ISSN: 2706-8870
Volume 6, Number 6 (2021)
Year Launched: 2016
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Rule of RUSH protocol in management of shocked patients

Volume 6, Issue 6, December 2021     |     PP. 652-673      |     PDF (606 K)    |     Pub. Date: November 23, 2021
DOI: 10.54647/cm32583    66 Downloads     5345 Views  

Author(s)

Hamdy A. Mohammadien, Departments of Chest Diseases, Sohag Faculty of Medicine, Sohag University, Egypt
Gamal M. Agamy, Assuit Faculty of Medicine, Assuit University, Egypt
Esrra F. Ahmad, Departments of Chest Diseases, Sohag Faculty of Medicine, Sohag University, Egypt
Azza M. Ahmad, Departments of Chest Diseases, Sohag Faculty of Medicine, Sohag University, Egypt

Abstract
Background: Clinical assessment and classification of shock is extremely difficult to conduct on critically ill patients. Rapid Ultrasound in Shock (RUSH) is an easily learned and quickly performed shock ultrasound protocol, it allows for rapid evaluation of reversible causes of shock and improves accurate diagnosis in undifferentiated hypotension.
Objectives: to evaluate the accuracy of early RUSH protocol performed by chest physicians to predict type of shock and its guide of resuscitation in critically ill patients. Patients and Methods: Study was conducted on 68 patients with shock state in Respiratory Intensive Care Unit (RICU) of Chest Department at Assuit University Hospital and evaluated for the cause of shock by performing early RUSH protocol for patients. Patients received all needed standard therapeutic and diagnostic interventions without delay and were followed to document their final clinical diagnosis. The agreement between the initial impression provided by RUSH and the final diagnosis was investigated by calculating the Kappa index. Sensitivity, Specificity, positive predictive value (PPV) and negative predictive value (NPV) of RUSH for diagnosis of each case.
Results: We performed RUSH examination on 68 shocked patients. 39 were males (58%) and 29 were females (41%), with mean age 58 years. Kappa index was 0.85 (P= 0.0001), reflecting acceptable general agreement between initial impression and final diagnosis. For hypovolemic, cardiogenic and obstructive shock, the protocol had an NPV above 97%, but it had low sensitivity. For shock with distributive or mixed etiology, RUSH showed a PPV of {97% & 100%} respectively, with high sensitivity. The agreement of protocol for final diagnosis was highest in distributive and obstructive shock followed by cardiogenic and hypovolemic shock [(94% & 93%), P < 0.001 & (84% & 73%), P < 0.001,] respectively. There was a statistically significant relationship between IVCe, IVCi & IVC index and different types of shock (P < 0.0001).Also There was a statistically significance relationship between CVP and different types of shock (P= 0.0001). There was a statistically significance correlation between CVP and IVC index (P < 0.0001), IVCe diameter (P < 0.0001), and IVCi diameter (P < 0.0002).
Conclusion: We highlight the role of integrating focused ultrasound techniques, such as the RUSH examination, in the physician resuscitation pathways to diagnose shock etiology, augment their clinical evaluation and guide resuscitation.
Clinical Implications: Early identification of causes of shock in critically ill patients allow good clinical evaluation and guide resuscitation and help physician to used correct treatment.

Keywords
cardiogenic shock, hypovolemic shock, obstructive shock, rapid ultrasound in shock, RUSH exam., Shock

Cite this paper
Hamdy A. Mohammadien, Gamal M. Agamy, Esrra F. Ahmad, Azza M. Ahmad, Rule of RUSH protocol in management of shocked patients , SCIREA Journal of Clinical Medicine. Volume 6, Issue 6, December 2021 | PP. 652-673. 10.54647/cm32583

References

[ 1 ] Seif D, Perera P, Mailhot T, Riley D, Mandavia D. Bedside Ultrasound in resuscitation and therapid ultrasound in shock protocol. Crit Care Res Pract. 2012; 2012: 503254. https://doi.org/10.1155/2012/503254.
[ 2 ] Wacker DA, Winters ME. Shock. Emerg Med Clin North Am. 2014; 32(4):747-58 .
[ 3 ] Nermeen MA, Maguid, HMA, Gamil NM, Tawfeek MM and Hegab SS: Evaluation of The Role Of Bedside Lung Ultrasound Versus Chest X-ray In Critically Ill Patients. Zagazig University Medical Journal, 2019, 25 (6), 887-897.‏
[ 4 ] Blanco, P., Aguiar, F. M., & Blaivas, M: Rapid ultrasound in shock (RUSH) velocity‐time integral: a proposal to expand the RUSH protocol. Journal of ultrasound in medicine, 2015, 34(9), 1691-1700.‏
[ 5 ] Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapidultrasound in shock in the evaluation of critically ill patient. Emerg MedClin North Am. 2010; 28(1):29-56.
[ 6 ] Amin NH, Jakoi A, Katsman A, et al. Incidence of orthopedic surgery intervention in a level I urban trauma center with motorcycle trauma. J Trauma. 2011;71:948e951.
[ 7 ] Keikha M, Salehi-Marzijarani M, SoldooziNejat R, Sheikh MotaharVahedi H, Mirrezaie SM.Diagnostic Accuracy of Rapid Ultrasound in Shock (RUSH) Exam; A systematic review and meta-analysis. Bull Emerg Trauma . 2018; 6(4):271-278.
[ 8 ] Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, Marshall J. C.A.U.S.E.: Cardiac arrest ultra-sound exam--a better approach to managing patients in primary non arrhythmogenic cardiac arrest. Resuscitation .2008; 76(2):198–206.
[ 9 ] Ghane MR, Gharib MH, Ebrahimi A, Saeedi M, Akbari-Kamrani M, Rezaee M and Rasouli H: Accuracy of Early Rapid Ultrasound in Shock (RUSH) Examination Performed by Emergency Physician for Diagnosis of Shock Etiology in Critically Ill Patients. J Emerg Trauma Shock, 2015, 8 (1):5-10. DOI: 10.4103/0974-2700.145406.
[ 10 ] Vignon P, Xavier R, Antoine VB and Eric M: Critical Care Ultrasonography in Acute Respiratory Failure. Critical Care 2016, 20 (228):1–11. DOI 10.1186/s13054-016-1400-8.
[ 11 ] Ibrahim I. Elmahalawy, Nagwa M. Doha, Osama M. Ebeid, Mohammed A. AbdelHady, and Ola Saied: Role of thoracic ultrasound in diagnosis of pulmonary and pleural diseases in critically ill patients. Egy Chest Dis Tuber J, 2017; 66: 261- 266.
[ 12 ] Volpicelli G, Caramello V, Cardinale L, Mussa A, Bar F, and Frascisco MF: Bedside Ultrasound of the Lung for the Monitoring of Acute Decompensated Heart Failure. American Journal of Emergency Medicine, 2008, 26 (5): 585–591. DOI:10.1016/j.ajem.2007.09.014.
[ 13 ] Mohammed, AES, Hagag, M GED, Mousa, WAEF, & Toulan, MTAH: Correlation of inferior vena cava diameter and collapsibility index with central venous pressure in shocked patients. Menoufia Medical Journal, 2020, 33, 1304-1308. DOI: 10.4103/mmj.mmj_65_20.
[ 14 ] Sefidbakht S., Assadsangabi R., Abbasi H. R. and Nabavizadeh A: Sonographic Measurement of the Inferior Vena Cava as a Predictor of Shock in Trauma Patients. Emergency Radiology, 2007, 14 (3):181–185.
[ 15 ] Lyon M, Blaivas M, and Brannam L: Sonographic Measurement of the Inferior Vena Cava as a Marker of Blood Loss. American Journal of Emergency Medicine, 2005, 23 (1):45–50. DOI:10.1016/J.AJEM.2004.01.004.
[ 16 ] Youssif, KYA, El Sayed, ZM, Ali, MA, & Moghazy, AM: Role of inferior vena cava ultrasound in diagnosis of shock in patients with trauma. The Egyptian Journal of Surgery, 2020, 39:194–198.
[ 17 ] Yanagawa Y, Nishi K, Sakamoto T, Okada Y. Early diagnosis of hypovolemic shock by sonographic measurement of inferior vena cava in trauma patients. J Trauma Acute Care Surg 2005; 58:825–829.
[ 18 ] Caplan M, Durand A, Bortolotti P, Colling D, Goutay J, Duburcq T, Drumez E ,Rouze A, Nseir S, Howsam M , Onimus T , Favory R and Preau S: Measurement site of inferior vena cava diameter afects the accuracy with which fuid responsiveness can be predicted in spontaneously breathing patients: a post hoc analysis of two prospective cohorts, Ann. Intensive Care,2020,10:(168),1-10. https://doi.org/10.1186/s13613-020-00786-1.
[ 19 ] Khalil A, Khan A, Hayat A. Correlation of inferior vena cava (IVC) diameter and central venous pressure (CVP) for fluid monitoring in ICU. Pak Armed Forces Med J 2015; 65:235–238.
[ 20 ] Ilyas A., Ishtiaq W., Assad S., Ghazanfar H., Mansoor S., Haris M. & Akhtar A: Correlation of IVC diameter and collapsibility index with central venous pressure in the assessment of intravascular volume in critically ill patients. Cureus, 2017, 9(2), 1-7.
[ 21 ] Ciozda W., Kedan, I. Kehl, D. W., Zimmer R., Khandwalla R. & Kimchi A: The efficacy of sonographic measurement of inferior vena cava diameter as an estimate of central venous pressure. Cardiovascular ultrasound, 2015,14 (1), 2-8.
[ 22 ] Wiryana M, Sinardja K, Aryabiantara W, Senapathi T, Widnyana M, Aribawa G, et al. Central venous pressure correlates with inferior vena cava collapsibility index in patients treated in intensive care unit. Bali J Anesthesiol 2017; 1:7–9.
[ 23 ] Thanakitcharu P, Charoenwut M, Siriwiwatanakul N. Inferior vena cava diameter and collapsibility index: a practical noninvasive evaluation of intravascular fluid volume in criticallyill patients. J Med Assoc Thai 2013; 96(Suppl 3):S14–S22.
[ 24 ] Stawicki SP, Braslow BM, Panebianco NL, Kirkpatrick JN, Gracias VH, Hayden GE, et al. Intensivist use of hand-carried ultrasonography to measure IVC collapsibility in estimating intravascular volume status: correlations with CVP. J AmColl Surg. 2009;209:55e61. https:// doi.org/10.1016/j.jamcollsurg.2009.02.062.
[ 25 ] Govender J, Postma I, Wood D, Sibanda W. Is there an association between central venous pressure measurement and ultrasound assessment of the inferior vena cava? Afr J Emerg Med 2018; 8:106–109.
[ 26 ] Maecken T, Grau T. Ultrasound imaging in vascular access. Crit Care Med 2007; 35 (5 Suppl):S178–S185.
[ 27 ] Bagheri-Hariri S, Yekesadat M, Farahmand S, Arbab M, Sedaghat M, Shahlafar N, Takzare A, Seyedhossieni-Davarani S, and Nejati A: The Impact of Using RUSH Protocol for Diagnosing the Type of Unknown Shock in the Emergency Department. Emergency Radiology, 2015, 22:517–520. DOI 10.1007/s10140-015-1311-z.
[ 28 ] Elbaih AH, Housseini AM , Khalifa MEM A.H: Accuracy and outcome of rapid ultrasound in shock and hypotension (RUSH) in Egyptian polytrauma patients. Chinese Journal of Traumatology 2018,21: 156-162.
[ 29 ] Tabibzadeh Dezfuli, SA, Ghasemi H, and Yazdani R: Investigation of Accuracy of Rapid Ultrasound in Shock (RUSH) on Detection of Early Rapid Shock Type in Emergency Patients. GMJ Medicine, 2019, 3, 149-155.‏ DOI 10.29088/GMJM.2019.149.
[ 30 ] Javali RH, Loganathan A, Srinivasarangan M, Akkamahadevi Patil A, Siddappa GB , Satyanarayana N, Bheemanna AS, Jagadeesh S, and Betkerur S: Reliability of Emergency Department Diagnosis in Identifying the Etiology of Nontraumatic Undifferentiated Hypotension. Indian J Crit Care Med. 2020 May; 24(5): 313–320. doi: 10.5005/jp-journals-10071-23429.
[ 31 ] Rahumalkur HH, Bhavin PR, Shreyas KP, Krunalkumar HP, Atulkumar S, and Bansari C: Utility of Point-of-Care Ultrasound in Differentiating Causes of Shock in Resource-Limited Setup. J Emerg Trauma Shock. 2019 Jan-Mar; 12(1): 10–17. doi: 10.4103/JETS.JETS_61_18