Sonography in Hypotension and Cardiac Arrest in the Emergency Department. (SHoC-ED)

SHoC-ED: Sonography in Hypotension and Cardiac Arrest in the Emergency Department.

This study is designed to determine if there is any relationship between performing an abdominal ultrasound on patients who present with hypotension and their clinical outcomes (as measured by 7, 30 day and discharge mortality).

Study Overview

• Status: Completed
• Conditions: Shock; Hypotension; Point of Care Ultrasound
• Intervention / Treatment: Device: Ultrasound (A point of care ultrasound protocol)

Detailed Description

STRUCTURED RESEARCH ABSTRACT

Introduction

Patients who present to the ED (emergency department) with undifferentiated, non-trauma associated hypotension are often affected by conditions with a prognosis largely dependent on the time taken from presentation to correct diagnosis and intervention. The ACES protocol (Abdominal and Cardiothoracic Evaluation with Sonography in Shock) provides a rapid focused ultrasound protocol for making or refining diagnoses in patients who present to the ED with this type of hypotension. This will be the first study to compare the clinical outcomes of patients who are assessed with the ACES protocol as part of their initial workup to those of patients who are assessed without any intervention by ultrasound. The goal of this study is to determine if ACES enhances the patient's clinical outcomes, as measured by: 1) Time to restoration (or improvement) of CVS (cardiovascular system) parameters, 2) Rate of normalization of acid-base balance, as well as venous lactate 3) Significant change in diagnosis or recommended intervention 4) Frequency of unexpected diagnosis, and 5) Patient 7 and 30-day, and discharge mortality rate.

Methods

SHoC-ED 1 is a stratified randomized control trial that will run in multiple centers across Canada and internationally. The data will be stratified in that each center involved will recruit equal amounts of control and intervention patients. While different centers will recruit different numbers of participants, each individual center will recruit near-equal amounts for each arm of the study.

ED nurses will identify potential candidates for the SHoC-ED 1 study, and flag their charts to notify the attending physician. ED Physicians trained on the ACES protocol will then proceed to review the exclusion criteria (part of patient inclusion sheet/patient flag) and where appropriate, obtain consent. After these are completed, the physician will retrieve an envelope that contains the already randomized forms appropriate for whichever arm the patient has been randomized to. This randomization will place patients in either the ACES group (to be referred to as Group 1), or the control group (to be referred to as Group 2). Physicians following the group 1 protocol will perform their normal initial assessment and then do ACES, recording their data after each step. Physicians in group 2 will simply record their data after the initial assessment. Both groups of physicians will then record their impressions at 60 minutes as this will enable this project to determine how changes in diagnoses are affected by non-ultrasound factors in the first hour a patient is in the ED. These diagnoses will then be compared against the "final" diagnoses made during the patient's admission. Exclusion criteria for this study include the following: A) necessity of CPR or other advanced life support interventions before enrollment, B) History of significant trauma in past 24 hours, C) A 12 lead ECG diagnostic of STEMI, D) Mechanism of shock is clear (i.e. not undifferentiated shock), E) previously known diagnosis from other hospital, F) previously confirmed pregnancy, G) vagal episode H) Low blood pressure is not actually pathologic hypotension, but instead a normal variant or some other phenomenon.

To ensure that scans are being performed properly and consistently at all sites included in this study local principal investigators will be responsible for ensuring appropriate training and monitoring of standards for the physicians at their center performing ACES.

The data collected from both Group 1 and Group 2 will then be compared against each other, and follow-up will be conducted to ascertain if the early intervention with ACES had any implications on long-term outcomes.

Results

Given that much of the data interpreted will be comparing numerical values from different strata (Example: Time taken to operating theatre compared between Group 1 and 2), ANOVA testing will be used. The results of the ANOVA test will be used to determine if there is a significant difference in outcome, as measured by 1) Time to restoration (or improvement) of CVS parameters, and 2) Rate of normalization of acid-base balance (using either venous or arterial blood gas), and blood lactate.

For categorical data (Example: Mortality rate between groups), chi-square analyses will be performed to determine statistically significant increase in clinical outcome. This will be done for:

• Significant changes in diagnosis/recommendations in intervention change, and
• Frequency of unexpected diagnosis.

Conclusion

This SRCT (stratified randomized control trial) will determine whether the ACES protocol leads to improved clinical outcomes in patients who present to the ED with undifferentiated, non-trauma associated shock. It will compare intervention with the ACES protocol to intervention with no ultrasound at all.

• Study Type: Interventional
• Enrollment (Actual): 273
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Canada
  • Manitoba
    • Winnipeg, Manitoba, Canada
      • University of Manitoba
  • New Brunswick
    • Saint John, New Brunswick, Canada, E2L 4L2
      • Saint John Regional Hospital
  • Saskatchewan
    • Saskatoon, Saskatchewan, Canada, S7K 0M7
      • Saskatoon Health Region
• South Africa
  • Cape Town, South Africa
    • Khayelitsha Hospital
  • Cape Town
    • Manenberg, Cape Town, South Africa, 7764
      • GF Jooste Hospital
  • Western Cape
    • Cape Town, Western Cape, South Africa
      • Tygerberg Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 19 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• 19 years of age or older
• Systolic Blood Pressure under 100 OR Systolic BP under pulse (up to 120)

Exclusion Criteria:

• Patients known to be pregnant at time of presentation
• Necessity of CPR or other advanced life support interventions before enrolment
• History of significant trauma in past 24 hours
• A 12 lead diagnostic of acute myocardial infarction
• Mechanism of shock is clear (i.e. not undifferentiated shock)
• Previously known diagnosis from other hospital
• Vagal episode (as cause of hypotension)
• Low blood pressure not actually being pathologic hypotension (Normal Variant or other)

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Diagnostic
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
No Intervention: Control; This arm of the study will NOT receive point of care ultrasound. They will receive all other standard care implemented during their visit to the ED (currently, ultrasound is NOT standard of care). The same blood tests will be done in both groups, as this will offer a means of comparing physiological changes between the two arms.
Experimental: Ultrasound; This group WILL receive point of care ultrasound. The protocol they will receive is the ACES protocol (described above).	Device: Ultrasound (A point of care ultrasound protocol); Bedside ultrasound will be used to view any intraperitoneal bleeding, pleural fluid, cardiac abnormalities, or structural abnormalities of major blood vessels. The results of this test will then be used to determine the best course of treatment for the patient.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Patient Mortality Rates (7-day, 30 Day or Hospital Discharge)	Determine the proportion of patients living at 7-day, 30 Day or Hospital Discharge	7-day, 30 Day or Hospital Discharge

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time taken to appropriate intervention	This is a measure that will be done to determine how long after initial diagnosis "appropriate" interventions are taken. This will be done by reviewing the patient's chart, identifying what the ultimate diagnosis for the patient was (resultant of testing that occurs as patient progresses through system), and seeing when propoer intervention was taken.	Within 8 hours
Unexpected change in diagnosis	If ED physician's expectations prior to performing ultrasound is AAA, but post ultrasound diagnosis is septic shock, this would be an example of an unexpected change in diagnosis. This measure will only be performed in the ultrasound group, as the purpose is to identify how often performing ultrasound will result in diagnosis changes.	First hour

Collaborators and Investigators

• Sponsor: Horizon Health Network
• Collaborators: University of Manitoba; University of British Columbia; University of Michigan; Dalhousie University; University of Saskatchewan; Harvard University; University of Stellenbosch; University of Cape Town; Royal College of Emergency Medicine; Canadian Association of Emergency Physicians; Saint Göran Hospital
• Investigators: Principal Investigator: James D Milne, MD (Student), Dalhousie Medical School; Principal Investigator: Paul Atkinson, MD, Saint John Regional Hospital, Horizon Health Network; Study Director: Jacqueline Fraser, BN, Saint John Regional Hospital, Horizon Health Network

Publications and helpful links

General Publications

• Atkinson PR, Milne J, Diegelmann L, Lamprecht H, Stander M, Lussier D, Pham C, Henneberry R, Fraser JM, Howlett MK, Mekwan J, Ramrattan B, Middleton J, van Hoving DJ, Peach M, Taylor L, Dahn T, Hurley S, MacSween K, Richardson LR, Stoica G, Hunter S, Olszynski PA, Lewis DA. Does Point-of-Care Ultrasonography Improve Clinical Outcomes in Emergency Department Patients With Undifferentiated Hypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators. Ann Emerg Med. 2018 Oct;72(4):478-489. doi: 10.1016/j.annemergmed.2018.04.002. Epub 2018 Jun 2.

Study record dates

Study Major Dates

• Study Start (Actual): August 1, 2011
• Primary Completion (Actual): June 1, 2018
• Study Completion (Actual): June 1, 2018

Study Registration Dates

• First Submitted: August 15, 2011
• First Submitted That Met QC Criteria: August 16, 2011
• First Posted (Estimate): August 17, 2011

Study Record Updates

• Last Update Posted (Actual): August 28, 2018
• Last Update Submitted That Met QC Criteria: August 24, 2018
• Last Verified: August 1, 2018

More Information

Terms related to this study

• Keywords: Shock; Hypotension; Emergency care; Point of care Ultrasound
• Additional Relevant MeSH Terms: Pathologic Processes; Heart Diseases; Cardiovascular Diseases; Vascular Diseases; Disease Attributes; Emergencies; Heart Arrest; Hypotension
• Other Study ID Numbers: 2011-1590