Shock Echocardiography — RUSH & FALLS Protocols

Also known as RUSH protocol · Rapid Ultrasound in Shock · FALLS protocol · Fluid Administration Limited by Lung Sonography · Shock ultrasound · Pump tank pipes · Bedside shock protocol

The RUSH protocol (Rapid Ultrasound in Shock) is a systematic bedside ultrasound exam for the shocked patient that integrates cardiac, lung, abdominal, and vascular ultrasound to determine the type of shock. It examines three things — the PUMP (the heart: LV function, RV dilatation, effusion), the TANK (the volume: IVC, lungs, FAST), and the PIPES (the vessels: aorta, DVT, pneumothorax). The findings map to the four shock types: hypovolaemic (hyperdynamic LV, empty IVC), cardiogenic (hypokinetic LV, B-lines), obstructive (RV dilated or effusion, DVT or pneumothorax), and distributive (hyperdynamic, empty IVC, dry lungs). The FALLS protocol (Lichtenstein) uses lung ultrasound to guide fluid resuscitation — give fluid until A-lines convert to B-lines (the tank is full), then stop.

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8 MCQs

The one-paragraph exam answer

The RUSH exam (Rapid Ultrasound in Shock) is one bedside scan that asks three questions and answers the diagnosis of shock. The pump (the heart — is the LV hyperdynamic, hypokinetic, or is the RV dilated; is there an effusion?), the tank (the volume — is the IVC collapsing or plethoric, are the lungs dry A-lines or wet B-lines, is there free fluid on FAST), and the pipes (the vessels — a DVT, an aortic aneurysm, absent lung sliding). The four shock types each leave a signature: hypovolaemic (hyperdynamic, empty, dry), cardiogenic (hypokinetic, full, wet), obstructive (RV-dilated or effused, blocked pipe), and distributive (hyperdynamic, empty, dry — the mimic). FALLS then titrates the fluid: fill while the lung is dry, stop when A-lines become B-lines, and call it cardiogenic if the shock persists.^[1]

Meet the patient

A 68-year-old man arrives confused and cold, BP 78/45, MAP 56, lactate 4.8, capillary refill 5 seconds. The history is thin and the differential is everything — a bleed, sepsis, pump failure, a clot in the lung, a tamponade. The stethoscope and the blood gas will not separate these in the next five minutes; the probe will.^[1]

You place the subcostal cardiac view, sweep to the IVC, check Morison's, the aorta, and the anterior pleura. In three to five minutes the RUSH exam names the shock and points at the action — fluid, inotrope, drain, decompress, or lyse. Everything below is the detail behind that five-minute scan.^[1]

References10Show

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