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The Speed of Sound

The Speed of Sound

A Game Changer and a Lifesaver for Sepsis

Butts, Christine MD

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doi: 10.1097/01.EEM.0000508280.67891.55
    Figure
    Figure:
    Ultrasound appearance of pneumonia with CT of the same area for comparison. The lung shows “hepatization,” in which the parenchyma begins to resemble the sonographic texture of liver. Air bronchograms can be seen within the consolidated area as the hyperechoic (bright white) areas.
    Figure
    Figure

    Ultrasound in diagnosing sepsis up until this point has primarily focused on volume resuscitation. Identifying those who are volume depleted and those who may respond to fluids has been the focus of a number of studies. A missing factor in these evaluations is getting to the root of the problem: identifying the source of sepsis. This is key as source control, and starting the appropriate antibiotic is critical in limiting mortality.

    The source diagnosis may be easily identified in patients with clear symptoms (cough, dysuria) and findings of systemic inflammatory response syndrome (tachycardia, tachypnea, fever, alterations in white blood cell count). The diagnosis may be less obvious in many patients, however, causing a delay in identifying the correct source and starting the right antibiotic.

    Where does ultrasound fit into all this? An article recommended by Anand Swaminathan, MD, in Life in the Fast Lane noted that POCUS swoops in for the win on this one. (http://bit.ly/2cCyXsn.) Several sonographically minded physicians in Italy recently looked at the use of bedside ultrasound in patients with suspected sepsis, with some promising findings. Cortellaro, et al., evaluated all patients presenting with suspected sepsis, as defined by the Surviving Sepsis Campaign. (Intern Emerg Med 2016 May 28 [Epub ahead of print].) These patients were evaluated with an initial clinical assessment (history and physical exam, ABG, lactate) to establish a presumptive source. This initial assessment was followed by a bedside ultrasound to establish or confirm a suspected source.

    This initial ultrasound was performed by the treating physician within 10 minutes of the initial assessment and included evaluation of the area of suspected source (patients with a cough, for example, had a lung ultrasound) or a more extensive scan in those with less pointed symptoms. The patient then underwent a standard workup and treatment, including further imaging as appropriate. The results of the initial bedside ultrasound diagnosis were compared with the ultimate diagnosis, as determined by chart review by independent physicians.

    The results were promising, with a sensitivity and specificity for identifying the correct source of 73% and 95%, respectively, for bedside ultrasound versus 48% and 89% for the initial clinical assessment. Overall, the use of ultrasound improved the accuracy of diagnosis by 22 percent. What's most interesting and probably the game changer of the study is that 130 of 178 diagnoses (73%) were correctly identified by ultrasound, and all of them were identified within 10 minutes after the initial assessment. The standard workup, in contrast, identified only 21 percent of the sources within one hour and only half within three hours.

    The study isn't perfect (it was not randomized or blinded), and the operators are highly skilled in bedside ultrasound, perhaps much more so than the average emergency physician. Determining whether this study protocol could be generalized to a fast-paced, community ED remains to be seen. Any advantage would seem to be worth implementing, however, with the emphasis on identifying and treating septic patients as quickly as possible. Identifying the source in these patients and starting the right antibiotic rapidly could be not just a game changer but a lifesaver.

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