SLICE

from Zhang et al. (1)

The Slice protocol (1) was published in EMA 2022. It describes the stepwise use of bedside US to simultaneously diagnose and resuscitate the shocked or dyspnoeic patient. It is easy to remember and I like the way it can guide resuscitation. 

SLICE = lungs, IVC, cardiac, extra views

LUNGS

Look for:

1. Lung sliding and A lines

If present bilaterally, trial fluids to treat hypotension

2. signs of APO: ie bilateral B lines with thin pleura 

If present consider APO and LV failure and withold fluids

3. Signs of pneumothorax: ie A lines, thin static pleura

If present consider tension pneumothorax and manage 

Complete the lung exam by looking at L3/4 and R3/4. If B lines and pleural effusions are seen bilaterally, be judicious with fluids.

IVC

1. Plethoric IVC with no respiratory variation

Consider tamponade or pericardial effusion and go on to cardiac views

The other differential is tension pneumothorax but this should have been diagnosed with the lung views

2. Small and collapsing IVC

Manage with fluids or inotropes

Look for source of fluid loss: EFAST, AAA

But don't forget high output LV failure and APO (eg MVP)

CARDIAC

1. Dilated RV, D shaped LV

Consider massive PE and manage

2. Pericardial effusion and tamponade

Consider tamponade and manage

Fluids may help temporise the patient

3. Cardiogenic shock

- decreased EF:

supportive inotropes, consider ECMO

3. Cardiogenic shock

- hyperdynamic

Consider LV failure due to acute valve dysfunction eg acute AR (look for dissection) or acute MR (look for MVP - A4C)

EXTRA VIEWS

AORTA 

AAA

Resuscitate with massive transfusion protocol and urgent vascular

AORTA 

Dissection or AAA

Resuscitate and cardiothoracics

EFAST

Free fluid - eg ectopic

Resuscitate and refer to relevant unit

RENAL, GB and DVT

Consider sepsis due to obstructed infected kidney

Consider sepsis due to ascending cholangitis

Look for signs of massive PE on cardiac views

REFERENCES

1. Zhang LF, Duong MT, Bowra J. SLICE: An algorithm for incorporating ultrasonography in the assessment of shocked or breathless patients. Emerg Med Australas. 2023 Apr;35(2):242-245.