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RUSH PROTOCOL Rapid Ultrasound for Shock and Hypotension

RUSH PROTOCOL Rapid Ultrasound for Shock and Hypotension. Ultrasound (US)-- “resuscitative.”. Patients with hypotension or shock Ultrasound is ideal for the evaluation of critically ill patients in shock, and ACEP guidelines

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RUSH PROTOCOL Rapid Ultrasound for Shock and Hypotension

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  1. RUSH PROTOCOL Rapid Ultrasound for Shock and Hypotension

  2. Ultrasound (US)-- “resuscitative.” • Patients with hypotension or shock • Ultrasound is ideal for the evaluation of critically ill patients in shock, and ACEP guidelines • Direct visualization of pathology and differentiation of shock states. • The RUSH Protocolfirst introduced in 2006 by Weingart SD et al, and later published in 2009. It was designed to be a rapid and easy to perform US protocol (<2 min) by most emergency physicians.

  3. What US probes do you need for the RUSH protocol? • Phased-array probe (3.5 - 5 MHz) • Linear probe (7.5 – 10 MHz) • What are the components of the RUSH protocol? • The components of the RUSH exam are: Heart, Inferior vena cava (IVC), Morrison’s/FAST abdominal views, Aorta, and Pneumothorax (HI-MAP). • A more simple method is to think of: • Pump (Heart): Tamponade, LVEF, and RV size • Tank (Intravascular): IVC, thoracic and abdominal compartments • Pipes (Large Arteries/Veins): Aorta and femoral/popliteal veins

  4. Summary TableResuscitation 2013 conference

  5. How do you evaluate the PUMP? • Component: Heart (parasternal long axis view) • Probe: Phased array probe (3.5 - 5 MHz) • Location: Just left of the sternum, 3rd and 4th intercostal space • Finding: Pericardial effusion (tamponade) • Small effusions are best identified posterior to left ventricle (dependent portion of pericardium) • Can find compression of the right ventricle (Singh S et alSens 92%, Spec 100%, PPV 100%)

  6. Finding: Left ventricular ejection fraction estimation • Look at anterior leaflet of mitral valve, which should normally touch septum • <30% difference of LV size between systole and diastole indicates severely decreased LV function • Finding: Right ventricular strain • Normally RV should be 60% of LV size (If RV = LV size, this is abnormal) • Lodato JC et al: If McConnell Sign (reduction in RV free wall motility with sparing of the apex) is present, specificity for PE is 96%, but sensitivity is 16%.

  7. Component: Heart (Subxiphoid) • Probe: Phased array probe (3.5 - 5 MHz) • Location: Subxiphoid, point toward left scapula

  8. How do you evaluate the TANK? • Component: Inferior Vena Cava • Probe: Phased array probe (3.5 - 5 MHz) • Location: Subxiphoid, slide to patient's right • Finding: Intravascular volume estimation • IVC <2 cm in diameter and inspiratory collapse greater than 50% approximates CVP <10 cmH20 • IVC >2 cm in diameter and inspiratory collapse less than 50% approximates CVP >10 cmH20 • Not applicable for intubated patients. Spontaneously breathing patients create negative intrathoracic pressure. ventilated patients create positive intrathoracic pressure.

  9. Component: FAST abdominal views • Probe: Phased array probe (3.5 - 5 MHz) • Location: Hepatorenal recess, Splenorenal recess, and bladder • Finding: Internal blood loss

  10. Component: Pneumothorax • Probe: Linear probe (7.5 – 10 MHz) • Location: Midclavicular line, 3rd – 5th intercostal space • Finding: Intrathoracic compromise • Normal: Should see lung sliding and comet tails. M-Mode will look like "waves on a beach". • Pneumothorax present: NO lung sliding and NO comet tails. M-Mode will look like a "bar graph" (no beach).

  11. How do you evaluate the PIPES? • Component: Aorta • Probe: Phased array probe (3.5 - 5 MHz) • Location: Longitudinal and transverse views of aorta at 4 levels (infracardiac, suprarenal, infrarenal, and right at the iliac bifurcation) • Measurement >3 cm is abnormal. If >5 cm consider ruptured AAA if no other cause found. • Most AAAs located below the renal arteries

  12. RUSH protocol to medical patients EFAST exam to trauma patients.

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