Use of bedside Ultrasound in ShockRUSH ProtocolDAN 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 LVLarge RV

Hyperdynamic LVLarge RVFlattening of septum

RV > LV

Dilated IVC> 2.1cm< 50% collapse

Non compressible clot in Femoral Vein

CASE 2

Dliated LVPoorly contractingBiatrial enlargement

Dilated IVC> 2.1cm< 50% collapse

Lung rocketsB lines> 3 = abnormal

Normal

Normal

CASE 3Hyperdynamic‘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.jp

eg https://www.dtod.ne.jp/ohtablog/images/article10_pdf_003.pdf http://emcrit.org/wp-content/uploads/2011/03/New-RUSH-Review-

Article1.pdf