Ultrasound: In Shock and Hypotension

Background

  • Several techniques are available for differentiating shock states
  • RUSH Protocol was conceived in 2008 and looks are 3 basic aspects of physiology[1]
  1. The Pump
    • RV:LV
    • Squeeze
    • Pericardial effusion
  2. The Tank
  3. The Pipes

The Protocol

Rapid Ultrasound for Shock and Hypotension(RUSH) using the HI-MAP approach[2]

  • H - Heart (parasternal and four-chamber views)
  • I - Inferior Vena Cava (for volume responsiveness)
  • M - Morison’s pouch (i.e., FAST exam) and views of thorax (looking for free fluid)
  • A - Aortic Aneurysm (ruptured abdominal aneurysm)
  • P - Pneumothorax (i.e., Tension pneumothorax)

Heart

Technique: see Cardiac ultrasound

  • Pericardial Effusion
    • Parasternal long
    • Change in size <30% between sys and dia = poor LV function
  • RV collapse
    • In 4-chamber view, RV should be <60% of LV; if larger think RV failure
  • Hyperdynamicity
    • Walls move >90% or touch at end of systole
      • May indicate hypovolemia or sepsis

IVC

Technique: see IVC ultrasound

  • Measure 2cm from RA-IVC junction
  • If IVC <1.5cm and collapses on inspiration then CVP is low
  • If IVC >2.5cm and noncollapsing then CVP is high
    • Suggests fluid unresponsive; patient requires inotropes

Morison's

Technique: see FAST exam

  • Assess for free fluid
    • Morison's pouch
    • Splenorenal
    • Bladder

Aorta

Technique: see Aortic ultrasound

  • If >5cm assume ruptured AAA until proven otherwise

Pulmonary

Technique: see Ultrasound: Lungs

  • Assess for subpleural interstitial edema
    • Look for multiple comet tail artifacts or "B lines"(a few, 3-4, are OK)
      • If multiple found, there is interstitial edema
  • Assess for pneumothorax
    • Scan longitudinally in anterior 2nd-3rd IC space, mid-clavicular line
    • Look for lack of sliding or "beach sign"

Other

Classic Ultrasound Findings For Critically Ill Patients

DiseaseIVCCardiacLung (Phased Array)Lung (Linear)
MIFocal WMA
Mod/Poor squeeze
NL or B-linesSliding
TamponadeRA collapse with filling
RV collapse with filling
NLSliding
PTXNL or HyperdynamicLung point
Consolidated lung
Absent lung sliding
SepsisHyperdynamic squeezeNL (see pneumonia)Sliding
PneumoniaNL or ↓Hyperdynamic squeezeUnilateral B-linesSliding
Decompensated HFMod/Poor squeezeBilateral B-linesSliding
PERV > LV
McConnell's sign
NL or Unilateral B-linesSliding

Video

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See Also

References

  1. Weingart - https://emcrit.org/rush-exam/
  2. Dina Seif. Bedside Ultrasound in Resuscitation and the Rapid Ultrasound in Shock Protocol Critical Care Research and Practice Vol 2012 http://downloads.hindawi.com/journals/ccrp/2012/503254.pdf
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