Lung Ultrasound Using KH Screening Tool in Undifferentiated Shock Patients Arriving to ER

INTRODUCTION

Because shock is the most common cause of death worldwide, the most important aspect of care is early recognition and response to restore perfusion. Assessing the patient in shock can be difficult due to its intricate pathophysiology and wide range of overlaid clinical signs. The emergency physician must determine the type and cause of shock to devise an emergency management strategy to avoid a negative outcome. Our study aims to define the role of emergency bedside lung ultrasound in the assessment of a patient in shock. In our emergency department, we conducted a prospective study using bedside lung ultrasound to evaluate patients admitted with undifferentiated shock using the KH hospital screening tool, which included the bedside lung ultrasound in emerge (BLUE) protocol, fluid administration limited by lung sonography (FALLS) protocol, rapid ultrasound in shock (RUSH) protocol, and extended focused abdominal sonogram for trauma (E-FAST) (Flowchart 1).

MATERIALS AND METHODOLOGY

RESULTS

Out of 159 cases, 41% of the cases are in the 61–70 age group, 27% of the cases are in the 51–60 age group, 13% in the >70 age group, 12% are in the 41–50 age group and only 8% in <40 age group.

73% of the patients are males and 27% of the patients are females in our study.

Out of 159 cases, the most common co-morbidities were diabetes mellitus in 147 patients; with the next 11 patients of COPD; 10 patients with systemic hypertension, chronic kidney disease and thyroid disorder; 8 cases of coronary artery disease; 7 cases of bronchial asthma and 6 cases of cerebrovascular attack (Fig. 1).

By investigations, Arterial blood gas analysis of pH and lactate level; 45% of cases in pH of 7.0–7.9, 6% of cases in 5.0–5.9 pH, 66% of cases in less than 2.0 lactate level, and 29% of cases in more than 9 lactate level.

By diagnosis distribution, 63 cases of hypovolemic shock, 45 cases of obstructive shock, 32 cases of cardiogenic shock and 19 cases of distributive shock.

By ultrasound protocol, 34 positive cases in BLUE protocol; 49 positive cases in FALLS protocol; ejection fraction (EF) of less than 20 in 3 cases of RUSH protocol and IVC compressible in 41 cases of RUSH protocol; and 47 positive cases in E-FAST protocol.

By diagnosis vs BLUE protocol, the p value is not significant in hypovolemic, cardiogenic, obstructive and distributive shock.

By diagnosis vs FALLS protocol, the p value is not significant in hypovolemic, cardiogenic, obstructive and distributive shock.

By diagnosis vs RUSH protocol, the p value is null in hypovolemic and cardiogenic shock; and not significant in obstructive and distributive shock (Figs 2 and 3).

By diagnosis vs E-FAST, the p value is not significant in hypovolemic, cardiogenic, obstructive and distributive shock.

By outcome, 71% of the patients have been discharged; 12% of the patients went against medical advice; and 17% of the patients were dead. In these 52 cases in hypovolemic shock have been discharged, 4 went against medical advice and 7 were dead; 21 cases in cardiogenic shock have been discharged, 6 went against medical advice and 5 were dead; 10 cases in distributive shock have been discharged, 3 went against medical advice and 6 were dead; 30 cases in obstructive shock have been discharged, 6 went against medical advice and 9 were dead.

DISCUSSION

In this study, the A lines/A profile of the lung ultrasound was done using the KH screening tool which was found to be positive in 30.81% of the patients. In which the hemodynamic stability of these patients were assessed and found to have decreased blood pressure due to volume loss and sepsis. Lichtenstein et al.,^1,2 stated hemodynamic assessment of shock using lung ultrasound (FALLS protocol) with positive A-lines in identifying hypovolemic shock and showed 93% specificity. It has many advantages as a simple, bedside to assess the volume status of the patient in shock, less time and can be performed even in an insufficient equipment setting. The B line/B profile of the lung ultrasound was done using the KH screening tool which was found to be positive in 21.38% of patients in our study. These patients had laboured breathing and the cause was ruled out by bedside lung ultrasound in which patients were found to have pulmonary oedema in our study. Lichtenstein et al.^3–7 stated that the BLUE protocol and use of lung ultrasound in acute respiratory failure diagnosis in 260 patients admitted to the intensive care unit (ICU) as an observational study with A-line and lung siding predicted asthma (sensitivity of 89% and specificity of 97%); diffuse B-lines with lung sliding predicted pulmonary oedema (sensitivity 97% and specificity 95%); typically normal anterior profile with deep vein thrombosis (DVT) stipulated pulmonary embolism (sensitivity 81% and specificity 99%); and absent lung sliding represented pneumothorax (sensitivity 81% and specificity 100%). The EF and inferior vena cava (IVC) compressibility were done using the KH screening tool to rule out the cardiac status of the patient, which was 25.7% and 21.38% respectively in our study.^8–11 Tanvi et al.,¹² stated ultrasonographic findings in different types of shock which showed the presence of hypovolemic shock of 71.8% in hyperdynamic heart, 90% A-profile of the lung, 100% inferior vena cava (IVC) collapsibility; the distributive shock of 71.8% in normal left ventricular function contractility, 79.5% A-profile of lungs, 79.5% IVC collapsible; the cardiogenic shock of the hyperdynamic left ventricle in all the patients, 81.1% B-profile of lungs; the obstructive shock of 60% in right ventricular strain patients and 40% in cardiac tamponade patients. Mohammad Reza Ghane et al.,¹³ stated RUSH assessment and its precision in different types of shock which comprised 77 patients in Iran tertiary care centre using kappa value between initial and final diagnosis after the RUSH examination. The free fluid accumulation surrounding the heart, in abdominal and pelvic cavities and also in the lung regions using the KH screening tool was done to rule the cause of undifferentiated shock which was positive in 29.55%. Dorothy Habrat⁵ stated E-FAST is the best ultrasonographic examination in trauma patients for identifying free fluid surrounding the heart, in the abdominal cavity, pelvis and also in the lung region. Sasmaz MI et al.,¹⁴ researched the POCUS protocol. 180 patients from Turkey’s emergency room (ER) participated in this study. The purpose of this study was to use ultrasound to compare the initial and final diagnoses.

CONCLUSION

To conclude the study, the KH screening tool helped identify the patients with undifferentiated shock presented to the Emergency Department and has proved to be successful in the majority of the patients in whom it was performed. The KH screening tool is quick, easy and done at the patient’s bedside and had shown greater outcomes in patients with undifferentiated shock in whom radiological imaging such as X-computed tomography (CT) is needed to rule out the cause and arrive at the diagnosis and appropriate management to the patient.

ORCID

Esther Monica J https://orcid.org/0009-0003-8086-1635

Rajadurai Meenakshisundaram https://orcid.org/0000-0002-5811-3062

REFERENCES

1. Lichtenstein D. The BLUE-protocol, venous part: Deep venous thrombosis in the critically ill. Technique, results for the diagnosis of acute pulmonary embolism. In: Lichtenstein D, ed. Lung Ultrasound in the Critically Ill. Berlin, Germany: Springer-Verlag; 2015. pp. 116–140.

2. Lichtenstein DA, Karakitsos D. Integrating lung ultrasound in the hemodynamic evaluation of acute circulatory failure (the fluid administration limited by lung sonography protocol). J Crit Care 2012;27(5):533.e11–533.e19.DOI: 0.1016/j.jcrc.2012.03.004.

3. Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure. The BLUE protocol. Chest 2008;134(1):117–125.DOI: 0.1378/chest.07-2800.

4. Ghane MR, Gharib MH, Ebrahimi A, et al. Accuracy of rapid ultrasound in shock (RUSH) exam for diagnosis of shock in critically Ill patients. Trauma Mon 2015;20(1):e20095.DOI: 0.5812/traumamon.20095.

5. Dorothy Habrat. How to do E-FAST examination. MSD manual. 2021.

6. Xirouchaki N, Kondili E, Prinianakis G, et al. Impact of lung ultrasound on clinical decision making in critically ill patients. Intensive Care Med 2014;40(1):57–65.DOI: 0.1007/s00134-013-3133-3.

7. Shah VP, Tunik MG, Tsung JW. Prospective evaluation of point-of-care ultrasonography for the diagnosis of pneumonia in children and young adults. JAMA Pediatr 2013;167(2):119–125.DOI: 0.1001/2013.jamapediatrics.107.

8. Oveland NP, Lossius HM, Wemmelund K, et al. Using thoracic ultrasonography to accurately assess pneumothorax progression during positive pressure ventilation: A comparison with CT scanning. Chest 2013;143(2):415–422.DOI: 0.1378/chest.12-1445.

9. Caiulo VA, Gargani L, Caiulo S, et al. Lung ultrasound characteristics of community-acquired pneumonia in hospitalized children. Pediatr Pulmonol 2013;48(3):280–287.DOI: 0.1002/ppul.22585.

10. Matamis D, Soilemezi E, Tsagourias M, et al. Sonographic evaluation of the diaphragm in critically ill patients. Technique and clinical applications. Intensive Care Med 2013;39(5):801–810.DOI: 0.1007/s00134-013-2823-1.

11. Lichtenstein D. The SESAME-protocol. In: Lichtenstein D (ed). Lung Ultrasound in the Critically Ill. Berlin, Germany: Springer-Verlag; 2015. pp. 240–251.

12. Vaidya T, D’costa P, Pande S. Role of Ultrasound in Evaluation of Undifferentiated shock in ICU setting. J Assoc Physicians India 2018;66(8):13–17.PMID: 31324077.

13. Ghane MR, Gharib M, Ebrahimi A, et al. Accuracy of early rapid ultrasound in shock (RUSH) examination performed by emergency physician for diagnosis of shock etiology in critically ill patients. J Emerg Trauma Shock 2015;8(1):5–10.DOI: 0.4103/0974-2700.145406.

14. Sasmaz MI, Gungor F, Guven R, et al. Effect of focused bedside ultrasonography in hypotensive patients on the clinical decision of emergency physicians. Emerg Med Int 2017;2017:6248687.DOI: 0.1155/2017/6248687.