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Use of bedside Ultrasound in Shock
RUSH Protocol
DAN STEVENS, ED REG SCGH
RUSH Protocol
 Rapid Ultrasound for Shock and Hypotension
 Other protocols
 ACES – Abdominal and Cardiac Evaluation (with ultrasound) in Shock
 FALLS protocol - Lichtenstein
 Early recognition and treatment of shock improves outcome
 Bedside ultrasound in undifferentiated hypotension in the
Emergency department leads to improved physician diagnosis1
Causes of Shock
 Cardiogenic
 MI
 Cardiac tamponade
 Hypovolaemic
 Bleeding
 Obstructive
 PE
 Pneumothorax
 Distributive
 Sepsis
 Anaphylaxis
RUSH Protocol
 The Pump
• The Heart
 The Tank
• Fullness of the tank
• IVC
• Emptiness of the tank
• EFAST
 The Pipes
• Leaking pipes
• AAA
• Blocked pipes
• DVT
Where to Scan
Parasternal long axis
• Pericardial effusion
• Pleural effusion
• LV contractility
• Normal
• Hyperdynamic
• Reduced
• RV size
Parasternal Short axis
• RV side
• Septal wall motion
Apical 4 chamber
• RV and LV size
• RV and LV function
Subcostal
• Pericardial effusion
IVC view
 > 2.1cm with < 50% collapse = high
CVP
 < 2.1cm with > 50% collapse = low
CVP
RUQ, LUQ, PELVIS
• Abdominal free fluid
• Pleural effusion
Aorta
• Aneurysm
• Dissection
Femoral Vein +/-
Popliteal
• Compressible / non compressible
Anterior chest wall
• Sliding / no sliding
• Lung rockets
CASE 1
Hyperdynamic LV
Large RV
Hyperdynamic LV
Large RV
Flattening of septum
RV > LV
Dilated IVC
> 2.1cm
< 50% collapse
Non compressible clot in Femoral Vein
CASE 2
Dliated LV
Poorly contracting
Biatrial enlargement
Dilated IVC
> 2.1cm
< 50% collapse
Lung rockets
B lines
> 3 = abnormal
Normal
Normal
CASE 3
Hyperdynamic
‘kissing LV’
IVC
< 2.1cm
> 50% collapse
Fluid in Morrisons Pouch
Empty uterus
+ve Bhcg
Fluid pouch of Douglas
CASE 4
Pericardial Effusion
?cardiac tamponade
Dilated IVC
> 2.1cm
< 50% collapse
Dissection to abdominal aorta
Final slide….
References
 1 Jones AE1, Tayal VS, Sullivan DM, Kline JA. Randomized, controlled trial
of immediate versus delayed goal-directed ultrasound to identify the
cause of nontraumatic hypotension in emergency department
patients. Crit Care Med. 2004 Aug;32(8):1703-8.
 http://emcrit.org/rush-exam/original-rush-article/
 http://sinaiem.us/wp-content/uploads/2012/05/31.-Sequencing.jpeg
 https://www.dtod.ne.jp/ohtablog/images/article10_pdf_003.pdf
 http://emcrit.org/wp-content/uploads/2011/03/New-RUSH-Review-
Article1.pdf

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