Rush Exam

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Overview of RUSH Exam

  • Heart: LV function, RV dilation, pericardial effusion/tamponade
  • IVC: size and collapsibility (volume responsiveness)
  • Lungs: B-lines (pulmonary oedema), pneumothorax (absence of sliding)
  • Abdomen: free fluid (haemoperitoneum, ruptured AAA)
  • Aorta: AAA
  • Lower limbs: DVT (if PE suspected)

Can use the mnemonic HI-MAP (Heart, IVC, Morrison’s pouch, Aorta, Pneumothorax) or alternatively go in the approach of pump (heart), tank (IVC, Morison’s pouch), and pipes (aorta, DVT)

Heart

  • Four standard views (PLAX, PSSA, A4C and subxiphoid)
  • Assess:
    • LV contractility (can be just a visual qualitative assessment)
      • Example of reduced LV function
    • RV strain and dysfunction
      • Example of RV strain with RV dilation on PLAX:
      • McConnell’s sign (suggests pulmonary embolism)
        • Decreased RV movement with apical sparing (apex moves normally)
    • Pericardial tamponade
      • Look for a circumferential anechoic fluid collection
      • Diagnostic Confirmation: Look for right ventricular end-diastolic collapse (highest specificity) or right atrial systolic collapse (highest sensitivity), paired with a plethoric IVC
      • Crucial Exception: A collapsed IVC in the presence of a pericardial effusion makes tamponade highly unlikely unless severe concurrent volume depletion is present

IVC view

  • Review the IVC in the subcostal view with the probe marker pointing towards the patient’s head
  • Qualitative assessment of IVC:
    • A flat IVC suggests distributive or hypovolaemic shock
    • Plethoric IVC (>2 cm in maximal diameter with minimal respiratory variation) suggests right or left ventricular failure or an obstructive process or volume overload
  • Collapsed (< 1.5 cm with complete/near-complete respiratory variation): Strongly points toward preload deficiency, matching hypovolemic or distributive shock states.
  • Normal (1.5 to 2.0 cm with standard respiratory variation): Indeterminate; does not cleanly rule out any shock type.
  • Plethoric (> 2.0 cm with minimal/no respiratory variation): Points toward obstructive aetiologies (tamponade, massive PE, tension pneumothorax) or cardiogenic failure.
  • Technical Pitfalls:
    • Diaphragmatic Tethering: Do not measure directly at the diaphragm, as mechanical attachment holds it artificially open. Always measure roughly 2 cm distal to the right atrial junction or just distal to the hepatic vein inflow.
    • Off-Axis Narrowing: Coming off the true vessel midline makes the IVC appear artificially narrow. Switch to a transverse plane to verify the true maximal diameter.
    • Aorta Confusion: Confirm identity by tracking the hepatic veins draining into the IVC or spotting the branch points of the celiac trunk and SMA on the aorta

Morrison’s Pouch

  • Right upper quadrant view is most sensitive so often start at this
  • Left upper qudrant view
  • Supra-pubic view

Aorta

  • Look in the 3cm just above the umbilicus
  • If the infra-renal abdominal aorta is >3cm and the patient is hypotensive, assume it is ruptured as POCUS is not sensitive enough for retroperitoneal bleed

Pneumothorax

  • Scanned using a high-frequency linear probe oriented sagittally at the anterior, least-dependent chest wall (typically 2nd to 4th intercostal spaces along the mid-clavicular line, where free air rises in a supine patient).
  • Look at both anterior lung zones to observe for lung sliding (see Lung POCUS) or B-lines suggesting fluid overload
  • Ruling Out Tension Pneumothorax:
    • Lung Sliding: A normal shimmering, horizontal relative movement along the hypoechoic pleural line. Its presence bilaterally completely excludes a tension pneumothorax at that site.
    • Comet-tail Artifacts / B-Lines: Vertical reverberation artifacts that cross the deep screen. Their presence confirms visceral and parietal pleural contact, ruling out a pneumothorax at that interspace.
  • Confirming Pneumothorax:
    • Absence of Lung Sliding: Highly suspicious for pneumothorax in this acute context.
    • Lung Point: The exact physical junction where the visceral and parietal pleura separate due to air. Finding a lung point is 100% diagnostic of a pneumothorax.
  • M-Mode Signatures:
    • Seashore Sign: Normal lung. Smooth, linear horizontal lines above the pleura (the “sky”) and a granular, sandy artifact pattern beneath the pleura due to lung movement (the “beach”).
    • Barcode / Stratosphere Sign: Pneumothorax. The lack of subpleural movement creates uniform, static horizontal lines tracking all the way down the screen.

Next Steps

  • Once the aetiology of shock is found, to determine whether the patient’s hypotension would respond with fluids or pressors assess their Fluid Responsiveness with the LVOT VTI

Source

Disclaimer: These notes are for educational purposes only and are not medical advice. I do not claim copyright for the content or images unless otherwise stated. For concerns or changes, create a new issue on GitHub.

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