II. Indications

  1. Undifferentiated Hypotension or shock evaluation

III. Approach

  1. Rapid Ultrasound in Shock (RUSH protocol) evaluates three components related to Hypotension and shock
  2. Pump Evaluation (cardiac function)
    1. See Cardiac Ultrasound
    2. Pericardial Effusion (or Cardiac Tamponade)
    3. Cardiac systolic function
    4. Right ventricular dilatation or strain
  3. Tank Evaluation (Vascular volume status)
    1. See Inferior Vena Cava Ultrasound for Volume Status
      1. Includes Respirophasic IVC Variation, Caval Aorta Index, Distensibility Index
    2. See eFAST Exam
    3. See Blue Protocol
    4. Inferior Vena cava size
    5. Intraabdominal fluid (FAST Exam)
    6. Chest Ultrasound (Pneumothorax, interstitial fluid, Pleural Effusions)
  4. Pipes Evaluation (Large vessel integrity)
    1. See Abdominal Aorta Ultrasound
    2. Abdominal Aortic Aneurysm

IV. Protocol: Pump Evaluation (cardiac function)

  1. See Cardiac Ultrasound
  2. Pericardial Effusion or Cardiac Tamponade
  3. Left ventricle size and function
    1. Myocardial Infarction
      1. Large left ventricle with poor contractility
    2. Hypovolemia
      1. Small left ventricle with hyperdynamic activity
  4. Right ventricle size and function
    1. Massive Pulmonary Embolism
      1. Large right ventricle with poor contractility
      2. In contrast, left ventricle is uncharacteristically smaller than right and may appear D-shaped

V. Protocol: Tank Evaluation (Vascular volume status)

  1. See Inferior Vena Cava Ultrasound for Volume Status
  2. Measurements
    1. Intravascular volume status: Inferior Vena Cava Ultrasound
      1. Non-Ventilated: Respirophasic IVC Variation or Caval Aorta Index
      2. Ventilated: Distensibility Index
    2. Intraabdominal free fluid (e.g. ruptured AAA, ruptured Ectopic Pregnancy, Trauma)
      1. FAST Exam
      2. Evaluate with patient flat or in trendeleburg position
    3. Chest (e.g. Pneumothorax, CHF, Pleural Effusion)
      1. FAST Exam
  3. Interpretation
    1. Hypovolemic (dehydration, Hemorrhage, Tension Pneumothorax)
      1. See eFAST Exam
      2. Evaluate for bleeding sites (Hemothorax, intraabdominal blood on FAST Exam)
      3. Evaluate for Tension Pneumothorax
    2. Hypervolemic (volume overload, CHF, Renal Failure, liver failure)
      1. See Blue Protocol
      2. Evaluate for third spacing of fluids (Pleural Effusion, Ascites)
      3. Evaluate for sonographic B-Lines on Ultrasound
    3. Venous Obstruction (Cardiac Tamponade, Tension Pneumothorax, Pulmonary Embolism)
      1. Inferior Vena Cava distended

VI. Protocol: Pipes Evaluation (Large vessel integrity)

  1. Thoracic Aortic Dissection evaluation
    1. See Suprasternal Echocardiogram View
  2. Abominal aortic aneurysm evaluation
    1. See Abdominal Aorta Ultrasound
  3. DVT Evaluation
    1. See Focused Lower Extremity Venous Ultrasound

VII. References

  1. Stowell, Kessler and Lotz (2017) Crit Dec Emerg Med 31(8): 13-22
  2. Hallemat (2013) Crit Dec Emerg Med 27(10): 14-21
  3. Perera (2010) Emerg Med Clin North Am 28(1): 29-56 [PubMed]

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