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

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Rapid Ultrasound for Shock and Hypotension (RUSH) using the HI-MAP approach
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==Background==
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*Several techniques are available for differentiating shock states
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*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>
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#The Pump
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#*RV:LV
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#*Squeeze
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#*[[Pericardial effusion]]
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#The Tank
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#*IVC
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#*[[Pleural effusions]]
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#*[[Pulmonary edema]]
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#The Pipes
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#*[[AAA]]
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#*[[Aortic dissection]]
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#*[[DVT]]
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==The Protocol==
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[[File:Cardiac Ultrasound.png|thumb|Step 1: The Pump]]
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[[File:Step 2.png|thumb|Step 2: The Tank]]
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[[File:Step 3.png|thumb|Step 3: The Pipes]]
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Rapid Ultrasound for Shock and [[Hypotension]](RUSH) using the HI-MAP approach<ref>Dina Seif. Bedside Ultrasound in Resuscitation and the Rapid Ultrasound
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in Shock Protocol Critical Care Research and Practice Vol 2012 http://downloads.hindawi.com/journals/ccrp/2012/503254.pdf </ref>
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*'''H''' - Heart (parasternal and four-chamber views)
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*'''I'''  - Inferior Vena Cava (for volume responsiveness)
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*'''M''' - Morison’s pouch (i.e., FAST exam) and views of thorax (looking for free fluid)
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*'''A''' - Aortic Aneurysm (ruptured abdominal aneurysm)
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*'''P''' - Pneumothorax (i.e., Tension pneumothorax)
  
 
==Heart==
 
==Heart==
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Technique: see [[Cardiac ultrasound]]
 
*Pericardial Effusion
 
*Pericardial Effusion
 
**Parasternal long
 
**Parasternal long
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==IVC==
 
==IVC==
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Technique: see [[IVC ultrasound]]
 
*Measure 2cm from RA-IVC junction
 
*Measure 2cm from RA-IVC junction
 
*If IVC <1.5cm and collapses on inspiration then CVP is low
 
*If IVC <1.5cm and collapses on inspiration then CVP is low
 
*If IVC >2.5cm and noncollapsing then CVP is high
 
*If IVC >2.5cm and noncollapsing then CVP is high
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**Suggests fluid unresponsive; pt requires inotropes
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**Suggests fluid unresponsive; patient requires inotropes
  
 
==Morison's==
 
==Morison's==
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*Look for fluid at lung/diaphragm interface
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Technique: see [[FAST exam]]
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*Assess for free fluid
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**Morison's pouch
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**Splenorenal
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**Bladder
 
   
 
   
 
==Aorta==
 
==Aorta==
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Technique: see [[Aortic ultrasound]]
 
*If >5cm assume ruptured AAA until proven otherwise
 
*If >5cm assume ruptured AAA until proven otherwise
  
 
==Pulmonary==
 
==Pulmonary==
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Technique: see [[Ultrasound: Lungs]]
 
*Assess for subpleural interstitial edema
 
*Assess for subpleural interstitial edema
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**Scan with the abdominal probe in the upper lateral chest bilaterally
 
 
**Look for multiple comet tail artifacts or "B lines"(a few, 3-4, are OK)
 
**Look for multiple comet tail artifacts or "B lines"(a few, 3-4, are OK)
 
***If multiple found, there is interstitial edema
 
***If multiple found, there is interstitial edema
 
*Assess for pneumothorax
 
*Assess for pneumothorax
 
**Scan longitudinally in anterior 2nd-3rd IC space, mid-clavicular line
 
**Scan longitudinally in anterior 2nd-3rd IC space, mid-clavicular line
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**Look for lack of sliding or use M-mode to look for reassuring "beach sign"
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**Look for lack of sliding or "beach sign"
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==Other==
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{{Ultrasound findings for critically ill patients table}}
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==Video==
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{{#widget:YouTube|id= tqBdKIdKqOc}}
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{{#widget:YouTube|id= IjmF-132sHA}}
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{{#widget:YouTube|id= oXiIU4mx-H8}}
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{{#widget:YouTube|id= 9UyVHqvGgHE}}
  
 
==See Also==
 
==See Also==
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*[[Ultrasound (Main)]]
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*[[Ultrasound (main)]]
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*[[Shock]]
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*[[Undifferentiated shock]]
  
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==Source==
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==References==
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*Weingart - http://emcrit.org/ultrasound/The%20RUSH%20Examfinal.htm
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<references/>
  
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[[Category:Airway/Resus]]
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[[Category:Critical Care]]
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[[Category:Cards]]
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[[Category:Cardiology]]
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[[Category:Rads]]
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[[Category:Radiology]]
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[[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
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