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Hypotension is a common presentation. At times, the available history is limited, and the physical exam alone can be misleading. Multiple ultrasound protocols have been proposed for the evaluation of the hypotensive patient. This activity reviews the commonly used rapid ultrasound in shock (RUSH) protocol and highlights the role of the interprofessional team in the management of hypotensive patients. Objectives: Identify the indications for the rapid ultrasound in shock (RUSH) protocol. Explain the steps involved in performing the rapid ultrasound in shock (RUSH) protocol. Summarize how ultrasound can be a useful modality for the evaluation of hypotensive patients. Explain interprofessional team strategies for enhancing care coordination and communication to advance the use of ultrasound to evaluate hypotensive patients to improve patient outcomes. Access free multiple choice questions on this topic.
Hypotension is a common presentation in the emergency department.[1] At times, the available history is limited, and the physical exam alone may be misleading.[2][3] In these life-threatening situations, waiting for laboratory studies or formal imaging studies may not be feasible. Instead, using bedside ultrasound can quickly narrow the potential etiologies of the hypotension.[4] Multiple ultrasound protocols have been proposed for the evaluation of the hypotensive patient. The commonly-used rapid ultrasound in shock (RUSH) exam will be reviewed here. This bedside protocol has been demonstrated to quickly and accurately determine the etiology of shock in the hands of an emergency medicine physician.[5] The HI-MAP mnemonic describes the components of the RUSH protocol: heart, inferior vena cava (IVC), Morrison’s pouch (focused assessment with sonography for trauma [FAST] views with thoracic windows), aorta, pulmonary. This allows for a systematic approach to the exam.[5] Others have also simplified the exam into the “pump, tanks, pipes” approach.
The management of undifferentiated hypotension is best done with an interprofessional team including clinicians, specialists, ICU nurses, and ultrasound technicians. The RUSH exam can be performed at the bedside and may provide a clue to the diagnosis. The imaging modality helps avoid transporting an unstable patient to an unmonitored radiology unit. Prompt diagnostic evaluation and interpretation by the interprofessional healthcare team will result in improved intervention and patient outcomes. [Level 5]