Ultrasound: In Shock and Hypotension

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Background

  • Several techniques are available for differentiating shock states
  • RUSH Protocol was conceived in 2008 and looks are 3 basic aspects of physiology[1]
  1. The Pump
  2. The Tank
  3. The Pipes

The Protocol

Step 1: The Pump
Step 2: The Tank
Step 3: The Pipes

Rapid Ultrasound for Shock and Hypotension(RUSH) using the HI-MAP approach[2]

  • H - Heart (parasternal and four-chamber views)
  • I - Inferior Vena Cava (for volume responsiveness)
  • M - Morison’s pouch (i.e., FAST exam) and views of thorax (looking for free fluid)
  • A - Aortic Aneurysm (ruptured abdominal aneurysm)
  • P - Pneumothorax (i.e., Tension pneumothorax)

Heart

Technique: see Cardiac ultrasound

  • Pericardial Effusion
    • Parasternal long
    • Change in size <30% between sys and dia = poor LV function
  • RV collapse
    • In 4-chamber view, RV should be <60% of LV; if larger think RV failure
  • Hyperdynamicity
    • Walls move >90% or touch at end of systole
      • May indicate hypovolemia or sepsis

IVC

Technique: see IVC ultrasound

  • Measure 2cm from RA-IVC junction
  • If IVC <1.5cm and collapses on inspiration then CVP is low
  • If IVC >2.5cm and noncollapsing then CVP is high
    • Suggests fluid unresponsive; patient requires inotropes

Morison's

Technique: see FAST exam

  • Assess for free fluid
    • Morison's pouch
    • Splenorenal
    • Bladder

Aorta

Technique: see Aortic ultrasound

  • If >5cm assume ruptured AAA until proven otherwise

Pulmonary

Technique: see Ultrasound: Lungs

  • Assess for subpleural interstitial edema
    • Look for multiple comet tail artifacts or "B lines"(a few, 3-4, are OK)
      • If multiple found, there is interstitial edema
  • Assess for pneumothorax
    • Scan longitudinally in anterior 2nd-3rd IC space, mid-clavicular line
    • Look for lack of sliding or "beach sign"

Other

Classic Ultrasound Findings For Critically Ill Patients

Disease IVC Cardiac Lung (Phased Array) Lung (Linear)
MI Focal WMA
Mod/Poor squeeze
NL or B-lines Sliding
Tamponade RA collapse with filling
RV collapse with filling
NL Sliding
PTX NL or Hyperdynamic Lung point
Consolidated lung
Absent lung sliding
Sepsis Hyperdynamic squeeze NL (see pneumonia) Sliding
Pneumonia NL or ↓ Hyperdynamic squeeze Unilateral B-lines Sliding
Decompensated HF Mod/Poor squeeze Bilateral B-lines Sliding
PE RV > LV
McConnell's sign
NL or Unilateral B-lines Sliding

Video

See Also

References

  1. Weingart - http://emcrit.org/ultrasound/The%20RUSH%20Examfinal.htm
  2. Dina Seif. Bedside Ultrasound in Resuscitation and the Rapid Ultrasound in Shock Protocol Critical Care Research and Practice Vol 2012 http://downloads.hindawi.com/journals/ccrp/2012/503254.pdf