1. RUSH: Rapid Ultrasound in Shock

2. RUSH: Overview
Early recognition and treatment of shock decreases mortality
Bedside ultrasound can rapidly evaluate for reversible causes of shock in the undifferentiated patient
Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients.
184 hypotensive pts randomized to early or 15min delayed POC U/S
“Incorporation of a goal-directed ultrasound protocol in the evaluation of nontraumatic, symptomatic, undifferentiated hypotension in adult patients results in fewer viable diagnostic etiologies and a more accurate physician impression of final diagnosis.”
RUSH exam or similar exams has been endorsed by ACEP and Critical Care societies in the diagnosis and resuscitation of critically ill patients
RUSH
“The Pump”
“The Tank”
“The Pipes”

3. Case #1
72yo M presents to ED with sharp pleuritic CP, cough, generalized weakness
PMH: HTN
Meds: Lisinopril, Metoprolol
VS: HR 120, BP 82/60, RR 24, SPO2 93%, T 100.9F
PE: Pale, diaphoretic. Rales in base of lungs b/l

4. Case #2 68yo M presents with weakness, fatigue PMH: HTN
Meds: Lisinopril
VS: T 99.8F, HR 110, BP 86/66, RR 18, SPO2 95%
PE: Obese, Pale, Diaphoretic, Tachycardic with NL S1 S2 no m/r/g and Respiratory exams NL, A and O x3, no focal weakness

5. RUSH: The Pump 1st step is evaluation of the cardiac status
Images: parasternal long, parasternal short, subxiphoid and apical 4 chamber
Evaluating for:
Pericardial effusion, LV contractility, RV Dilation
5 Es: Effusion, Ejection, Equality, Entrance and Exit
Ddx: Cardiac Tamponade, Heart Failure, PE

6. The Pump: Effusion
Evaluating for large effusions causing Tamponade physiology
Pericardial fluid: Anechoic +/- hyperechoic clots
Pitfall: PE with Clot v. fat pad
Pitfall: Pleural effusion v. pericardial effusion
Ant. To posterior pericardial reflection and descending aorta

7. The Pump: Tamponade Physiology
Pericardial effusion causes elevated pressure which prevents the heart from expanding and filling during diastole
Low Pressure RV affected first
Tx: unstable pt with tamponade physiology need emergent Pericardiocentesis
Ultrasound finding:
Inward “serpentine” deflection of RA and RV
RV wall looks like a trampoline
Can progress to complete diastolic collapse
IVC Plethoric

9. The Pump: LV Contractility
LV analyzed for global contractility
Evaluate for severely reduced CO as cause of shock
Critical for guiding fluid resuscitation
A poorly contracting heart will have small percent change in ventricle size between systole and diastole
Hyperkinetic contraction may close the ventricle in systole
Distributive or hypovolemic shock
Global functioning: “Eyeball it”
Good squeeze on gross examination
2) Fractional Shortening
= (EDD-ESD)/EDD
M-mode beyond MV, measuring largest and smallest LV diameters
NL 30-45%
3)E-point septal separation
-ant. MV leaflet distance to septal wall
Less squeeze = less early filling = large EPSS
NL <7mm.
Limitations: MV Stenosis/regurg, Aortic Regurg, LV hypertrophy

11. The Pump: RV Size
Evaluate for RV Strain which can signify a massive PE in the setting of shock
Back pressure in pulmonary arteries causes increase in RV pressure and result in acute dilation of RV
NL ratio of LV: RV is 1:0.6
Septal bowing can indicate RV Strain
D sign on parasternal short

13. The Tank: Intravascular volume status
“Fullness of the Tank” assessed by looking at IVC
Vessel size and respiratory dynamics
Evaluated just beyond Hepatic v. approx. 2cm from RA
IVC diameter < 2.1cm that collapses >50% with sniff correlates to low CVP
Distributive and hypovolemic states
IVC >2.1cm, <50% collapse w/ sniff
Obstructive and cardiogenic states
Can help guide fluid resuscitation
Limitation: Intubated patient 2/2 positive pressure breathing
P. Perera, T. Mailhot, D. Riley, and D. Mandavia, “The RUSH exam: rapid Ultrasound in SHock in the evaluation of the critically ill patient,” Ultrasound Clinics, vol. 7, no. 2, pp. 255–278, 2012

14. The Tank: Leakiness
Hemodynamic compromise due to loss of fluids from vasculature
Hemoperitoneum and Hemothorax
Standard FAST exam combined with Thoracic US looking for B lines
Tank Compromise 2/2 Tension Pneumothorax

15. The Pipes: AAA and Dissection
AAA: Vessel diameter >3cm, in patient with clinical symptoms and hypotension should be assumed to be Ruptured AAA
Aorta retroperitoneal and therefor rupture will be poorly visualized on US
Aortic Dissection: Aortic intimal flap on PS Long with Aortic root >4cm
sensitivity of 67–80% and specificity of 99–100% for dissection
 Fojtik JPaortic d, Costantino TG, Dean AJ. The diagnosis of issection by emergency medicine ultrasound.J Emerg Med. 2007;32:191–6.

16. The Pipes: DVT If thromboembolic event is suspected
Assess venous side of the Pipes
Lack of complete compression at Femoral v. and Popliteal v. sites

19. Multiple approaches Multiple approaches similar to the RUSH exam
ACES, BEAT, BLEEP ,Boyd, EGLS, Elmer, FALLS, FATE, FEEL, FEER, FREE, POCUS, HIMAP, Trinity, UHP
All similar with variation in exam order and prioritization
Dina Seif, Phillips Perera, Thomas Mailhot, David Riley, and Diku Mandavia, “Bedside Ultrasound in Resuscitation and the Rapid Ultrasound in Shock Protocol,” Critical Care Research and Practice, vol. 2012, Article ID , 14 pages, doi: /2012/503254

20. Rapid Ultrasound in Shock Velocity-Time Integral: A Proposal to expand the RUSH Protocol
The goal of RUSH is to evaluate a source of shock
Addition of Stroke Volume to the RUSH protocol as a way to trend a patient’s response to treatment
Fluid responsiveness= inc in SV by greater than 15% after fluid challenge
Contractile reserve= inc in SV by 20% after inotrope
SV approximated by using pulsed wave Doppler at the LVOT to get Velocity-time Integral (Distance)
Velocity-time Integral is measured by the area under the velocity –time curve at the LVOT
LVOT area remains constant so any change in SV results from changes in VTI
SV= LVOT area x VTI
Normal VTI 18-22cm
Blanco, Pablo. "Rapid Ultrasound in Shock (RUSH) Velocity-Time Integral: A Proposal to Expand the RUSH Protocol." Journal of Ultrasound in Medicine, 12 Sept  

21. A: VTI 18 B: VTI 9.69 in Cardiogenic shock c: VTI 29 in septic shock

22. Ref
P. Perera, T. Mailhot, D. Riley, and D. Mandavia, “The RUSH exam: rapid Ultrasound in SHock in the evaluation of the critically ill patient,” Ultrasound Clinics, vol. 7, no. 2, pp. 255–278, 2012
Dina Seif, Phillips Perera, Thomas Mailhot, David Riley, and Diku Mandavia, “Bedside Ultrasound in Resuscitation and the Rapid Ultrasound in Shock Protocol,” Critical Care Research and Practice, vol. 2012, Article ID , 14 pages, doi: /2012/503254
 Fojtik JP, Costantino TG, Dean AJ. The diagnosis of aortic dissection by emergency medicine ultrasound.J Emerg Med. 2007;32:191–6.
Jones, Alan E., et al. "Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients." Critical care medicine 32.8 (2004):
Blanco, Pablo. "Rapid Ultrasound in Shock (RUSH) Velocity-Time Integral: A Proposal to Expand the RUSH Protocol." Journal of Ultrasound in Medicine, 12 Sept