Ultrasound can be useful in the evaluation and diagnosis of patients presenting in shock. Integrating bedside ultrasound allows for a more accurate initial diagnosis and earlier treatment. The RUSH protocol assesses the heart, IVC, pericardial space and lungs to help classify the type of shock. Ultrasound findings of a dilated and collapsing IVC along with evidence of free fluid suggest the patient has hypovolemic shock likely due to internal bleeding.

1. Is ultrasound useful in
shock?
Jo McDonnell

2. Aim
 Highlight what
you could have a
go at…
 Highlight what the
sonoboys could do
for you to help
assess your
patient

3. Shock
Clinical situation where there is
hypoperfusion of the cells and tissues

4. Background
 Patients with shock have high mortality rates and these
rates are correlated to the amount and duration of
hypotension.
 Diagnosis and initial care must be accurate and prompt
to optimise patient outcomes.
 Studies have demonstrated that initial integration of
bedside ultrasound into the evaluation of the patient with
shock results in a more accurate initial diagnosis with
earlier definitive treatment.
 Bedside USS allows direct visualisation of pathology or
abnormal physiological states.

5. Remember…
 Ultrasound is a tool to aid diagnosis, but it won’t tell you
everything…
 When using it we should always have a clinical question you
would like it to answer

6. Case 1:
 75 yo male, unwell, chest pain, SOB, dirty productive cough
 Lung cancer, angina and CCF
 pyrexic at 38.2
 HR 110
 BP 80/50
 Swollen pitting oedema bilaterally

7. Case 1-
What clinical question can the
probe answer for you with this
patient?

8. RUSH

Rapid ultrasound in shock and hypotension- US protocol published
with aim to differentiate classification of shock
 Perera P et al, Emerg Med Clin N Am 2010

H eart

I vc

M orrisons pouch/FAST

A orta

P neumothorax

9. Himap-THE PUMP
 Contractility-
Hyperdynamic LV- sepsis, hypovolaemia
 Hypodynamic- late sepsis, cardiogenic shock
 What’s the RV like? – collapsing? Dilated?

 Obstructive shock
 Gross valvular dysfunction

10. Cardiac assessment

11. Parasternal long axis

Transducer at left sternal
edge between 2nd -4th
intercostal space

Probe marker pointing to
patients R shoulder

Probe aligned along the
long axis: from R shoulder
to cardiac apex.

Useful view to assess
contractility

12. 
Transducer at 4th-6th intercostal
space in the midclavicular to
anterior-axillary line.

Probe directed towards patient’s
right shoulder with the marker
directed towards the left
shoulder.

Important view to give relative
dimensions of L and R ventricle.

Normal ventricular diameter
ratio of R ventricle to L ventricle
is <0.7.

14. Pericardial Tamponade

Remember tamponade is a clinical diagnosis based on
patient’s haemodynamics and clinical picture.

Ultrasound may demonstrate early warning signs of
tamponade before the patient becomes haemodynamically
unstable.

Haemodynamic effects
 Its PRESSURE NOT SIZE THAT COUNTS!
 Rate of formation affects pressure-volume relationship and
is therefore more important than volume of fluid.

15. Tamponade using ultrasound
 A moderate-large effusion.
 Right atrial collapse
 Atrial contraction normal in atrial systole
 Collapse throughout diastole or inversion is abnormal.
 RV collapse during diastole when meant to be filling
(‘scalloping’ seen)
 Whats seen in the IVC…

16. I
h map
 IVC

17. Where to put the probe…
 Probe position
Subxiphoid
 Orientate probe in
longitudinal plane with
probe indicator to
patient’s head
 Slightly to right of
midline


18. Bowel gas causing problems….

19. The FAST view…
 Probe goes longitudinally in right mid axillary line with
marker towards head.
 Look for IVC running longitudinally adjacent to the liver
crossing the diaphragm
 Track superiorly until it enters the RA confirms it’s the IVC not
the aorta

20. Assessing the IVC
 During inspiration, intrathoracic pressure becomes more
negative, abdominal pressure becomes more positive,
resultant increase in the pressure gradient between the
supra and infra-diaphragmatic vena cava, increases
venous return to the heart.
 Given the extrathoracic IVC is a very compliant vessel
this causes diameter of IVC to decrease with normal
inspiration.
 In patients with low intravascular volume, the inspiration
to expiration diameters change much more than those
who have normal or high intravascular volume.

21. Estimating the CVP
Right atrial pressures, representing central venous pressure, can be estimated
by viewing the respiratory change in the diameter of the IVC.

22. American society of Echocardiography
2010 guidelines

24. Subxiphoid long; shocked and dry

27. Subxiphoid transverse view of the IVC
and aorta

28. Complicating the picture
 Valvular disease
 Pulmonary hypertension
 Increased intraabdominal pressure

29. hiMAp
eFAST/Aorta scan

30. himaP
 Multiple studies have shown ultrasound to be more
sensitive than supine CXR for the detection of
pneumothorax.
 Sensitivities ranged from 86-100% with specificities from
92-100%.
 Furthermore USS can be performed more rapidly at the
bedside.
 Detection with ultrasound relies on the fact that free air is
lighter than normal aerated lung tissue, and thus will
accumulate in the nondependent areas of the thoracic
cavity. (ie anteriorly when patient is supine).

31. To get the lung window

Patient should be supine.

Use high frequency linear
array or a phased array
transducer.

Position in the
midclavicular line, 3rd to 4th
intercostal space with
probe oriented
longitudinally.

Position between ribs.

32. Pneumothorax

33. Abdominal and cardiac evaluation with sonography in the
hypotensive patient (ACES)

35. Our case…
 H- no pericardial effusion
 I- 1cm and collapses >50%
 M- Free fluid in the LUQ/RUQ
 Aorta- no AAA
 P – No pneumothorax

36. Next time…Give the probe a go…