Background
Methods
Study design and setting
Selection of patients
Clinical evaluation
Multiorgan point-of-care USG
Cardiac USG
Lung USG
IVC USG
Renal USG
ADHF (systolic dysfunction) | Acute interstitial syndrome (the presence of multiple diffuse bilateral B-lines) with LV dysfunction on cardiac USG |
Acute pneumonia | Lung USG showing focal B-lines, subpleural echo poor region with tissue-like echotexture and dynamic air bronchogram with normal LV function. |
ARDS | Acute interstitial syndrome (presence of multiple diffuse bilateral B-lines) in non-homogenous distribution and anterior subpleural consolidation, reduced lung sliding normal LV function with suggestive clinical presentation (sudden onset and suggestive sepsis). |
COPD or Obstructive airway disease | Bilateral A-lines with decreased lung sliding on lung USG with normal LV function and normal kidneys with key indicators of COPD present clinically. |
Acute Pulmonary Embolism | Normal LV function, A-lines on lung USG with or without focal B-lines, dilated RV, dilated IVC with low collapsibility index with high pre-test probability of PE. |
Chronic lung disease (ILD or chronic lung fibrosis) | Normal LV function, irregular fragmented pleural line, subpleural abnormalities, bilateral B-lines in non- homogenous distribution with or without dilated RV and dilated IVC with low collapsibility index with suggestive clinical picture (h/o chronic exertional dyspnea and cough). |
Diastolic Heart Failure | Normal LV function with LV hypertrophy (LVH), left atrial enlargement, multiple diffuse bilateral B-lines, dilated IVC with low collapsibility index with suggestive clinical presentation (e.g., hypertensive, diabetic) |
Volume overload | Normal LV function, normal RV, multiple diffuse bilateral B-lines, dilated IVC, contracted kidneys. |
Pneumothorax | Normal LV function, bilateral A-lines with absent lung sliding with observed lung point with suggestive clinical picture. |
Tamponade | Normal LV function, pericardial effusion with dilated and non-collapsible IVC and RA/RV diastolic collapse with suggestive clinical signs. |
Statistical analysis
Results and discussion
Patient characteristics
Cardiac patients mean ± SD and (95% CI) | Non-cardiac patients mean ± SD and (95% CI) | Both mean ± SD and (95% CI) | P value | |
---|---|---|---|---|
Age | 53.55 ± 16.16 (48.58–58.05) | 45.31 ± 14.05 (39.36–50.6) | 49.53 ± 16.31 (43.2–55.8) | 0.093 |
Systolic blood pressure | 139.302 ± 31.04 (129.74–148.85) | 119.65 ± 25.28 (110.03–129.27) | 143.57 ± 45.88 (125.78–161.63) | 0.002 |
Diastolic blood pressure | 85.81 ± 15.77 (80.96–90.68) | 74.82 ± 13.26 (69.78–79.87) | 91.42 ± 27.31 (80.83–102.02) | 0.005 |
Heart rate | 111.465 ± 20.83 (105.03–117.08) | 117.00 ± 31.15 (105.14–128.24) | 113.89 ± 21.53 (105.54–122.24 | 0.642 |
Respiratory rate | 28.44 ± 4.22 (27.14–29.74) | 33.138 ± 6.610 (30.62–35.65) | 30.536 ± 3.2028 (29.29–31.77) | 0.00 |
SpO2 | 89.93 ± 8.90 (87.18–92.62) | 82.964 ± 13.16 (77.85–88.07) | 80.82 ± 14.46 (75.21–86.42) | 0.004 |
IVC maximum diameter | 18.91 ± 3.87 (17.71–20.10) | 10.46 ± 6.89 (7.84–13.08) | 17.17 ± 5.147 (15.17–19.16) | 0.00 |
IVC minimum diameter | 12.86 ± 4.53 (11.46–14.25) | 5.26 ± 5.50 (3.17–7.36) | 11.06 ± 5.993 (8.74–13.38) | 0.00 |
LV systolic diameter in PLAX | 3.85 ± 1.213 (3.48–4.22) | 2.82 ± 0.583 (2.60–3.04) | 3.56 ± 0.975 (3.18–3.94) | 0.00 |
EPSS | 12.007 ± 6.80 (9.912–14.10) | 3.624 ± 1.70 (2.97–4.27) | 9.039 ± 5.93 (6.73–11.34) | 0.00 |
Kidney size | 9.60 ± 0.667 (9.39–9.80) | 9.57 ± 1.36 (9.05–10.05) | 8.96 ± 1.16 (8.50–9.41) | 0.031 |
Blood urea nitrogen | 39.69 ± 13.06 (35.67–43.71) | 57.65 ± 43.71 (41.02–74.28) | 65.42 ± 30.97 (53.41–77.43) | 0.001 |
Serum creatinine | 1.295 ± 0.66 (1.09–1.51) | 3.093 ± 3.58 (1.72–4.45) | 3.476 ± 2.669 (2.46–4.53) | 0.00 |
Time to relief from dyspnea in Hrs | 22.64 ± 18.85 (16.36–28.93) | 18.00 ± 21.015 (4.64–31.35) | 32.00 ± 21.91 21.09–42.90) | 0.139 |
Likert scale | 2.816 ± 0.729 (2.57–3.05) | 2.87 ± 1.027 (2.26–3.45) | 3.3 ± 0.656 (2.99–3.60) | 0.075 |
Hospital LOS | 6.034 ± 3.109 (5.07–6.99) | 4.86 ± 4.434 (3.22–6.51) | 7.56 ± 5.998 (5.24–9.89) | 0.01 |
Modified Boston Criteria for HF | 8.07 ± 1.334 (7.65–8.48) | 6.86 ± 1.156 (6.442–7.302) | 7.893 ± 1.065 (7.48–8.306) | 0.00 |
Distribution of patients according to diagnosis
Emergency department diagnosis | Number of patients | Number of incorrect ED diagnosis | Final discharge diagnosis of incorrect ED diagnosis cases |
---|---|---|---|
ADHF (systolic or diastolic heart failure) | 43 | 2 | 1. Volume overload/AKI 2. Acute bilateral bronchopneumonia |
COPD | 4 | Nil | |
ARDS | 7 | 1 | Anaphylaxis |
Acute pulmonary embolism | 7 | 4 | 1. ASD/Beri beri 2. Pneumonia/sepsis with DIC 3. ADHF/pneumonia/severe anemia 4. ILD with Ac exacerbation of PAH |
Acute pneumonia | 4 | 1 | Severe anemia with ADHF |
Volume overload (AKI, CKD) | 4 | Nil | |
Massive pleural effusion | 3 | Nil | |
Both (cardiac and non-cardiac) | 28 | 3 | 1. IPF acute exacerbation/RV failure 2. ADHF/malignant effusion 3. Severe anemia/RPGN |
Variable | Category of diagnosis | |||
---|---|---|---|---|
Cardiac | Non-cardiac | Both | P value | |
Exertional dyspnea | 23 | 6 | 13 | .019 |
Orthopnea | 29 | 8 | 17 | .003 |
Paroxysmal nocturnal dyspnea | 9 | 2 | 3 | .204 |
Previous heart failure | 6 | 0 | 2 | .093 |
Chronic kidney disease | 0 | 0 | 4 | NA |
Chronic respiratory disease | 2 | 0 | 3 | .185 |
Coronary artery disease | 5 | 0 | 0 | .031 |
Fever and cough | 2 | 16 | 12 | .000 |
Any cardiac murmur | 1 | 0 | 1 | .616 |
Peripheral edema | 23 | 7 | 11 | .045 |
Jugular venous distension | 18 | 1 | 7 | .001 |
Displaced apex beat | 10 | 0 | 4 | .020 |
S3 | 3 | 0 | 0 | .133 |
Wheeze | 3 | 6 | 5 | .203 |
Rhonchi and rales | 0 | 2 | 3 | .110 |
Basal rales | 13 | 3 | 6 | .135 |
Rales > 1/3 lung fields | 4 | 3 | 8 | .060 |
ECG abnormality | 27 | 10 | 20 | .011 |
Lung sliding (absent to decreased) | 3 | 10 | 0 | .002 |
Pleural effusion | 3 | 3 | 3 | .827 |
B profile | ||||
Bilateral | 31 | 12 | 20 | .07 |
Focal | 2 | 4 | 2 | |
A lines | 10 | 13 | 6 | |
EF eyeball method | ||||
Severe LV dysfunction | 19 | 0 | 6 | .000 |
Moderate LV dysfunction | 9 | 2 | 8 | |
Normal | 13 | 29 | 14 | |
Need for ABG analysis | 2 | 13 | 16 | .000 |
Dilated RV | 15 | 7 | 15 | .06 |
Increased kidney echotexture | 13 | 12 | 15 | .144 |