Hypotension

Case: RUSH Exam Part 1

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Series 1 of 4, This video represents a comprehensive algorithm for the integration of bedside ultrasound for patients in shock. By focusing on "Pump, Tank, and the Pipes," clinicians will gain crucial anatomic and physiologic data to better care for these patients.

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Cardiology

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Case Study Videos

Subtitles

- [Phil] Hello, and welcome back to Soundbytes Ultrasound.
My name is Dr. Phil Perera and in this video module
we're going to cover an advanced application of ultrasound.
That of the RUSH Exam which stands for Rapid Ultrasound
in Shock in the Critically Ill Patient.
This module will be video part one,
and will cover how the RUSH exam,
a series of ultrasound applications,
can be combined into one whole protocol
for the assessment of the patient in shock.
Let's begin with a clinical case
that outlines the power of the RUSH exam.
Here we have a 67 year old male presenting via paramedics
for acute shortness of breath for several hours.
The medics phone ahead with the vital signs,
and they have a blood pressure of 90 over palp,
a heart rate of 120, and a respiratory rate of 32.
They're calling ahead for notification because the patient
appears to be in severe respiratory distress.
The patient has a significant past medical history
significant for COPD, congestive heart failure,
and hypertension on multiple medications.
He states that his baseline blood pressure
runs about 160 to 170 systolic
and that he has been compliant
with his blood pressure medications
making the blood pressure of 90 over palp
a big change from his baseline.
As the patient arrives into the emergency department
he's immediately placed into the resuscitation area
and the vital signs are reconfirmed
showing significant hypotension
as well as a low grade fever and hypoxia.
The patient is talking to you,
but does appear to be in respiratory distress.
On lung exam he has diffuse expiratory wheezing
and inspiratory rales at the bases,
and edema is present in the lower extremities.
So the question for you
is how best to proceed at this point?
Well most of us would order a portable chest x-ray,
an EKG, and some baseline labs.
Here's the patients chest x-ray and it's read as
no acute infiltrate, effusion, no pneumothorax,
the heart size was seen as normal, and notice here
there's no real evidence here for pulmonary edema,
i.e. no real infiltrate or sephilization.
The patient's vital signs clearly indicate
an advanced type of shock
and the clinical question here is what type of shock
is this patient suffering from
and what is the best treatment option for the patient?
Could he have: A. Distributive shock
of which sepsis would be the most common
B. Cardiogenic shock
C. Hypovolemic or hemmorhagic shock,
or D. An obstructive kind of shock
of which the three main causes,
cardiac tamponade, pulmonary embolus,
or tension pneumothorax must be considered.
Thus in the resuscitation area it's a little unclear
as to which type of shock our patient is suffering from
as he has elements in his physical exam and his evaluation
that overlap between the four different types of shock
as detailed here.
In the past it would have been relatively easier
to figure out which type of shock
this patient was suffering from by placement
of an invasive pulmonary artery catheter
or a Swan-Ganz catheter.
This was commonly done when I was training
in internal medicine back in the 90s
and gave an amazing amount of physiological detail
with regard to the patient's state.
Unfortunately multiple studies looking at these PA catheters
found an increased rate of complications
and no improvement in overall morbidity or mortality
of these patients.
Thus their use has drastically declined in the recent past
setting the stage for the use of noninvasive measures
of shock assessment.
The RUSH exam was initially written to fit the void
for non invasive evaluation of physiology
in this case using bedside ultrasound.
The RUSH exam, a series of ultrasound elements
that was combined into a protocol, was initially published
in Emergency Medicine Clinics of North America in 2010
and then republished several more times in 2012.
The RUSH exam was therefore written as a three part
ultrasound evaluation of the patient in shock.
The first step was evaluation of the pump.
Here we were looking for three main things.
First of all assessing the heart for the presence
of a pericardial effusion or cardiac tamponade.
Number two, evaluating the left ventricle for contractility.
And number three, evaluating the right ventricle for strain
or dilatation that could indicate a large pulmonary embolus
in the crack clinical scenario.
Number two was the evaluation of the tank
or inter vascular volume.
The first assessment here was how full is the tank
and this was performed by an evaluation
of the inferior vena cava or internal jugular veins.
The second part was to evaluate
if the tank was leaking or compromised
and this involved elements of the Extended-FAST exam,
an also lung ultrasonography
looking for the presence of pneumothorax
or ultra sonic B Lines.
The third part of the RUSH exam was the evaluation
of the pipes first looking at the arterial circuit
for problems such as abdominal aortic aneurysm
or thoracic aortic aneurysm
which could be the cause of the patient's shock.
Second was the evaluation for the major venous circuit
mainly focusing on the legs for assessment for
deep venous thrombosis.
And this part would be included
especially if the echo showed right ventricular strain
to confirm the presence of a possible pulmonary embolus.
The RUSH exam is therefore an easily remembered
ultrasound protocol for the assessment
of the patient in shock that utilizes
the mnemonic of pump, tank, and pipes
to incorporate many ultrasound elements into an evaluation.
Here's a table that encompasses
many of the major resuscitation shock protocols
that have been published to date,
and we see them across the top of the table.
Let's look specifically
at the RUSH pump, tank, pipes protocol.
To the left we can see the protocol ultrasound elements
that have been combined
into many of these resuscitation protocols.
And we can see that the RUSH exam
combines many of the protocols to date,
starting with Cardiac and IVC exam,
and continuing on through the FAST exam,
the Aorta exam, Lung ultrasound,
and finally the DVT examination.
In a series of upcoming videos we'll go over
how to use the RUSH exam
i.e., how to evaluate the pump, the tank, and the pipes
to figure out exactly what type of shock
the patient is suffering from and how best to treat
the patient in the resuscitation area.
And hopefully by the time we go through all these videos
this table will make a lot more sense.
We'll be able to use the RUSH exam
to figure out the specific type of shock
that the patient is suffering from.
Is it hypovolemic, cardiogenic,
obstructive, or distributive?
And we can see how the different findings
within the pump, tank, and pipe categories
can help us in determining this etiology for the shock.
So I look forward to seeing you back
as Soundbytes continues and as we further explore
the RUSH Exam in the upcoming series of videos.

Brightcove ID

5754395461001

https://youtube.com/watch?v=tqBdKIdKqOc

M-Turbo: Apical 4 Chamber

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M-Turbo: Apical 4 Chamber.

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M-Turbo: Abdomen 03

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M-Turbo: Spleen Longitudinal.

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Liver: Hepatic Veins

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Central Venous Pressure

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Edge

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3D How To: Ultrasound Guided Pericardiocentesis

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3D animation demonstrating an ultrasound guided Pericardiocentesis Procedure.

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Cardiology

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Subtitles

- [Voiceover] A phased array transducer
with a cardiac exam type,
is used to perform an ultrasound guided
trans-thoracic pericardiocentesis.
The patient is placed in a
left lateral decubitus position, if possible.
Place the transducer at the apex or point
of maximum impulse, with the orientation marker
to the patients left side, at a three o'clock position.
The apex of the heart is visualized closest
to the transducer.
Move between the apical and parasternal
long axis views of the heart, to determine the
most superficial and largest pocket of fluid.
The myocardium will appear grey,
and the blood filled chambers will appear hypoechoic.
The ventricles are in the near field,
and the atria are in the far field of the image.
A pericardial effusion will appear as
a dark anechoic fluid collection surrounding the heart.
For direct needle guidance, using an in plane technique,
the transducer is rotated 90 degrees counterclockwise.
So the orientation marker is at the 12 o'clock position.
This will create a view of the heart
that is between the apical fore chamber
and parasternal long axis views.
Note the absence of the lung,
to ensure it is not in the needle path.
The needle is inserted in the skin,
just proximal to the transducer,
opposite to the side of the orientation marker.
The needle is slowly advanced,
and is seen as a bright hypoechoic linear structure.
The needle is slowly advanced,
under direct ultrasound visualization,
until the tip is seen to puncture the
pericardial fluid collection.
The needle should be advanced until the needle tip
lies within the fluid collection,
which can then be aspirated.
Vascular structures to be avoided
include the internal mammary,
and the intercostal arteries.

Brightcove ID

5508123528001

https://youtube.com/watch?v=T6Z9DvPPmXg

3D How To: Female Pelvis Exam

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3D animation demonstrating a Female Pelvis ultrasound exam.

Publication Date

Thu, 05/05/2016 - 12:00

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- [Voiceover] A curved, or phased array transducer,
with a pelvis exam type,
is used to perform the pelvis ultrasound exam.
A full bladder is used as an acoustic window
to view the pelvic organs.
The pelvis is evaluated in two plains.
Place the transducer in a long axis position
with the orientation marker to the patient's head,
at the level of the symphysis pubis.
Angle the transducer inferiorly into the pelvis.
The bladder appears in the near-field of the image,
as a hypoechoic triangular structure.
The uterus is gray in appearance
and located either directly posterior
or superior to the bladder.
The endometrial stripe will appear as
a bright echogenic line from the fundus to the cervix.
The uterus does not always lay directly in the midline
so it may be necessary to slightly rotate the transducer
to view the entire length of the uterus.
Sweep the transducer from side to side
to see the entire uterus.
The ovaries may be seen by sweeping the transducer
to the lateral aspects of the pelvis.
They are almond-shaped and slightly hypoechoic structures.
Follicles may appear as multiple
hypoechoic, cystic structures within the ovaries.
Some follicles may be quite prominent,
depending upon the luteal stage.
To obtain a transverse view of the uterus,
rotate the transducer 90 degrees,
so the orientation marker is to the patient's right.
The bladder appears more rectangular in shape in this view.
Sweep the transducer superiorly
from the level of the cervix to the fundus
to see the entire uterus.
The ovaries will be seen on either side of the uterus
and can vary in location,
from a superior to inferior position.

Brightcove ID

5750473717001

https://youtube.com/watch?v=ebpcUlQVmLE

3D How To: Parasternal Short Axis View

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3D animation demonstrating a Parasternal Short Axis view of the heart.

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Cardiology

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Anesthesiology (Regional)

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- [Voiceover] A phased array transducer
with a cardiac exam type is used to perform
the parasternal short axis view of the heart.
If possible, place the patient in a left lateral
decubitus position to reduce any lung artifact
and to bring the heart closer to the anterior chest wall.
Place the transducer at the third or fourth
intercostal space immediately left of the sternum.
Move between the third and fourth intercostal space
and slide the transducer toward and away from the sternum
to identify the optimal scanning window.
Assuming the short axis of the heart to be positioned
on a plane from the patient's right shoulder
to the left hip.
Rotate the transducer to adjust
for the body habitus of the patient.
The orientation marker will be at approximately
the two o'clock position.
As an alternative approach, this exam may be performed
using an abdomen exam type with an orientation marker
to the patient's left side at approximately
the eight o'clock position.
The myocardium will appear gray
and the blood-filled chambers will appear hypoechoic.
The left ventricle will appear as a doughnut shape
in the center of the image.
The anterior, septal, inferior, and posterior
lateral walls of the ventricle can be identified.
The mitral valve will be seen in cross section.
From this position, the transducer can be tilted upward
to visualize the aortic valve in cross section.
End downward to visualize the myocardium
of the left ventricle.
Note the wall motion of the myocardial segments
and function of the valves.

Brightcove ID

5752141722001

https://youtube.com/watch?v=EaLuCBXXINg

3D How To: Parasternal Long Axis View

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3D animation demonstrating a Parasternal Long Axis view of the heart.

Applications

Cardiology

Clinical Specialties

Anesthesiology (Regional)

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Subtitles

- [Voiceover] A phased array transducer with a cardiac
exam type, is used to perform parasternal long axis
view of the heart.
If possible, place the patient in a left lateral
decubitus position to reduce any lung artifact,
and to bring the heart closer to the anterior chest wall.
Place the transducer at the third, or fourth, intercostal
space immediately left of the sternum.
Move between the third, and fourth intercostal space,
and slide the transducer toward, and away from the sternum
to identify the optimal scanning window.
Assuming the long axis of the heart to be positioned on a
plane from the patients right shoulder to left hip, rotate
the transducer to adjust for the body
habitus of the patient.
The orientation marker, will be at approximately
the 10 o'clock position.
As an alternative approach, this exam may be performed using
an abdomen exam type, with the orientation marker
to the patients right side at approximately
the 4 o'clock position.
They myocardium will appear gray, and the blood filled
chambers will appear hypoechoic.
The descending aorta is seen in cross section as a round
structure posterior to the atrioventricular junction.
This view is used to evaluate the right ventricle, left
ventricle outflow tract, and left ventricle.
Note overall activity of the heart.
Any wall motion abnormality, valve abnormalities,
and the presence of pericardial effusion.

Brightcove ID

5794989686001

https://youtube.com/watch?v=4qerzEW_ASU

3D How To: Apical 4-Chamber View

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3D animation demonstrating an Apical 4-Chamber view of the heart.

Applications

Cardiology

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Subtitles

- [Voiceover] A phased array transducer
with a cardiac exam type is used to perform
the apical four chamber view of the heart.
If possible, place the patient
in a left-lateral decubitus position
to reduce any lung artifact and to bring the heart
closer to the anterior chest wall.
Place the transducer at the apex
or point of maximum impulse,
with the orientation marker to the patient's
left side at a three o'clock position.
As an alternative approach, this exam may be
performed using an abdomen exam type,
with the orientation marker to the patient's right side.
Aim to the right shoulder.
The apex of the heart is visualized
closest to the transducer.
The myocardium will appear gray,
and the blood-filled chambers will appear hypoechoic.
The ventricles are in the near field,
and the atria are in the far field of the image.
This view is used to compare the size of the right
and left ventricles and evaluate contractility.
The right side of the heart,
which is located on the left side of the screen,
should be smaller than the left.
Th apical, septal, and lateral walls
of the left ventricle are visualized in this view.

Brightcove ID

5508134322001

https://youtube.com/watch?v=_eHZz-OCc_M

3D How To: Abdominal Aorta Exam

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3D animation demonstrating an Aorta ultrasound exam.

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Subtitles

- [Voiceover] A curved or phased array transducer
with an abdomen exam type is used to perform
an aorta ultrasound exam.
The entire length of the aorta from
the level of the diaphragm
to the bifurcation of the iliac arteries
must be evaluated in two planes.
The examination begins with the transducer
placed transversely in the epigastric mid line,
with the marker directed to the patient's right.
The aorta is seen as a round, pulsatile structure,
anterior to the bright reflection of the vertebrae.
The vena cava is an oval structure
immediately to the left of the aorta on the screen,
which changes in caliber with compression
or deep inspiration.
The abdominal aorta will course gradually,
becoming more superficial as it progresses distally.
The transducer is slowly moved distally
to identify the celiac trunk,
renal arteries,
superior mesenteric artery,
and bifurcation to the iliac arteries.
Note the location of any change in size
of the aorta or iliac arteries,
and measure in long and short axis views
from outer wall to outer wall
to determine the true diameter.
The transducer is returned to the epigastric area
and rotated 90 degrees clockwise,
with the orientation marker to the patient's head.
The transducer is swept side to side
to identify the maximal diameter of the aorta.
The abdominal aorta will have proximal to distal taper.
The transducer is moved distally
to evaluate the walls of the aorta
for any change in the shape or size.
If the aorta is difficult to visualize
due to overlying bowel, gentle downward transducer pressure
may encourage peristalsis of the overlying bowel.
Alternatively, consider moving the patient
into a left lateral decubitus position
to re-position the bowel away from the field of view.

Brightcove ID

5508114778001

https://youtube.com/watch?v=NI-tU5w-gzg

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Case: RUSH Exam Part 1

Case: RUSH Exam Part 1

M-Turbo: Apical 4 Chamber

M-Turbo: Apical 4 Chamber

M-Turbo: Abdomen 03

M-Turbo: Abdomen 03

Liver: Hepatic Veins

Liver: Hepatic Veins

3D How To: Ultrasound Guided Pericardiocentesis

3D How To: Ultrasound Guided Pericardiocentesis

3D How To: Female Pelvis Exam

3D How To: Female Pelvis Exam

3D How To: Parasternal Short Axis View

3D How To: Parasternal Short Axis View

3D How To: Parasternal Long Axis View

3D How To: Parasternal Long Axis View

3D How To: Apical 4-Chamber View

3D How To: Apical 4-Chamber View

3D How To: Abdominal Aorta Exam

3D How To: Abdominal Aorta Exam

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