RAPID ULTRASOUND IN SHOCK AND

HYPOTENSION
Rush protocol
DR. J. SHIVA RANJAN REDDY
CONSULTANT EMERGENCY MEDICINE
SRI CHANDRA SEKARA HOSPITALS
IMPORTANCE OF RUSH

 RUSH HELPS US IN QUICK ASSESSMENT OF HEMODYNAMICS OF A PATIENT

WITH UNDIFFERENTIATED SHOCK .

 POTENTIAL AETIOLOGIES CAN BE NARROWED DOWN .

 RUSH IS GAINING OVER CONVENTIONAL LAB TESTING AND IMAGING WHICH

ARE MORE TIME TAKING - LEADING TO DELAY IN TREATMENT .
PREVALANCE OF SHOCK

 IN THE ED , THE PERCENTAGE OF EACH TYPE OF SHOCK SEEN DEPENDS UPON

THE POPULATION SERVED BY THE ED.
 SHOCK REMIANS THE MAJOR CAUSE OF ICU ADMISSION
OBJECTIVES

WHEN TO RUSH
WHERE TO RUSH
WHY TO RUSH
CASE SCENARIO

 63 YEARS MALE PRESENTED TO ER WITH COMPLAINTS OF ACUTE SHORTNESS OF

BREATH SINCE SEVERAL HOURS
 VITALS : BP – 70/-- MMHG ; HR – 144/MIN ; RR – 38/MIN ; SPOD2 88% @ RA. TEMP
– 100.4F
 PAST MHX : COPD , CCF ( LAST ECHO –EF 35% ), HTN ON MEDICATIONS.
 PATIENT IN RESPIRATORY DISTRESS ( CALL SENIOR FOR HELP ), BUT REAMINS
CONSCIOUS ALERT.
 RS- DIFFUSE CREPTS AND EXPIRATORY WHEEZE
 BILETARAL PEDAL EDEMA PRESENT .
 WHAT TO DO ?
QUESTION

WHAT TYPE OF SHOCK IS THE PATIENT IN ?

 DISTRIBUTIVE
 CARDIOGENIC
 HYPOVOLEMIC
 OBSTRUCTIVE
SHOCK

 SHOCK IS LIFE THREATENING AND TIME SENSITIVE EMERGENCY.

 SHOCK IS A MEDICAL CONDITION IN WHICH THE BLOOD PRESSURE OF A

PATIENT BECOMES TOO LOW, MEANING THAT THERE’S NOT ENOUGH
OXYGENATED BLOOD IN THE BODY TO SUSTAIN VITAL LIFE FUNCTIONS. IN
SIMPLE WORDS, WHEN THE PATIENT’S BODY IS NOT GETTING ENOUGH
BLOOD FLOW, IT IS SAID THAT THEY ARE IN SHOCK.

 UN DIFFERENTIATED SHOCK REFERS TO THE SITUATION WHERE SHOCK IS

RECOGNISED,BUT THE CAUSE IS UNCLEAR / UNKNOWN.
TYPES OF SHOCK

 CARDIOGENIC SHOCK - HEART FAILS TO PUMP

 OBSTRUCTIVE SHOCK - HEART PUMPS WELL, OUTFLOW IS OBSTRUCTED
 HYPOVOLEMIC SHOCK - HEART PUMPS WELL , NOT ENOUGH BLOOD TO PUMP
 DISTRIBUTIVE SHOCK - HEART PUMPS WELL, PERIPHERAL VASODIALTION.
POINT OF CARE US

ADVANTAGES :
 PORTABLE
 INEXPENSIVE
 NO EXPOSURE TO RADIATION
 A RAPID EXAMINATION OF MULTIPLE ORGANS PARTICULARLY HEART TO
NARROW THE DIFFERENTAIL DIAGNOSIS AND IDENTIFY A POTENTIAL
AETIOLOGY FOR SHOCK.
 WHERE TO RUSH

RUSH IS EVALUATED UNDER 3 STEPS FOR EASY UNDERSTANDING :

 STEP I :
A) EVALUATION OF THE PUMP ?
B) LOOKING FOR 3 MAIN THINGS : PERICARDIAL EFFUSION, TAMPONADE,LV
CONTRACTILITY, RV STRAIN
 STEP II :
A) EVALUATION OF TANK ( INTRAVASCULAR VOLUME )
HOW FULL IS THE TANK BY EVALUATING IVC / JUGULAR VEINS
B) IS TANK IS LEAKING OR COMPROMISED ?
E-FAST EXAM, LUNG USG ( FOR PTX, B-LINES )
 WHERE TO RUSH

RUSH IS EVALUATED UNDER 3 STEPS FOR EASY UNDERSTANDING :

 STEP III :
A) EVALUATION OF PIPES ?
B) BY LOOKING AT AORTA FOR AAA AND THORACIC AORTIC DISSECTION
LEG VEINS FOR DVT
 STEP I

 FOR THE EVALUATION OF PUMP

 ECHO STANDARD WINDOWS :
A) PROBE POSITION –A (PARA
STERNAL VIEWS –LONG/SHORT AXIS)
B) PROBE POSITION –B (SUB COSTAL
VIEW)
C) PROBE POSITION –C (APICAL VIEW)
 PARA STERNAL LONG AXIS
VIEW(PLAX)

RV FW
PROBE PLACED LEFT TO STERNUM

INTERCOSTAL SPACE 3RD AND 4TH AORTA

IVS LVOT
MARKER TOWARDS RIGHT ELBOW AML
PML
USG SCREEN INDICATIOR TO THE RIGHT

LEFT LETERAL POSITION LV FW

MAY HELP IN BETTER IMAGING
 PERICARDIAL EFFUSION IN PLAX
PERI EFF

PERICARDIAL EFFUSION IS
ANTERIOR TO AORTA
AND PERICARDIUM
INDICATING EARLY
TAMPONADE

PERI EFF

AORTA
 PLEURAL EFFUSION IN PLAX

 BOTH PLEURAL AND

PERICARDIAL EFFUSION
IN PLAX

 PLEURAL EFFUSION LIES

POSTERIOR TO PERICARDIUM AND
DESENDING AORTA.
LV CONTRACTILITY IN PLAX

 DURING SYSTOLE ENDOCARDIAL WALL OF LEFT VENTRICLE ALMOST CLOSE

DOWN COMPLETLY INDICATING GOOD LV / ANTERIOR MITRAL LEAFLET FLIPS
OPEN TO SLAP THE INTER VENTRICULAR SEPTUM

 M-MODE ACROSS THE LV

M-MODE IN LV

 PLACE THE CURSER ACROSS THE LEFT

VENTRICLE IN PLAX
 CALCULATE END DIASTOLIC AND
SYSTOLIC DIAMETER
 ANYTHING ABOVE 50% IS
CONSIDERED AS NORMAL .
PARASTERNAL SHORT AXIS VIEW

 PROBE PLACED LEFT TO STERNUM

 INTERCOSTAL SPACE 3RD AND 4TH

 MARKER TOWARDS LEFT SHOULDER

 USG SCREEN INDICATIOR TO THE LEFT

 LEFT LETERAL POSITION

 MAY HELP IN BETTER IMAGING PERICARDIAL
EFFUSION
SUB XIPHIOD VIEW

 PROBE IS PLACED UNDER THE

XIPHOID PROCESS
 POSITION THE PROBE DOWN
AND UP OVER THE PATIENT

AIMING THE MARKER

TOWARDS RIGHT
APICAL VIEW

 PROBE PLACED UNDER LEFT NIPPLE

 POINT OF MAXIMAL IMPLUSE OF THE HEART
 POINT MARKER TOWARDS RIGHT
 USG SCREEN INDICATES RIGHT
 LEFT LATERAL DICUBITUS VIEW
 STEP II – EVALUATION OF
TANKS
A) EVALUATION B) EVALUATION C) EVALUATION
OF TANK OF TANK OF TANK
VOLUME LEAKINESS COMPROMISE

EXAM : EXAM :
EXAM : LUNG SLIDE
E FAST
IVC FOR TENSION PTX
PLEURAL EFFUSION
JUGULAR VEINS
B LINES ( P.EDEMA )
TANK OVERLOAD
POSITIONING OF PROBE FOR EVALUATION OF TANK
A) EVALUATION OF IVC

 SUB XIPHOUID POSITION

POINTER TOWARDS HEAD
 LOOKIN AT HEART
 ROTATING TOWARDS RIGHT
OF PATIENT
 IVC IS SEEN IN TUBULAR SHAPE
IVC INSPIRATION AND EXPIRATION
EXCEPTIONS:
SOMETIMES IVC CANNOT OR HAVING A LIMITED ACCESSIBILITY LIKE GAS, FLUID
FILLED INTESTINE OR STOMACH IN SUCH CASES VISUALIZATION OF IJV WILL
ACT AS AN ALTERNATE MEASURE FOR ASSESSING CVP
EVALUATION OF IJV
B) EVALUATION OF LEAKINESS

 DONE BY E- FAST ( EXTENDED FOCUSED ASSESSMENT WITH SONOGRAPHY IN

TRRAUMA ) EXAM – THIS WILL DETERMINE THE PRESENCE OF FREE FLUID IN
ABDOMENAL , PELVIC AND THORACIC CAVITY
 HEPATO RENAL VIEW
 SPLENO RENAL VIEW
 SUB XIPHOID VIEW
 SUPRA PUBIC VIEW
 RUSH EXAM IS NOT DESIGNES FOR TRAUMA PATIENT BUT CAN BE USED FOR
THE PATIENT IN DELAYED PRESENTATION AFTER TRAUMA
E FAST VIEWS
LUNG ULTRASOUND IN HYPOTENSION/ DYSPNOEA

 PROBE POSITION – POINTER TOWARDS HEAD AND PLACING PROBE

ANTERIORLY AND LATERALLY OVER CHEST

 A LINES – LUNG IS FILLED WITH AIR

MULTIPLE B LINES BILATERALLY
INDICATES PULMONARY EDEMA
TANK COMPROMISE

 R/O TENSION PTX

M MODE OF LUNG
EVALUATION OF PIPES

 IMAGING FOR RV DILATATION / PAH

 NORMAL LV : RV SIZE RATIO 1: 0.6

 IN CASE OF ACUTE PTE THE - GRATER SIDE OF RV INDICATES RV STRAIN

 HOW ?

 POSITION A – ARCH OF AORTA / THORACIC

AORTA FOR ANURYSM OR DISSECTION

 POSITION B – MOSTLY THORACIC

ANURYSMS

 POSITION C & D – ABDOMINAL AORTIC

ANURYSMS

 POSITION E & F – FOR DVT AND SHOULD BE

PERFORMED
IF PATIENT IS HAVING PTE
 IN PLAX IF U FIND A DILATED AORTA MORE THAN SIDE OF 3.8 CM SUSPECT
AORTIC ANURYSM / IF FLAP SEEN IN AORTA, IT INDICATES DISSECTION
 LETS THINK OF A CASE

 PATIENT CAME WITH SHORTNESS OF

BREATH SUDDEN ONSET,
PALPITATIONS , SWEATING ?

 H/O RTC LOWER LIMB FRACTURE ON

POP FOR A MONTH .
SUMMARY