Pediatric Rapid Ultrasound in Shock and Hypotension (RUSH) Exam

July 29, 2021

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00:00Hi, my name is Julie Leviter.
00:04I'm an assistant professor of
00:05clinical Pediatrics at Yale
00:07University School of Medicine.
00:09Let's talk about the pediatric rush exam.
00:12Let's start with a case.
00:14We have a 6 month old boy presenting
00:17with fussiness and grunting.
00:18Here are his vital signs.
00:20He looks ill and he is pale and you
00:23identify correctly that he is in shock.
00:26But the question is what
00:28type of shock is he in?
00:30And we're going to use Pocus to
00:32help us narrow our differential.
00:37Let's talk first broadly
00:39about the types of shock.
00:41So here on the left hand
00:43column we have hypovolemic,
00:45cardiogenic obstructive and distributive.
00:48And then in each of these columns,
00:52we're going to find the pokus
00:54findings for each of the heart IVC,
00:58abdomen, and lungs.
01:01In the right hand column,
01:02now you see the differential for
01:04each different type of shock,
01:06and we're going to figure out how we can
01:09use focus to to narrow our differential.
01:12And figure out how to best treat
01:15our patient in the acute setting.
01:18Let's go back to our case.
01:20In this six month old in shock,
01:22we started with a cardiac ultrasound.
01:27This is a phased array probe with the
01:30probe marker pointed toward the right
01:33shoulder in a parasternal Longview.
01:35Here are the different chambers seen
01:38the left ventricle left atrium,
01:40right ventricle and aortic outflow tract.
01:42Let's go through this systematically.
01:45So in this view we can look for
01:47a fusion ejection and equality.
01:50Let's first talk about ejection fraction so
01:53that LV has very poor ejection fraction.
01:56Here I would say about 15% in
01:59terms of effusion,
02:00even though there's a small small sliver
02:03of a black line at the posterior.
02:06Of the heart here I would say there's
02:08no significant pericardial effusion,
02:10and I don't see any signs of RV strain here.
02:13Let's look at the next slide.
02:16So this is a parasternal short
02:18view with the probe marker pointed
02:21toward the patients right hip.
02:23Here we see the left ventricle and
02:26again evidence of very poor squeeze,
02:29about 15%.
02:30Still no design or signs of
02:32right ventricle strain.
02:36And here we're looking at the IVC view.
02:39So we're going to look for signs of
02:42collapse, ability with inspiration.
02:43And here I would say it looks
02:46fairly plethoric that it's not
02:48really collapsing with respiration.
02:53So here I've labeled the IVC and
02:56this is going to tell us that we
02:59really need to be very judicious
03:01with fluids in this patient.
03:04So what type of shock did this patient have?
03:08This patient had cardiogenic shock.
03:10The heart was hypo dynamic.
03:11The IVC was plethoric.
03:13We didn't look in the abdomen or lungs,
03:16but if we looked in the abdomen it
03:18probably would have been normal and if we
03:21looked in the lungs we might have seen
03:24signs of alveolar interstitial syndrome
03:26or AI S where we would see beelines.
03:29The diagnosis here was heart failure.
03:33Our next patient is a 15 year
03:35old gentleman with chest pain.
03:37He had chest pain and shortness
03:39of breath starting this morning,
03:40no fevers, nausea, vomiting,
03:42or upper respiratory symptoms.
03:43His vitals are as you see here.
03:45He appears short of breath clutching
03:47his chest and he has decreased breath
03:49sounds in the right hemithorax.
03:51So what would you like to do first?
03:56Let's go ahead and take our linear
03:58probe in the longitudinal axis at
04:00the 3rd to 4th intercostal space,
04:03and you can put the depth at
04:05about 4 centimeters unless they
04:07have an obese body habitus.
04:13So here's what we see in the
04:15left and right lung fields.
04:17So in the left lung field you see here
04:20ribbon pleura and there's lung sliding.
04:23You see that nice ants analogue appearance
04:26where there's movement along the pleura.
04:29On the right side here.
04:32You see the ribbon pleura
04:34and the pleural line.
04:36There's no motion so this is very
04:39concerning for a pneumo thorax.
04:42Now we can go ahead and look for
04:45the lung point as well to see where
04:48in the thorax the pneumo thorax
04:50ends and meets the ventilated lung,
04:53but this patient had no lung
04:55point on the right side,
04:57indicating a substantial pneumo thorax.
05:00We can also use M mode to differentiate
05:03normal lung versus pneumothorax.
05:05So in the left lung here we see the
05:08seizure sign indicating a normally
05:10ventilated lung in the right lung.
05:13We have the barcode sign indicating a
05:16pneumothorax or lack of ventilation.
05:18So in this patient before an
05:20X ray was even obtained,
05:22the patient was moved into
05:24the critical care Bay.
05:26A needle decompression was performed.
05:28Pediatric surgery was consulted
05:29and preparations.
05:30Were made for procedural sedation
05:32and angsty lysis so that a
05:35chest tube could be placed.
05:36The chest X ray confirmed the
05:38right sided pneumothorax with
05:40left sided mediastinal shift
05:41highly concerning for tension,
05:43Physiology and management of this tension.
05:45Pneumothorax was already in
05:46progress before at the chest.
05:48X Ray was obtained based
05:50on the Pokus findings.
05:54So what type of shock did this patient have?
05:58This was obstructive shock.
06:00So let's go through the different types
06:03of obstructive shock and what you'd
06:05find in each of these categories.
06:07So in the heart you might find a pericardial
06:10effusion if the causes cardiac tamponade,
06:13or you might see right ventricle strain
06:15if the cause was a pulmonary embolism,
06:18the IVC will look plethoric no matter
06:21what the abdomen would be normal and
06:23the lungs if it was a pneumothorax
06:25would have absent lung sliding on
06:28the side of the pneumo thorax.
06:33Our next case is a 17 year old woman
06:36presenting with severe abdominal pain,
06:38emesis and diarrhea.
06:40Here are her vitals.
06:41She has rebound tenderness to
06:43palpation in her lower abdomen
06:45and is diffusely guarding.
06:47So what are the most pressing diagnosis
06:50you would like to rule out with pokus?
06:56So here we're looking at the right upper
06:59quadrant using our curvilinear probe in
07:01a corona plane with the probe marker
07:04pointed towards the patients head we
07:06see the liver and the. Kidney here.
07:09And we're looking in Morrison's pouch,
07:12and at the tip of the liver liver, no.
07:15At the inferior tip.
07:18We are seeing some free fluid
07:21that black sliver there that.
07:24Is a very concerning fast.
07:31Here are the transverse and sagittal pelvic
07:34views in the transverse pelvis view.
07:36You see the bladder as a
07:39rectangular anechoic structure
07:40in the beginning of the clip,
07:42and then as we sweep the pelvis,
07:45we see all that free fluid coming
07:48into view in that sagittal view.
07:50The bladder is that circumscribed
07:53structure on the right side of
07:55the screen and then everything
07:57superior to it is black free fluid.
08:01So what type of shock was this?
08:04This is hypovolemic shock so you
08:07can see this in trauma situations
08:09in a ruptured ectopic like this
08:12one and other examples as well.
08:15In hypovolemic shock,
08:16the heart will typically look hyperdynamic.
08:18The IVC will be collapsed.
08:20The abdomen may be positive if
08:23this is the source of bleeding
08:26and the lungs will be normal.
08:29Our next case is a 10 month old
08:31boy with emesis and lethargy.
08:34He had been seen in an outside
08:36hospital the day prior with emesis
08:39diagnosed with gastroenteritis.
08:40Tolerated PO in Vincent home,
08:42then he returned early the next
08:45morning with recurrent vomiting and
08:47respiratory distress was sent to your
08:49hospital with concern for sepsis,
08:51an exam this patient is ill
08:54appearing minimally responsive,
08:55cyanotic with significant abdominal
08:57distention. Here are his vitals.
08:59His blood pressure 70.
09:01/ 30 in heart rate 205.
09:04How would you like to use pocus
09:06in this patient to differentiate
09:07the source of shock?
09:11So in this patient.
09:13The user started with the
09:15linear probe on the abdomen.
09:18Because of that abdominal
09:20distention on the left,
09:22you see the classic target sign
09:26of ileocolic intussusception.
09:28The whole target sign is greater
09:30than two centimeters diameter,
09:31so this is more likely ileo colic
09:34as opposed to ilio ilio and in
09:36the center you see a lymph node
09:38which is a frequent lead point of
09:41intussusception in kids these age.
09:43On the right side you see.
09:46Dilated non peristalsis in loops of bowel.
09:51This is consistent with sbo
09:53secondary to intussusception,
09:54and can also be consistent with
09:57ileus in this very sick infant.
10:02Here are the radiographs which
10:04demonstrate dilated small bowel loops
10:07with air fluid levels in the left
10:09side of the abdomen with a paucity
10:12of gas in the small bowel loops
10:14on the right side of the abdomen
10:16and large bell concerning for high
10:19grade small bowel obstruction.
10:21This patient was taken emergently to
10:23the OR where they resected bowel.
10:26Here pokus expedited diagnosis
10:28and operative management.
10:30So what type of shock was this?
10:34This was distributive shock.
10:35Some things you might see in a patient
10:39with distributive shock might be a
10:42perforated appendicitis in the abdomen
10:44and intussusception or in the lungs.
10:46You might see pneumonia.
10:49In general,
10:50the heart will be hyperdynamic and
10:52the IVC will be normal or collapsed.
10:58Here's an illustration of the
11:00Rush algorithm suggestion.
11:01There are a couple of Numonyx that
11:05people use to remember the different
11:07components to the Rush protocol,
11:10and remember that this was
11:12developed in adult patients.
11:14So one is the pump, the tank,
11:17the pipes, the pump being the heart,
11:20the tank being the thorax and
11:23abdomen and the pipes being the
11:26aorta and IVC another mnemonic.
11:28Is high map HIMAP for heart IVC,
11:32Morrison's aorta, pulmonary?
11:34And then you can also
11:37consider adding DVT into that.
11:40In pediatric patients in general,
11:42we're not that interested in the aorta
11:45or DVT unless there are risk factors.
11:49But I do encourage you to look
11:52for intussusception as part of the
11:55abdomen portion of the Rush protocol.
11:58Some people have termed this
12:00component as the pediatric pipes,
12:02so always look for those pediatric
12:05pipes being intussusception and
12:07some have also advocated for
12:10looking for intracranial hemorrhage.
12:12In through that with the trans.
12:15Fontanelle ultrasound in infants.
12:19Let's talk about some of the
12:21literature behind the Rush protocol.
12:24So this was one prospective
12:26observational study in an academic Ed.
12:29They used a convenience sample
12:32of 118 patients with systolic
12:34blood pressure less than 90.
12:36After an initial fluid bullets without
12:39obvious source of hypo tension,
12:42they found a significant decrease
12:44in diagnostic uncertainty when
12:46Pocus was used and in increase.
12:49In the proportion with a definitive
12:51diagnosis from .8 to 12.7 percent,
12:5425% had a significant change
12:56in the use of Ivy fluids,
12:59vasoactive agents,
13:00or blood products,
13:01and 30% had a change in the
13:04major diagnostic imaging used.
13:09Here's another study.
13:10This was a prospective,
13:12observational controlled study
13:14in an academic hospital floor.
13:17It included 165 patients.
13:19Including 83 in the focus group
13:23and 82 in the control group.
13:26They had two hospital floor teams
13:29which alternated every other day
13:32on patients with acute respiratory
13:34and or circulatory failure.
13:36Only one of the teams used an ultrasound
13:40device that was the focus group,
13:43so they found that the proportion
13:46of adequate immediate diagnosis
13:48was 94% in the focus group.
13:51And 80% in the control group that
13:54was statistically significant.
13:55There was also a statistically
13:57significant time difference in the
14:00time to 1st treatment or intervention.
14:04And it was shorter in the focus group.
14:06So 15 minutes in that group,
14:0834 minutes in the control group.
14:11They found that pokas may improve
14:13the proportion of patients
14:15with an adequate diagnosis.
14:16The time to initial treatment,
14:18and perhaps survival.
14:24Let's go back to this chart of
14:26the different types of shock.
14:28Where might you start with your probe?
14:30I'll tell you that the first
14:32thing that I look like like to
14:34look at is the heart and IBC.
14:36The heart and IVC can tell you immediately
14:39if you need to be judicious with fluids,
14:42or if you need to start major fluid
14:44resuscitation which is of utmost importance
14:46to differentiate in a patient in shock,
14:48then you can tailor the rest of
14:50your assessment based on your
14:52suspicion for different pathologies
14:53or do a complete assessment.
14:55In the undifferentiated patient,
14:57use a mnemonic of your choosing and
14:59go out there and save some lives.
15:02Thank you so much.
15:03I would love to hear your questions,
15:06comments and stories.
15:07You can email me at julieleviter@yale.edu.
15:10Thank you again.