Rush protocol
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Rush protocol
- 1. RUSH PROTOCOL Rapid Ultrasound in Shock Evaluation of the Critically l ll Majidi Alireza MD Assistant Professor of Emergency Medicine
- 3. Shock can be one of the most challenging issues in emergency medicine suggestive of specific pathology, bedside ultrasound now allows direct visualization of pathology or abnormal physiological states. Thus, bedside ultrasound has become an essential component in the evaluation of the hypotensive patient Majidi Alireza MD.SBMU
- 4. CLASSIFICATION OF SHOCK Majidi Alireza MD.SBMU
- 5. 4 classic subtypes 1. Hypovolemic shock 2. Obstructive shock 3. Distributive shock 4. Cardiogenic shock Majidi Alireza MD.SBMU
- 6. Hypovolemic shock • Nonhemorrhagic Extensive loss of body fluids GI fluid loss from 1. vomiting 2. diarrhea • Hemorrhagic Majidi Alireza MD.SBMU
- 7. Distributive shock 1. Sepsis 2. Neurogenic shock 3. Spinal cord injury 4. Anaphylactic shock 5. Severe allergic response Majidi Alireza MD.SBMU
- 8. Cardiogenic shock Pump Failure 1. Cardiomyopathy 2. Myocardial infarction 3. Acute valvular Majidi Alireza MD.SBMU
- 9. Obstructive Shock 1. Cardiac tamponade 2. Tension pneumothorax 3. Large pulmonary embolus Need an acute intervention: 1. Pericardiocentesis 2. Tube thoracostomy 3. Anticoagulation 4. Thrombolysis Majidi Alireza MD.SBMU
- 11. THE RUSH EXAM •Step 1: The pump •Step 2: The tank •Step 3: The pipes Majidi Alireza MD.SBMU
- 12. The pump • 3 Main Findings • First: pericardial sac(pericardial effusion that may be leading to obstructive shock) • Second: left ventricle (global contractility and size - cardiogenic cause of shock ) • Third: goal-directed examination (focuses on size of the left ventricle to the right ventricle) Majidi Alireza MD.SBMU
- 13. The tank: (IVC) • Placement of the probe: Subxiphoid position Long axis Short axis Respiratory dynamics ‘‘how full is the tank? Majidi Alireza MD.SBMU
- 14. The tank: Internal jugular veins • size and changes in diameter with breathing to further assess volume. Meniscus Majidi Alireza MD.SBMU
- 15. Assessment of the lung 1. Pleural cavity 2. Abdominal cavities 3. Pneumothorax Majidi Alireza MD.SBMU
- 16. The Pipes Clinicians should answer: • Pipes ruptured or obstructed abdominal and thoracic aorta for an aneurysm or dissection • venous side of the vascular system (DVT) Majidi Alireza MD.SBMU
- 17. Evaluation of the Pump Step 1 Majidi Alireza MD.SBMU
- 18. Cardiomyopathy with enlarged heart Subxiphoid view Majidi Alireza MD.SBMU
- 19. large pericardial effusion Parasternal long-axis viewMajidi Alireza MD.SBMU
- 20. Cardiac tamponade Subxiphoid viewMajidi Alireza MD.SBMU
- 21. ‘‘Squeeze of the pump’’ how strong the pump is vigorously contracting ventricle ventricular cavity during systole. poorly contracting heart will have a small percentage change in the movement of the walls between diastole and systole. left ventricular function Majidi Alireza MD.SBMU
- 22. parasternal long-axis view • excellent starting view to assess ventricular contractility • Good= walls of the ventricle contracting well during systole • Poor = endocardial walls changing little in position from diastole to systole • Intermediate = walls moving with a percentage change Majidi Alireza MD.SBMU
- 23. Strain of the pump In the normal : left ventricle is larger than the right ventricle. normal ratio of the left to right ventricle: 1:0.6 Assessment of right ventricular strain large central pulmonary embolus Majidi Alireza MD.SBMU
- 24. Right ventricular strain Parasternal long-axis viewMajidi Alireza MD.SBMU
- 25. Floating thrombus in right atrium Apical view Majidi Alireza MD.SBMU
- 26. THE RUSH EXAM •Step 1: The pump •Step 2: The tank •Step 3: The pipes Majidi Alireza MD.SBMU
- 27. Fullness of the tank evaluation of the inferior cava and jugular veins for size and collapse with inspiration Majidi Alireza MD.SBMU
- 28. low cardiac filling pressures Inferior vena cava sniff test Majidi Alireza MD.SBMU
- 29. M-mode Doppler showing collapsible IVC Inferior vena cava sniff test Majidi Alireza MD.SBMU
- 30. Low Central Venous Pressure Inferior Vena Cava Sniff Test Majidi Alireza MD.SBMU
- 31. High Central Venous Pressure Majidi Alireza MD.SBMU
- 32. 2 < IVC < 2 • IVC <2 cm inspiratory collapse greater than 50% CVP less than 10 cm hypovolemic and distributive shock • IVC >2 cm less than 50% in inspiration CVP more than 10 cm cardiogenic and obstructive shock Majidi Alireza MD.SBMU
- 33. High cardiac filling pressures Inferior vena cava Majidi Alireza MD.SBMU
- 34. High cardiac filling pressures • Cardiogenic and Obstructive shock states Two caveats to this rule exist 1.The first received treatment with vasodilators and/or diuretics prior to ultrasound (IVC may be smaller than prior to treatment . 2.The second caveat exists in intubated patients (positive pressure ) in which the respiratory dynamics of the IVC are reversed. Majidi Alireza MD.SBMU
- 35. Internal jugular veins Patient’s head is placed at a 30 angle • first *The location of the superior closing meniscus is determined by the point at which the walls of the vein touch each other. Similar to the IVC, the jugular veins can also be examined during respiratory phases to view inspiratory collapse. • Veins distended + closing meniscus suggest a higher CVP. Majidi Alireza MD.SBMU
- 37. Meniscus Majidi Alireza MD.SBMU LOW Central Venous Pressure
- 38. Internal Jugular Venous Distention Elevated Central Venous Pressure Majidi Alireza MD.SBMU
- 39. Leakiness of the tank leading to hemodynamic compromise: 1. internal blood loss 2. fluid extravasation 3. other pathologic fluid collections FAST exam and pleural fluid assessment Majidi Alireza MD.SBMU
- 40. Leakiness of the tank • In traumatic conditions 1. Hemoperitoneum 2. Hemothorax ‘‘hole in the tank’’ • In nontraumatic conditions 1. Abdominal (ascites) 2. Chest cavities (pleural effusions) ‘‘tank overload’’ Majidi Alireza MD.SBMU
- 41. FAST: free fluid Right upper quadrant/hepatorenal view Majidi Alireza MD.SBMU
- 44. E-FAST: pleural effusion Left upper quadrantMajidi Alireza MD.SBMU
- 45. ‘‘Tank compromise’’ pneumothorax • According to this theory, severely increased intrathoracic pressure produces mediastinal shift, which kinks and compresses the inferior and superior vena cava at their insertion into the right atrium, obstructing venous return to the heart. Majidi Alireza MD.SBMU
- 46. Normal lung Long-axis view Majidi Alireza MD.SBMU
- 47. Normal lung versus pneumothorax M-modeMajidi Alireza MD.SBMU
- 48. lung sliding presence of lung sliding = rule out pneumothorax absence of lung sliding may be seen in other conditions: 1. Pneumothorax 2. COPD bleb 3. Consolidated pneumonia 4. Atelectasis 5. Mainstem intubation absence of lung sliding, especially as defined in one intercostal space, is not by itself diagnostic of a pneumothorax. Majidi Alireza MD.SBMU
- 49. ‘‘Tank overload’’ pulmonary edema Pulmonary edema often accompanies cardiogenic shock, in which weakened cardiac function causes a backup of blood into the pulmonary vasculature, leading to tank overload. Yet the clinical picture can be misleading, as patients in pulmonary edema may present with wheezing, rather than rales, or may have relatively clear lung sounds. Majidi Alireza MD.SBMU
- 50. Edema with B lines ‘‘lung rockets phased-array transducer Lung ultrasoundMajidi Alireza MD.SBMU
- 51. lung rockets Comet tail artifacts = normal lung ( fade out within a few cm of the pleural line) B lines = extend to the far field B lines + Low cardiac contractility + Plethoric IVC = pulmonary edema Majidi Alireza MD.SBMU
- 52. THE RUSH EXAM •Step 1: The pump •Step 2: The tank •Step 3: The pipes Majidi Alireza MD.SBMU
- 53. Rupture of the pipes aortic aneurysm and dissection Majidi Alireza MD.SBMU
- 54. large abdominal aortic aneurysm Short-axis viewMajidi Alireza MD.SBMU
- 55. Short-axis view: aortic dissection Majidi Alireza MD.SBMU
- 56. Aortic dissection Suprasternal viewMajidi Alireza MD.SBMU
- 57. Clogging of the pipes • Thromboembolic event is suspected as a cause of shock • majority of pulmonary emboli originate from lower extremity DVT venous thromboembolism Majidi Alireza MD.SBMU
- 61. Femoral vein deep venous thrombosis with fresh clot Majidi Alireza MD.SBMU
- 63. The end • For educational ultrasound videos covering all RUSH applications, please go to • http://www.sound-bytes.tv • where a downloadable pocket card on RUSH is also available. Majidi Alireza MD.SBMU
Editor's Notes
- A heart that has an increased size of the right ventricle relative to the left ventricle may be a sign of acute right ventricular strain from a massive pulmonary embolus in the hypotensive patient
- Tension pneumothorax presumably limits venous return into the heart due to increased pressure within the chest cavity.17,18 The lung can also be examined for ultrasonic B lines, a potential sign of volume overload and pulmonary edema. The clinician can further examine the thoracic cavity for a pleural effusion. Last, the clinician can perform a FAST exam (Focused Assessment with Sonography in Trauma examination), to look for fluid in the abdomen, indicating a source for ‘‘loss of fluid from the tank.’’
- The femoral and popliteal veins can be examined with a high frequency linear array transducer for compressibility. Lack of full venous compression with direct pressure is highly suggestive of a deep venous thrombosis (DVT).19,20 Presence of a venous thrombus in the hypotensive patient may signal a large pulmonary thromboembolus.
- Intensive Care patients suffering acute shortness of breath, respiratory failure, or shock have found effusions in as many as 13% of these patients. The apical position at the point of maximal impulse on the left lateral chest wall was chosen in 80% of these procedures, based on these variables. The subxiphoid approach was only chosen in 20% of these procedures, as the investigators recognized the large distance the needle had to travel through the liver to enter the pericardial sac. If the apical approach is selected, the patient should optimally be rolled into a left lateral decubitus position to bring the heart closer to the chest wall, and after local anesthesia, a pericardiocentesis drainage catheter should be introduced over the rib and into the pericardial sac.
- A ventricle that has good contractility will be observed to have a large percentage change from the 2 cycles, with the walls almostcoming together and touching during systole
- left lateral decubitus position and examining from the apical view often gives crucial data on left ventricular contractility. The subxiphoid view can be used for this determination, but the left ventricle is farther away from the probe in this view.
- optimal cardiac views for determining this ratio of size between the 2 ventricles are the parasternal long and short-axis views and the apical 4- chamber view. The The subxiphoid view can be used, but care must be taken to fan through the entire right ventricle, as it is easy to underestimate the true right ventricular size in this view. Any condition that causes pressure to suddenly increase within the pulmonary vascular circuit will result in acute dilation of the right heart in an effort to maintain forward flow into the pulmonary artery. The classic cause of acute right heart strain is a large central pulmonary embolus. Any condition that causes pressure to suddenly increase within the pulmonary vascular circuit will result in acute dilation of the right heart in an effort to maintain forward flow into the pulmonary artery. The classic cause of acute right heart strain is a large central pulmonary embolus.
- Due to the sudden obstruction of the pulmonary outflow tract by a large pulmonary embolus, the right ventricle will attempt to compensate with acute dilation. This process can be seen on bedside echocardiography by a right ventricular chamber that is as large, or larger, than the left ventricle
- In rare cases, intracardiac thrombus may be seen floating free within the heart. Acute right heart strain thus differs from chronic right heart strain in that although both conditions cause dilation of the chamber, the ventricle will not have the time to hypertrophy if the time course is sudden. The EP should also proceed directly to evaluation of the leg veins for a DVT (covered in detail later under ‘‘Evaluation of the pipes’’).
- The ultrasound transducer should be positioned in the epigastric area in a long-axis configuration along the IVC as it runs from the abdomen into the heart. A good way of obtaining this image is to first examine the heart in the subxiphoid 4-chamber plane and then to move the probe into the subxiphoid 2-chamber plane, with the probe marker oriented anteriorly. The IVC should be examined at the junction of the right atrium and the cava and followed 2 to 3 cm caudally along the vessel.
- As the patient breathes, the IVC will have a normal pattern of collapse during inspiration, due to the negative pressure generated in the chest, causing increased flow from the abdominal to the thoracic cavity
- M-mode Doppler, positioned on the IVC, can graphically document the dynamic changes in the vessel caliber during the patient’s respiratory cycle
- *( high-frequency linear array transducer). *-short-axis plane, then long-axis configuration. Ultrasound of the IJ in Dyspnea Ultrasound of the IJ in Dyspnea Study with patient at 45° Find the meniscal level at end expiration Measure height from sternal notch and add 5cm for pressure in cmH20 American Journal of Emergency Medicine 2000;18(4):432) ULTRASOUND OF NECK VEINS WITH NORMAL CVP As the patient with a normal CVP (0 to 10 cm of H2O) assumes a semiupright position, the pressure in the jugular vein falls. At some point in the neck, the extravascular tissue pressure is greater than the local venous pressure and the vessel collapses. In the longitudinal plane, the shape of the IJV in this transitional zone resembles a wine bottle with a wide inferior base tapering to a narrow superior neck (Figure 3). It is in this tapering portion of the IJV that the vein walls will appear to flutter in real-time. This is the site of the jugular venous pulse. The most superior point of this tapering portion is the location of vein collapse and is the sonographic equivalent of the top of the column of blood in the jugular vein. Occasionally, this point has been referred to as a meniscus.2 It is an inaccurate analogy, because a true meniscus does not exhibit this tapering shape. In the sitting position, the patient with a normal CVP will have an IJV that is almost completely collapsed. In the transverse plane it will either be nonvisualized or appear as a small crescent or slit (Figure 4). The IJV will transiently distend with forced expiration or Valsalva but will promptly collapse with normal respiration. In the semiupright position with a normal CVP, the top of the column of blood will be inferior to the clavicles and the IJV will be collapsed in the middle of the neck. The reclining angle must be lowered until the IJV becomes distended. The vein should be visualized by scanning the neck in the transverse plane. The probe is then moved in a superior direction on the neck to locate the point of vein collapse. The point under the transducer on the neck is marked. The vertical distance in cm between this point and the angle of Louis is measured; 5 cm is added to obtain the estimated CVP. ULTRASOUND OF NECK VEINS WITH ELEVATED CVP If the CVP is elevated above 10 cm of H2O, the IJV becomes distended, even in the semiupright position. Scanning the midneck in the transverse plane, the IJV will assume an oval or round appearance. With the patient in a semiupright position it will appear as large or larger than the adjacent CCA (Figure 1). Occasionally, a patient with an extremely elevated CVP (above 20 cm of H2O) must be scanned in the standing position to locate the point of vein collapse between the clavicle and the angle of the mandible. Again, the vertical distance between the point of collapse and the angle of Louis is measured; 5 cm is added to obtain the estimated CVP. ULTRASOUND OF NECK VEINS WITH LOW CVP If the CVP is very low (less than 0 cm of H2O) the vein will appear almost collapsed, even in the supine position. The sonographic appearance will be similar to the patient with a normal CVP in the upright position (Figure 4). TECHNICAL POINTS Several caveats are important when scanning the IJV. Veins are low-pressure vessels and when located superfi- cially are easily compressed. Gentle pressure with the transducer is all that is necessary; too much pressure will collapse the vein and mislead the clinician. Because the examination is performed in real-time, any operator-induced collapse should be obvious. If a high frequency transducer is not available, a lower frequency probe (5 MHz) may be substituted, but image resolution will be poorer. Image depth must be decreased manually to optimally visualize superfi- cial structures. The vessels should be scanned with the head in a neutral position, as the IJV tends to collapse with extension of the neck.12 The point of collapse may fluctuate up and down slightly with normal respiration, as pressure in the central veins is affected by intrathoracic pressure. There is usually a fall of the point of collapse of several cm on normal inspiration.7,13 Mark the point in the neck at endexpiration; this is the same phase of respiration that the CVP is measured with a central catheter and pressure transducer.14 Position the patient so the point of vein collapse is located in the middle third of the neck. The IJV, even with a normal CVP, may be distended at the base of the neck. This is because the vessel is splinted open by the negative intrathoracic pressure as it enters the chest cavity. This is also where thin, mobile valves in the IJV are often located. e thyroid gland is located medial to the vessels low in the neck. Cysts and nodules are common and are usually clinically insignificant. Always start by scanning the right IJV but confirm findings by examining the contralateral vein. If the patient has had previous neck surgery, IJV cannulation, or irradiation, the vein may not distend normally with elevated pressure. ROLE OF JUGULAR VENOUS ULTRASOUND Ultrasound of the internal jugular vein is probably the easiest examination for the novice sonographer to master. However, not every patient needs an ultrasound examination of his or her jugular vein. As clinicians, it is important to perform an adequate visual inspection of the jugular pulse.15 Nonetheless, there are situations with some patients where the physical examination does not furnish the information needed. Bedside sonography performed by emergency physicians provides immediate, important information that would otherwise require the use of invasive catheters.
- The peritoneal cavity can be readily evaluated with bedside ultrasound for the presence of an abnormal fluid collection in both trauma and nontrauma states. This assessment is accomplished with the FAST exam.
- The FAST exam has been reported to detect intraperitoneal fluid collections as small as 100 mL, with a range of 250 to 620 mL commonly cited. The overall sensitivity and specificity of the FAST exam have been reported to be approximately 79% and 99%, respectively
- Aiming the probe above the diaphragm will allow for identification of a thoracic fluid collection. If fluid is found, movement of the probe 1 or 2 intercostal spaces cephalad provides a better view of the thoracic cavity, allowing quantification of the fluid present. Pleural effusions often exert compression on the lung, causing ‘‘hepatization,’’ or an appearance of the lung in the effusion similar to a solid organ, like the liver.
- The pleural line consists of both the visceral and parietal pleura closely apposed to one another. In the normal lung, the visceral and parietal pleura can be seen to slide against each other, with a glistening or shimmering appearance, as the patient breathes
- This lung sliding motion can be graphically depicted by using M-mode Doppler. A normal image will depict ‘‘waves on the beach,’’ with no motion of the chest wall anteriorly, represented as linear ‘‘waves,’’ and the motion of the lung posteriorly, representing ‘‘the beach’’ In pneumothorax, the pleural line seen consists only of the parietal layer, seen as a stationary line. M-mode Doppler through the chest will show only repeating horizontal linear lines, demonstrating a lack of lung sliding or absence of the ‘‘beach’’
- The clinician can examine through several more intercostal spaces, moving the transducer more inferiorly and lateral, to increase the utility of the test. This maneuver may also help identify the lung point, or the area where an incomplete pneumothorax interfaces with the chest wall, as visualized by the presence of lung sliding on one side and the lack of lung sliding on the other. Comet tail artifact is a form of reverberation echo that arises from irregularity of the lung surface. This phenomenon appears as a vertical echoic line originating from the pleural line and extending down into the lung tissue. The presence of comet tail artifact rules out a pneumothorax.80 The combination of a lack of lung sliding and absent comet tail artifacts strongly suggests pneumothorax.
- To assess for pulmonary edema with ultrasound, the lungs are scanned with the phased-array transducer in the anterolateral chest between the second and fifth rib interspaces. Detection of pulmonary edema with ultrasound relies on seeing a special subtype of comet tail artifact, called B lines. These B lines appear as a series of diffuse, brightly echogenic lines originating from the pleural line and projecting in a fanlike pattern into the thorax (described as ‘‘lung rockets’’).
- Blines result from thickening of the interlobular septa, as extravascular water accumulates within the pulmonary interstitium.81,83 The presence of B lines coupled with decreased cardiac contractility and a plethoric IVC on focused sonographic evaluation should prompt the clinician to consider the presence of pulmonary edema and initiate appropriate treatment.
- Pipes’looking first at arterial side of circulatory system and then at the venous side. Vascular catastrophes, such as ruptured abdominal aortic aneurysms (AAA) and aortic dissections, are life-threatening causes of hypotension. A ruptured AAA is classically depicted as presenting with back pain, hypotension, and a pulsatile abdominal mass. However, fewer than half of cases occur with this triad, and some cases will present with shock as the only finding.
- Application of steady pressure to the transducer to displace bowel gas, while sliding the probe inferiorly from a position just below the xiphoid process down to the umbilicus, allows for visualization of the entire abdominal aorta. The aorta should also be imaged in the longitudinal orientation for completion. Measurements should be obtained in the short axis, measuring the maximal diameter of the aorta from outer wall to outer wall, and should include any thrombus present in the vessel. A measurement of greater than 3 cm is abnormal and defines an abdominal aortic aneurysm
- Sonographic findings suggestive of the diagnosis include the presence of aortic root dilation and an aortic intimal flap. The parasternal long-axis view of the heart permits an evaluation of the proximal aortic root, and a measurement of more than 3.8 cm is considered abnormal. An echogenic intimal flap may be recognized within the dilated root or anywhere along the course of the thoracic or abdominal aorta
- The suprasternal view allows imaging of the aortic arch and should be performed in high-suspicion scenarios by placing the phased-array transducer within the suprasternal notch and aiming caudally and anteriorly. Color flow imaging can further delineate 2 lumens with distinct blood flow, confirming the diagnosis. Abdominal aortic ultrasound may reveal a distal thoracic aortic dissection that extends below the diaphragm, and in the hands of skilled sonographers has been shown to be 98% sensitive.
- As the majority of pulmonary emboli originate from lower extremity DVT, the examination is concentrated on a limited compression evaluation of the leg veins. Simple compression ultrasonography, which uses a high frequency linear probe to apply direct pressure to the vein, has a good overall sensitivity for detection of DVT of the leg.97 An acute blood clot forms a mass in the lumen of the vein, and the pathognomonic finding of DVT will be incomplete compression of the anterior and posterior walls of the vein. The proximal femoral vein just below the inguinal ligament is evaluated first, beginning at the common femoral vein, found below the inguinal ligament. Scanning should continue down the vein through the confluence with the saphenous vein to the bifurcation of the vessel into the deep and superficial femoral veins. The second area of evaluation is the popliteal fossa. The popliteal vein, the continuation of the superficial femoral vein, can be examined from high in the popliteal fossa down to trifurcation into the calf veins. If an upper extremity thrombus is clinically suspected, the same compression techniques can be employed, following the arm veins up to the axillary vein and into the subclavian vein. Although a good initial test, the sensitivity of ultrasound for proximal upper extremity clots is lower than for lower extremity clots, as the subclavian vein cannot be fully compressed behind the clavicle.104 Although clinically less common, an internal jugular vein thrombosis that may form in a patient with a previous central line can also be well seen with ultrasound.