Rapid Ultrasound for Shock and Hypotension, widely known as the RUSH Protocol exam, was first introduced by Scott D. Weingart, MD RDMS, in 2006. It was later published in 2009 as a method for conducting a rapid and easy-to-perform ultrasound procedure by most emergency healthcare providers. Patients suffering from hypertension or shock have high mortality rates. A quick and precise diagnosis are essential in order to reduce risks. Often, a traditional physical exam is inaccurate or, at most, misleading. An accurate diagnosis leading to the appropriate care is of the utmost importance to optimize life-saving measures.
Bedside ultrasound, i.e., point-of-care ultrasound (POCUS) has become the gold standard for evaluating critically ill patients in shock as it allows for direct visualization of pathology and differentiation of shock states. This includes the detection of a spontaneous retroperitoneal hemorrhage. Retroperitoneal bleeding is a severe condition. It is described as such when blood enters the space in the back of the belly. In most cases, the cause is related to a traumatic injury. However, when defined as spontaneous, bleeding within the retroperitoneum occurs without trauma or iatrogenic manipulation.
The retroperitoneum is an anatomical space located behind the peritoneum. The retroperitoneal space is a channel for blood vessels, lymphatic vessels, and nerves. Several individual spaces make up the retroperitoneum, and a number of organs are housed within. There are three main anatomical spaces: the anterior pararenal space, the posterior pararenal space, and the perirenal space. Combined, they include organs that contribute to several systems in the body, from the urinary to circulatory systems.
The pancreas’s head, neck, and body are located in the anterior pararenal space, along with the ascending and descending colon and the duodenum. The adrenal gland, kidney, ureters, and renal vessels are structures contained within the perirenal space. The posterior pararenal space houses no major organs but comprises fat, blood vessels, and lymphatics. Because the retroperitoneum includes several vital structures, delayed treatment can create significant complications. Infection or sepsis, symptomatic anemia, exsanguination, and abdominal compartment syndrome are all probable outcomes if not treated promptly and precisely.
One of the difficulties with bleeding in the retroperitoneal space is that it can accommodate large volumes of blood before any symptoms or clinical signs are evident. Hypovolemic shock can occur too late to take the proper course of action resulting in the heart’s inability to pump enough blood throughout the body. This type of shock can cause organ failure. POCUS is paramount to intervene before too late in the clinical course. The RUSH exam is conducted to narrow the differential and identify the cause of a patient’s shock as soon as possible. The exam should be undertaken in the HI-MAP order and performed in the emergency department (ED) at the patient’s bedside. Remember, the idea isn’t to get detailed measurements as with the E-FAST (Extended Focused Assessment with Sonography in Trauma) exam. Instead, it is to conduct a rapid, goal-directed evaluation of potential causes of shock.
An early RUSH exam helps quickly identify the etiology of a patient’s non-traumatic shock. Early identification of the cause leads to rapid definitive management. Studies have shown that the RUSH exam adds value to the ED workup of shock. Dr. Zouheir Ibrahim Bitar presented his case results for detecting spontaneous retroperitoneal hemorrhage using a modified RUSH Protocol at the 2022 POCUS World Conference. He shared with attendees various proof points for why the integration of POCUS in the assessment of shocked patients is so critical, how the RUSH protocol can help, and the risk factors associated with the formation of spontaneous retroperitoneal hematomas in elderly patients.
Additionally, Dr. Bitar discussed the findings and results of the case report presented. He and his colleagues found that integrating POCUS into the assessment of shocked patients leads to an earlier and more accurate initial diagnosis. With a timely prognosis in hand, a clear patient care plan can be developed and implemented. A POCUS examination should include assessing the retroperitoneal space in every patient presenting with shock. Because of the success rate in doing so, bedside ultrasound has evolved into an essential component of the evaluation of hypotensive patients.
Read Dr. Bitar’s full case report for details. Also, test your knowledge of Abdominal Trauma POCUS with this knowledge check! Get a full explanation with each question, and receive feedback on your final score.
Bitar, Z.I., Elshabasy, R.D., Elzoueiry, M.M., Gohar, M.R., Maadarani, O.S., Mohsen, M.J. (2022). Detecting spontaneous retroperitoneal hemorrhage using a modified RUSH protocol: A case report. International Journal of Surgery Case Reports, 92(106830). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8857422/
Maguire, N.J., Mondie, C., Rentea, R.M. (2022). Retroperitoneal hematoma. StatPearls.
Rezaie, S. (2013) Rush protocol: Rapid ultrasound for shock and hypotension. Academic Life in Emergency Medicine. https://www.aliem.com/rush-protocol-rapid-ultrasound-shock-hypotension/