A 74-year-old man presented to the emergency department with general weakness, anorexia, and abdominal pain. His blood pressure was low at 90/p and heart rate was 100. An ultrasound was performed which showed signs of cardiogenic shock, including a dilated inferior vena cava and reduced ejection fraction of 30%. Based on the ultrasound findings and hemodynamic instability, fluid resuscitation was not recommended and vasopressor or inotrope support would be needed to increase blood pressure in this case of cardiogenic shock.

1. Point of Care Ultrasound
in
Critically ill patients (Shock)
- RUSH Exam
- BLUE Protocol
Dr. AliReza Bahmani
(Assistant Professor of Emergency Medicine)
(Evidence-Base-Medicine Fellowship)
Point of Care Ultrasound Instructor)
)
- Diagnosis
- Treatment

2. The “RUSH Exam” (Rapid Ultrasound for Shock and Hypotension), first introduced by Weingart et al in
2006, is designed to provide a quick bedside assessment of a patient with undifferentiated shock.
With the use of the RUSH protocol, the potential etiologies of shock can be quickly narrowed down.
It has been available on emcrit.org since
March 2008 and was the first hit on a
google search of 'RUSH Exam' from this
date on.

3. The RUSH protocol is a rapid evaluation of cardiac function
and key vascular structures for the diagnosis of sources
Hypotension

4. The RUSH protocol is a rapid evaluation of cardiac
function and key vascular structures for the
diagnosis of sources Hypotension (J. Ultrasound Med,2015)

5. Step-By-Step RUSH Exam protocol
Step 1: Heart
Ejection Fraction Assessment
Observe the left ventricle throughout the cardiac cycle. Is it
hyperdynamic or hypodynamic? Does it squeeze uniformly?
Next, note the anterior leaflet of the mitral valve. Does it move
freely and approach the interventricular septum with each diastolic
filling? If not, the heart’s contractile function may be impaired and
the patient may be experiencing an exacerbation of systolic heart
failure resulting in hypotension.
If the heart appears hyperdynamic, the source of hypotension may
be related to hypovolemia or sepsis.
This can be determined by continuing to evaluate the patient
using the rest of the RUSH exam.

6. Hyperdynamic
or
Hypodynamic?
American College of Cardiology
(ACC) that is used clinically as
follows:
Hyperdynamic = LVEF
greater than 70%
Normal = LVEF 50% to 70%
(midpoint 60%)
Mild dysfunction = LVEF 40%
to 49% (midpoint 45%)

7. Does it squeeze
uniformly?
Regional Wall Motion
Abnormality -> Myocardial
Infarction

8. Next, note the anterior leaflet of the mitral valve.
Does it move freely and approach the interventricular
septum with each diastolic filling?
The formula that was derived from their calculations
[LVEF = 75.5 – (2.5 x EPSS)]
allows EPSS to be utilized as a continuous variable in assessing LV
function as opposed to the dichotomous classification of “normal” or
“abnormal” provided by previous EPSS researchers (Silverstein, 2006)

9. ‘Eyeball’ ejection fraction?

10. Right Ventricular Strain
Pulmonary Embolism
The RV chamber normally size should be about ⅔ the size of the LV chamber.
• If you notice an increase in this ratio, or bowing of the interventricular septum towards the left side of the
heart, this may indicate RV strain Look out for McConnell’s Sign which is hypokinesis of the right ventricular
free wall with sparing of the Apex.
• You can also look for the “D Sign” on the parasternal short axis view and occurs when the increased pressure
of the RV pushes the interventricular septum into the LV

11. In addition to comparison of
chamber size, one can further
quantify RV function by using
Tricuspid Annular Plane Systolic
Excursion (TAPSE).
A normal TAPSE is generally
20mm or greater.
A TAPSE less than 16mm is
concerning for RV strain.

14. Note that the presence of any of the above-
mentioned findings is suggestive of RV strain
and not specific to PE.
If any evidence of right heart strain is found,
the exam should proceed directly to the
evaluation of the legs to scan for a possible
deep vein thrombosis by looking for a
noncompressible vein. Findings of DVT in
the setting of RV strain will greatly increase the
chances the patient has a significant pulmonary
embolism

16. Pericardial Effusion and Tamponade
• Pericardial effusion with Tamponade is another cardiac pathology you
should screen for in the RUSH Protocol.
• Look at the border of the heart. Is there a significant anechoic border
surrounding it? If so, a pericardial effusion is likely.
• Be sure to distinguish a pericardial effusion from a pleural effusion by
identifying the location of the fluid with help from the descending aorta.
Anechoic fluid anterior to the descending aorta is a pericardial effusion,
whereas fluid posterior to the descending aorta is a pleural effusion.

18. Bp: 70/p

19. Pericardial Effusion and Tamponade
A sonographic finding with strong specificity for cardiac tamponade is right ventricular wall
collapse during DIASTOLE , Remember that Diastole is when the mitral valve is OPENING
toward the septum

21. Note that a pericardial fat pad can mimic a pleural effusion so
it is important to distinguish between the two.
Fat is usually more anterior, less mobile, and more echogenic
than the fluid of an effusion.

22. Cardiac Output Assesment
You can also measure the patient’s cardiac output during the RUSH Exam to help
determine the type of Shock a patient is in.
This is a more advanced technique and can be done by measuring the Left Ventricular
Outflow Tract Diameter and the Velocity Time Integral (VTI) to calculate the cardiac
output.
Type of Shock
LV Ejection
Fraction
Cardiac Output IVC
Distributive High High Collapsible
Obstructive Normal/High Low Noncollapsible
Cardiogenic Low Low Noncollapsible
Hypovolemic High Low Collapsible

23. Step 2: IVC
The next part of the RUSH Exam, we look at the Inferior Vena Cava (IVC) to
assess the patient’s central venous pressure (or right atrial pressure).
Is there a leak somewhere causing hypotension? Is there fluid overload that is
causing the heart to not pump adequately? In the context of shock, we also want to
know whether CVP is high or low. This will further categorize the likely type of
shock.
The IVC measurement is mostly used to assess fluid tolerance rather than fluid
responsiveness. Using the IVC collapsibility Index (below), the diameter and
collapsibility during inspiration or with a sniff test can be used to estimate CVP
IVC Diameter (cm)
Percent
Collapsible (%)
Estimated CVP
(mmHg)
<
1.5 >
50 0
-
5
1.5
-
2.5 >
50 6
-
10
1.5
-
2.5 <
50 11
-
15
>
2.5 <
50 16
-
20
Type of Shock
LV Ejection
Fraction
Cardiac Output IVC
Distributive High High Collapsible
Obstructive Normal/High Low Noncollapsible
Cardiogenic Low Low Noncollapsible
Hypovolemic High Low Collapsible

24. A high CVP suggested by a dilated and noncollapsible IVC may hint
towards an obstructive or cardiogenic etiology.
A low CVP suggested by a small and collapsible IVC may hint towards a
distributive or hypovolemic etiology.

25. Step 3: Morison’s Pouch/eFAST

26. Step 4: Aorta
A Abdominal Aortic Aneurysm (AAA).
Ruptured abdominal AAA can lead to severe hypotension, especially in elderly patients presenting with acute
abdominal pain. A ruptured AAA has a very high mortality.
A normal aorta is usually ~2.0cm in diameter. An abdominal aortic aneurysm is defined as: (Mokashi)
≥ 3cm diameter for the abdominal aorta or a > 50% increase in the aortic diameter.
≥ 1.5cm diameter for the iliac arteries.
Anytime a patient presents with a AAA of >/= 5cm and hypotension, assume a rupture until proven otherwise.
Be sure to measure Outer wall to Outer wall for accurate aorta measurements.
Aortic Dissection.
Transthoracic Echocardiography (TTE) can be used to try to detect dissections and are specific but not
very sensitive.
If there is a high clinical suspicion for aortic dissection and the TTE is negative, you may need to proceed
with Transesophageal Echocardiography (TEE) or a CT angiogram (it patient is stable enough).
An aortic dissection may present as a free flap in the aortic lumen of either the descending abdominal
aorta, ascending aorta, and/or the aortic arch.

29. Step 5: Pulmonary
Here are three important steps to evaluating for pneumothorax:
First, if lung sliding is present, you can rule out pneumothorax with 100% accuracy at that
ultrasound point (Husain LF).
Remember that presence of lung sliding only rules out pneumothorax at that specific point you
are scanning. Make sure to maximize your sensitivity by scanning multiple points on the chest.

30. Second, if lung sliding is ABSENT, you should not
automatically assume pneumothorax.
Recall other causes of reduced/absent lung sliding: severe
consolidation, acute infectious or inflammatory states, fibrotic
lung diseases, acute respiratory distress syndrome, or mainstem
intubation.

31. Third, if a lung point is present, you can rule in pneumothorax
with 100% accuracy (Chan S).
To confirm the presence of a pneumothorax, you should look for
the “Lung Point Sign.“
The lung point is when you can see the transition between normal
lung sliding and the absence of lung sliding. The Lung point sign
also helps you quantify how large a pneumothorax is.

32. Summary of types of shock
Type of Shock
LV Ejection
Fraction
Cardiac Output IVC
Distributive High High Collapsible
Obstructive Normal/High Low Noncollapsible
Cardiogenic Low Low Noncollapsible
Hypovolemic High Low Collapsible

35. DDX?

37. Narrowing the
Differential Diagnosis
with Ultrasound
ACLS guidelines organize
reversible causes of cardiac
arrest into the mnemonic
of
“Hs and Ts.”

38. Hi-MAPS, adding stomach (S) to the RUSH protocol in
undifferentiated hypotension and shock to evaluate upper GI
bleeding.

39. BLUE (bedside lung ultrasound in emergency)
protocol

42. Case 1
58 y.o man with a history of Sever Covid 19, 4 months ago, came
to the emergency room for weakness and Palpitation.
- Bp: 80/ 65 PR: 135 Spo2: 88 %
No history of ACS and HTN

45. Bp: 110/70
Time :20:00

48. Bp: 70/p

50. Apical approach
• The apical pericardiocentesis approach reduces
the risk of cardiac complications by taking
advantage of the proximity to the thick-walled
left ventricle and the small apical coronary
vessels. However, proximity to the left pleural
space increases the risk for pneumothorax.
• The apical insertion site is at least 5 cm lateral to
the parasternal approach within the fifth, sixth,
or seventh intercostal space. Advance the
needle over the cephalad border of the rib and
towards the patient's right shoulder.
• Once fluid is aspirated, stop advancing.
• If ventricular irritability coincides with the
advancement of the needle, stop advancing and
withdraw slowly.
• Post procedure, assess for pneumothorax.

51. Preparations are made
for emergent
pericardiocentesis. The
largest pocket of fluid is
visualized just medial to
the left midclavicular
line in the fifth
intercostal space.
Under ultrasound
guidance, a long Angio
catheter is placed into
the pericardial sac, and
200 mL of serous fluid
are removed.

52. Case
A 22-year-old female is brought in by ambulance after
collapsing in the shower at 5 am.
She is pale and lethargic. Vital signs are significant for a heart
rate of 135 and a blood pressure of 70/palp.
The physical exam is remarkable for pallor, poor inspiratory
effort, and lower quadrant abdominal distension.

53. What Type of Shock
Distributive: Septic shock
Cardiogenic
Hypovolemic/Hemorrhagic
Obstructive : Cardiac Tamponade / pulmonary
Embolus / Tension pneumothorax

60. As staff quickly draw blood and insert IV lines, a bedside
ultrasound is performed.
- No pericardial effusion is visualized,
- Right heart size is smaller than left,
- The left ventricle is markedly hyperdynamic.
- The IVC is small and collapsing completely with respiration.
- The FAST scan reveals free fluid in Morison’s pouch and
pelvis as well as a slightly enlarged yet empty uterus.

61. Operating Room
A right interstitial ectopic pregnancy is removed while 3 L
of blood are suctioned from the abdomen. A partial
hysterectomy is performed to preserve the patient’s
fertility.

62. Case
A 16-year-old male presents with the acute onset of left-
sided chest pain after falling from a 2 meter height tree.
he has had significant dyspnea, which worsens when he is
in the supine position.
He is tachycardic and tachypneic and pale on
examination. His lung examination is difficult and limited,
secondary to poor effort by the patient, given significant
pain on inspiration. Weak peripheral pulses.
Bp 60/p

66. A point-of-care ultrasound is immediately performed, which
reveals a large, left-sided pneumothorax.
The patient was given oxygen and needle Thoracentesis.
Chest tube inserted immediately , a repeat lung ultrasound is
performed, which shows normal lung sliding with the
“seashore” sign on M-mode
But still blood pressure stayed low

67. What HIMAP parts we left
behind?!?!?
?

70. We forgot the FAST

71. Oops!!!

72. Case
A 36-year-old woman with no history of the disease was admitted
to Emergency Department after he had a syncopal episode in his
home.
The patient was in his usual good state of health until he suddenly
collapsed while standing and lost consciousness for approximately
five minutes.
He recovered spontaneously but was extremely weak and
dyspneic.

76. Obstructive
Shock

77. Schematic-of-echocardiographic-findings-in-acute-pulmonary-embolism-RVOTright

81. 57 y.o woman with Dyspnea and
weakness,
Auricle or Clot?
Tips and tricks

82. Case
A 74-year-old retired man was brought to the emergency
department with :
General weakness
Anorexia
Abdominal pain.
Bp: 90/p PR: 100
History : DM+ , HTN +

89. Case
A 77-year-old man presented to the emergency
department with fever.
His medical history included treated hypertension and
hypercholesterolemia, he was drowsy and confused when
roused and was peripherally cold with cyanosis.
The systemic arterial blood pressure was 75/50 mm Hg,
and the heart rate was 125 beats per minute.

96. Case
A 70 years old man brought to the emergency department
with shortness of breath and chest pain
Bp 100/60 HR: 90 RR 17
No Fever
Vague history of COPD or CHF

105. Cardioigenic shock with Pulmonary Edema

106. Case
A 60-year-old male is brought in by ambulance after
collapsing in the Hotel, He is pale and lethargic. Vital signs
are significant for a heart rate of 150 and a blood pressure of
60/p.

107. EPSS: 20 mm, EF: 3o%

108. Cardiogenic Shock

109. Accurate Management of Hemodynamics with Echocardiography :
Fluid? Vasopressor? Inotrope?
Which one is your choice for Hemodynamic Management?
Bp: 70 /p IVC: Dilated EF: 30
Cardiogenic Shock

110. Fluid or Vasopressor or Inotrope ???
How can we calculate SVR ?
SVR is calculated by subtracting the central venous pressure (CVP) from the
mean arterial pressure (MAP) , divided by the cardiac output and multiplied
by 80.
Normal SVR is 700 to 1,500 dynes/seconds/cm-5.
Here’s an example:
- If a patient's MAP is 68 mmHg,
his CVP is 12 mmHg,
and his cardiac output is 4.3 L/minute,
his SVR would be 1,042 dynes/sec/cm-5.

112. - CSA : 3.14 VTI: 19 → SV: 60 cc
- HR : 100 Cardiac out put : 6 L/min
- MAP : 55 mmHg
- CVP with IVC size : 20 mmHg
- SVR = 460 dynes/sec/cm-5
What do you do now?
- Fluid?
- Vasopressor??
- Inotrope???

113. A 56-year-old man with a history of COPD was
admitted to the Emergency Department after he had a
syncopal episode in his home and called EMS.
He was confused and
hypotension
BP:80/65 , PR:96
NL FAST,NO DVT,NL Lung
After Echo and IVC Size👇🏻
EF: 65 %
LVOT: 1.7 cm
IVC = 18-15 mm
VTI= 12.5 cm
Case

114. What is the best treatment for Hypotension at this
patient?
Cardiac output :
We need LVOT area that (Aortic
diameter/2)2 * 3.14 = 2.26 mm2
And VTI was 12.5 m
SV = 30 cc per Cycle
CO = SV * HR => 30 * 100 = 3 L
Now SVR :
60 - 10 / 3 * 80 = 1350
Normal SVR is 700 - 1500
And this patient is 1350
Tips and tricks

115. A 45 y.o man with Cardiac arrest , after 20min CPR ,we saw the onset of
clotting in the left ventricle during CPR, Seeing clots in the ventricles means
that CPR is not effective Or It’s normal happening in during CPR?
Case 9

116. - You may object to me that this is not a clot or thrombus in LV,
we have to separate fully formed clots from spontaneous echo
contrast.
-The latter can be seen in low flow states artifact even in “alive”
patients.
-There is not any evidence for relating thrombus in LV and
efficient CPR, but there is some evidence that clots are seen in
half of the patients during CPR
-Thrombosis or spontaneous echo contrast is a poor prognostic
sign but don’t know if it has anything to do with the efficacy of
CPR.
https://www.sciencedirect.com/science/article/pii/S2666520422
000182
Tips and tricks

117. Thanks for your Attention