1. M O H A M A D YA A K U B
E m e r g e n c y D e p a r t m e n t
H o s p i t a l D u c h e s s o f K e n t
2. Content
• Introduction
• Shock and types of shock
• Rush protocol
– PUMP (Heart)
– Tank (Volume status)
– Pipes (Vascular system)
• Conclusion
3. ACEP statement
1. Clinical point-of-care ultrasound
performed, by emergency physicians is
a fundamental skill in the practice of
emergency medicine.
4.
5. SHOCK
• State of cellular and tissue hypoxia due to
reduced oxygen delivery and/or increased oxygen
consumption or inadequate oxygen utilization.
• Commonly occurs with circulatory failure
manifested as hypotension.
• Initially reversible, but rapidly become
irreversible, resulting in multiorgan failure and
death.
• Need to rapidly identify the etiology to prevent
morbidity and mortality.
6. Types of shock
• Distributive — due to severe peripheral
vasodilatation
• Cardiogenic — due to intracardiac causes of cardiac
pump failure that result in reduced cardiac output
(CO).
• Hypovolemic — due to reduced intravascular volume
which, in turn, reduces cardiac output.
• Obstructive — due to extracardiac causes of cardiac
pump failure and often associated with poor cardiac
output.
10. Bear in mind that it could be mixed
type of shock causes…
• Patients with shock from sepsis primarily have
distributive shock (due to venodilation and vasodilation);
however, they also often have a hypovolemic component
(often due to decreased oral intake and GI losses) and a
cardiogenic component (septic cardiomyopathy).
• Patients with a ruptured left ventricular free wall
aneurysm can have cardiogenic shock from primary
pump failure, obstructive shock from cardiac tamponade
when blood loss is contained by the pericardial sac, and
hypovolemic (hemorrhagic) shock when blood loss is not
contained by the pericardial sac.
11. RUSH PROTOCOL
• RAPID ULTRASOUND IN SHOCK
–3 Step algorithm
•The pump : Cardiac evaluation
•The Tank : Volume status (IVC, LUNG,
PERITONEAL SPACE)
•The Pipes : Vascular system (AORTA,
DEEP VEINS)
12. Step 1 : How is the pump(Heart)?
• Examine for pericardial effusion and potential
cardiac tamponade.
• Evaluation of LV Contractility
• Assessment of Right Ventricular strain
21. large pericardial effusion causing diastolic collapse of the right atrium and
ventricle, a result of tamponade.
Cardiac Tamponade
22. Evaluation of LV Contractility
• Normal LV function
– Anterior leaflet of MV touch the septum
• E-Point Septal Separation
– Significant change in LV thickness during systole
and asystole (30%)
• Count fractional shortening (%)
23. Good LV Contractility
1. Mitral valve
touching
septum
2. Significant
change in LV
thickness
during
systole and
diastole
(>30%)
24. Good LV Contractility
In general, fractional shortening of 30–45% correlates to normal ejection
fraction
27. E-Point Septal Separation (EPSS)
Studies have demonstrated that
EPSS greater than 1 cm reliably
correlates with a low ejection
fraction.
EPSS is the minimal distance
between the E-wave and the septum and
is normally less than 7mm [34]. Studies
have demonstrated that EPSS greater
than 1 cm reliably correlates with a low
ejection fraction
28. Assessment of Right Ventricular
strain
• Look for RV strain
– RV Dilation ( normal RV: LV - 0.6:1)
– D-sign
32. Difference between acute vs
chronic RV strain
ACUTE RV Strain
• Commonly due
Pulmonary embolus
• Only dilated RV
CHRONIC RV Strain
• Due to pulmonary
hypertension
• RV Dilation and
Hypertropied of RV
wall.
33. Pulmonary Embolism
• Diagnosis of PE is supported on echocardiography by the
presence of clot in the right heart or NEW right heart strain
BUT
• nonspecific as can be due to chronic cause (since right
ventricle [RV] abnormalities can be seen in other conditions
including chronic pulmonary disease, pulmonary
hypertension, and right ventricular infarction)
Pulmonary embolism → Increasd pulmonary resistance →
Increased RV afterload → RV Dilatation/Dysfunction →
Decreased RV cardiac output → Decreased LV preload →
Decreased LV output → Hypotension
35. Physiology of McConnell’s sign
• The right ventricle has a complex shape: distribution
of this stress is not uniform, there is mid right
ventricle free wall bulging and localized ischemia of
free wall due to increased stress.
• The apical section of the RV is not exposed to this
stress due to its location next to the LV. RV apex is
anatomically tethered with LV apex. The LV is usually
hyperkinetic due to tachycardia and this pulls the RV
apex along with it for a proxy contraction.
37. RUSH PROTOCOL
• RAPID ULTRASOUND IN SHOCK
– 3 Step algorithm
• The pump : Cardiac evaluation
• The Tank : Volume status (IVC, LUNG,
PERITONEAL SPACE)
• The Pipes : Vascular system (AORTA, DEEP VEINS)
38. Step 2 : Assessment of the Tank
1. Evaluation of Tank Fullness
• Inferior vena cava (IVC)
2. Evaluation of Tank Leakiness and overload
• E-Fast exam
3. Evaluation of Tank Compromise
• Lung –Sliding sign ,look for pnemothrax
IVC LUNG
PERITONEAL
SPACE
