View source for Ultrasound: in shock and hypotension

==Background==
*A bedside ultrasound paradigm for differentiating differentiating shock states (cardiogenic, obstructive, hypovolemic, distributive)
**Tailor specific protocol to the patient at hand
*RUSH Protocol was conceived in 2008 and looks are 3 basic aspects of physiology<ref>Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am. 2010 Feb;28(1):29-56, vii. doi: 10.1016/j.emc.2009.09.010. PMID: 19945597.</ref><ref>Weingart - https://emcrit.org/rush-exam/</ref>
#The Pump
#*RV:LV
#*Squeeze
#*[[Pericardial effusion and tamponade]]
#The Tank
#*IVC
#*[[Pleural effusions]]
#*[[Pulmonary edema]]
#*[[Tension pneumothorax]]
#The Pipes
#*[[AAA]]
#*[[Aortic dissection]]
#*[[DVT]]

==The Protocol==
[[File:Cardiac Ultrasound.png|thumb|Step 1: The Pump]]
[[File:Step 2.png|thumb|Step 2: The Tank]]
[[File:Step 3.png|thumb|Step 3: The Pipes]]
Rapid Ultrasound for Shock and [[Hypotension]](RUSH) using the HI-MAP approach<ref>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 </ref>

*'''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
**May be most obvious with PLAX or subxiphoid views<ref>Alerhand S, Carter JM. What echocardiographic findings suggest a pericardial effusion is causing tamponade? Am J Emerg Med. 2019 Feb;37(2):321-326. doi: 10.1016/j.ajem.2018.11.004. Epub 2018 Nov 17. PMID: 30471929.</ref>
***In PLAX, pericardial fluid is anterior to descending aorta, while pleural fluid is posterior to it
**Isolated anterior anechoic areas may be an anterior fat pad
**Assess for tamponade physiology including diastolic collapse of RA or RV; see [[Pericardial effusion and tamponade]]
*LV squeeze
**PLAX and PSAX are good views to estimate contractility
**Change in size <30% between sys and dia = poor LV function
**Hyperdynamicity, as determined by walls moving >90% or touching at end of systole, may indicate hypovolemia or sepsis
**May direct fluid therapy
*RV strain
**In 4-chamber view, RV should be <60% of LV; if dilated/larger think RV strain
**While chronic RV strain (ex. cor pulmonale) may cause RVH, massive PE will not have time to cause RVH

==IVC==
Technique: see [[IVC ultrasound]]
*Measure 2cm caudally from RA-IVC junction
*If IVC <2.1cm and collapses >50% on inspiration then RAP/CVP is low<ref>Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, Solomon SD, Louie EK, Schiller NB. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010 Jul;23(7):685-713; quiz 786-8. doi: 10.1016/j.echo.2010.05.010. PMID: 20620859.</ref>
*If IVC >2.1cm and collapses <50% then RAP/CVP is high
**Suggests fluid unresponsive; patient requires inotropes
*IVC measurements may be altered in patients receiving vasoactive medications or positive pressure ventilation 

==Morison's==
Technique: see [[FAST exam]]
*Assess for free fluid
**Morison's pouch (hepatorenal space)
**Splenorenal
**Bladder, including retrovesicular space
**As part of E-FAST, when in hepatorenal or splenorenal views, aim/slide probe above diaphragm to assess for pleural effusion
*Note that while ascitic fluid often appears anechoic, blood may appear with mixed echogenicity due to the presence of clots 
 
==Aorta==
Technique: see [[Aortic ultrasound]]
*Steady pressure with probe can displace bowel gas, improving view
*If >5cm assume ruptured AAA until proven otherwise
*In PLAX, aortic root >3.8cm may be seen in proximal aortic dissection or aortic aneurysm<ref>Seif D, Perera P, Mailhot T, Riley D, Mandavia D. Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol. Crit Care Res Pract. 2012;2012:503254. doi: 10.1155/2012/503254. Epub 2012 Oct 24. PMID: 23133747; PMCID: PMC3485910.</ref>

==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 pulmonary edema
*Assess for pneumothorax
**Scan longitudinally in anterior 2nd-3rd IC space, mid-clavicular line, looking for echogenic pleural line
**On M-mode, look for lack of pleural sliding, aka "Barcode sign"
**Presence of lung point is highly specific for PTX

==Other==
{{Ultrasound findings for critically ill patients table}}

==See Also==
*[[Ultrasound (main)]]
*[[Undifferentiated shock]]

==External Links==

==References==
<references/>

[[Category:Critical Care]]
[[Category:Cardiology]]
[[Category:Radiology]]
[[Category:Ultrasound]]