Clinics in Medical Education

RUSH Ultrasound

Module 1: Introduction to RUSH / FAST

This module focuses on conceptual framework of the “Pump, Tank, and Pipes” and will explore key ultrasound views used to identify the type and cause of shock. The module consists of two instructional videos:

  1. Introduction to Shock and the RUSH Protocol
  2. RUSH Protocol: Components and Ultrasound Views

Learning Objectives

By the end of this module, learners will be able to:

  1. Describe the clinical indications for using the RUSH protocol in shock evaluation.
  2. Understand and apply the “Pump, Tank, and Pipes” framework for structured bedside assessment.
  3. Identify and interpret the ultrasound views relevant to each component of the RUSH exam:
    • Pump: Parasternal, subxiphoid, and apical cardiac views
    • Tank: IVC, FAST (right upper quadrant, left upper quadrant, pelvis)
    • Pipes: Aorta, lung (anterior, lateral), femoral vein
  4. Identify the four standard FAST exam views:
    • Right upper quadrant (Morrison’s pouch)
    • Left upper quadrant (splenorenal space)
    • Pelvis (pouch of Douglas/rectovesical space)
    • Pericardial view (subxiphoid or parasternal)
  5. Recognize key ultrasound findings associated with the four main types of shock:
    • Hypovolemic shock
    • Cardiogenic shock
    • Obstructive shock
    • Distributive shock
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Introduction

A. Identify and interpret ultrasound views associated with each component of the RUSH (Rapid Ultrasound in Shock and Hypotension) exam:

  • Pump: Parasternal, subxiphoid, and apical cardiac views
  • Tank: Inferior vena cava (IVC) and FAST views (right upper quadrant, left upper quadrant, pelvis)
  • Pipes: Aorta, lung (anterior and lateral views), and femoral vein 

B. Recognize key ultrasound findings associated with the four major types of shock:

  • Hypovolemic
  • Cardiogenic
  • Obstructive
  • Distributive

Protocol

 1. Cardiac Views

  • Parasternal Long Axis 
  • Parasternal Short Axis
  • Apical Four-Chamber 
  • Subcostal Four-Chamber 
  • Subcostal IVC

2. Respiratory Views

  • Clinical Importance
  • Basic Lung Anatomy and Sonographic Landmarks

3. Abdominal Views (Focused Assessment with Sonography for Trauma – FAST)

  • Right Upper Quadrant (RUQ)
  • Left Upper Quadrant (LUQ)
  • Pelvic View

4. Review Questions

  • Case-based or image-based questions to reinforce key concepts 

Module 2: Evaluation and Pathologies

This module includes an overview of the structured approach (Pump, Tank, Pipes) and demonstrates the use of ultrasound to evaluate each component. Learners will also review the ultrasound findings associated with key types of shock and learn to compare pathologies. The module includes two instructional videos:

  1. Evaluation of RUSH Components: Pump, Tank, and Pipes
  2. Shock Pathologies and Ultrasound Comparison

Learning Objectives

By the end of this module, learners will be able to:

  1. Perform a systematic ultrasound exam targeting the three RUSH components:
    • Pump: Evaluate for pericardial effusion, global cardiac function, and right heart strain.
    • Tank: Assess volume status using IVC, and scan for free fluid with abdominal FAST views.
    • Pipes: Evaluate for aortic aneurysm/dissection, deep vein thrombosis, and pneumothorax.
  2. Recognize and differentiate key ultrasound findings associated with major types of shock:
    • Hypovolemic shock: Small IVC, hyperdynamic heart, absence of free fluid or effusion.
    • Cardiogenic shock: Poor left ventricular function, possible pulmonary edema.
    • Obstructive shock:
      • Tamponade: Pericardial effusion with RV diastolic collapse.
      • PE: Dilated RV, McConnell’s sign.
      • Tension pneumothorax: Absent lung sliding, barcode sign.
    • Distributive shock: Hyperdynamic heart, flat IVC, no obstructive or hypovolemic signs.
  3. Compare the sonographic patterns of each shock type across multiple systems to aid diagnosis and guide early treatment.
  4. Integrate findings from cardiac, respiratory, and abdominal ultrasound views to create a complete clinical picture in patients with hypotension or shock.

Evaluation and Pathologies

A. Pump: Cardiac Assessment 

Left Ventricle:

  • Qualitative assessment: size, contractility (squeeze), segmental motion 
  • Detection of regional wall motion abnormalities
  • Identification of LV hypokinesia and akinesia 

Right Ventricle

  • Morphological assessment: size, shape, wall thickness, tricuspid valve evaluation
  • Functional assessment: free wall motion, tricuspid annular motion, septal wall movement 

Effusion Identification

  • Differentiation between pericardial effusion and pericardial fat pad
  • Recognition of pleural effusions 

TTE Evaluation of Cardiac Tamponade

  • Assessment of right atrium and right ventricle collapse
  • IVC size and collapsibility
  • Mitral and tricuspid valve inflow variation

B. Tank: Volume Status Assessment

  • IVC diameter and collapsibility index
  • FAST exam: right upper quadrant, left upper quadrant, pelvis

C. Pipes: Vascular Evaluation

  • Aortic aneurysm detection

  • Evaluation for aortic dissection

Comparing Pathologies

  • Pleural effusion
  • Severe LV systolic dysfunction
  • LV hypertrophy
  • Subpleural interstitial edema