use of bedside ultrasound in shock: rush protocol
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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
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