This document discusses the use of ultrasound in critically ill patients. It aims to explain how ultrasound can guide management of hemodynamically unstable patients by rapidly evaluating for reversible causes of shock. The RUSH (Rapid Ultrasound in Shock) protocol is described, which involves using ultrasound to examine the heart (the pump), assess intravascular volume status (the tank), and check for issues with blood vessels (the pipes). Common pathologies that can be identified include cardiac tamponade, pulmonary embolism, hemorrhage, aortic dissection, and thrombosis. Examples of abdominal ultrasound findings in critical illnesses such as gangrenous cholecystitis, emphysematous cholecystitis, liver abscess

1. Ultrasound in critically ill patients.
The essentials
Dr/Ahmed Bahnassy
Consultant Radiologist
MBCHB-MSc-FRCR(UK)

2. Aim of the lecture
• understanding the rationale of ultrasound
imaging of critically ill patients in ICU and
ER.
• explaining how ultrasound can guide the
management of haemodynamically
unstable patients.
• illustrating role of ultrasound in chest
diseases in ICU or ER departments.
• Highlighting different causes of septic
shock .

3. Rationale of examination

4. New targets

6. RUSH: Rapid
Ultrasound in
Shock

7. RUSH: Overview
• Early recognition and
treatment of shock decreases
mortality
• Bedside ultrasound can
rapidly evaluate for reversible
causes of shock in the
undifferentiated patient.

8. • Randomized, controlled trial of immediate
versus delayed goal-directed ultrasound to
identify the cause of nontraumatic hypotension
in emergency department patients.
– 184 hypotensive pts randomized to early or
15min delayed POC U/S
– “Incorporation of a goal-directed ultrasound
protocol in the evaluation of nontraumatic,
symptomatic, undifferentiated hypotension in
adult patients results in fewer viable
diagnostic etiologies and a more accurate
physician impression of final diagnosis.”

9. • RUSH exam or
similar exams has
been endorsed by
ACEP and Critical
Care societies in the
diagnosis and
resuscitation of
critically ill patients
• RUSH
– “The Pump”
– “The Tank”
– “The Pipes”

10. RUSH: The Pump
• 1st
step is evaluation of the cardiac status
• Images: parasternal long, parasternal short,
subxiphoid and apical 4 chamber
• Evaluating for:
– Pericardial effusion, LV contractility, RV Dilation
• Look for: Cardiac
Tamponade, Heart Failure,
PE.

11. The Pump:
Effusion
• Evaluating for large
effusions causing
Tamponade .
• Pericardial fluid:
Anechoic +/-
hyperechoic clots
• Pitfall: PE with Clot v. fat
pad
• Pitfall: Pleural effusion v. pericardial
effusion.

12. The Pump: Tamponade
Physiology
• Pericardial effusion causes elevated
pressure which prevents the heart from
expanding and filling during diastole
• Tx: unstable pt with tamponade
physiology need emergent
Pericardiocentesis

13. Ultrasound finding:
–Inward “serpentine” deflection of
RA and RV
–RV wall looks like a trampoline
–Can progress to complete diastolic
collapse
–IVC Plethoric

15. Pericardial versus pleural effusion

16. The Pump: LV Contractility
• LV analyzed for global contractility
• Evaluate for severely reduced CO as cause of
shock
• Critical for guiding fluid resuscitation
• A poorly contracting heart will have small
percent change in ventricle size between
systole and diastole
• Hyperkinetic contraction may close the
ventricle in systole
Distributive or hypovolemic shock

17. How to diagnose
1) Global functioning: “Eyeball it”
- Good squeeze on gross examination
2) Fractional Shortening
- (EDD-ESD)/EDD
- M-mode beyond MV, measuring largest and smallest LV diameters
- NL 30-45%
3)E-point septal separation
- ant. MV leaflet distance to septal wall
- Less squeeze = less early filling = large EPSS
- NL <7mm.
- Limitations: MV Stenosis/regurg, Aortic Regurg, LV hypertrophy

19. The Pump: RV Size
• Evaluate for RV Strain which can
signify a massive PE in the setting
of shock
• Back pressure in pulmonary arteries
causes increase in RV pressure and
result in acute dilation of RV
• NL ratio of LV: RV is 1:0.6
• Septal bowing can indicate RV
Strain

20. Normal

21. ratio

22. Ratio

23. Septum

24. Septum

25. measure

26. The Tank: 1.Intravascular volume
status
• “Fullness of the
Tank” assessed
by looking at
IVC
–Vessel size and
respiratory
dynamics
–Evaluated just
beyond Hepatic
v. approx. 2cm
from RA

27. • IVC diameter < 2.1cm
that collapses >50%
with sniff correlates
to low CVP
– Distributive and
hypovolemic states
• IVC >2.1cm, <50%
collapse w/ sniff
– Obstructive and
cardiogenic states
• Can help guide fluid resuscitation
• Limitation: Intubated patient ...
positive pressure breathing
2 lines

28. The Tank:
2.Leakiness
• Hemodynamic
compromise due to loss
of fluids from
vasculature
– Hemoperitoneum and
Hemothorax
FAST EXAMINATION.
CHEST examination
(B lines)..see later

29. The Pipes: AAA and
Dissection
• AAA: Vessel diameter
>3cm, in patient with
clinical symptoms and
hypotension should be
assumed to be Ruptured
AAA
– Aorta retroperitoneal and
therefor rupture will be
poorly visualized on US
• Aortic Dissection: Aortic
intimal flap .

30. The Pipes: DVT
• If thromboembolic
event is
suspected
• Assess venous
side of the Pipes
• Lack of complete
compression at
Femoral v. and
Popliteal v. sites

31. asking yourself

32. categorize the patient

34. How to scan

35. lines

36. additional scanning sites

38. Normal scan

40. A lines

41. B (for bad) lines

42. Confluent B

43. Overall view

45. Revise

46. Others

47. sternal fracture

48. Bony lesions

49. Lung cancer

50. Pleural fluid

52. Consolidation

53. Lung abscess

54. Pulmonary embolism

55. Infarction

56. Follow up

57. Pneumothorax

60. no sandy beach

62. I-Gangrenous Cholecystitis
• Necrotizing inflammation.
• Clinical and laboratory criteria are
nonspecific.
• US or CT diagnosis can be life
saving

63. DD:Acute Cholecystitis

66. Debris filled

67. Membranes filed

68. very thickened wall

69. Pericholecystic fluid

70. Perforation

71. CT findings
• air in gallbladder lumen
Intraluminal linear densities
(black arrows) corresponding to
intraluminal membranes. Note
lack of contrast enhancement of
gallbladder wall (open arrow).
Pericholecystic inflammation
(white arrow)

72. • irregularity of wall (black
arrows) of gallbladder (g)
and inflammation in
pericholecystic fat (white
arrow).
• loculated fluid attenuation
abnormality adjacent to gallbladder,
consistent with abscess (a). Defect
in gallbladder wall is shown (black
arrow). White arrow shows
pericholecystic inflammation

73. II-Emphysematous cholecystitis.
• Emphysematous
cholecystitis is an
unusual but life-
threatening form
of acute
cholecystitis
caused by the
presence of gas-
forming bacteria in
the gallbladder.

74. Pathophysiology
• Emphysematous cholecystitis frequently affects
elderly men, associated with diabetes mellitus.
• The risk of gangrene and perforation of the
gallbladder is high for patients with
emphysematous cholecystitis, and the mortality
rate is 15%, as compared with 4% for acute
cholecystitis.
• The etiology of emphysematous cholecystitis is
controversial, but it is considered to be due to
ischemia of the gallbladder from primary
vascular compromise, with secondary
proliferation of gas-producing bacteria .

76. US diagnosis

77. US diagnosis.

78. gas presence is the essence

79. 3.Perforated DU +abnormal GB

80. 4.Xanthogranulomatous
Cholecystitis

81. 5.Liver abscess
• On ultrasound, a liver abscess most
commonly appears as a complex cystic
mass with an irregular, shaggy border that
demonstrates increased through
transmission
use tissue harmonic imaging

82. hepatitis stage can manifest
only by
decreased echogenicity

83. Gray scale image demonstrating a complex hypoechoic
cystic lesion in the liver (calipers). Echogenic material with
dirty distal shadowing represents air in the abscess
look in different angles
to avoid impedance from gas

84. 6.Acute pancreatitis
swollen hypoechoic pancreas
normal size

85. Oblique view through the right flank in a patient with upper abdominal
pain reveals fluid in the peri-renal space and para-renal space. Note
hypoechoic, thickened para-renal fat linear, hypoechoic plane between
the pancreas (P) and splenic vein/portal confluence .

86. peripancreatic/perirenal fluid

87. Acute fluid collection/pseudocyst.

88. 7.Pyonephrosis

89. 8.Acute pyelonephritis
size
parenchyma
thickness

90. Pyelonephritis+GB wall thickening

91. 9.Renal abscess

92. 10 .Emphysmatous pyelonephritis