Rapid Ultrasound for Shock and Hypotension (RUSH)

The HIMAP protocol was originally published by Weingart et al in 2009 after being discussed publicly in lecture format. The original article appears here.  The protocol examines the following areas:

  • H – Heart (parasternal and four-chamber views)
  • I – Inferior Vena Cava (for volume responsiveness)
  • M – Morison’s pouch (i.e., FAST exam) and views of thorax (looking for free fluid)
  • A – Aortic Aneurysm (ruptured abdominal aneurysm)
  • P – Pneumothorax (i.e., Tension pneumothorax)
  1. Heart:
    • Parasternal view:
      • Pericardial effusion (more than trace)
      • Tamponade – collapse of right atrium and ventricle in diastole
      • LV function –
        • <30% change diastole to systole = MI, myopathy, sepsis, toxin
        •  >90% wall come close to touching = hypovolemia, blood loss, sepsis (pre-resus)
    • Four chamber view:
      • RV dilatation due to infarct or massive PE (RV equal to or larger then LV)
  2. IVC:
    • Sub-xyphoid view: longitudinal (indicator to head) view in a spontaneously breathing patient
      • Diameter < 1.5cm and collapse in inspiration = give fluid
      • Diameter > 2.5cm and no collapse in inspiration = no benefit from fluid
    • Ventilated patients have an enlarged IVC and calculation of ins/exp percent change is necessary
      • (Insp size – Exp Size)/ Exp Size
      • More than 18% change = likely to benefit from fluid challenge.
  3. Morrison’s (FAST):
    • Standard views of FAST exam
      • RUQ – indicator to head
      • LUQ – indicator to head
      • Suprapubic – indicator to patient’s right.
    • If time limited, Morrison’s pouch alone, in trendelenburg, is sensitive.
    • Tilting probe to view diaphragm in upper quadrant views shows presence of pleural effusion / hemothorax.
  4. Aorta:
    • Scan aorta with probe in transverse position, indicator to patient’s right
    • Continuous motion from xyphoid to aortic bifurcation.
    • Note 4 locations: below heart, supra-renal, infra-renal, and bifurcation
    • >5cm + shock = rupture until excluded
  5. Pneumothorax:
    • Right and Left, anterior 3rd intercostal space, longitudinal probe placement (indicator to head)
    • Note that main stem intubation can cause false appearance of pneumothorax due to lack of pleural movement.
Notes: 
  • Cardiac setting on some machines places probe indicator to right side of screen.
  • Keep Indicator on probe pointed to right shoulder or right side of body depending on view.
Sources:
  1. S. D. Weingart, D. Duque, and B. Nelson, Rapid Ultra- sound for Shock and Hypotension (RUSH-HIMAPP), 2009 EMCrit
  2. P. Perera, T. Mailhot, D. Riley, and D. Mandavia, “The RUSH exam: rapid ultrasound in SHock in the evaluation of the critically lll,” Emergency Medicine Clinics of North America, vol. 28, no. 1, pp. 29–56, 2010.
  3. Dina Seif. Bedside Ultrasound in Resuscitation and the Rapid Ultrasound in Shock Protocol Critical Care Research and Practice Vol 2012 PDF
  4. EMCrit RUSH Update: EMCrit
  5. ALiEM RUSH protocl, includes images: ALiEM
  6. Wiki EM, includes images: RUSH Protocol

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