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The RUSH Exam: Critical Care Ultrasound

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by

James Cody Ford

on 7 March 2016

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Transcript of The RUSH Exam: Critical Care Ultrasound

Critical Care Ultrasound
The RUSH (Rapid Ultrasound for Shock and Hypotension) Exam


J. Cody Ford, MD
CCM Fellow
East Carolina University
Department of Pulmonary and Critical Care Medicine

The Tank
-IVC size and collapsability ?
-Is the LV getting adequate Preload?
-Are there signs of pulmonary edema?
Static Parameters: CVP, IVC diameter, LVEDD
Dynamic Parameters: Kissing Sign, IVC collapsability Index, Delta VTI, Passive Leg Raise
All taken into consideration with respiratory mechanics and clinical picture
Pipes -Aorta Evaluation
Normal Aortic Diameter < 3 cm
Difficult for us to see secondary to:
Patient Size
Intraabdominal free air
No Curvelinear probe - biphasic array probe does not have enough penetration (usually)
Aortic Evaluation - Aneurysm
Aortic diameter 2.0-3.7 cm is normal
Surgery considered if > 5cm
A leaking or rapidly enlarging aneurysm can mimic angina.
Rapidly enlarging aneurysms can lead to dissection/rupture or valve compromise
DVT Assessment:
IVC
Use both B and M Mode
Pitfalls
Must take into consideration respiratory mechanics
Clinical Picture
Physical findings
Ultrasound findings
Leaky Tank - Pulmonary Evalution
-A lines should be present - normal lung artifact
-B line - interstital fluid
Contractility of the LV
Right Ventricular Strain
Right Sided Heart Failure
Left sided heart failure
Obstructive Shock (Pulmonary Embolism)
Valve Failure
The Pump
-Evaluation of the following
Contractility of the LV
RV strain
pericarial effusions
Focal wall motion abnormalities
Catastrophic Valve Failure
Objectives:
Discuss the role of bedside ultrasound in the assessment and treatment of undifferentiated shock
Rapid Ultrasound in SHock (RUSH) protocol: Ultrasonographic evaluation of the following:
The Pump
The Tank
The Pipes
-The Eyeball method is reproducible
and adequately accurate in the setting of acute decompensation/hypothension
Pericardial Effusions
pulsus paradoxus
Distant Heart Sounds
Dyspnea and cyanosis
Signs of right heart failure
Hypotension


What does it really mean?
Other Lung Findings:
Beware Consolidation and
atelectasis. Look for lung pulse
Consolidation
with
legionella
PNA
Leaky Tank - Free Fluid
in the Abdomen
Hypertrophic Obstructive Cardiomyopathy with SAM (systolic Anterior Motion) of the Mitral valve
Tension Pneumothorax
associated with obstructive shock
Summary of shock
The Pump Hypercontractile
Heart, Small sized
chamber

Hypovolemic
Cardiogenic
Obstructive
Distributive
Hypocontracile heart
Dilated Heart
Hypercontractile heart
Pericardial effusion
Cardiac tamponade
RV strain
Cardiac thrombus
Hypercontractile Heart (early)
Hypocontractile Heart (late)
The Tank
Flat IVC
Flat jugular veins
Peritoneal Fluid
Pleural Fluid
Distended IVC without
Changes
Distended jugular veins
B lines and Pleural Fluid
Distended IVC
Distended jugular veins
Absent Lung Sliding
Normal or small IVC (early)
Peritoneal Fluid (source)
Pleural Fluid (source)
B lines, peritoneal fluid (SIRS
The Pipes
Abdominal Aneurysm
Aortic Dissection
Normal
DVT
Normal
Nothing in Isolation: This is just one more tool in your armamentarium
Some Things to Remember:
Keep an open mind, don't discard information that doesn't agree with your diagnosis, incorporate it
Don't make a diagnosis from one view, one piece of information. One view may look normal, while another may show a game changing abnormality
The more normal Echo/ultrasounds you see, the better you will be at spotting something "not right"
don't get hung up on getting the perfect windows, the perfect view, or "the" diagnosis
Know your limitations, but don't ignore your findings
http://www.ultrasoundpodcast.com/
http://emergencyultrasoundteaching.com/
Full transcript