Freidoon Ghazi, MD,FACC,FASCI, FESC TriHealth Heart Institute Quick and Reliable Bedside ultrasound in Diagnosis and Management of Shock Freidoon Ghazi, MD,FACC,FASCI, FESC TriHealth Heart Institute

Definition of shock: A state of hemodynamic collapse due to ineffective circulation of blood

Etiology Of Shock Hypovolemic →→Hemorrhage Cardiogenic →→ Myocardial infarction Obstructive →→ Cardiac tamponade and pulmonary embolism Distributive →→ Sepsis, Pleural effusion, Ascites

Shock In Obstetric Patients: Massive bleeding Myocardial Infarction due to coronary artery dissection Pulmonary embolism Amniotic fluid embolism

Rapid Ultrasound In Shock “ RUSH” Protocol Step 1: The Pump Left ventricular contractility Right ventricular size and contractility Pericardial effusion Step 2: The Tank Assessment of intravascular volume Size of the IVC and vena contract IVC < 2.1 cm that collapses > 50% with inspiration seen in hypovolemic shock IVC > 2.1 cm that collapses <50% seen in pulmonary embolism and cariogenic shock

Rapid Ultrasound In Shock “ RUSH” Protocol, continued Step 3: The Pipes Dissection or rupture of an abdominal aortic aneurysm AAA Deep vein thrombosis DVT

RUSH Protocol Summary: “Pump” Hypovolemic shock: Hypercontractile  heart Small heart size Cariogenic shock: Hypocontractile heart Dilated heart Obstructive shock: Pericardial effusion RV strain in PE Distributive shock: Hypercontractile heart in early sepsis Hypocontractile heart in late sepsis

RUSH Protocol: “Tank” Hypovolemic shock: Obstructive shock: Flat IVC Peritoneal fluid Pleural fluid Cariogenic shock: Distended IVC Flat JV Pleural effusion Obstructive shock: Tamponade and PE Distended IVC Distended JV Distributive Shock: Normal IVC Normal JV Pleural effusion Ascites 

“ Pipes” Hypovolemic shock: Obstructive shock: Distributive shock: AAA rupture Aortic dissection Cariogenic shock: Normal Pipes Obstructive shock: DVT Distributive shock: Normal pipes

conclusion Bedside ultrasound examination is a quick and effective diagnostic tool for many life threatening conditions Early recognition and appropriate treatment of shock decreases mortality. Incorporation of bedside ultrasound in patient with undifferentiated shock allows rapid evaluation of reversible causes of shock. “RUSH” protocol is a valuable tool in the emergency room for quick differentiation of shock etiology and providing life saving treatment.