HWN Suggests

Original RUSH Article

It is now the standard of care to perform focused assessment using sonography for trauma (FAST) early in the evaluation of a sick trauma patient. There seems to be far less urgency to use ultrasound to evaluate the medical patient with hypotension 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 rationale for the rapid ultrasound for shock and hypotension (RUSH) exam.

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 An approach to undifferentiated hypotension

At the end of the RUSH exam, you might have a definitive answer such as AAA, tension pneumothorax, or tamponade. If so, just start treatment. If you don’t have a definitive answer, you should have some clues.

 Big Shock…..Do we ❤ POCUS?

Part of the RUSH exam is the measurement of the IVC and is a controversial topic. Good evidence for where to actually measure the IVC, whether to measure in M-mode or B-mode, what ‘normal’ measurements are and how the IVC diameter changes in ventilated versus spontaneously breathing patients is currently lacking.

 The Best Article on The RUSH Ultrasound Exam for Medical Shock

This post contains a few quotes and the pictures from the above outstanding article–The BEST INTRODUCTION TO THE SUBJECT I’VE SEEN. And you will get a quick complete review of the exam just by looking at the pictures. But you need to read the whole article.

 The RUSH Protocol

Most views required are already used in other studies and easy to learn. You do not need to obtain every view, tailor your exam to the clinical context.

 US Case of the Month: Ultrasound RUSHes to the Rescue

While multiple variations of whole body ultrasound in shock have been proposed, The RUSH exam (Rapid Ultrasound for Shock and Hypotension) is commonly used. The curvilinear probe may be used for all views, eliminating the need to switch probes.

 Video: RUSH Protocol - Rapid Ultrasound for Shock and Hypotension

Rapid Ultrasound for Shock and Hypotension tutorial for EM & Critical Care clinicians taught by Anantha Mallia from MedStar Washington Hospital Center. It includes evaluation of the “Pump, Tank, and Pipes” including external landmarks and sample images to help guide resuscitation of the patient in shock.

Articles of Interest

Should Your RUSH to the Ultrasound in Hypotension?

The most common category of shock was non-cardiogenic at 87.6% with the most common diagnosis being sepsis (52%).

Advanced Critical Care Ultrasound: The RUSH Exam - Slow Is Smooth and Smooth Is Fast

The RUSH Exam can be remembered by the HI-MAP mnemonic (your goal is to increase the patient's MAP): Heart, IVC, Morrison's Pouch (and complete the FAST), Aorta, and Pneumothorax. The exam should be undertaken in the HI-MAP order and should be done in a timely manner at bedside in the ED. Just as for the E-FAST in traumatic hypotension, the idea isn’t to get detailed measurements but to perform a rapid, goal-directed evaluation of potential causes of shock.

Rapid Ultrasound for Shock and Hypotension (RUSH)

Research studies evaluating the utility of POCUS in shock report improved diagnostic accuracy. One study showed that diagnostic accuracy for determining the cause of undifferentiated shock improved from 60.6% to 85% with addition of a structured point of care ultrasound protocol. This also altered the initial management approach in as many as 50% of patients.

Rapid Ultrasound for Shock and Hypotension – the RUSH Exam

This concept was first conceived by the authors above in 2006 and discussed in national lectures in 2007 and on. It has been 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 on Emedhome in May 2009.

RUSH ("Rapid Ultrasound for Shock") Protocol

Three categories: Pump – Cardiac evaluation, Tank – Volume status, Pipes – Vascular system.

RUSH Exam Ultrasound Protocol: Step-By-Step Guide

A common question that comes up is what is the difference between the RUSH Exam vs the FAST/eFAST Exam. The FAST Scan is used in the trauma setting to figure out where a patient may be hemorrhaging from. The RUSH Exam on the other hand is a more broad ultrasound protocol used on any patient with undifferentiated hypotension. Simply put, this protocol addresses the components of the cardiopulmonary system, summarized in the RUSH Exam mnemonic HI MAP...

RUSH protocol: Rapid Ultrasound for Shock and Hypotension

Ultrasound is ideal for the evaluation of critically ill patients in shock, and ACEP guidelines now delineate a new category of ultrasound (US)– “resuscitative.” Bedside US allows for direct visualization of pathology and differentiation of shock states. The RUSH Protocol was first introduced in 2006 by Weingart SD et al, and later published in 2009. It was designed to be a rapid and easy to perform US protocol (<2 minutes) by most emergency physicians.

RUSH to Resus: Components of the RUSH Exam

When you are unsure of why your patient is hemodynamically unstable, use the RUSH exam: Rapid Ultrasound for Shock and Hypotension. Using the curvilinear or phased array probes, obtain these views...