock was approximately 0.2.

CONCLUSIONS

The identification of the etiology for each type of shock using POCUS was characterized by high sensitivity and positive likelihood ratios, especially for obstructive shock.

Evaluate the incidence, topography, management, and outcomes in patients with polytrauma in the Suez Canal and Sinai areas

Introduction

The global prevalence of trauma-related mortality ranges from 2% to 32%; however, In Egypt, it reaches 8%. Trauma chiefly affects people in the productive age group; seriously ill patients with multiple injuries present with various levels of polytrauma. Application of incorrect triage systems and improperly trained trauma teams increase mortality and morbidity rates in non-dedicated institutions; however, these rates can decrease with appropriate infrastructure. This study aimed to improve the quality of care for patients with polytrauma through improved knowledge of the different severity levels of polytrauma and defined databases, using a suitable triage trauma system, well-trained trauma team, and appropriate infrastructure.

Methods

This observational cross-sectional study was conducted at the emergency department (ED), over a study period of 7 months, from August 10, 2019, to March 09, 2020. This study included 458 patients with polytrauma who had met the inclusion and exclusion criteria and attended the ED of Suez Canal University Hospital.

Results

The incidence of trauma among all emergency cases in the ED was 5.3%. However, most multiple injuries are mild, accounting for 44.4%, while 27.3% of the cases had life-threatening injuries. Moreover, 41.9% of the patients were managed non-operatively, whereas 58.1% of the patients required surgical interventions. Concerning the outcome, 56% and 6.9% of patients with and without life-threatening injuries respectively, died.

Conclusion

Facilities of the highest quality should be available for patients with polytrauma, especially those with life-threatening injuries. In addition, training emergency medical service staff for trauma triage is essential, and at least one tertiary hospital is required in every major city in the Suez Canal and Sinai areas to decrease trauma-related mortality.

Multifactorial Shock: A Neglected Situation in Polytrauma Patients

Background: Shock after traumatic injury is likely to be hypovolemic, but different types of shock (distributive shock, obstructive shock, or cardiogenic shock) can occur in combination, known as multifactorial shock. Multifactorial shock is a neglected area of study, and is only reported sporadically. Little is known about the incidence, characteristics, and outcomes of multifactorial shock after polytrauma. Methods: A retrospective, observational, multicenter study was conducted in four Level I trauma centers involving 1051 polytrauma patients from June 2020 to April 2022. Results: The mean Injury Severity Score (ISS) was 31.1, indicating a severely injured population. The most common type of shock in the early phase after polytrauma (≤48 h) is hypovolemic shock (83.2%), followed by distributive shock (14.4%), obstructive shock (8.7%), and cardiogenic shock (3.8%). In the middle phase after polytrauma (>48 h or ≤14 days), the most common type of shock is distributive shock (70.7%), followed by hypovolemic shock (27.2%), obstructive shock (9.9%), and cardiogenic shock (7.2%). Multifactorial shock accounted for 9.7% of the entire shock population in the early phase and 15.2% in the middle phase. In total, seven combinations of multifactorial shock were described. Patients with multifactorial shock have a significantly higher complication rate and mortality than those with single-factor shock. Conclusions: This study characterizes the incidence of various types of shock in different phases after polytrauma and emphasizes that different types of shock can occur simultaneously or sequentially in polytrauma patients. Multifactorial shock has a relatively high incidence and mortality in polytrauma patients, and trauma specialists should be alert to the possibility of their occurrence.

Comparison of inferior vena cava collapsibility and central venous pressure in assessing volume status in shocked patients

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An accurate diagnosis of shock state can be challenging, particularly in low-income countries, such as African countries, because physical signs of hypovolaemic, distributive, cardiogenic, and obstructive shock frequently overlap.

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Low-income countries therefore require easy and noninvasive methods, such as ultrasound devices.

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This study aims to provide an accurate estimation of intravascular volume status using bedside noninvasive methods as an essential part of the management of shocked patients.

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We discovered that the inferior vena cava collapsibility index (IVC-ci) could be a good tool with moderate reliability for detecting fluid responsiveness because it is a less invasive and fast method.

Introduction

Determination of intravascular volume status in patients admitted to the emergency centre is critical. Physical signs of hypovolaemic, distributive, cardiogenic, and obstructive shock frequently overlap, making an accurate diagnosis of shock state difficult. This is problematic because fluid loading is considered the first step in haemodynamically unstable patients’ resuscitation. Yet, multiple studies have shown that only approximately 50% of haemodynamically unstable patients in the intensive care unit and operating theatre respond to a fluid challenge. This study aims to provide an accurate estimation of intravascular volume status using bedside noninvasive methods as an essential part of the assessment of volume status in shocked patients.

Methodology

This is a cross-sectional analytical study conducted on 102 shocked patients presented to the emergency centre. IV fluid boluses were standardized to be administered at 500 mL every 30 min over 120 min, as clinically indicated. Concurrent measurements of inferior vena cava collapsibility index (IVC-ci) were performed shortly before the initiation of IV bolus (i.e., time 0), and then at 30, 90, and 120 min, we measured both venous collapsibility index (CI) and central venous pressure (CVP). At each session, we recorded patient demographics, fluid responsiveness, and vital sign assessments.

Results

We discovered that IVC-ci at cut-off point 40 has a sensitivity of 93.3% and specificity of 70.7% with an AUC of 0.908 and a good 95% CI (0.84–0.975), implying that IVC-ci of 40% or higher can indicate fluid responsiveness in shocked patients. CVP, despite having a good sensitivity of 88.6%, high specificity of 100%, and a significant p-value, is not a reliable detector of fluid responsiveness due to its small AUC value and low 95% CI.

Conclusion

IVC-ci could be a good tool with moderate reliability for detecting fluid responsiveness because it is a less invasive and fast method.

Impact of implementation of sequential trauma education programs (STEPs) course on missed injuries in emergency polytrauma patients, Ismailia, Egypt

INTRODUCTION

Trauma deaths account for 8% of all deaths in Egypt. Patients with multiple injuries are at high risk but may be saved with a good triage system and a well-trained trauma team in dedicated institutions. The incidence of missed injuries in the Emergency Centre (EC) of Suez Canal University Hospital (SCUH) was found to be 9.0% after applying Advanced Trauma Life Support (ATLS) guidelines. However, this rate is still high compared with many trauma centers.

AIM

Improve the quality of management of polytrauma patients by decreasing the incidence of missed injuries by implementing the Sequential Trauma Education Programs (STEPs) course in the EC at SCUH.

METHODS

This interventional training study was conducted in the SCUH EC that adheres to CONSORT guidelines. The study was conducted during the one month precourse and for 6 months after the implementation of the STEPs course for EC physicians. Overall, 458 polytrauma patients were randomly selected, of which 45 were found to have missed injuries after applying the inclusion and exclusion criteria. We assessed the clinical relevance of these cases for missed injuries before and after the STEPs course.

RESULTS

Overall, 45 patients were found to have missed injuries, of which 15 (12%) were pre-STEPs and 30 (9%) were post-STEPs course. The STEPs course significantly increased adherence to vital data recording, but the reduction of missed injuries (3.0%) was not statistically significant in relation to demographic and trauma findings. However, the decrease in missed injuries in the post-STEPs course group was an essential clinically significant finding.

CONCLUSION

STEPs course implementation decreased the incidence of missed injuries in polytrauma patients. Thus, the STEPs course can be considered at the same level of other advanced trauma courses as a training skills program or possibly better in dealing with trauma patients. Repetition of this course by physicians should be mandatory to prevent more missed injuries. Therefore, the validation of STEPs course certification should be completed at least every two years to help decrease the number of missed injuries, especially in low-income countries and low-resource settings.

Rapid Ultrasound for Shock and Hypotension: A Clinical Update for the Advanced Practice Provider: Part 1

The Rapid Ultrasound for Shock and Hypotension (RUSH) examination is used for patients with hypotension without clear cause or undifferentiated hypotension. In the emergency department setting, clinicians may perform the RUSH examination to supplement the physical assessment and differentiate the diagnosis of hypovolemic, obstructive, cardiogenic, and distributive forms of shock. The key elements of the RUSH examination are the pump, tank, and pipes, meaning potentially causes of the hypotension are examined within the heart, vascular volume and integrity, and the vessels themselves. Clinicians follow a systemic protocol to seeking evidence of specific conditions including heart failure exacerbation, cardiac tamponade, pleural effusion, pneumothorax, abdominal aortic aneurysm, and deep vein thrombosis. Because ultrasonography is a user-dependent skill, the advanced practice nurse in the emergency department should be educated regarding the RUSH protocol and prepared to implement the examination.