Whats new in emergencies, trauma and shock? Shock, Sonography and survival in emergency care! Dale S. Birenbaum, Sarathi Kalra1 Department of Emergency Medicine, Florida Hospital, Orlando, Florida, 1Post-Doctoral Fellow, Department of Emergency Medicine, Baylor College of Medicine and The University of Texas MD Anderson Cancer Center, Houston, Texas, USA

The presence of hypotension or shock in the setting of acute illness is associated with high mortality rates. Early assessment for the etiology of shock and prompt treatment have been shown to have a profound effect on the disease outcome;[1,2] however, clinical evaluation has certain limitations. Shock has been categorized into four classic subtypes.[3] These include: a. Hypovolemic shock e.g., massive hemorrhage, gastrointestinal (GI) losses; b. Distributive shock e.g., anaphylactic shock, neurogenic shock; c. Cardiogenic shock, due to pump failure, e.g., myocardial infarction, advanced cardiomyopathy; and d. Obstructive shock e.g., cardiac tamponade, tension pneumothorax, massive pulmonary embolism. At the bedside, it is often difficult to accurately categorize the patient’s clinical condition into one of the subtypes of shock and the physical findings may overlap. In addition, it is not easy to perform Swan-Ganz catheterization in hypotensive patients for rapid assessment of intravascular hemodynamic status. Because of the noninvasive nature of ultrasound and the feasibility to perform repeated quick assessment in sick patients, this modality has become the frontline diagnostic tool for emergency care. In critically ill-patients with multiple injuries, focused assessment using sonography for trauma (FAST) has now become the standard of care; however, use of ultrasound for evaluation of medical patients with shock is not being routinely used in clinical practice. Since the turn of the century, there Address for correspondence: Dr. Sarathi Kalra, E-mail: [email protected] Access this article online Quick Response Code: Website: www.onlinejets.org

DOI: 10.4103/0974-2700.150385

Journal of Emergencies, Trauma, and Shock I 8:1 I Jan - Mar 2015

have been several attempts at using this diagnostic modality for evaluation of patients with hypotension and shock. Rose et al. described the role of ultrasound approach for empiric evaluation of the undifferentiated hypotensive patients (UHP protocol).[4] Early goal-directed ultrasound for emergency department (ED) patients with hypotension have been shown to decrease the time to the final diagnosis.[5] Since bedside ultrasound and echocardiography are becoming and integral component of emergency medicine, several other protocols have been developed during the last few years for evaluation of patients with shock, poly-trauma, sepsis, respiratory, distress, and cardiac arrest. Some of these include: TRINITY,[6] Extended-FAST,[7] FATE,[8] BLEEP,[9] FEER,[10] BEAT,[11] The Rapid Ultrasound for SHock (RUSH) HI-MAP,[12] ACES,[13] Boyd Echo,[14] FEELResuscitation,[15] Elmer/Noble Protocol,[16] EGLS,[17] FREE,[18] FALLS,[19] POCUS-Fast and Reliable[20] and RUSH-Pump/ Tank/Pipes.[20,21] Some of the protocols such as BLUE[22] and RADIUS[23] have been devised for the assessment of dyspnea. Use of sonography has been shown to help stabilize patients in the ED[24] and also in management of patients with primary non-arrhythmogenic cardiac arrest.[25] In order to amalgamate different components of ultrasonic evaluation of various organs for quick diagnosis of underlying cause of shock, Weingart et al.[12] developed RUSH protocol in a rapid, standardized sequence. The RUSH protocol aims at early integration of bedside ultrasound into clinical assessment for rapid and accurate diagnosis of shock in the ED. The RUSH protocol involves a three-stage bed-side assessment of various physiological components simplified as: Step 1 – The pump (cardiac evaluation), Step 2 – The tank (volume status), Step 3 – The pipes (vascular system). The entire examination can be completed in less than 2 min by using standard portable ultrasound machines. It is recommended to use a phased-array transducer (3.5-MHz) to allow adequate thoracoabdominal intercostal scanning, and a linear array transducer (7.5-10 MHz) for the required venous examinations and for the assessment of pneumothorax. The procedure should be done in a sequence in the order of the HI-MAP acronym: Heart, Inferior Vena Cava, Morrison’s and FAST abdominal views, Aorta and Pneumothorax. Using the HI-MAP sequence for evaluation, we 1

Birenbaum and Kalra: Rapid ultrasound for shock

can recognize the cause of shock in majority of the cases and institute appropriate treatment promptly. It may appear that there are multiple protocols for assessment of various physiological functions in patients with shock; however, careful examination of these would reveal common features in most of these protocols. In most cases, it is advisable for the clinicians to start with the evaluation of the heart and inferior vena cava and other components may be added, as required. Further, it may be pointed out that in a given case, based on the clinical scenario, it may not be mandatory to go through the entire protocol and the physician may tailor the assessment to conduct more focused evaluation. Ghane et al. have assessed the accuracy of RUSH protocol in categorizing the type of shock. The predictability was determined using sensitivity, specificity, positive and negative predictive value and kappa index. It was seen that RUSH protocol had high sensitivity in determining hypovolemic, cardiogenic and obstructive shock and high specificity in determining hypovolemic, cardiogenic, obstructive and mixed etiology shock. The authors have also tried to highlight the importance of using the RUSH protocol as an additional tool to the clinical picture of the patient. Future studies focusing on the strength of associations between various components of the RUSH protocol with possibly larger sample size will help in improving the RUSH protocol from where it stands today. REFERENCES 1.


Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001 8;345:1368-77. Sebat F, Musthafa AA, Johnson D, Kramer AA, Shoffner D, Eliason M, et al. Effect of a rapid response system for patients in shock on time to treatment and mortality during 5 years. Crit Care Med 2007;35:2568-75.


Kline JA. Shock. In: Rosen P, Marx J, editors. Emergency Medicine; Concepts and Clinical Practice. 5th ed. St. Louis (MO): Mosby; 2002. p. 33-47.


Rose JS, Bair AE, Mandavia D, Kinser DJ. The UHP ultrasound protocol: A novel ultrasound approach to the empiric evaluation of the undifferentiated hypotensive patient. Am J Emerg Med 2001;19:299-302.


Jones AE, Tayal VS, Sullivan DM, Kline JA. Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients. Crit Care Med 2004;32:1703-8.


Bahner DP. Trinity: A hypotensive ultrasound protocol. J Diagn Med Sonogr 2002;18:2002.


Kirkpatrick AW, Sirois M, Laupland KB, Liu D, Rowan K, Ball CG, et al. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: The Extended Focused Assessment with Sonography for Trauma (EFAST). J Trauma 2004;57:288-95.



Jensen MB, Sloth E, Larsen KM, Schmidt MB. Transthoracic

echocardiography for cardiopulmonary monitoring in intensive care. Eur J Anaesthesiol 2004;21:700-7. 9.

Pershad J, Myers S, Plouman C, Rosson C, Elam K, Wan J, et al. Bedside limited echocardiography by the emergency physician is accurate during evaluation of the critically ill patient. Pediatrics 2004;114:e667-71.

10. Breitkreutz R, Walcher F, Seeger FH. Focused echocardiographic evaluation in resuscitation management: Concept of an advanced life supportconformed algorithm. Crit Care Med 2007;35:S150-61. 11. Gunst M, Ghaemmaghami V, Sperry J, Robinson M, O’Keeffe T, Friese R, et al. Accuracy of cardiac function and volume status estimates using the bedside echocardiographic assessment in trauma/critical care. J Trauma 2008;65:509-16. 12. Weingart SD, Duque D, Nelson B. Rapid Ultrasound for Shock and Hypotension (RUSH-HIMAPP); 2009. 13. Atkinson PR, McAuley DJ, Kendall RJ, Abeyakoon O, Reid CG, Connolly J, et al. Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): An approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension. Emerg Med J 2009;26:87-91. 14. Boyd JH, Walley KR. The role of echocardiography in hemodynamic monitoring. Curr Opin Crit Care 2009;15:239-43. 15. Breitkreutz R, Price S, Steiger HV, Seeger FH, Ilper H, Ackermann H, et al. Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: A prospective trial. Resuscitation 2010;81:1527-33. 16. Elmer J, Noble VA. An Evidence based approach for integrating bedside ultrasound into routine practice in the assessment of undifferentiated shock. ICU Dir 2010;1:163-74. 17. Lanctot YF, Valois M, Bealieu Y. EGLS: Echo guided life support. An algorithmic approach to undifferentiated shock. Crit Ultrasound J 2011;3:123-9. 18. Ferrada P, Murthi S, Anand RJ, Bochicchio GV, Scalea T. Transthoracic focused rapid echocardiographic examination: Real-time evaluation of fluid status in critically ill trauma patients. J Trauma 2011;70:56-62. 19. Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: The BLUE protocol. Chest 2008;134:117-25. 20. Liteplo A, Noble V, Atkinson P. My patient has no blood pressure: point of care ultrasound in the hypotensive patient-FAST and RELIABLE. Ultrasound 2012;20:64-8. 21. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in shock in the evaluation of the critically lll. Emerg Med Clin North Am 2010;28:29-56 22. Lichtenstein DA, Karakitsos D. Integrating ultrasound in the hemodynamic evaluation of acute circulatory failure (FALLS-the fluid administration limited by lung sonography protocol). J Crit Care 2012;27:53.e11-533.19. 23. Manson W, Hafez NM. The rapid assessment of dyspnea with ultrasound: RADiUS. Ultrasound Clin 2011;6:261-76. 24. Weekes AW. Symptomatic hypotension: ED stabilization and the emerging role of sonography. EM Pract 2007;9. 25. Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, Marshall J. C.A.U.S.E.: Cardiac arrest ultra-sound exam – A better approach to managing patients in primary non-arrhythmogenic cardiac arrest. Resuscitation 2008;76:198-206. How to cite this article: Birenbaum DS, Kalra S. Whats new in emergencies, Trauma and shock? Shock, Sonography and survival in emergency care!. J Emerg Trauma Shock 2015;8:1-2. Received: 24.01.15. Accepted: 25.01.15. Source of Support: Nil. Conflict of Interest: None declared.

Journal of Emergencies, Trauma, and Shock I 8:1 I Jan - Mar 2015

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Whats new in emergencies, trauma and shock? Shock, Sonography and survival in emergency care!

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