Episode 4: RUSH Part 1 - Intro and the Pipes

by Bob Stuntz in

Your patient is crashing, and you don't know why.  It could be hypovolemia, cardiogenic shock, PE, tamponade.  How do you make your way through this diagnostic dilemma? Grab the ultrasound machine and see for yourself!  In this first of three podcasts on the RUSH exam, Dr. Tom Kehrl gives you an intro to the exam, and Dr. Dan Kaminstein talks about the evaluation of "The Pipes."

Overview (Tom Kehrl, MD, RDMS):

  • RUSH: Rapid Ultrasound in SHock: Using ultrasound to evaluate the undifferentiated hypotensive patient to determine the source of shock
  • Think of the cardiovascular system as a plumbing system with three components
    • The pump: Is the heart functioning normally and without obstruction
    • The tank: Is the tank full or empty (IVC, FAST)
    • The pipes: Are there problems with the blood vessels (IJ, DVT, AAA and aortic dissection)
  • This is a rule in study.  Just because, for instance, you do not see a DVT or definite signs of right heart strain does not rule out a PE.  You also have to go with what you find if it fits the clinical picture.  
  • Can be done in a very short time, these are rapid, abbreviated versions of more complete exams.  

The Pipes (Dan Kaminstien, MD)

  • Aorta
    • Abdominal for AAA:  Start subxyphoid, curvilinear probe with the indicator to the patient’s right (standard transverse view)and pan down through the entire aorta first
      • Aorta should be anterior to the spinous process, which causes posterior shadowing
      • > 3 cm is abnormal
      • Perform along with FAST as intraabdominal rupture is possible (although rarely make it to the ED)
      • Proximal Aorta: Just above SMA
      • Mid aorta: Below SMA
      • Distal aorta and bifurcation
      • AAA > 5 cm, rapidly increased in size with known aneurysm, or with thrombus more likely to rupture
      • Measure outer wall to outer wall
    • Transthoracic views to evaluate for thoracic aneurysm/dissection
      • Parasternal long cardiac: look for effusion, descending AO size (posterior to LA in TRV), aortic root (should be < 3.8 cm, look for dissection flap.  
      • Can also do suprasternal view to evaluate the arch, again looking for dilation or flap.  This is very difficult in most of our patients.  
      • Look for flap for possible aortic dissection
  • Lower extremity for DVT
    • Linear probe, indicator to the patient’s right (standard transverse view)
      • Common femoral vein near entry of the greater saphenous (groin crease)
      • Superficial femoral vein (after CFV bifurcates): THIS IS A DEEP VEIN!!!
      • Popliteal vein
    • Evaluate for source of PE
    • Positive if you see clot OR if anterior and posterior wall do not touch
    • NO COLOR DOPPLER!!  This is a limited, compression only study.  

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