RUSH Course for Medical Students

Dear students,

We are pleased to open our third course for you; Rapid Ultrasound in Shock and Hypotension (RUSH).

As a part of our social responsibility initiative, iem-course.org will continue to provide free open online courses related to emergency medicine. We hope our courses help you to continue your education during these difficult times.

Please send us your feedback or requests about courses.

We are here to help you.

Best regards.

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

iEM Course is a social responsibility initiative of iEM Education Project

Hypotension is a high-risk sign which is associated with increased morbidity and mortality rate. The differential diagnosis for hypotension is broad and the treatment depends on the underlying etiology. In most cases of hypotension, patients present with limited history and physical examination may be inaccurate making the management of the condition a great challenge for emergency physicians.

The use of POCUS in undifferentiated hypotension has been shown to help correctly and rapidly identify the etiology and therefore initiate the appropriate management. Since 2001, there are many protocols published describing a systematic approach to the use of POCUS in undifferentiated hypotension. 

In this course, we will focus on the Rapid Ultrasound in Shock and Hypotension (RUSH) protocol.

This course aims to provide the necessary information on ultrasonography, its use in a hypotensive patient, and to prepare you for a RUSH practice session.

The course content is prepared and curated from iEM Education chapters, iEM image and video archives, and various FOAMed resources.

At the end of this course, you will be able to;

  • Describe the basics of ultrasound (terminology, knobology, image acquisition, artifacts, etc.)
  • Describe indications of RUSH protocol
  • Describe patient and machine preparations
  • Describe ultrasound examination views
  • Recognize normal anatomical structures
  • Recognize abnormal findings
  • Feel confident to take a practical session for RUSH protocol

Who can get benefit from this course?

  • Junior and senior medical students (course specifically designed for these groups)
  • Interns/Junior emergency medicine residents/registrars

Other Free Online Courses

Home Made IV Access Ultrasound Phantoms

home made IV access ultrasound phantom

We recently had the 3rd Tanzanian Conference on Emergency Medicine. Point of Care Ultrasound (PoCUS) training was one of the pre-conference workshops. Ultrasound-guided intravenous cannulation can be very challenging for many doctors in the emergency department.

Therefore, we had a station providing a real-time opportunity to practice IV access using our homemade ultrasound phantoms. And I shall share with you how we came up with this solution.

Ingredients

  • A plastic container (dimensions used here 8 x 5.5 x 5inches)
  • Long balloons
  • Assorted food colors
  • Gelatin
  • Metamucil (psyllium)
  • Powdered household detergent
  • Spoon, sieve, hand mixer, measuring cup, cooking pot and cooker
  • Filler syringes
  • Gloves
Ingredients for making the mixture
Ingredients for making the mixture
Food coloring dye
Food coloring dye
Equipment for making vessels
Equipment for making vessels

How to make your mixture

Take a cooking pot and fill it with 1200 mls of water (we used this as our molding device could accommodate this amount of mls) bring it to a boil (just as it begins to form tiny bubbles on the base add gelatin powder 8 tablespoons and stir with a hand mixer until it completely dissolves. Thereby add 2 tablespoons of Metamucil and 1 tablespoon of detergent and continue stirring with low flame until the mixture begins to thicken. At this point, you will also see foam that sits on top of the mix. Use a sieve to get the foam out. You can, at this point, add any colors that you would want. Let the mixture cool a little before pouring it into the container. As it cools, you will notice it becoming thicker.

How to set-up your mold/containers

You will need to make a hole on both ends on the container using a hand drill or a hot pointed knife. For this case, since we didn’t have a drill, we used a knife with a pointed tip – heated it up in a burner until it was hot enough and used it to make holes through the plastic container using a circular motion. It is important for the holes not to be too big but estimated to the caliber/ diameter of the long balloons since we need just enough space to pass the balloons across.

For our case, we made 4 holes, 2 on each end. But you can do more if you want. You can arrange balloons in superficial or deeper locations.

To setup the vessels using the long balloons, you will need half cup of water and red color dye. Mix just enough to make a mixture that looks like blood. This can be filled in the balloons with a syringe. Since the color dye can stain your fingers, it is important to use gloves just to prevent your fingers from staining.

Tip: To make an artery, you can fill the balloon much more so that there is minimal compressibility and for the vein, you can fill just enough and have room for compressibility. Don’t fill the balloons before passing it through the container; if you do this, the filled balloon won’t manage to fit into the holes. Once fixed, tie both ends to make knots that are big enough to cover the seal the holes made.
Before pouring the mixture into the container, spray it with some oil, or you can use a cloth dip it in oil and apply it on the inside of the container.

After that, pour your mixture in the container and let it cool. You can place it in the refrigerator and use it the next day. We left ours for 24 hrs prior use.

You can use silicone seals at the holes if you notice to have any leaks. Otherwise, if you don’t have this, you can use plastic food wrap to create a seal between the balloon knots and the container just so the mixture does not leak out until it has set.

Cooling in the refrigerator, note the plastic food wraps used as seal here and the knots
Cooling in the refrigerator, note the plastic food wraps used as seal here and the knots
6 hours after refrigeration
6 hours after refrigeration
Final product
Final product

And finally, the images that you will have on ultrasound.

Short axis/transvers view
Short axis/transvers view
Long/longitudinal axis view
Long/longitudinal axis view
TACEM - IV access workshop under US guidance
TACEM - IV access workshop under US guidance
Cite this article as: Masuma Ali Gulamhussein, "Home Made IV Access Ultrasound Phantoms," in International Emergency Medicine Education Project, November 18, 2019, https://iem-student.org/2019/11/18/home-made-iv-access-ultrasound-phantoms/, date accessed: May 30, 2020

Interview – Vicky Noble – US training in medical schools

We interviewed with world renowned emergency and critical care US expert “Vicky Noble” about US training in medical schools.

https://youtu.be/3Bh2uCyESuM

Read US Chapters and Posts

Bat Sign

Dear students/interns, learn ultrasonographic anatomy and clinical ultrasound basics to improve your decision making processes.

bat2

The bat sign is critical for correct identification of the pleural line. Always begin lung ultrasound by identifying the bat sign before proceeding to look for artifacts and pathologies.

This sign is formed when scanning across 2 ribs with the intervening intercostal space.

The wings are formed by the 2 ribs, casting an acoustic shadow. The body is the first continuous horizontal hyperechoic line that starts below one rib and extends all the way to the other. (see above video) The body is the pleural line, i.e., parietal pleural. Normally, the pleural line is opposed to and hence indistinguishable from the lung line (formed by the visceral pleura).

To learn more about it, read chapter below.

Read "Blue Protocol" Chapter

From experts to our students! – eFAST

Selected Imaging Modalities

628.14 - acetabular fx 2

eFAST

by Ashley Bean, Brian Hohertz and Gregory R. Snead Introduction The objective of the extended focused assessment for sonography in trauma (eFAST) is to detect

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PoCUS – RUSH Protocol

by Rasha Buhumaid Why use POCUS in undifferentiated hypotension? Hypotension is a high-risk sign which is associated with increased morbidity and mortality rate. The differential

Read More »

BLUE protocol

by Toh Hong Chuen Case Presentation A 68-year-old man with a history of congestive cardiac failure (CCF) and chronic obstructive pulmonary disease (COPD) presented with breathlessness

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How to Read C-Spine X-Ray

by Dejvid Ahmetović and Gregor Prosen Introduction C-spine x-ray interpretation is one of the fundamental skills of emergency physicians. Although current guidelines lead us to

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How to read chest x-rays

by  Ozlem Koksal Introduction Chest X-ray interpretation is one of the fundamental skills of every doctor. Emergency physicians are particularly exposed to various chest x-rays

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How to read head CT

by Reza Akhavan and Bita Abbasi For a standard approach to read head/brain computed tomography (CT) scan, one should adhere to systematic algorithms. The predefined

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How to read pelvic x-rays

by Sara Nikolić and Gregor Prosen Introduction Pelvic fractures carry life‐threatening injury potential which should be identified or suspect during the primary assessment of patients with

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A 22-year-old male

Appendicitis

Acute Appendicitis

by Ozlem Dikme, Turkey

A previously healthy 22-year-old male was brought to the emergency department (ED) with recently-started abdominal pain. He had not eaten anything since that morning due to loss of appetite. He was nauseated and vomited three times. His abdominal pain started around the umbilicus and epigastric area. His pain increased as it moved towards his right lower quadrant (RLQ). The maximum pain was felt on the right iliac fossa. He had not taken any medication. His social history revealed that he was non-drinker, non-smoker and did not use any illicit drugs. His diet mostly consisted of carbohydrates. The past and family histories were unremarkable. His blood pressure was 120/70 mmHg, pulse rate was 100/min, the temperature was 37.8°C (100°F), and respiration rate was 22/min. 

What is the cut-off number in Alvarado score to suspect appendicitis?

Touch Me

Alvarado Score

1-4 appendicitis unlikely, 5-6 appendicitis possible, 7-8 appendicitis probable, 9-10 appendicitis very probable
Answer
51.1 - abdominal - pain - appendicitis ultrasound

Physical examination showed normal bowel sounds, tenderness and voluntary guarding, particularly over the right iliac fossa. The costa-vertebral angles were not tender. Oral intake was stopped, intravenous (IV) catheter was inserted, blood and urine tests were planned, and fluid therapy was started. The urinalysis was normal. White blood cell (WBC) count was 14,500 with 89% polymorphous and 11% lymphocytes. The ultrasonography (USG) showed a non-compressible tubular structure of 9 mm in diameter at RLQ. He admitted to the surgical ward with the diagnosis of acute appendicitis.