Ultrasound Teaching Atlas
Draft — not yet peer-reviewedadvancedMulti-region / ShockRUSH

RUSH — Rapid Ultrasound for Shock & Hypotension

A structured 'Pump, Tank, Pipes' exam to rapidly classify undifferentiated shock at the bedside.

This module is a content/teaching-structure draft. Images shown are illustrative schematics — real, de-identified, license-verified ultrasound clips replace them before peer review.

Learning objectives

  • Perform the RUSH exam as Pump (heart), Tank (volume), and Pipes (vessels).
  • Integrate findings to distinguish hypovolemic, cardiogenic, obstructive, and distributive shock.
  • Recognize the time-critical patterns: tamponade, massive PE, tension pneumothorax, ruptured AAA.

Maps to

  • Resident: ACEP Emergency Ultrasound — Integration / undifferentiated hypotension
  • Resident: ACEP Emergency Ultrasound — Cardiac, IVC, aorta, thoracic
  • Tech: Critical care POCUS — shock assessment

Acquisition — getting the view

Probe
phased-array
Patient position
Supine; left lateral decubitus optional to improve cardiac windows.
Orientation convention
cardiology
Probe placement
Begin at the cardiac window (parasternal/subxiphoid), then proceed through all windows
Marker direction
Cardiology convention for cardiac views; radiology convention elsewhere

Probe placement (3D)

Begin at the cardiac window (parasternal/subxiphoid), then proceed through all windows

Structures in the imaging plane (near → far): Chest wall · Right ventricle · Left ventricle · Pericardium

Step by step

  1. PUMP — image the heart (parasternal, apical, subxiphoid): look for pericardial effusion/tamponade, global LV function, and RV strain.
    Why: Effusion → obstructive; poor LV → cardiogenic; large RV/D-sign → massive PE.
  2. TANK — assess the IVC, FAST views, and lungs: IVC size/collapse for volume status, free fluid for 'tank leak', B-lines for overload, pneumothorax for 'tank compromise'.
    Why: Flat IVC → hypovolemic/distributive; plethoric IVC + B-lines → cardiogenic.
  3. PIPES — scan the aorta (AAA/dissection) and the femoral/popliteal veins (DVT supporting PE).
    Why: Ruptured AAA or a DVT can be the source of the shock state.

Troubleshooting

Findings seem contradictory.
Re-image the heart and IVC together; integrate the whole picture rather than any single window.
Poor cardiac windows.
Roll to left lateral decubitus, or rely on the subxiphoid view.

Findings: normal

Normal / non-diagnostic RUSH

Good LV function, a normally collapsing IVC, no effusion, no free fluid, no AAA, and no DVT — pushes toward distributive shock (e.g., sepsis) as a diagnosis of exclusion.

Schematic summarizing a non-diagnostic RUSH exam
Schematic: integrate Pump, Tank, and Pipes.
Original schematic, dedicated to the public domain (CC0).

Findings: pathology

Shock-type patterns

Hypovolemic: hyperdynamic small LV, flat collapsing IVC, ± free fluid/AAA. Cardiogenic: poor dilated LV, plethoric IVC, B-lines. Obstructive: tamponade, or large RV + plethoric IVC + DVT (PE), or pneumothorax. Distributive: hyperdynamic LV, variable IVC, no fluid.

Signs: Tamponade; RV strain / D-sign (PE); Flat vs. plethoric IVC; AAA; B-lines

Schematic of RUSH shock-type patterns
Schematic: matching findings to shock type.
Original schematic, dedicated to the public domain (CC0).

Interpretation practice

A hypotensive patient has a dilated, poorly contracting left ventricle, a plethoric non-collapsing IVC, and diffuse B-lines. Which shock type does this fit?

RUSH findings of poor LV, plethoric IVC, B-lines
Poor LV + plethoric IVC + B-lines — classify the shock.
Original schematic, dedicated to the public domain (CC0).

Check your understanding

What does the 'Pump, Tank, Pipes' framework correspond to?

A large right ventricle with septal flattening and a coexisting DVT suggests which cause of shock?

References

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