Accuracy of bedside physical examination in distinguishing categories of shock

Abstract

Disclosure: Nothing to report.HYPOTHESIS: Selected elements of a simple physical examination algorithm accurately predict categories of shock. SETTING: A 350-bed community teaching hospital. METHODS: Resident trainees who manage all critically ill and medically unstable patients were instructed to document capillary refill, (palpated) pulse volume, skin temperature, jugular venous pressure (JVP) and lung examination in all patients with prolonged (>30 minutes hypotension <90 mmHg). Treatment was determined by house officers guided by attending physicians of record. All cases were retrospectively reviewed by a senior clinician who applied consensus criteria/definitions to categorize shock as septic, cardiogenic or hypovolemic. Operating characteristics of examination findings for predicting categories of shock were computed. RESULTS:A total of 68 patients, averaging 71 6 16 years, were studied. A total of 37 patients were diagnosed with septic shock, 18 with cardiogenic shock of and 13 with hypovolemic shock. Capillary refill and skin temperature predicted septic shock with sensitivity of 89%, specificity of 68%, positive predictive value (PPV) of 77%, negative predictive value (NPV) of 84%, and overall accuracy of 79%. Presence of JVP >7 cmH 2 O was more accurate than bilateral pulmonary crackles (>1/3 from bases) in predicting cardiogenic shock for low-output patients with sensitivity of 82%, specificity of 79%, PPV of 75%, NPV of 85%, and overall accuracy of 80%. Using just skin temperature and JVP, the bedside approach correctly diagnosed 52/68 cases (overall accuracy ¼ 76%). CONCLUSIONS:Simple bedside clinical examination findings correctly predict categories of shock in a majority of cases.

Understanding Decision Making in Critical Care

“…Showing the interplay between hypothesis formation, gathering of information, and its ability to change probabilities may help validate the use of the history and physical as an efficient diagnostic tool, and not an exhaustive and antiquated exercise. 70,71 Finally, many critical care trainees organize thoughts and data into organbased categories that serve the interests of completeness but may oppose reflection upon key problems and findings. Demanding clarity in data acquisition and synthesis during all phases of patient care is likely to strengthen both analytic and intuitive modes of thought.…”

SMASH standardised perioperative management of patients operated with acute abdominal surgery in a high-risk setting

“…2. Physical examination: the responsible surgeon and the anaesthesiologist assess the patient at bedside immediately after notification of surgery [13]. The assessment is supported by the vital signs and the result of blood chemical analysis.…”

Clinical examination for diagnosing circulatory shock

“…The presence of all three physical signs had a high specificity (98%) but a low sensitivity (12%) for diagnosing shock, suggesting that these three signs accurately rule in, but inaccurately rule out circulatory shock. Varying types of shock are probably associated with varying clinical signs [70], so that a ‘one size fits all’ approach seems inappropriate. Roughly, one-third of all patients with circulatory shock suffer from a low CO , whereas two-thirds have distributive shock with associated high CO [1,71].…”