Rapid Ultrasound for Shock and Hypotension takes the undifferentiated hypotensive patient and sorts them into a shock category in about two minutes — without pausing the resuscitation. Three questions: how's the pump, how full is the tank, are the pipes intact?
RUSH is not a new scan — it's a sequence of scans you already know, assembled into one decision framework.
Curated from the POCUS 101 RUSH Exam Ultrasound Protocol: Step-By-Step Guide. Their walkthrough of each component with matched clips is the best way to see the framework assembled.
Effusion / tamponade, global squeeze (EF), and RV size. See TTE Basics and Echo for PE.
Parasternal, apical, and subxiphoid cardiac views
Answer three questions in order of lethality: Is there a pericardial effusion with tamponade? Is the LV hyperdynamic, normal, or severely reduced? Is the RV enlarged (acute cor pulmonale suggesting massive PE)?
IVC, then lungs, then the FAST windows
The IVC estimates the tank's fullness: flat and collapsing suggests an empty tank (hypovolemic/distributive), plump and fixed suggests a full or obstructed one (cardiogenic/obstructive). Then check whether the tank is leaking (free fluid on FAST) or overflowing (diffuse B-lines) or compromised (pneumothorax, large effusion).
Abdominal aorta sweep, then leg vein compression
Interrogate the aorta for an aneurysm (a ruptured AAA is a rapidly fatal cause of hypotension), then the femoral and popliteal veins for DVT — which, with a strained RV on the pump exam, supports massive PE as the cause.
| Shock type | Pump | Tank (IVC) | Pipes / other |
|---|---|---|---|
| Hypovolemic | Hyperdynamic, small chambers | flat, collapsing | Free fluid (hemorrhage) or normal |
| Distributive (septic) | Hyperdynamic early; may depress late | flat / normal | Source-dependent; lungs may show pneumonia |
| Cardiogenic | Poor contractility | plump, fixed | Diffuse B-lines (pulmonary edema) |
| Obstructive | Tamponade, or big RV (PE) | plump, fixed | Effusion; PTX; DVT + RV strain = PE |
The categories overlap and shock is often mixed — use the pattern to prioritize the next intervention, then reassess. RUSH is a starting hypothesis, not a final diagnosis.
Structure the pump exam by what kills fastest: tamponade, then pump failure, then RV strain. You can act on tamponade before you've finished the rest of the scan.
IVC assessment is crude and confounded by ventilation, PEEP, and RV failure. Read it alongside the heart and lungs, never in isolation, and prefer trends over a single still.
Finding a flat IVC and stopping there misses the concurrent tamponade or the ruptured AAA. Complete all three components before committing to a category.
A septic patient can also have cardiac dysfunction; a trauma patient can have both hemorrhage and tension physiology. Let the exam show more than one contributor.
RUSH is designed to run alongside ongoing care. Scan during natural pauses, keep it under a couple of minutes, and never let the probe delay compressions, blood, or the airway.
The value is in the trend. Rescan the pump and tank after the fluid bolus, the pressor, or the pericardiocentesis to confirm the response and catch the evolving second cause.
A starting template for a RUSH procedure note. Fields in blue are wildcards to complete. Build it as a SmartPhrase, then edit every field to match the actual study.
POINT-OF-CARE ULTRASOUND: RUSH EXAM
Indication: undifferentiated shock / hypotension [***]
Exam type: Focused / limited, bedside, during resuscitation
Operator: @ME@ Interpretation: independent, real-time
Probe: phased array + curvilinear
Consent: emergent, not obtained / [***]
PUMP (heart)
- Pericardial effusion: {none : present [***], tamponade physiology {no : yes}}
- LV function: {hyperdynamic : normal : moderately reduced : severely reduced}
- RV size: {normal : enlarged, D-sign {no : yes}}
TANK (volume)
- IVC: {flat, >50% collapse : normal : plethoric, <50% collapse}
- Lungs: {A-lines / dry : diffuse B-lines : effusion : pneumothorax [side ***]}
- FAST windows: {no free fluid : free fluid [***]}
PIPES (vessels)
- Aorta: {normal caliber <3 cm : aneurysm [*** cm]}
- Leg veins: {compressible / no DVT : non-compressible / DVT [side ***] : not assessed}
IMAGE QUALITY: adequate / limited by [***]
Images saved and archived to [PACS / Qpath / ***].
IMPRESSION: findings most consistent with {hypovolemic : distributive :
cardiogenic : obstructive : mixed} shock. [***]
Resuscitation adjusted accordingly; reassessment planned.
I personally performed and interpreted this study in real time.
Electronically signed: @ME@ @TD@ @NOW@
Sample template only — not a validated institutional SmartPhrase. Verify wording, image-archival, and attestation requirements against your department's POCUS credentialing, coding, and compliance policies before clinical use. Documentation supports, but does not replace, the medical record and QA workflow.