R.U.S.H.

(Rapid Ultrasound in SHock in

the Evaluation of the Critically ill)
( Blue Protocol)

ACLS/AILS/NRP provider
ETTC/APLS instructor



Winfocus WBE/ULS instructor

Case Scenario

77
,
UTI

Vital signs: Blood

Pressure: 95/58mmHg, Pulse Rate: 114/min,
Respiratory Rate: 18/min, Temperature: 37.3,
SPO2: 93

?
?

Subxiphoid view

RUQ view

Causes of Hypotension

Hypovolaemia

Obstructive (tamponade)

Obstructive (PE)

Cardiogenic

Distributive (septic)

Hypovolaemia
Two aims of ACES scan:

To establish existence of hypovolaemic state

IVC

Cardiac

collapse index
Small chamber size small heart
Aggressive wall motion hyperdynamic

To identify possible causes

AAA
Free fluid (haemoperitoneum)

Abdominal aorta

IVC scanning

CVP vs IVC size

Collapse Index

Inspiration IVC collapses slightly

Expiration IVC maximal diameter

Collapse Index (CI)

Max diameter Min diameter
CI =

x 100%

Max diameter
Maximum diameter - expiration
Minimum diameter - inspiration

Collapse Index

CI > 50% = RA pressure < 10mmHg

CI < 50% = RA pressure > 10mmHg

Noninvasive estimation of right atrial

pressure from the inspiratory collapse of the
inferior vena cava
Kircher BJ et al
Am J Cardiol 1990 Aug 15;66(4):493-6

Tamponade
Aims of ACES scan to:

Identify pericardial effusion

Collapse RA/RV during diastole = tamponade

Pulmonary embolism
ACES scan aims to identify: RV dilatation
RV

hypokinesis
Paradoxical septal motion

IVC distension
(Peripheral views for DVT)

Cardiogenic
ACES scan aims to identify gross abnormalities of
cardiac: Size

Normal
Small
Dilated

Motion

Normal
Hyperdynamic
Hypodynamic

Hypodynamic myocardium = cardiogenic

Sepsis
ACES scan aims to identify: Hyperdynamic left ventricular function

Hyperdynamic heart has sensitivity of 33% and a

specificity of 94% for sepsis
Diagnostic accuracy of left ventricular function for identifying sepsis among emergency
department patients with non traumatic symptomatic undifferentiated hypotension
Jones A et al
Shock 2005 Dec;24(6) :513-7

ACES scan - 6 windows

1.
2.
3.
4.
5.
6.

Cardiac
IVC
Aorta
RUQ
LUQ
Pelvis

The crushing patient

Chest : BAT sign

Normal lung artifact

A line
B line : comet tail
artifact

Interstitial syndrome

Thickening of interlobular septa(B7 lines)

Ground-grass area(B3 lines)

Pitfalls and take home message

History and PE
Resuscitation

, IVCMorrison pouch
DVTDVT
proximal DVT(Femoral vein
Politeal vein)DVT

Thanks for your attention !!