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Clinical examination for diagnosing circulatory shock

Hiemstra, Bart; Eck, Ruben J.; Keus, Frederik; van der Horst, Iwan C.C.

Current Opinion in Critical Care: August 2017 - Volume 23 - Issue 4 - p 293–301
doi: 10.1097/MCC.0000000000000420
CARDIOVASCULAR SYSTEM: Edited by Thomas W.L. Scheeren

Purpose of review In the acute setting of circulatory shock, physicians largely depend on clinical examination and basic laboratory values. The daily use of clinical examination for diagnostic purposes contrasts sharp with the limited number of studies. We aim to provide an overview of the diagnostic accuracy of clinical examination in estimating circulatory shock reflected by an inadequate cardiac output (CO).

Recent findings Recent studies showed poor correlations between CO and mottling, capillary refill time or central-to-peripheral temperature gradients in univariable analyses. The accuracy of physicians to perform an educated guess of CO based on clinical examination lies around 50% and the accuracy for recognizing a low CO is similar. Studies that used predefined clinical profiles composed of several clinical examination signs show more reliable estimations of CO with accuracies ranging from 81 up to 100%.

Summary Single variables obtained by clinical examination should not be used when estimating CO. Physician's educated guesses of CO based on unstructured clinical examination are like the ‘flip of a coin’. Structured clinical examination based on combined clinical signs shows the best accuracy. Future studies should focus on using a combination of signs in an unselected population, eventually to educate physicians in estimating CO by using predefined clinical profiles.

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Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

Correspondence to Iwan C.C. van der Horst, Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30.001, 9713 GZ Groningen, The Netherlands. Tel: +31 50 361 5617; e-mail:

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