Difference between revisions of "Ultrasound: In Shock and Hypotension"

(Created page with "Rapid Ultrasound for Shock and Hypotension (RUSH) using the HI-MAP approach ==H – Heart== Pericardial effusion can be seen with parasternal long view. LV assessment is al...")
 
 
(43 intermediate revisions by 7 users not shown)
Line 1: Line 1:
Rapid Ultrasound for Shock and Hypotension (RUSH) using the HI-MAP approach
+
==Background==
 +
*Several techniques are available for differentiating shock states
 +
*RUSH Protocol was conceived in 2008 and looks are 3 basic aspects of physiology<ref>Weingart - http://emcrit.org/ultrasound/The%20RUSH%20Examfinal.htm</ref>
 +
#The Pump
 +
#*RV:LV
 +
#*Squeeze
 +
#*[[Pericardial effusion]]
 +
#The Tank
 +
#*IVC
 +
#*[[Pleural effusions]]
 +
#*[[Pulmonary edema]]
 +
#The Pipes
 +
#*[[AAA]]
 +
#*[[Aortic dissection]]
 +
#*[[DVT]]
  
+
==The Protocol==
 
+
[[File:Cardiac Ultrasound.png|thumb|Step 1: The Pump]]
==H – Heart==
+
[[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
Pericardial effusion can be seen with parasternal long view. LV assessment is also from the parasternal long view. A change in size less than 30% between systole and diastole indicates poor LV function. Alternatively, the LV is hyperdynamic if walls move more than 90% or touch at the end of systole, which can happen with hypovolemia or sepsis.
+
in Shock Protocol Critical Care Research and Practice Vol 2012 http://downloads.hindawi.com/journals/ccrp/2012/503254.pdf </ref>
 
 
 
 
 
In four-chamber view, RV should  be <60% of LV size – when RV is about the same size or larger than LV, think RV failure.
 
 
 
  ==I – IVC==
 
 
 
 
 
Start with the probe longitudinal and subxiphoid and slide  1-2 cm to the patient’s right. Look at IVC changes to inspiration. If the IVC is less than 1.5 cm and collapses on inspiration, the CVP is low and the patient probably needs fluid. A larger (>2.5cm) noncollapsing IVC suggests high CVP and the patient’s hypotension may require inotropes or reducing afterload.
 
 
 
 
 
 
**Note: IVC assessment in vented patients requires a tidal volume of 10 mL/kg during the exam. A change in [(inspiratory size – expiratory size) / expiratory size] > 18% predicts good response to IVF.
 
 
 
 
  
==M – Morison's==
+
*'''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
  
the familiar Morison’s pouch and FAST views, covered in Ultrasound Basics. Tilting the probe chestward can show fluid at the lung/diaphragm interface.
+
==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
  
==A – Aorta==
+
==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"
  
The aorta (also covered in ultrasound basics) can be seen in cross section sliding down from the subxiphoid to the umbilicus. If the aorta is larger than 5 cm below the heart or in the suprarenal, infrarenal or bifurcation views, you must assume ruptured AAA.
+
==Other==
 
+
{{Ultrasound findings for critically ill patients table}}
 
 
 
==P – Pneumothorax==
 
 
 
 
 
PTX can be seen by ultrasound. Using a high-frequency  probe, scan longitudinally in both anterior 3rd intercostal spaces
 
 
 
using M-mode. Finding an ocean/beach or seashore sign reassures that there is no pneumothorax under the probe (immobile soft tissue and
 
 
 
muscle on the top of the M-mode image looks like an ocean, and the sliding lung tissue looks on the bottom looks like a beach). If the
 
 
 
whole image looks like the ocean pattern (stratosphere sign), a pneumothorax is likely.
 
 
 
 
  
==Source==
+
==Video==
 +
{{#widget:YouTube|id= tqBdKIdKqOc}}
  
 +
{{#widget:YouTube|id= IjmF-132sHA}}
  
Adapted from Scott Weingart and others -- http://emcrit.org/ultrasound/The%20RUSH%20Examfinal.htm
+
{{#widget:YouTube|id= oXiIU4mx-H8}}
  
 +
{{#widget:YouTube|id= 9UyVHqvGgHE}}
  
 +
==See Also==
 +
*[[Ultrasound (main)]]
 +
*[[Undifferentiated shock]]
  
 +
==References==
 +
<references/>
  
[[Category:Rads]]
+
[[Category:Critical Care]]
 +
[[Category:Cardiology]]
 +
[[Category:Radiology]]
 +
[[Category:Ultrasound]]

Latest revision as of 17:52, 27 June 2017

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
  2. The Tank
  3. The Pipes

The Protocol

Step 1: The Pump
Step 2: The Tank
Step 3: The Pipes

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

Disease IVC Cardiac Lung (Phased Array) Lung (Linear)
MI Focal WMA
Mod/Poor squeeze
NL or B-lines Sliding
Tamponade RA collapse with filling
RV collapse with filling
NL Sliding
PTX NL or Hyperdynamic Lung point
Consolidated lung
Absent lung sliding
Sepsis Hyperdynamic squeeze NL (see pneumonia) Sliding
Pneumonia NL or ↓ Hyperdynamic squeeze Unilateral B-lines Sliding
Decompensated HF Mod/Poor squeeze Bilateral B-lines Sliding
PE RV > LV
McConnell's sign
NL or Unilateral B-lines Sliding

Video

See Also

References

  1. Weingart - http://emcrit.org/ultrasound/The%20RUSH%20Examfinal.htm
  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