Episode 5: RUSH Part 2 - The Pump

by Bob Stuntz in


Your patient is crashing...again.  In part 2 of our 3 part series on the RUSH exam, we talk about the pump, or the cardiac portion of the RUSH exam. 

The Pump (Bob Stuntz, MD)

  • Need a review of how to do the cardiac exam? Click here
  • Pericardial effusion/tamponade
    • Identify the descending thoracic aorta on parasternal long axis view (PSLA)
      • Fluid anterior/separating descending thoracic aorta from pericardium is pericardial effusion
      • Fluid lateral or posterior is pleural fluid
    • Tamponade:
      • Disatolic collapse of R side of the heart due to impaired filling from pericardial effusion exerting R sided pressure
      • How to ID:
        • Clinical picture (hypotension, shock) PLUS:
        • RV/RA diastolic collapse during diastole
          • Freeze your image and look at RV when LV is full at end diastole
          • Serpiginous motion of the RV free wall
          • RV/LV dissociation
          • M mode shoing end-diatolic RV collapse
          • Plethoric IVC without respiratory variation
      • Disposition: pericardiocentesis/pericardial window
  • Ejection fraction: Keep it simple
    • Hyperdynamic: near total collapse of LV cavity, tachycardic, strong fast squeeze
    • Normal: nice symmetric squeeze, MV hits septum, good collapse > 50% LV cavity
    • Low/please check a pulse
      • MV does not hit septum
      • No wall intrusion
      • No collapse of LV cavity
      • May see mitral regurgitation, LA enlargement as well
  • Right heart strain
    • McConnel’s sign: RV apical movement with stunned RV free wall
      • Cover up the apex of the RV: RV wall stunned, not moving
      • Cover up the RV free wall: apex movement appears normal
      • Helpful if known acute:
        • 94% Specific
        • 77% Sensitive
        • Can be secondary to chronic conditions
    • D sign: PSSA view, flattening of the septum with D shaped appearance of the LV (secondary to increased RV pressure from large PE)
      • RV:LV ratio > 0.7
          • Sensitivity 66%
          • Sensitivity 77%
      • With large acute R sided pressures, may see tricuspid regurgitation or plethoric IVC with minimal respiratory variability

References

  1. McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT (1996). "Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism". Am. J. Cardiol. 78 (4): 469–73
  2. Lodato JA, Ward RP, Lang RM.  Echocardiographic predictors of pulmonary embolism in patients referred for helical CT.   Echocardiography. 2008 Jul;25(6):584-90.

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