Gestalt for shock and mortality in the emergency department: A prospective study

Abstract

© 2017 Elsevier Inc. Objective: The diagnosis of shock in patients presenting to the emergency department (ED) is often challenging. We aimed to compare the accuracy of experienced emergency physician gestalt against Li's pragmatic shock (LiPS) tool for predicting the likelihood of shock in the emergency department, using 30-day mortality as an objective standard. Method: In a prospective observational study conducted in an urban, academic ED in Hong Kong, adult patients aged 18 years or older admitted to the resuscitation room or high dependency unit were recruited. Eligible patients had a standard ED workup for shock. The emergency physician treating the patient was asked whether he or she considered shock to be probable, and this was compared with LiPS. The proxy ‘gold’ or reference standard was 30-day mortality. The area under the receiver operating curve (AUROC) was used to predict prognosis. The primary outcome measure was 30-day mortality. Results: A total of 220 patients fulfilled the inclusion criteria and were included in the analysis. The AUROC for LiPS (0.722; sensitivity = 0.733, specificity = 0.711, P < 0.0001) was greater than emergency physician gestalt (0.620, sensitivity = 0.467, specificity = 0.774, P = 0.0137) for diagnosing shock using 30-day mortality as a proxy (difference P = 0.0229). LiPS shock patients were 6.750 times (95%CI = 2.834–16.076, P < 0.0001) more likely to die within 30-days compared with non-shock patients. Patients diagnosed by emergency physicians were 2.991 times (95%CI = 1.353–6.615, P = 0.007) more likely to die compared with the same reference. Conclusions: LiPS has a higher diagnostic accuracy than emergency physician gestalt for shock when compared against an outcome of 30-day mortality.