1

OCULAR ULTRASOUND
Ultrasound
Optic Nerve / Pupil / Ocular
Protocol in Shock

Objec&ves 2

At the end of this presenta/on, you should be able to:

Understand the ultrasound views to assess a

pa/ent with undifferen/ated shock using ACES/
ACES protocol

Be able to recognize the possible cause and

evaluate treatment response for pa/ents with
shock

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

3
The n e w e ng l a n d j o u r na l of m e dic i n e

review article

critical care medicine

Simon R. Finfer, M.D., and Jean-Louis Vincent, M.D., Ph.D., Editors

Circulatory Shock
Jean-Louis Vincent, M.D., Ph.D., and Daniel De Backer, M.D., Ph.D.

From the Department of Intensive Care,
Erasme Hospital, Université Libre de Brux-
elles, Brussels. Address reprint requests to
Dr. Vincent at the Department of Intensive
Care, Erasme University Hospital, Rte. de
Lennik 808, B-1070 Brussels, Belgium, or
at jlvincen@ulb.ac.be.
N Engl J Med 2013;369:1726-34.
DOI: 10.1056/NEJMra1208943
Copyright © 2013 Massachusetts Medical Society.
S
The n e w e ng l a n d j o u r na l of m e dic i n e
hock is the clinical expression of circulatory failure that
results in inadequate cellular oxygen utilization. Shock is a common condi-
tion in critical care, affecting about one third of patients in the intensive care review article
unit (ICU).1 A diagnosis of shock is based on clinical, hemodynamic, and bio-
chemical signs, which can broadly be summarized into three components. First,
systemic arterial hypotension is usually present, but the magnitude of the hypoten- critical care medicine
sion may be only moderate, especially in patients with chronic hypertension. Typi-
Simon R. Finfer, M.D., and Jean-Louis Vincent, M.D., Ph.D., Editors
cally, in adults, the systolic arterial pressure is less than 90 mm Hg or the mean
arterial pressure is less than 70 mm Hg, with associated tachycardia. Second, there
are clinical signs of tissue hypoperfusion, which are apparent through the three
Circulatory Shock
“windows” of the body2: cutaneous (skin that is cold and clammy, with vasocon- Jean-Louis Vincent, M.D., Ph.D., and Daniel De Backer, M.D., Ph.D.
striction and cyanosis, findings that are most evident in low-flow states), renal
(urine output of <0.5 ml per kilogram of body weight per hour), and neurologic

S
(altered mental state, which typically includes obtundation, From thedisorientation,
Department of IntensiveandCare, hock is the clinical expression of circulatory failure that
Erasme Hospital, Université Libre de Brux- results in inadequate cellular oxygen utilization. Shock is a common condi-
confusion). Third, hyperlactatemia is typically present, indicating abnormal
elles, Brussels. cellular
Address reprint requests to
oxygen metabolism. The normal blood lactate level is approximately
Dr. Vincent at1themmol per liter,
Department of Intensive tion in critical care, affecting about one third of patients in the intensive care
Care, Erasme University Hospital, Rte. de unit
but the level is increased (>1.5 mmol per liter) in acute circulatory failure. (ICU).1 A diagnosis of shock is based on clinical, hemodynamic, and bio-
Lennik 808, B-1070 Brussels, Belgium, or chemical signs, which can broadly be summarized into three components. First,
at jlvincen@ulb.ac.be.
systemic arterial hypotension is usually present, but the magnitude of the hypoten-
Pathoph ysiol o gic a l Mech aNnisms
Engl J Med 2013;369:1726-34. sion may be only moderate, especially in patients with chronic hypertension. Typi-
DOI: 10.1056/NEJMra1208943
cally, in adults, the systolic arterial pressure is less than 90 mm Hg or the mean
Shock results from four potential, and not necessarily exclusive, pathophysiological
Copyright © 2013 Massachusetts Medical Society.

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

mechanisms3: hypovolemia (from internal or external fluid loss), cardiogenic fac-
tors (e.g., acute myocardial infarction, end-stage cardiomyopathy, advanced valvular
heart disease, myocarditis, or cardiac arrhythmias), obstruction (e.g., pulmonary
embolism, cardiac tamponade, or tension pneumothorax), or distributive factors
(e.g., severe sepsis or anaphylaxis from the release of inflammatory mediators)
An interactive (Fig. 1A and the interactive graphic, available at NEJM.org). The first three mech-
graphic showing anisms are characterized by low cardiac output and, hence, inadequate oxygen trans-
initial assessment of
shock is available
port. In distributive shock, the main deficit lies in the periphery, with decreased
systemic vascular resistance and altered oxygen extraction. Typically, in such cases
arterial pressure is less than 70 mm Hg, with associated tachycardia. Second, there
are clinical signs of tissue hypoperfusion, which are apparent through the three
“windows” of the body2: cutaneous (skin that is cold and clammy, with vasocon-
striction and cyanosis, findings that are most evident in low-flow states), renal
(urine output of <0.5 ml per kilogram of body weight per hour), and neurologic
(altered mental state, which typically includes obtundation, disorientation, and
confusion). Third, hyperlactatemia is typically present, indicating abnormal cellular
oxygen metabolism. The normal blood lactate level is approximately 1 mmol per liter,
but the level is increased (>1.5 mmol per liter) in acute circulatory failure.
 The n e w e ng l a n d j o u r na l of m e dic i n e
4
A B Types of shock
Arterial hypotension
62%
Distributive (septic)

Absent Signs of tissue hypoperfusion Present

Brain
Altered mental
Chronic
state
hypotension?
Syncope Circulatory
(if transient) shock 4% 2%
Distributive Obstructive
Tachycardia (nonseptic)
16% 16%
Skin Elevated Estimate cardiac Cardiogenic Hypovolemic
blood output or SvO2
Mottled,
clammy lactate

Normal Low
or high
Kidney The n e w e ng l a n d j o u r na l of m e dic i n e
Oliguria CVP

Low High

Normal cardiac
chambers and (usually)
preserved contractility
Distributive shock
review article
Echocardiography In tamponade: pericardial
effusion, small right and
Small cardiac left ventricles, dilated
Large ventricles and
chambers and normal inferior vena cava; in
or high contractility poor contractility
pulmonary embolism or
pneumothorax: dilated right
critical care medicine
ventricle, small left ventricle
Simon R. Finfer, M.D., and Jean-Louis Vincent, M.D., Ph.D., Editors
Hypovolemic shock Cardiogenic shock Obstructive shock

Circulatory Shock
C

Distributive shock Hypovolemic shock Cardiogenic shock Obstructive shock

Loss of Obstruction
Vasodilatation plasma or
blood Jean-Louis Vincent, M.D., Ph.D., and Daniel De Backer, M.D., Ph.D.
volume

S
From the Department of Intensive Care, hock is the clinical expression of circulatory failure that
Ventricular Pericardial Erasme Hospital, Université Libre de Brux- results in inadequate cellular oxygen utilization. Shock is a common condi-
failure tamponade elles, Brussels. Address reprint requests to
Dr. Vincent at the Department of Intensive tion in critical care, affecting about one third of patients in the intensive care
Care, Erasme University Hospital, Rte. de unit (ICU).1 A diagnosis of shock is based on clinical, hemodynamic, and bio-
Lennik 808, B-1070 Brussels, Belgium, or chemical signs, which can broadly be summarized into three components. First,
at jlvincen@ulb.ac.be.
Figure 1. Initial Assessment of Shock States.
COLOR FIGURE
systemic arterial hypotension is usually present, but the magnitude of the hypoten-
Shown is an algorithm for the initial assessment of a patient in shock (Panel A), relative frequencies of the main types of shock (Panel B),
and schematic representations of the four main types of shock (Panel C). The algorithm starts with the most common Draft 9presentation 10/10/13
N Engl J Med 2013;369:1726-34. sion may be only moderate, especially in patients with chronic hypertension. Typi-
Author Vincent DOI: 10.1056/NEJMra1208943
(i.e., arterial hypotension), but hypotension is sometimes minimal or absent. CVP denotes central venous pressure,
venous oxygen saturation.
Fig #
and
1
SvO2 mixed
Copyright © 2013 Massachusetts Medical Society.
cally, in adults, the systolic arterial pressure is less than 90 mm Hg or the mean
Title

ME
arterial pressure is less than 70 mm Hg, with associated tachycardia. Second, there
DE
Artist
Drazen
Knoper
are clinical signs of tissue hypoperfusion, which are apparent through the three
“windows” of the body2: cutaneous (skin that is cold and clammy, with vasocon-
Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)
AUTHOR PLEASE NOTE:
Figure has been redrawn and type has been reset

1728 Please check carefully

n engl j med 369;18 nejm.org october 31, 2013 Issue date 10/31/13 striction and cyanosis, findings that are most evident in low-flow states), renal
The New England Journal of Medicine
Downloaded from nejm.org on April 3, 2015. For personal use only. No other uses without permission. (urine output of <0.5 ml per kilogram of body weight per hour), and neurologic
Copyright © 2013 Massachusetts Medical Society. All rights reserved.
(altered mental state, which typically includes obtundation, disorientation, and
confusion). Third, hyperlactatemia is typically present, indicating abnormal cellular
oxygen metabolism. The normal blood lactate level is approximately 1 mmol per liter,
but the level is increased (>1.5 mmol per liter) in acute circulatory failure.

Pathoph ysiol o gic a l Mech a nisms

5
Shock results from four potential, and not necessarily exclusive, pathophysiological
mechanisms3: hypovolemia (from internal or external fluid loss), cardiogenic fac-
tors (e.g., acute myocardial infarction, end-stage cardiomyopathy, advanced valvular
heart disease, myocarditis, or cardiac arrhythmias), obstruction (e.g., pulmonary
embolism, cardiac tamponade, or tension pneumothorax), or distributive factors
(e.g., severe sepsis or anaphylaxis from the release of inflammatory mediators)
An interactive (Fig. 1A and the interactive graphic, available at NEJM.org). The first three mech-
graphic showing anisms are characterized by low cardiac output and, hence, inadequate oxygen trans-
initial assessment of
port. In distributive shock, the main deficit lies in the periphery, with decreased
shock is available Search this site
at NEJM.org systemic vascular resistance and altered oxygen extraction. Typically, in such cases
cardiac output is high, although it may be low as a result of associated myocardial
depression. Patients with acute circulatory failure often have a combination of these
mechanisms. For example, a patient with distributive shock from severe pancreatitis,
anaphylaxis, or sepsis may also have hypovolemia and cardiogenic shock from
myocardial depression.

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obstructive shock is relatively rare (Fig. 1B and 1C). In a trial involving more than
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1726 n engl j med 369;18 nejm.org october 31, 2013
Education
The New England Journal of Medicine
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Copyright © 2013 Massachusetts Medical Society. All rights reserved. Medical Student Education
An extracurricular opportunity for all 1st year medical students to experience ultrasound while learning a vital application Communities of Practice
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Residents And Faculty

Trinity Tutorials
The Basics of Ultrasound
Aorta Exam
All first year medical students at OSU are given the Cardiac Ultrasound
opportunity to participate in the "Trinity Project". This program FAST Scan
consists of multiple didactic sessions and a minimum of 3 Tutorials
hands­on session that should be attended by each student.
Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES) Events
During this time they learn to attain the 8 views of the Trinity
UltraFest
scan in a standardized fashion and how these views may be SUSME's WCUME 2014
applied in the clinical setting. They are taught to evaluate the Calendar
primary etiologies of hypotension using ultrasound by
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Search all journals Advanced Search  Search History  Browse Journals  Request US Models
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Journal of Diagnostic Medical Sonography The UHP Ultrasound Protocol: A Novel
jdm.sagepub.com
Ultrasound Approach to the Empiric Evaluation
doi: 10.1177/875647930201800402
of the Undifferentiated Hypotensive Patient
Journal of Diagnostic Medical Sonography July 2002 vol. 18 no. 4 193­198
1. Cardiac Parasternal Long Axis
Trinity: 2. Cardiac Parasternal Short Axis
JOHN S. ROSE, MD,* AARON E. BAIR, MD,* DIKU MANDAVIA, MD, t
3. Subxiphoid of Heart and IVC
A Hypotensive Ultrasound Protocol AND DONNA J. KINSER, MD*
4. Aorta at Level of SMA
David Paul Bahner, MD, RDMS
5. Aorta at Bifurcation
This report describes a novel sonographic protocol for the evaluation of
the undifferentiated hypotensiveDepartment of Emergency Medicine, The Ohio State University College of
patient. This protocol combines com- 6. Suprapubic Including Bladder
bets. The patient had complained earlier in the evening of a
"stomach ache" and gone to bed early. Family members
ponents of 3 sonographic applications: free fluid, cardiac, and abdomi-
Medicine and Public Health, Columbus, Ohio; Department of Emergency
nal aorta into a single protocol. We believe this protocol and its under-
7. Perihepatic
remarked to the paramedics that they heard a crash in the
lying principles should be a routine part of the empiric evaluation of the 8. Perisplenic
woman's room and immediately went to investigate where
Medicine, 016 Prior Health Sciences Library, The Ohio State University,
she was found on the floor. At the time of arrival in the ED
patient with undifferentiated hypotension or pulseless electrical activity.
Columbus, OH 43210; bahner.4@osu.edu her blood pressure was 80/palpation, heart rate of 120
(Am J Emerg Med 2001;19:299-302. Copyright © 2001 by W.B. Saunders
Company) beats/min, respiratory rate of 30 breaths/min. Her pulse
Abstract oximetry was 100% on high flow oxygen. The only past
medical history available was hypotension for which she
Many critical conditions Hypotension is a common endpoint to many disease processes and can be evaluated
in emergency medicine involve took a single unknown prescription medication. On exami-
the use of empiric protocols or techniques to facilitate the nation she was mumbling and disoriented. There was no
with ultrasonography at the bedside. This ultrasound protocol can be used to examine
detection of reversible and time-dependent conditions. Car- gross evidence of trauma. Her chest was clear to ausculta-
the key organs involved in maintaining a blood pressure and the areas within the torso
ing for a patient with an unknown cause of hypotension can tion and her heart is regular without murmurs. Her abdomen
where fluid can collect. Systematically investigating these areas can provide the health
be one of the most challenging situations in emergency was obese and soft without apparent masses. Mild tender-
medicine. We describe care 
the team 
use ofwith  key  focused,
novel information goal-concerning 
ness,the  hypotensive 
without state. 
peritoneal signs,This 
was protocol
noted in the midepigas-
directed ultrasound protocol examines the torso from the geometric perspective of a cross (Trinity).
as a part of the empiric evalu- Knobology with Dr. B
trium. Initial standard resuscitative measures included crys-
ation of the patient with hypotension of uncertain origin. We talloid infusion. An electrocardiogram (ECG) was obtained
have termed this sonographic evaluation the undifferenti-
hypotension   ultrasound   Trinity
and was  normal.
emergency   shock
While awaiting the return of the portable
ated hypotensive patient (UHP) ultrasound protocol. The chest x-ray machine, the UHP ultrasound protocol was
Knobology
UHP protocol uses components of 3 accepted emergency
department (ED) ultrasound applications: free fluid evalua-
performed as a routine component of her hypotension eval-
uation. The hepatorenal interface view showed grossly nor-
Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)
tion, qualitative cardiac Articles citing this article
evaluation, and abdominal aorta Dr. Bahner discusses some of the basics to improving
mal anatomy without evidence of free intraperitoneal fluid.
evaluation. The rationale for the UHP protocol is to facili- The cardiac view revealed normal cardiac activity without
tate the rapid and systematic evaluation of reversible causes pericardial effusion. Evaluation of the aorta revealed a images using the options available on most standard
Brightness Mode Quality Ultrasound Imaging Examination Technique
of hypotension when the clinical history is limited or un- 6-centimeter aneurysm with associated intraluminal clot.
(B­QUIET): Quantifying Quality in Ultrasound Imaging
known. We describe 3 actual cases where the UHP protocol
ultrasound machines. 
The vascular surgeon on call was immediately notified and
was pivotal in the emergency Journal of Ultrasound in Medicine December 1, 2011 30: 1649­1655
evaluation of an undifferen- the patient was taken directly to the operating room where
tiated hypotensive patient. A description
Abstract and discussion
Full Text of her aorta was successfully repaired. The total time in the ED
Full Text (PDF)
the protocol follow the case presentations. We believe this was less than 20 minutes.
sonographic approach to be an important addition to the role
of emergency ultrasound for the practicing emergency phy- CASE 2
sician.
 7

Randomized, controlled trial of immediate versus delayed

goal-directed ultrasound to identify the cause of nontraumatic
hypotension in emergency department patients*
Alan E. Jones, MD; Vivek S. Tayal, MD; D. Matthew Sullivan, MD; Jeffrey A. Kline, MD

Objective: We examined a physician-performed, goal-directed
ultrasound protocol for the emergency department management
of nontraumatic, symptomatic, undifferentiated hypotension.
Design: Randomized, controlled trial of immediate vs. delayed
ultrasound.
Setting: Urban, tertiary emergency department, census >100,000.
Patients: Nontrauma emergency department patients, aged
>17 yrs, and initial emergency department vital signs consistent
with shock (systolic blood pressure <100 mm Hg or shock index
>1.0), and agreement of two independent observers for at least
one sign and symptom of inadequate tissue perfusion.
Interventions: Group 1 (immediate ultrasound) received standard
care plus goal-directed ultrasound at time 0. Group 2 (delayed
ultrasound) received standard care for 15 mins and goal-directed
viable physician diagnoses at 15 mins and the rank of their likelihood of
occurrence at both 15 and 30 mins. One hundred eighty-four patients
were included. Group 1 (n ! 88) had a smaller median number of viable
diagnoses at 15 mins (median ! 4) than did group 2 (n ! 96, median
! 9, Mann-Whitney U test, p < .0001). Physicians indicated the correct
final diagnosis as most likely among their viable diagnosis list at 15 mins
in 80% (95% confidence interval, 70–87%) of group 1 subjects vs.
50% (95% confidence interval, 40–60%) in group 2, difference of 30%
(95% confidence interval, 16–42%).
Conclusions: Incorporation of a goal-directed ultrasound pro-
tocol in the evaluation of nontraumatic, symptomatic, undifferen-
tiated hypotension in adult patients results in fewer viable diag-
nostic etiologies and a more accurate physician impression of
final diagnosis. (Crit Care Med 2004; 32:1703–1708)

EMCrit
ultrasound with standard care between 15 and 30 mins after time 0. KEY WORDS: hypotension; shock; ultrasound; diagnosis; mortal-
Measurements and Main Results: Outcomes included the number of ity; clinical trial

PEMCrit rior research has suggested etiology of hypotension in only 24% of pital with "100,000 patient visits per year. Ex-
that emergency department patients (2). plicit criteria for enrollment included the follow-Search the site ...
Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)
(ED) patients with symptom- Ultrasound has emerged as a useful ing: a) age "17 yrs; b) written agreement of two
HOME DEEP DIVE PROCEDURES EM CRIT CARE
atic hypotension in the ab- diagnostic tool for a variety of emergent independent physician observers on the pres-
sence of trauma have a high mortality situations, and both its availability and ence of the first measured vital signs consistent
rate. Jones et al. (1) found that symptom- incorporation into emergency medicine with shockSearch (systolicthe
blood
sitepressure
... !100 mm
DELAYED
with a SEQUENCE INTUBATION (DSI) are increasing (3). The diag- Hg or shock index (pulse rate/systolic blood
atic patients
ABOUT systolic
LEARN blood FOAM practice
TO pres- ARCHIVES CONTACT
sure !100HOME
mm Hg measured nostic utility of ultrasound
during am-PROCEDURES
DEEP DIVE EM CRIT CAREin patients pressure) "1.0); and c) a minimum of both one
bulance transport had an in-hospital with nontraumatic, undifferentiated sign and one symptom listed in Table 1, re-

EMCrit
mortality rate of 25%. Moore et al. (2) hypotension has not been systemati- corded by each observer independently and
DELAYED
found an 18%
YouABOUT
SEQUENCE
in-hospital
are here: Home
INTUBATION
mortality
/ Rapid
LEARN Ultrasound for
TO FOAM
evaluated. The hypothesis of the blinded to the other observers’ observations. Ex-
(DSI)
rate cally
Shock and Hypotension
ARCHIVES CONTACT – the RUSH Exam / Original RUSH Article
in 50 consecutive ED patients presenting present study was that the results of an clusions included a) either observer found no
8
with nontraumatic, symptomatic hypo- emergency physician performed, goal- symptom or sign in Table 1; b) history of “low
tension. In the latter study, emergency directed ultrasound protocol would sig- blood pressure” reported by the patient or dis-
covered from chart review;
Searchc) cardiopulmonary
the site ...
physicians accurately determined final nificantly narrow the number of poten-
Original RUSHnontraumatic,
Article
You are here: Home / Rapid Ultrasound
HOME
tialfor
DEEP DIVE
Shockdiagnoses
viable
symptomatic, undiffer-
and Hypotension – the with
of patients
PROCEDURES
RUSH Exam
resuscitation, defibrillation, or advanced cardiac
EM CRIT CARE life support medications before enrollment; d)
history of significant trauma to the chest or
entiated hypotension and would signif-
abdomen in the previous 24 hrs; e) a 12-lead
*See This
also p.concept
1798. was first conceived by the icantly
authors improve
above in 2006 and discussed
physician accuracyin national
in lectures in 2007 and on. It has been
Rapid Ultrasound
From the DepartmentDELAYED
forsymptomatic,
Shockundiffer-
and
of Emergency SEQUENCE
Medicine, INTUBATION (DSI) electrocardiogram diagnostic of acute myocar-
TOidentifying the
firstcorrect
hit on a diagnosis
searchofof ‘RUSH
Carolinas available on emcrit.org
ABOUT sinceLEARN March 2008 and was the
FOAM ARCHIVES google
CONTACT Exam’ f)from
dial infarction; this date
presence of an on. It was
obvious cause of
Medical Center, Charlotte, NC.
Presented
nontraumatic,
at the annual meeting of the
in Society for
Hypotension – the RUSH Exam
published on Emedhome May 2009. shock that would mandate immediate specific
Academic Emergency Medicine, Orlando, FL, May entiated hypotension.
treatment (active gastrointestinal bleeding,
2004.
known drug overdose, external hemorrhage); g)
Address requests forYoureprints to: Jeffrey
are here: Home A. Kline,
/ Rapid Ultrasound for Shock and Hypotension – the RUSH Exam
MD, 1000  Blythe Boulevard, Charlotte, NC 28203. MATERIALS AND METHODS referral from another hospital with a known
The RUSH Exam: Rapid Ultrasound for Shock and
E-mail: jkline@carolinas.org diagnosis; h) development of signs and symp-
Copyright © 2004 by the Society of Critical Care Patients were enrolled from July 2002 toms of shock in the ED after the results of
Hypotension
Medicine and Lippincott Williams & Wilkins
Rapid Ultrasound for Shock and Hypotension through September 2003 in the ED at Carolinas diagnostic testing (radiographic imaging and

Rapid Ultrasound for Shock and

DOI: 10.1097/01.CCM.0000133017.34137.82 Medical Center, an urban 800-bed teaching hos-
Scott D. Weingart, MD RDMS, Daniel Duque MD RDMS, Bret Nelson MD RDMS
laboratory results) were known to the treating

Hypotension – the RUSH Exam

It is now the standard of care to perform focused assessment using sonography for trauma (FAST) early in the
Crit Care Med 2004 Vol. 32, No. 8
evaluation of a sick trauma patient. There seems to be far less urgency to use ultrasound to evaluate the medical
1703

Hear thehypotension
Lecture
The RUSH Exam: Rapid Ultrasound for Shock and
patient with or signs of shock. We believe that part of the reason for this discrepancy is the lack of an
accepted way to refer to the exam and a standardized sequencing. In this paper, we outline the components and
00:00
Hypotension
rationale for the rapid ultrasound for shock and hypotension (RUSH) exam.
00:00

This concept was first conceived by the authors above in 2006 and discussed in national lectures in 2007 and on. It has been
Scott
available on D. Weingart,
emcrit.org MD2008
since March RDMS,
andDaniel
was theDuque
first hit MD
on a RDMS, Bret Nelson
google search of ‘RUSHMD RDMS
Exam’ from this date on. It was
In 2001, Rose et al. reviewed an ultrasound protocol they had created to evaluate the undifferentiated hypotension
published on Emedhome in May 2009.
patient.(1)Hear
In 2004,the
JonesLecture
et al. studied the effects of early goal-directed ultrasound for ED patients with
hypotension.(2) This study showed reduction in the number of conditions that needed to be ruled out, as well as a
Original RUSH
00:00 Article 00:00
quicker time to final diagnosis. Recently, additional articles have discussed the use of focused ultrasound for
cardiac
This This
article onconcept
arrest (3)
theand was
RUSH firstpatients
shock
Exam conceived by the authors
without
was published in May above
obvious in 2006 and discussed in national lectures in 2007 and on. It has been
etiology.(4)
2009
available on emcrit.org since March 2008 and was the first hit on a google search of ‘RUSH Exam’ from this date on. It was
published The RUSH Exam:
on Emedhome in the
Mayvarious
2009. diagnostic ultrasound techniques applicable to these patients into a
Additional Resources for the RUSH Exam
In an effort to conglomerate all of
Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)
R a pwei d
memorable approach, U lthe
created t rRUSH
aso u nThedRUSH exam was designed to be rapid and easy to perform
exam.
Original
Newest RUSH Review RUSH
i n S(Critical
H o cCarekArticle
i n t handePractice 2012;doi:10.1155/2012/503254)
Research

E v a l u a t i o n o f th e
This article on the RUSH Exam was published in May 2009
An article on the benefits of multiorgan ultrasound in shock patients (Inten Care Med PMID: 23584471)
Critically lll
Additional Resources for the RUSH Exam
Phillips Perera, MD, RDMS, FACEPa,*, Thomas Mailhot, MD, RDMSb,
David Riley, MD, MS, RDMSa, Diku Mandavia, MD, FACEP, FRCPCb,c
Newest RUSH Review (Critical Care Research and Practice 2012;doi:10.1155/2012/503254)
9
KEYWORDS
An article on the
! Rapid benefits
ultrasound of multiorgan
in shock examinationultrasound
! RUSH examin shock patients (Inten Care Med PMID: 23584471)

The RUSH Exam:

! Shock ! Ultrasound

Rapid Ultrasound
Care of the patient with shock can be one of the most challenging issues in emergency
medicine. Even the most seasoned clinician, standing at the bedside of the patient in

in SHock in the
extremis, can be unclear about the cause of shock and the optimal initial therapeutic
approach. Traditional physical examination techniques can be misleading given the
complex physiology of shock.1 Patients in shock have high mortality rates, and these

E v a l u a t i o n o f th e
rates are correlated to the amount and duration of hypotension. Therefore, diagnosis
and initial care must be accurate and prompt to optimize patient outcomes.2 Failure to
make the correct diagnosis and act appropriately can lead to potentially disastrous

Critically lll
outcomes and high-risk situations.
Ultrasound technology has been rapidly integrated into Emergency Department
care in the last decade. More practicing emergency physicians (EPs) are now trained
in bedside point of care or goal-directed ultrasound, and this training is now included
in all United States Accreditation Council for Graduate Medical Education Emergency
a, b
Phillips Perera,
Medicine residency
MD, programs.
3,4
RDMS, FACEP *, Thomas
Furthermore, Mailhot,
the American CollegeMD, RDMS ,
of Emergency
Physicians (ACEP) has formallya endorsed and embraced bedside ultrasoundb,c by the
DavidEPRiley, MD,applications.
for multiple , Diku
MS, RDMS5 This Mandavia,
technology MD,
is ideal in the FACEP,
care of the FRCPC
critical patient
in shock, and the most recent ACEP guidelines further delineate a new category of

KEYWORDS
a
New York Presbyterian Hospital, Columbia University Medical Center, Division of Emergency
! Rapid
Medicine, 622 West 168th Street, PH1-137, New York, NY!10032, USA
b ultrasound in shock examination RUSH exam
LA County1USC Medical Center, Department of Emergency Medicine, General Hospital, 1200
! Shock ! Ultrasound
State Street, Room 1011, Los Angeles, California 90033, USA
c
Cedars-Sinai Medical Center, Department of Emergency Medicine, General Hospital, 1200
State Street, Room 1011, Los Angeles, California 90033, USA
* Corresponding author.
E-mail address: pperera1@mac.com (P. Perera).

Care of theMed
Emerg patient with
Clin N Am shock
28 (2010)
doi:10.1016/j.emc.2009.09.010
29–56 can be one of the most challenging issues in emergency
emed.theclinics.com
medicine. Even –the
0733-8627/09/$ most
see front seasoned
matter ª 2010 Elsevierclinician,
Inc. All rights standing
reserved. at the bedside of the patient in
extremis, can be unclear about the cause of shock and the optimal initial therapeutic
approach. Traditional physical examination techniques can be misleading given the
complex physiology of shock.1 Patients in shock have high mortality rates, and these
rates are correlated to the amount and duration of hypotension. Therefore, diagnosis
Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)
and initial care must be accurate and prompt to optimize patient outcomes.2 Failure to
make the correct diagnosis and act appropriately can lead to potentially disastrous
outcomes and high-risk situations.
Ultrasound technology has been rapidly integrated into Emergency Department
care in the last decade. More practicing emergency physicians (EPs) are now trained
in bedside point of care or goal-directed ultrasound, and this training is now included
in all United States Accreditation Council for Graduate Medical Education Emergency
Hindawi Publishing Corporation
Critical Care Research and Practice
Volume 2012, Article ID 503254, 14 pages
doi:10.1155/2012/503254 10

Review Article
Bedside Ultrasound in Resuscitation and the Rapid Ultrasound in
Shock Protocol

Dina Seif,1 Phillips Perera,2 Thomas Mailhot,1 David Riley,3 and Diku Mandavia1
1 Department of Emergency Medicine, Los Angeles County+USC Medical Center, General Hospital, 1200 State Street, Room 1011,
Los Angeles, CA 90033, USA
2 Division of Emergency Medicine, Stanford University Medical Center, 300 Pasteur Drive, Alway Building, M121, Stanford,
CA 94305, USA
3 Division of Emergency Medicine, New York-Presbyterian Hospital, Columbia University Medical Center, 622 West 168th Street,

New York, NY 10032, USA

Correspondence should be addressed to Dina Seif, seifdina@gmail.com

Received 9 July 2012; Accepted 22 August 2012

The RUSH Exam 2012:

Academic Editor: Luciano Cesar Pontes Azevedo

Rapid Ultrasound
Copyright © 2012 Dina Seif et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
in status
Assessment of hemodynamic Shock in
in a shock state the
remains a challenging issue in Emergency Medicine and Critical Care. As the

Evaluation ofsimplythe
use of invasive hemodynamic monitoring declines, bedside-focused ultrasound has become a valuable tool in the evaluation and
management of patients in shock. No longer a means to evaluate organ anatomy, ultrasound has expanded to become
Critically Illpathways.
Patient
a rapid and noninvasive method for the assessment of patient physiology. Clinicians caring for critical patients should strongly
consider integrating ultrasound into their resuscitation
Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)
Phillips Perera, MD, RDMSa,*, Thomas Mailhot, MD, RDMSa,
David Riley, MD, MS, RDMSb, Diku Mandavia, MD, FRCPCa

1. Introduction KEYWORDS
will be compared to the RUSH exam to describe the core
exam elements they share, as well as to demonstrate how they
Early recognition and appropriate! Rapidtreatment
ultrasound of shockexamination
in shock have ! RUSH exam
! Shock ! Ultrasound
differ.
been shown to decrease mortality [1, 2]. Incorporation of
bedside ultrasound in patients with undifferentiated shock
allows for rapid evaluation of reversible causes of shock and
improves accurate diagnosis inCare
undifferentiated
of the patient with hypotension
2. Clinical Cases
shock can be one of the Medicine Residency Programs under the current
11
most challenging
[3]. Reflecting a trend to integrate ultrasoundissues early
in emergency 2.1. Caseguidelines
into medicine from the Accreditation
1. A 72-year-old male presents Council
to thefor Emergency
and critical care. Even the most seasoned clini- Graduate Medical Education Emergency Medicine
the care of the critically ill patient, multiple resuscitation
cian, standing at the bedside of the patient in ex-
Department (ED) for evaluation of chest pain, cough, and
residency programs.3–5 Furthermore, the Amer-
protocols have been recentlytremis,
developed [4–26]. Each of of generalized ican weakness. He describes the chest pain as sharp
The RUSH Exam 2012:
these protocols combines many
elements, differing mainly in
andof
tional
can be unclear
thethe same
optimal
thephysical
core
initial
priority
about the cause
ultrasound
therapeutic
of the techniques
examination exam can
shock
approach. and
Tradi-pleuritic,
pain.
be Hisdency
College of Emergency
and the with associated
Council
past Directors
of Emergency
medical (CORD)
historyhave
Physicians
backMedicine
is significant
(ACEP)
and upper Resi- abdominal
for hypertension,
formally endorsed
sequence.
Rapid Ultrasound
misleading given the complex physiology of
shock.1 Patients in shock have high mortality
In this paper, we will discuss twothese
rates, and clinical
rates arescenarios
correlatedof
for which bedside ultrasound by the EP for multiple applica-
he takes several medications including lisinopril
tions.6,7 This technology is ideal for the care of the
and metoprolol.
to the amount Onin shock,
critical patient physical examination,
and the most recent ACEP his vital signs

i n S h o c k in t h e
hypotension that will highlight
bedside ultrasound into clinical
rapid and accurate diagnosis of
how early
and duration
evaluation
and initial
integration
of hypotension.
care must can
of diagnosis
Therefore,
assist and
be accurate in prompt
optimize patient outcomes.2 Failure to make the
shock. An easily learned and
include guidelines
beats
a blood further
to per
pressure
‘resuscitative’
of 82/60
delineate
ultrasound.8 Over
minute, respiratory
a new mm Hg, heart
category
ratethe24lastbreaths
addition to the original RUSH protocol published
temperature
of rate 120
years, inper minute,
100.8 F, and pulse oximetry 92% on room air.
Evaluation of the
correct diagnosis and act appropriately can lead
quickly performed shock ultrasound
to potentially
exam (Rapid Ultrasound in Shock),
protocol,
disastrousthe
willforbetheapplied
risk situation
RUSHand a He
outcomes
provider.in both
in 2010, there have been a number of new resusci-
high-is diaphoretic
tation ultrasound
rales in both
andprotocols
lungdiagnose
accurately
ill appearing.
bases, but
developedLung
is otherwise
the patient
to more exam reveals
in shockunremarkable.
and to An

Critically Ill Patient

cases [19, 20]. The RUSH exam
physiologic assessment simplified
involvestechnology
Ultrasound
gratedas into
a 3-parthasbedside
“thegeneral
pump,” medicine
been rapidlyelectrocardiogram
inte-
and specifically,
“the tank,”
Emergency Department care, in the last decade.
and “the pipes.” Several otherMore
major resuscitation protocols
which was
portable
more rapidly (EKG)
the initial
present
develop shows
stages
onofamedical
a left care
an improved
test performed
bundle
have also expanded these resuscitation protocols
plan branch
care.1,9–21 Clinicians
in block,
one year prior. A
practicing emergency physicians (EP’s) and tochest radiograph
encompass demonstrates
the ultrasound evaluationinfiltrates
of the at both
critical care physicians are now trained in bedside patient presenting with unexplained dyspnea,
Phillipspoint
Perera, MD,
of care, or RDMSa,ultrasound
goal directed, *, Thomasand this Mailhot,
incorporatingMD, of the asame
manyRDMS , ofexam compo-
22–25
training is now both supportedbby the American nents utilized in the evaluation
a shock.
David Riley, MD, MS,and
Medical Association RDMS , Diku
included Mandavia,
in the formal MD,
Instead of FRCPC
relying on older techniques, like
curriculum of all United States Emergency listening for changes in sound coming from the

KEYWORDS
ultrasound.theclinics.com

! RapidThis article was previously published in the February 2010 issue of Emergency Medicine Clinics.
a ultrasound in shock examination ! RUSH exam
Department of Emergency Medicine, Los Angeles County1USC Medical Center, General Hospital, 1200 State
! ShockStreet,
b
! Ultrasound
Room 1011, Los Angeles, CA 90033, USA
Division of Emergency Medicine, New York Presbyterian Hospital, Columbia University Medical Center,
622 West 168th Street, New York, NY 10032, USA
* Corresponding author.
E-mail address: pperera1@mac.com

Ultrasound Clin 7 (2012) 255–278

Care of the patient with shock can be one of the
doi:10.1016/j.cult.2011.12.010 Medicine Residency Programs under the current
most challenging
1556-858X/12/$ issues
– see front in ! 2012 Elsevier Inc.
emergency
matter medicine guidelines from the Accreditation Council for
All rights reserved.

and critical care. Even the most seasoned clini-
cian, standing at the bedside of the patient in ex-
Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)
tremis, can be unclear about the cause of shock
and the optimal initial therapeutic approach. Tradi-
tional physical examination techniques can be
misleading given the complex physiology of
shock.1 Patients in shock have high mortality
rates, and these rates are correlated to the amount
and duration of hypotension. Therefore, diagnosis
and initial care must be accurate and prompt to
optimize patient outcomes.2 Failure to make the
correct diagnosis and act appropriately can lead
to potentially disastrous outcomes and a high-
risk situation for the provider.
Ultrasound technology has been rapidly inte-
grated into general medicine and specifically,
Emergency Department care, in the last decade.
More practicing emergency physicians (EP’s) and
critical care physicians are now trained in bedside
point of care, or goal directed, ultrasound and this
training is now both supported by the American
Medical Association and included in the formal
curriculum of all United States Emergency
Graduate Medical Education Emergency Medicine
residency programs.3–5 Furthermore, the Amer-
ican College of Emergency Physicians (ACEP)
and the Council of Emergency Medicine Resi-
dency Directors (CORD) have formally endorsed
bedside ultrasound by the EP for multiple applica-
tions.6,7 This technology is ideal for the care of the
critical patient in shock, and the most recent ACEP
guidelines further delineate a new category of
‘resuscitative’ ultrasound.8 Over the last years, in
addition to the original RUSH protocol published
12
in 2010, there have been a number of new resusci-
tation ultrasound protocols developed to more
accurately diagnose the patient in shock and to
more rapidly develop an improved care plan in
the initial stages of medical care.1,9–21 Clinicians
have also expanded these resuscitation protocols
to encompass the ultrasound evaluation of the
patient presenting with unexplained dyspnea,
incorporating many of the same exam compo-
nents utilized in the evaluation of shock.22–25
Instead of relying on older techniques, like
listening for changes in sound coming from the
ultrasound.theclinics.com

This article was previously published in the February 2010 issue of Emergency Medicine Clinics.
a
Department of Emergency Medicine, Los Angeles County1USC Medical Center, General Hospital, 1200 State
Street, Room 1011, Los Angeles, CA 90033, USA
b
Division of Emergency Medicine, New York Presbyterian Hospital, Columbia University Medical Center,
622 West 168th Street, New York, NY 10032, USA
* Corresponding author.
E-mail address: pperera1@mac.com

Ultrasound Clin 7 (2012) 255–278

doi:10.1016/j.cult.2011.12.010
1556-858X/12/$ – see front matter ! 2012 Elsevier Inc. All rights reserved.

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

2109-06.qxd 11/2/04 3:36 PM Page 700

European Journal of Anaesthesiology 2004; 21: 700–707

© 2004 European Academy of Anaesthesiology
13
ISSN 0265-0215

Original Article
Focus Assessed Transthoracic Echo (FATE)
Transthoracic echocardiography for cardiopulmonary Scanning through position 1-4 in the most favourable sequence
monitoring in intensive care Basic FATE views

Disclaimer: The authors do not assume any responsibility for the use of this FATE card. Layout: Department of Communication, Aarhus University Hospital, Skejby • ES0410LB
0°

M. B. Jensen, E. Sloth, K. M. Larsen, M. B. Schmidt Point right Point right

(patient´s left) (patient´s
left back)
Aarhus University Hospital, Department of Anaesthesiology and Intensive Care, Skejby Sygehus, Denmark
RV LV
RA RV
LV
Summary
Background and objective: To evaluate the feasibility of an abbreviated focus assessed transthoracic echocardio- RA LA
LA
graphic protocol, consisting of four standardized acoustic views for cardiopulmonary screening and monitoring.
Methods: The protocol was applied in 210 patients in a 20-bed multidisciplinary intensive care unit in a univer-
sity hospital. When inconclusive, an additional transoesophageal echocardiographic examination was performed.
Diagnosis, indication, acoustic window, position and value were recorded. Significant pathology, load, dimensions Pos 1: Subcostal 4-chamber Pos 2: Apical 4-chamber
and contractility were assessed.
Results: Two-hundred-and-thirty-three transthoracic and four transoesophageal echoes were performed. The
protocol provided usable images of the heart in 97% of the patients, 58% subcostal, 80% apical and 69% Point left Point right
parasternal. Images through one window were obtainable in 23%, through two windows in 41% and through (patient´s right (patient´s left
shoulder) shoulder)
three windows in 34%. In 227 patients (97.4%) the focus assessed echo protocol contributed positively. In
24.5% of cases the information was decisive, in 37.3% supplemental and in 35.6% supportive. RV RV
Conclusions: By means of an abbreviated, focus assessed transthoracic echo protocol it is feasible to visualize
the haemodynamic determinants for assessment and optimization. One or more useful images are obtainable in LV AO LV
97% of critically ill patients.
LA
Keywords: ECHOCARDIOGRAPHY, transthoracic, transoesophageal; CRITICAL CARE, monitoring; HEART
DISEASES, cardiac output low, heart failure, myocardial ischaemia.
Pos 3: Parasternal long axis Pos 3: Parasternal LV short axis

Point cranial Right Left

Monitoring and treatment of the haemodynamically
unstable patient in the intensive care unit (ICU) is a
complex challenge. Often the time factor is a major
concern and the outcome depends on a rational and
problem focused approach. Two dimensional imaging
of the heart, with the ability to characterize the indi-
vidual haemodynamic determinants and exclude or
confirm different conditions in a quick and non-
invasive way, is an attractive thought. Ultrasound is, at
present, the only method which can provide bedside
real-time and dynamic imaging of the heart – either
Correspondence to: Erik Sloth, Department of Anaesthesiology and Intensive
Care, Aarhus University Hospital, Skejby Sygehus, Denmark. E-mail: sloth@
Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)
dadlnet.dk; Tel: !45 8949 8822; Fax: !45 8617 3988
Accepted for publication March 2004 EJA 1603
from the transthoracic echocardiographic (TTE)
approach or by means of transoesophageal echocardio-
graphy (TOE). With these methods, the heart, Liver/spleen
the
great vessels and the pleurae can be visualized, giving Diaphragm
important information about cardiac morphology, sys-
tolic and diastolic function, and significant pathology
[1–6]. Measurements of wall thickness and cavity Lung
dimensions are essential parameters for assessment of
the major determinants of haemodynamics, namely
preload, afterload and contractility. In addition, dias-
tolic function as well as ventricular interdependency Pos 4: Pleural scanning
may be described by echocardiography. In this way
the examination provides information of paramount
importance for further therapeutic decisions. TOE
has been claimed to be the method of choice in the
ICU and many investigations have demonstrated

14

Focused echocardiographic evaluation in resuscitation

management: Concept of an advanced life support– conformed
algorithm
Raoul Breitkreutz, MD; Felix Walcher, MD, PhD; Florian H. Seeger, MD

Emergency ultrasound is suggested to be an important tool in minimal interruptions to reduce the no-flow intervals. However,
critical care medicine. Time-dependent scenarios occur during they also recommended identification and treatment of reversible
preresuscitation care, during cardiopulmonary resuscitation, and causes or complicating factors. Therefore, clinicians must be
in postresuscitation care. Suspected myocardial insufficiency due trained to use echocardiography within the brief interruptions of
to acute global, left, or right heart failure, pericardial tamponade, advanced life support, taking into account practical and theoret-
and hypovolemia should be identified. These diagnoses cannot be ical considerations. Focused echocardiographic evaluation in re-
made with standard physical examination or the electrocardio- suscitation management was evaluated by emergency physicians
gram. Furthermore, the differential diagnosis of pulseless electri- with respect to incorporation into the cardiopulmonary resusci-
cal activity is best elucidated with echocardiography. Therefore, tation process, performance, and physicians’ ability to recognize
we developed an algorithm of focused echocardiographic evalu- characteristic pathology. The aim of the focused echocardio-
ation in resuscitation management, a structured process of an graphic evaluation in resuscitation management examination is to
advanced life support– conformed transthoracic echocardiogra- improve the outcomes of cardiopulmonary resuscitation. (Crit
phy protocol to be applied to point-of-care diagnosis. The new Care Med 2007; 35[Suppl.]:S150–S161)
2005 American Heart Association/European Resuscitation Coun- KEY WORDS: emergency echocardiography; focused echocardio-
cil/International Liaison Committee on Resuscitation guidelines graphic evaluation in resuscitation; resuscitation; cardiopulmo-
recommended high-quality cardiopulmonary resuscitation with nary resuscitation; algorithm; critical care ultrasound

I
n emergency and critical care support (ALS). Time is an essential com- after thoracic and cardiac surgery and in
medicine, the old and new Amer- ponent for successful cardiopulmonary nontrauma in-hospital emergencies (7, 8).
Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)
ican and European resuscitation resuscitation (CPR) (5). Any diagnostic Another important issue is the differential
guidelines of the American Heart procedures and interventions must yield diagnosis of pulseless electrical activity
Association, European Resuscitation quick results to identify the underlying (PEA), which essentially requires echocar-
Council, and the International Liaison cause. “Point-of-care focused ultrasound” diography to either rule in or rule out crit-
Committee on Resuscitation (1– 4) rec- or “goal-directed ultrasound” in the eval- ical findings (9 –13). However, the new Eu-
ommended identifying and treating cor- uation of nontraumatic, symptomatic, ropean Resuscitation Council 2005
rectable causes of cardiopulmonary ar- undifferentiated hypotension in adult pa- guidelines recommend echocardiography
rest. Patients must be treated using tients results in a narrower differential in PEA or asystole after cardiotomy only,
algorithm-based management such as ba-
sic life support (BLS) and advanced life
diagnosis and a more accurate physician
impression of final diagnosis (6). These
but they do not stipulate how it is to be
performed (7). Furthermore, the new Amer-
15
authors have shown that, in emergency ican Heart Association/European Resuscita-
rooms, the immediate application of tion Council/International Liaison Commit-
sonography could result in improved pa- tee on Resuscitation 2005 resuscitation
From the Department of Anesthesiology, Intensive
Care, and Pain therapy (RB), the Department of Trauma tient outcome (6). Myocardial function guidelines set narrow time intervals for
Surgery (FW), and the Department of Cardiology (FHS), during CPR is still underdiagnosed and echocardiographic examination, due to po-
Hospital of the Johann-Wolfgang-Goethe University, remains a “black box” in most cases. Po- tential detrimental effects and the require-
Frankfurt am Main, Germany. tentially treatable causes of sudden car- ment of rebuilding coronary perfusion
The authors have not disclosed any potential con-
flicts of interest.
diac arrest, such as pericardial tampon- pressure (14). Pauses in chest compression
Presented, in part, at the First and Second World ade, cardiogenic shock, myocardial were recommended to be “brief interrup-
Congresses on Ultrasound in Emergency and Critical insufficiency (resulting from coronary or tions” for adult ALS (4, 7) and of a maxi-
Care Medicine, Milan, Italy, June 2005, and New York, pulmonary artery thrombosis), or hypo- mum of 10 secs for pediatric ALS (15) to
NY, June 2006 (http://www.winfocus.org).
For information regarding this article, E-mail:
volemia, should be detected or excluded reduce the duration of no-flow intervals
raoul.breitkreutz@gmail.com. as soon as possible, even on scene. (NFIs), thereby limiting potential transtho-
Copyright © 2007 by the Society of Critical Care Important treatable causes of asystole racic ultrasound examinations. Unfortu-
Medicine and Lippincott Williams & Wilkins are large, hemodynamically relevant peri- nately, there is a lack of recommendations
DOI: 10.1097/01.CCM.0000260626.23848.FC cardial effusions, which are regularly found regarding time frames of any interruptions,

S150 Crit Care Med 2007 Vol. 35, No. 5 (Suppl.)

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

 ACES windows : 16

1. Heart 4. Right upper quadrant

2. Inferior vena cava 5. Left upper quadrant

3. Abdominal aorta 6. Pelvic

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

1. Heart 17

A focused view of the heart :
The ini/al view should be a transverse
1
subxiphoid four-chamber view looking at
general overall contrac/lity, right and leG
ventricular chamber size and
contrac/lity,and for the presence of
pericardial fluid with evidence of
tamponade.

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

2. IVC 18

An inferior vena cava (IVC) diameter and

2
collapse index, measured using the
longitudinal subxiphoid window looking at
the IVC as it passes posterior to the liver
and into the heart.

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

3. Aorta 19

A focused assessment of the
abdominal aorta obtained by a
sliding transverse view from the
diaphragm to its bifurca/on. 3

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

4. RUQ 20

A right upper quadrant

hepatorenal/lung base view
looking for free peritoneal or
4
pleural fluid.

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

5. LUQ 21

A leG upper quadrant
splenorenal/lung base view,
again looking for peritoneal or
5
pleural free fluid.

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

6. Pelvis 22
A transverse pelvic view
looking at bladder
volume and for free
pelvic fluid.
6

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

23

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

Rapid Ultrasound in SHock 24

An ultrasound protocol involves 3-part bedside

physiologic assessment
Pump
Tank
Pipes

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

RUSH protocol - Summary 25

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

Evalua&on of ‘the pump’ 26

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

A The Pump
Step 1. Pericardial Effusion ?
Step 2. LV Contractility ?
Step 3. RV Strain ? 27

Signs of tamponade :
Diastolic collapse of RV +/- RA
Step 1 :
Pericardial effusion
/ Tamponade

Pleural effusion may mimic

pericardial effusion

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

 The Pump 28

A Step 1. Pericardial Effusion ?

Step 2. LV Contrac&lity ?
Step 3. RV Strain ?

Step 2. LV contractility
Normal
Can tolerate more fluid ? Hypokine/c
Hyperkine/c

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

The Pump 29

A
Step 1. Pericardial Effusion ?
Step 2. LV Contrac&lity ?
Step 3. RV Strain ?

Step 2. LV contrac&lity Normal

Hypokine/c
Can tolerate more fluid ? Hyperkine/c

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

The Pump 30

A
Step 1. Pericardial Effusion ?

Step 2. LV Contrac/lity ?
Step 3. RV Strain ?

PiTall :
Chronic Pulmonary
HPT also causes RV
dilata/on PLUS RV
Hyperthrophy

Step 3. Right Ventricle Strain

Increased RV size ?
Septal displacement from Rt to Lt ?

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

The Tank 31

B Assess the effec/ve intravascular volume status

Step 1. Fullness of tank (IVC / IJC)
Step 2. Leakiness of the tank ( FAST / Thoracic )
Step 3. Tank compromise ( Tension pneumothorax )

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

1. Fullness of the Tank 


IVC variation The Tank 32

B
Step 1. Fullness of the tank
Step 2. Leakiness of the tank
Step 3. Compromise of the tank

Need more fluid ?

Leaking ?
Obstructed ?
Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

1. Fullness of the Tank 


IJC variation
The Tank 33

B Step 1. Fullness of the tank

Step 2. Leakiness of the tank
Step 3. Compromise of the tank

Need more fluid ?

Leaking ?
Obstructed ?
Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)
 The Tank 34

B 2. Leakiness of the Tank 


Step 1. Fullness of the tank
Step 2. Leakiness of the tank
Step 3. Compromise of the tank

Fluid in abdomen / thorax / lung

Need more fluid ?

Leaking ?
Obstructed ?

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

The Tank 35

B 2. Leakiness of the Tank 


Fluid in abdomen / thorax / lung
Step 1. Fullness of the tank
Step 2. Leakiness of the tank
Step 3. Compromise of the tank

Need more fluid ?

Pulmonary oedema can indicate
Leaking ?
tank overload & leakiness
Obstructed ?
Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

The Tank 36

B
Step 1. Fullness of the tank
Step 2. Leakiness of the tank
Step 3. Compromise of the tank
3. Compromise of Tank 

Tension pneumothorax

Pneumothorax :
- Presence of Lung Point
- Absence of Lung sliding
- Absence of B-lines
- Absence of lung pulse
Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)
 The Pipes 37

C
Assess both the
arterial and venous
system
Rupture of the pipes
( Aor/c aneurysm &
dissec/on )
Obstruc/on of the
pipes ( DVT )

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

38
Rupture of the pipes 

1
Step 1. Abd Aorta Aneurysm ?
Step 2. Thoracic Aorta Aneurysm ?

Abdominal aortic aneurysm

Step 3. Deep Vein Thrombosis ?

Abdominal aorta > 3cm ?

Iliac artery > 1.5cm ?
Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

39
Rupture of the pipes 

2
Step 1. Abd Aorta Aneurysm ?
Step 2. Thoracic Aorta Aneurysm ?

Thoracic aortic aneurysm

Step 3. Deep Vein Thrombosis ?

Aortic root > 3.8cm ?

Intimal flap ?
Thoracic aorta > 5cm ?
Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)
 40

3 Obstruction of the pipes 


Deep Vein Thrombosis
Step 1. Abd Aorta Aneurysm ?
Step 2. Thoracic Aorta Aneurysm ?
Step 3. Deep Vein Thrombosis ?

Non compressible deep veins

(femoral & popliteal)
Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

Shock - Ultrasound Protocols 41

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

RUSH protocol - Summary 42

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

RUSH protocol summary 43

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)

Thank you 44

Systematic Ultrasound for Critical Care and Emergency Scenarios (SUCCES)