The RUSH Exam

We would like to share this article with you in your quest to become ultrasound gurus.

The article itself, although 20 pages long, summarizes the various applications and interpretation of ultrasound in evaluating undifferentiated shock in a complete and concise fashion.  It offers a stepwise, sequential approach in using US to aid in making the diagnosis of particular types of shock.

To summarize, the authors propose the sequential evaluation of 3 physiological variables:

1. “The Pump”

This is the heart.  Use your cardiac, or phased array, probe to get the 3 main views of the cardiac exam: parasternal long axis, parasternal short axis, 4 chamber view.

Main things to look out for:

  1. Pericardial effusion/tamponade
  2. Global contractility
  3. Acute RV strain/dilation

2. “The Tank”

This is our intravascular volume.  The authors advocate looking at the subxiphoid, long and short axis views of the IVC and measurement of respiratory dynamics (ie. IVC collapse on inspiration), FAST, pneumothorax/lung studies as means of assessing whether effective intravascular volume is being compromised.

Main things to look out for

  1. IVC collapsibility as marker of ECV/fluid responsiveness
  2. FAST for intraperitoneal free fluid
  3. Lung studies to assess for pleural effusion, pulmonary vascular congestion
  4. PTX study for possible tension PTX causing decreased EDV

3. “The Pipes”

This is our evaluation of vasculature, the large arteries and veins of the body.  The question to be answered: “Are the pipes ruptured or obstructed?”

Main things to look out for:

  1. Examine abdominal and thoracic aorta for aneurysm or dissection
  2. Examine femoral, popliteal veins for signs of DVT (non-compressibility)

And there you have it in a nutshell.  There is a solid table in the article that summarizes the key findings for each portion of the exam in the different types of shock.  We encourage all of you to look at it.

Figure A: "The Pump" - Cardiac Tamponade

Figure A: "The Pump" - Cardiac Tamponade

Figure B: "The Tank" - Pleural Effusion

Figure B: "The Tank" - Pleural Effusion

Figure C: "The Tank" - Normal Lung and Pneumothorax

Figure C: "The Tank" - Normal Lung and Pneumothorax

Figure D: "The Pipes" - Abdominal Aorta Aneurysm

Figure D: "The Pipes" - Abdominal Aorta Aneurysm

Also, EMCrit has a great article as well.