• Registration
  • Login
JETem
  • Home
  • About
    • Aim and Scope
    • Our Team
    • Editorial Board
    • FAQ
  • Issues
    • Current Issue
    • Ahead of Print
    • Past Issues
  • Visual EM
    • Latest Visual EM
    • Search Visual EM
    • Thumbnail Library
  • For Authors
    • Instructions for Authors
    • Submit to JETem
    • Photo Consent
    • Policies
      • Peer Review Policy
      • Copyright Policy
      • Editorial Policy, Ethics and Responsibilities
      • Conflicts of Interest & Informed Consent
      • Open Access Policy
  • For Reviewers
    • Instructions for JETem Reviewers
    • Interested in Being a JETem Reviewer?
  • Topic
    • Abdominal / Gastroenterology
    • Administration
    • Board Review
    • Cardiology / Vascular
    • Clinical Informatics, Telehealth and Technology
    • Dermatology
    • EMS
    • Endocrine
    • ENT
    • Faculty Development
    • Genitourinary
    • Geriatrics
    • Hematology / Oncology
    • Infectious Disease
    • Miscellaneous
    • Neurology
    • Ob / Gyn
    • Ophthalmology
    • Orthopedics
    • Pediatrics
    • Procedures
    • Psychiatry
    • Renal / Electrolytes
    • Respiratory
    • Toxicology
    • Trauma
    • Ultrasound
    • Wellness
    • Wilderness
  • Modality
    • Curricula
    • Innovations
    • Lectures
    • Oral Boards
    • Podcasts
    • Simulation
    • Small Group Learning
    • Team Based Learning
    • Visual EM
  • Contact Us

Using Bedside Ultrasound to Rapidly Differentiate Shock

Mohamad Moussa, MD*, Jacob Willen, BS* and Sudipa Biswas, BS, MS*

*University of Toledo Medical Center, Department of Emergency Medicine, Toledo, OH

Correspondence should be addressed to Mohamad Moussa, MD at Mohamad.Moussa@UToledo.edu

DOI: https://doi.org/10.21980/J8S047 Issue 2:3
Infectious DiseaseUltrasoundVisual EM
No ratings yet.

History of present illness:

A 62-year-old female presented from a nursing home for altered mental status. She had an initial Glascow coma score of 9. Her blood pressure was 70/44, temperature 36.8 C, heart rate 82, respiratory rate 23, and oxygen saturation 88% on room air. The patient’s initial lactate was 3.1 mmol/L. A rapid ultrasound for shock and hypotension (RUSH) exam demonstrated the need for fluid resuscitation. 2 liters of normal saline was given, resulting in the improvement of her blood pressure to 93/53. Ultimately, the patient required intubation because of the severity of her pneumonia. A subsequent lactate of 0.8 mmol/L demonstrated adequate resuscitation.

Significant findings:

A RUSH exam demonstrated hyperdynamic cardiac contractility and collapse of the inferior vena cava (IVC) with probe compression more than 50% suggesting hypovolemia likely secondary to sepsis.  Incidentally, Morrison’s pouch revealed a large right renal cyst but no signs of free fluid. A computed tomography of abdomen/pelvis showed a 10.8 x 9.5 cm right renal cyst and left lower lobe pneumonia.

Discussion:

Sepsis is defined as organ dysfunction in a patient with a known source of infection. Signs of sepsis include hypotension, tachypnea, and altered mental status.1 Although not a standard of care yet, the RUSH exam proves to be a valuable and rapid instrument to evaluate the cause of shock and hypotension in critically ill patients in the emergency department (ED). The components of the RUSH exam can be remembered by the mnemonic HI-MAP: Heart, IVC, Morrison’s/FAST abdominal views, Aorta, and Pneumothorax scanning.2 Ultrasound can be used to quickly differentiate cardiogenic, distributive, and hypovolemic shock. RUSH has a sensitivity of 72.7% and specificity of 100% for shock with distributive etiology.3 Measurement of the IVC diameter can be used to estimate CVP and thus a patient’s likelihood to respond to fluid resuscitation. A maximum IVC diameter of <2 cm with >50 % collapsibility, such as in our patient, was found to correlate with a low central venous pressure (CVP) (<5 mm Hg).4 There are several instances in which IVC measurement does not correlate to CVP, such as mechanical ventilation, valvular abnormalities, pulmonary hypertension, congestive heart failure, liver cirrhosis, elevated intra-abdominal pressures, and many other pathologies that affect flow to the right heart.5 Therefore, the RUSH exam should be interpreted with the patient’s entire clinical presentation.

Topics:

Sepsis, shock, hypotension, Rapid Ultrasound for Shock and Hypotension (RUSH), ultrasound, pneumonia.

References:

  1. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (sepsis-3).  JAMA. 2016;315(8):801-810. doi: 10.1001/jama.2016.0287
  2. Weingart S. Original RUSH article. EMCrit Blog. https://emcrit.org/rush-exam/original-rush-article/. Published March 2008. Accessed July 11, 2017.
  3. Ghane MR, Gharib MH, Ebrahimi A, Samimi K, Rezaee M, Rasouli HR, et al. Accuracy of rapid ultrasound in shock (RUSH) exam for diagnosis of shock in critically ill patients.  Trauma Mon. 2015;20(1):e20095. doi: 10.5812/traumamon.20095
  4. Volpicelli G, Lamorte A, Tullio M, Cardinale L, Giraudo M, Stefanone V, et al. Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department.  Intensive Care Med. 2013;39(7):1290-1298. doi: 10.1007/s00134-013-2919-7
  5. Dina S, Thomas M, Phillips P, Diku M. Caval sonography in shock: a noninvasive method for evaluating intravascular volume in critically ill patients.  J Ultrasound Med. 2012;31(12):1885-1890. doi: 10.7863/jum.2012.31.12.1885.
  6. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically ill. EMCrit. Emerg Med Clin North Am. 2010;28(1):29-56,vii. doi: 10.1016/j.emc.2009.09.010
Icon

Bedside US to Differentiate Shock - Case Report

1 file(s) 494 KB
Download
Icon

Bedside US to Differentiate Shock - Images

1 file(s) 11.93 MB
Download
Issue 2:3Ultrasound

Reviews:

No ratings yet.

Please rate this





Corneal Sparing Conjunctival Abrasion

04 Jul, 17

Choledocholithiasis

04 Jul, 17
JETem is an online, open access, peer-reviewed journal-repository for EM educators

Most Viewed

  • Telemedicine Consult for Shortness of Breath Due to Sympathetic Crashing Acute Pulmonary Edema
  • Anticholinergic Toxicity in the Emergency Department
  • The Suicidal Patient in the Emergency Department Team-Based Learning Activity
  • Child Maltreatment Education: Utilizing an Escape Room Activity to Engage Learners on a Sensitive Topic
  • Acute Chest Syndrome

Visit Our Collaborators

About

Education

Learners should benefit from active learning. JETem accepts submissions of team-based learning, small group learning, simulation, podcasts, lectures, innovations, curricula, question sets, and visualEM.

Scholarship

We believe educators should advance through the scholarship of their educational work. JETem gives educators the opportunity to publish scholarly academic work so that it may be widely distributed, thereby increasing the significance of their results.

Links

  • Home
  • Aim and Scope
  • Current Issue
  • For Reviewers
  • Instructions for Authors
  • Contact Us

Newsletter

Sign up to receive updates from JETem regarding newly published issues and findings.

Copyright © 2016 JETem. All rights reserved.