1. 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

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

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

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

5. 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

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

7. 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

8. 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 

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

15. 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.