This document outlines the RUSH protocol for using bedside ultrasound to evaluate undifferentiated shock. The RUSH protocol examines four areas: the pump (heart), the tank (intravascular volume status via IVC scan), the pipes (vessels for leaks or blocks via abdominal, lower extremity scans), and lung sliding. It then presents four case examples where ultrasound identified cardiogenic shock, hypovolemic shock, pulmonary embolism, and aortic dissection as the causes of undifferentiated hypotension. The RUSH protocol aims to rapidly identify the cause of shock through focused bedside ultrasound exams of the heart, vessels, lungs and IVC to guide resuscitation efforts.

1. Use of bedside Ultrasound in Shock
RUSH Protocol
DAN STEVENS, ED REG SCGH

2. RUSH Protocol
 Rapid Ultrasound for Shock and Hypotension
 Other protocols
 ACES – Abdominal and Cardiac Evaluation (with ultrasound) in Shock
 FALLS protocol - Lichtenstein
 Early recognition and treatment of shock improves outcome
 Bedside ultrasound in undifferentiated hypotension in the
Emergency department leads to improved physician diagnosis1

3. Causes of Shock
 Cardiogenic
 MI
 Cardiac tamponade
 Hypovolaemic
 Bleeding
 Obstructive
 PE
 Pneumothorax
 Distributive
 Sepsis
 Anaphylaxis

4. RUSH Protocol
 The Pump
• The Heart
 The Tank
• Fullness of the tank
• IVC
• Emptiness of the tank
• EFAST
 The Pipes
• Leaking pipes
• AAA
• Blocked pipes
• DVT

5. Where to Scan

6. Parasternal long axis
• Pericardial effusion
• Pleural effusion
• LV contractility
• Normal
• Hyperdynamic
• Reduced
• RV size

7. Parasternal Short axis
• RV side
• Septal wall motion

8. Apical 4 chamber
• RV and LV size
• RV and LV function

9. Subcostal
• Pericardial effusion

10. IVC view
 > 2.1cm with < 50% collapse = high
CVP
 < 2.1cm with > 50% collapse = low
CVP

11. RUQ, LUQ, PELVIS
• Abdominal free fluid
• Pleural effusion

12. Aorta
• Aneurysm
• Dissection

13. Femoral Vein +/-
Popliteal
• Compressible / non compressible

14. Anterior chest wall
• Sliding / no sliding
• Lung rockets

15. CASE 1
Hyperdynamic LV
Large RV

16. Hyperdynamic LV
Large RV
Flattening of septum

17. RV > LV

18. Dilated IVC
> 2.1cm
< 50% collapse

19. Non compressible clot in Femoral Vein

20. CASE 2
Dliated LV
Poorly contracting
Biatrial enlargement

21. Dilated IVC
> 2.1cm
< 50% collapse

22. Lung rockets
B lines
> 3 = abnormal

23. Normal

24. Normal

25. CASE 3
Hyperdynamic
‘kissing LV’

26. IVC
< 2.1cm
> 50% collapse

27. Fluid in Morrisons Pouch

28. Empty uterus
+ve Bhcg
Fluid pouch of Douglas

29. CASE 4
Pericardial Effusion
?cardiac tamponade

30. Dilated IVC
> 2.1cm
< 50% collapse

31. Dissection to abdominal aorta

32. Final slide….

33. References
 1 Jones AE1, Tayal VS, Sullivan DM, Kline JA. Randomized, controlled trial
of immediate versus delayed goal-directed ultrasound to identify the
cause of nontraumatic hypotension in emergency department
patients. Crit Care Med. 2004 Aug;32(8):1703-8.
 http://emcrit.org/rush-exam/original-rush-article/
 http://sinaiem.us/wp-content/uploads/2012/05/31.-Sequencing.jpeg
 https://www.dtod.ne.jp/ohtablog/images/article10_pdf_003.pdf
 http://emcrit.org/wp-content/uploads/2011/03/New-RUSH-Review-
Article1.pdf