SEARCH 8Es: A novel point of care ultrasound protocol for patients with chest pain, dyspnea or symptomatic hypotension in the emergency department

Abstract

ObjectiveThis study was conducted to evaluate a problem-oriented focused torso bedside ultrasound protocol termed “Sonographic Evaluation of Aetiology for Respiratory difficulty, Chest pain, and/or Hypotension” (SEARCH 8Es) for its ability to narrow differential diagnoses and increase physicians’ diagnostic confidence, and its diagnostic accuracy, for patients presenting with dyspnea, chest pain, or symptomatic hypotension.MethodsThis single-center prospective observational study was conducted over 12 months in an emergency department and included 308 patients (184 men and 124 women; mean age, 67.7 ± 19.1 years) with emergent cardiopulmonary symptoms. The paired t-test was used to compare the number of differential diagnoses and physician’s level of confidence before and after SEARCH 8Es. The overall accuracy of the SEARCH 8Es protocol in differentiating 13 diagnostic entities was evaluated based on concordance (kappa coefficient) with the diagnosis made by the inpatient specialists. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated.ResultsSEARCH 8Es narrows the number of differential diagnoses (2.5 ± 1.5 vs. 1.4 ± 0.7; p < 0.001) and improves physicians’ diagnostic confidence (2.8 ± 0.8 vs. 4.3 ± 0.9; p < 0.001) significantly. The overall kappa coefficient value was 0.870 (p < 0.001), with the overall sensitivity, specificity, positive predictive value, and negative predictive value at 90.9%, 99.0%, 89.7%, and 99.0%, respectively.ConclusionThe SEARCH 8Es protocol helps emergency physicians to narrow the differential diagnoses, increase diagnostic confidence and provide accurate assessment of patients with dyspnea, chest pain, or symptomatic hypotension.

Diagnostic accuracy of combined thoracic and cardiac sonography for the diagnosis of pulmonary embolism: A systematic review and meta-analysis

“…Seven articles [17][18][19][20][21][22][23] could be included in the meta-analysis, incorporating 3872 patients. Two papers used CTPA as the reference diagnostic standard [19,20], and five papers used clinically derived diagnosis as the reference standard [17,18,[21][22][23] Clinically derived diagnosis adjudicators were blinded from the CPUS results in each of these studies. One study of acutely breathless patients [20] identified PE by exclusion following ultrasound examination for other candidate diagnoses.…”

Neurosonology for Unconscious or Neurocritically Ill Patients

“…Point-ofcare ultrasonography is especially valuable in patients requiring neurocritical care, due to the occurrence of frequent systemic comorbidities in these patients. Ultrasound can be used at the bedside in a variety of situ-ations including for the 1) evaluation of cardiothoracic comorbidities such as atrial septal defect and patent foramen ovale, global/segmental ventricular dysfunction, pericardial effusion/cardiac tamponade, and sources of emboli upon admission to the neurocritical care unit; 65 2) differential diagnosis of acutely developed symptoms including hypotension, chest pain, and dyspnea; 66,67 3) serial follow-up of pulmonary or cardiologic dysfunctions such as improvement or aggravation of pulmonary edema or pneumonia; and 4) evaluation and management of volume status in situations where cerebral perfusion pressure optimization is needed, including hypertensive therapy for ischemic stroke 68 or preventing delayed cerebral ischemia after SAH. 69 For these patients, lung ultrasound, echocardiography, and vascular ultrasound (inferior vena cava [IVC], aorta, and deep veins of the lower extremity) can be sequentially performed.…”

“…69 For these patients, lung ultrasound, echocardiography, and vascular ultrasound (inferior vena cava [IVC], aorta, and deep veins of the lower extremity) can be sequentially performed. 67,70 While there is no universally accepted sequence, scanning of the lung and IVC with the abdominal aorta, followed by heart and abdominal evaluations when required, is practical. 71 Sonography of the lower-extremity deep veins is performed in clinical situations when needed.…”

“…Basic point-of-care cardiothoracic ultrasound for managing patients in the neurocritical care unit. A series of examinations including lung ultrasound, echocardiography, and vascular ultrasound (IVC and aorta) can be performed for patients in the neurocritical care unit (modified from Ahn et al 67 ). Throughout this process, evidence of the "8 Es," a mnemonic for the eight potential goals to identify, is sought according to the clinical situation.…”

“…Journal of Neurosonology and Neuroimaging small-sized left ventricle or hyperkinetic normal-sized left ventricle). 67 The parasternal long axis view can be initially insonated. The global ejection fraction is easily evaluated by eyeballing 85 in this view, along with regional wall motion.…”