EMS World

AUG 2018

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34 AUGUST 2018 | EMSWORLD.com ISSUE FOCUS: ADVANCED CARE RUSH exam. This protocol is a quick and relatively easy exam to per form that is designed to help the provider either rule in or reduce their index of suspicion for six emergent causes of shock and allow for more informed clinical decision-making. The RUSH exam typically consists of six dif ferent ultrasound "views." These views can be easily remembered using the acronym HI-MAP. Heart—Ultrasound examination of the heart allows for immediate visualization of any large pericardial effusion that may b e im p ac ting th e p atient 's h em o d y- namics and also allows for a qualitative assessment of the patient's ventricular function and fluid status. Low cardiac output caused by reduced contractility can indicate cardiogenic shock, while conversely a hyperdynamic left ventricle may indicate a hypovolemic state, two conditions that require ver y dif ferent inter ventions. IVC— Considerable controver s y sur- rounds the ability of ultrasound exami- nation of the inferior vena cava to accu- rately assess a patient's fluid status. That being said, there is a body of evidence that suggests ultrasonographic exami- nation of IVC diameter in spontaneously breathing patients can provide valuable information about the patient's fluid and preload status. 4 This, combined with the overall clinical picture, can help provid- ers assess the appropriateness of fluid resuscitation in hypotensive patients. M o r r i s o n' s p o u c h —T h e i n t e r f a c e between the liver and the kidney in the right upper quadrant, a space known as Morrison's pouch, can be examined with ultra sound to detec t the presence of free fluid with a high degree of sensitivity and specificity in the setting of trauma. 5 This translates well for medical causes of intra-abdominal hemorrhage, such as acute pancreatitis or an actively dissect- ing aortic aneur ysm. A o r t a — P a t i e n t s w i t h a b d o m i n a l aor tic catastrophe can rapidly dissect and decompensate, requiring a g gres- sive management and rapid transpor t; unfortunately, their symptoms can often mimic those of other conditions, lead- ing providers down a fruitless treatment pathway that quickly spirals out of con- trol. Ultrasound examination of the aorta, however, is extremely sensitive and spe- cific for the detection of AAA, clarif ying an other wise obscure clinical picture for these patients. 6 Pneumothorax—Perhaps the easiest of all the examinations to per form and interpret with even a minimum of train- ing, 7 examination of the lung with POCUS can detect pneumothorax with a sensi- tivity and specificity far better than aus- cultation of lung sounds or a chest x-ray. 8 Bringing it All Together Let's turn our attention back to the patient one last time. Last year you would have given this patient a rapid fluid bolus to check for fluid responsiveness and only after that considered administering a vasopressor to manage her hemodynamics. But now your agency has provided you with ultrasound. You take a couple of minute s and quickly per form a RUSH exam. All your findings are normal except for the fact that her left ventricle is barely squeezing. Now that you know her shock is cardio- genic in nature and her preload status is sufficient, you reduce the amount of fluid you administer and instead turn quickly to an inotrope for circulator y suppor t. Her condition stabilizes, and you avoid fluid- overloading her and are able to safely transport her to an area hospital, where she is admitted and treated for heart failure. Final Thoughts Ultrasonography, in the hands of compe- tent, confident clinician paramedics, is a powerful tool that has the potential to guide the care of critically ill patients across the spectrum of disease. More than any other emerging prehospital technology, POCUS has the potential to make a greater impact on the diagnosis and treatment of our patients than anything since the intro- duction of prehospital EKGs. This level of practice, however, requires more of a shif t in thinking than simply buying a machine and training provid- ers. It requires us to acknowledge that the dichotomy of "stay and play" ver - sus "load and go" is outdated and in some instances potentially harmful to patients. Providers need to be encour- aged to effectively resuscitate critically ill patients, rather than providing minimal care and simply driving fast. Agency managers and medical direc- tors owe it to their providers and the patients they ser ve to consider incor - porating POCUS into their daily practice. The RUSH exam consists of six views represented by the mnemonic HI-MAP.

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