Ultrasound (US)-- “resuscitative.” Patients with hypotension or shock Ultrasound is ideal for the evaluation of critically ill patients in shock, and ACEP guidelines Direct visualization of pathology and differentiation of shock states. The RUSH Protocol first introduced in 2006 by Weingart SD et al, and later published in It was designed to be a rapid and easy to perform US protocol (<2 min) by most emergency physicians.RUSH Protocol

What US probes do you need for the RUSH protocol? Phased-array probe ( MHz) Linear probe (7.5 – 10 MHz) What are the components of the RUSH protocol? The components of the RUSH exam are: Heart, Inferior vena cava (IVC), Morrison’s/FAST abdominal views, Aorta, and Pneumothorax (HI-MAP). A more simple method is to think of: Pump (Heart): Tamponade, LVEF, and RV size Tank (Intravascular): IVC, thoracic and abdominal compartments Pipes (Large Arteries/Veins): Aorta and femoral/popliteal veins

Summary Table Resuscitation 2013 conference

How do you evaluate the PUMP? Component: Heart (parasternal long axis view) Probe: Phased array probe ( MHz) Location: Just left of the sternum, 3rd and 4th intercostal space Finding: Pericardial effusion (tamponade) Small effusions are best identified posterior to left ventricle (dependent portion of pericardium) Can find compression of the right ventricle (Singh S et al Sens 92%, Spec 100%, PPV 100%)Singh S et al

Finding: Left ventricular ejection fraction estimation Look at anterior leaflet of mitral valve, which should normally touch septum <30% difference of LV size between systole and diastole indicates severely decreased LV function Finding: Right ventricular strain Normally RV should be 60% of LV size (If RV = LV size, this is abnormal) Lodato JC et al: If McConnell Sign (reduction in RV free wall motility with sparing of the apex) is present, specificity for PE is 96%, but sensitivity is 16%. Lodato JC et al

Component: Heart (Subxiphoid) Probe: Phased array probe ( MHz) Location: Subxiphoid, point toward left scapula

How do you evaluate the TANK? Component: Inferior Vena Cava Probe: Phased array probe ( MHz) Location: Subxiphoid, slide to patient's right Finding: Intravascular volume estimation IVC <2 cm in diameter and inspiratory collapse greater than 50% approximates CVP <10 cmH20 IVC >2 cm in diameter and inspiratory collapse less than 50% approximates CVP >10 cmH20 Not applicable for intubated patients. Spontaneously breathing patients create negative intrathoracic pressure. ventilated patients create positive intrathoracic pressure.

Component: FAST abdominal views Probe: Phased array probe ( MHz) Location: Hepatorenal recess, Splenorenal recess, and bladder Finding: Internal blood loss

Component: Pneumothorax Probe: Linear probe (7.5 – 10 MHz) Location: Midclavicular line, 3rd – 5th intercostal space Finding: Intrathoracic compromise Normal: Should see lung sliding and comet tails. M-Mode will look like "waves on a beach". Pneumothorax present: NO lung sliding and NO comet tails. M-Mode will look like a "bar graph" (no beach).

How do you evaluate the PIPES? Component: Aorta Probe: Phased array probe ( MHz) Location: Longitudinal and transverse views of aorta at 4 levels (infracardiac, suprarenal, infrarenal, and right at the iliac bifurcation) Measurement >3 cm is abnormal. If >5 cm consider ruptured AAA if no other cause found. Most AAAs located below the renal arteries

RUSH protocol to medical patients EFAST exam to trauma patients.