Shankar Takshak, Kaeley Nidhi, Sasidharan Parvathy, Bairwa Archana, Ameena M S Salva, Jayachandran Sreejith, Jose Jewel Rani, Yadav Jitendra Kumar
Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India.
Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India.
Turk J Emerg Med. 2025 Apr 1;25(2):100-106. doi: 10.4103/tjem.tjem_121_24. eCollection 2025 Apr-Jun.
Nontraumatic undifferentiated shock is difficult to manage in the emergency department due to unclear causes, lack of history, and rapid patient deterioration. Timely and appropriate resuscitation is crucial, but both inadequate and excessive resuscitation increase mortality risks. Focused cardiac ultrasound (FoCUS) offers a timely and noninvasive cardiac assessment. The echoSHOCK protocol is derived from FoCUS and improves the ability to identify the etiology of shock in patients at the emergency department. This study's primary objective was to validate the echoSHOCK protocol for diagnosing the cause of shock in patients arriving at the emergency department. This study's secondary objective was to determine the prevalence of different etiologies of shock in patients arriving at the emergency department.
Adult patients presenting to the emergency department in shock were included in the study after informed consent was obtained. The shock was defined as a systolic blood pressure of <90 mmHg or a mean arterial pressure of <65 mmHg with signs of poor tissue perfusion. Each patient underwent a detailed history, physical examination, and standard investigations. Clinicians reported a presumed etiology and management plan with a confidence level (0-10). The echoSHOCK protocol was then executed and its results were recorded with the respective confidence levels. The protocol used a phased array probe in B-mode solely and assessed left ventricle function, compressive pericardial effusion, right ventricular dilatation, interventricular septum flattening, and indicators of hypovolemia. The time taken to perform the protocol and the difficulty level were noted. An expert panel followed the patient till hospital discharge and provided the final diagnosis and intervention.
The study enrolled 223 patients with a mean age of 49.12 years. The echoSHOCK protocol showed a 94.2% agreement with expert panel diagnoses on the cause of shock and proposed interventions, with a statistically significant near-perfect agreement (Cohen's Kappa -0.896, < 0.001 and 0.897, < 0.001, respectively). In contrast, the agreement between the clinical assessment, routine workup, and expert panel diagnoses was 46.2% on the cause of shock and 45.7% on the proposed interventions, respectively. The echoSHOCK protocol's median feasibility score was 7 (interquartile range [IQR]: 6-8), and its median performance time was 7 min (IQR: 6-10). Confidence in diagnoses was significantly higher with echoSHOCK (mean: 7.14) than with clinical examination (mean: 4.47) (Wilcoxon Test: <0.001).
The echoSHOCK protocol rapidly identifies shock etiology in patients at the emergency department. This aids in rapid resuscitation.
非创伤性未分化休克在急诊科难以处理，原因包括病因不明、缺乏病史以及患者病情迅速恶化。及时且恰当的复苏至关重要，但复苏不足和过度都会增加死亡风险。床旁心脏超声（FoCUS）可提供及时且无创的心脏评估。echoSHOCK方案源自FoCUS，能提高在急诊科识别休克病因的能力。本研究的主要目的是验证echoSHOCK方案用于诊断急诊科休克患者病因的有效性。本研究的次要目的是确定急诊科休克患者不同病因的患病率。
获得知情同意后，将急诊科出现休克的成年患者纳入研究。休克定义为收缩压<90 mmHg或平均动脉压<65 mmHg且伴有组织灌注不良体征。对每位患者进行详细病史询问、体格检查和标准检查。临床医生报告推测的病因和管理计划，并给出置信度（0 - 10）。然后执行echoSHOCK方案，并记录其结果及相应的置信度。该方案仅使用B模式的相控阵探头，评估左心室功能、心包积液、右心室扩张、室间隔扁平以及血容量不足指标。记录执行该方案所需时间和难度级别。一个专家小组跟踪患者直至出院，并提供最终诊断和干预措施。
该研究纳入了223例患者，平均年龄49.12岁。echoSHOCK方案在休克病因和建议干预措施方面与专家小组诊断的一致性为94.2%，具有统计学意义的近乎完美的一致性（科恩kappa系数分别为 -0.896，<0.001和0.897，<0.001）。相比之下，临床评估、常规检查与专家小组诊断在休克病因方面的一致性为46.2%，在建议干预措施方面的一致性为45.7%。echoSHOCK方案的可行性中位数评分为7（四分位间距[IQR]：6 - 8），执行时间中位数为7分钟（IQR：6 - 10）。使用echoSHOCK诊断的置信度（平均：7.14）显著高于临床检查（平均：4.47）（Wilcoxon检验：<0.001）。
echoSHOCK方案能快速识别急诊科患者的休克病因。这有助于快速复苏。
