Lung Ultrasound for the Diagnosis and Management of an Acute Circulatory Failure: The FALLS-Protocol (Fluid Administration Limited by Lung Sonography) – One Main Extension of the BLUE-Protocol

  • Daniel A. Lichtenstein


The potential of lung ultrasound in detecting interstitial syndrome provides an original piece of information which will be used for the sequential diagnosis of a circulatory failure. In the management of shock, it allows to avoid two issues: giving too much fluid, a concern for the modern generation, and keeping a patient in occult hypovolemia, another killer, probably as substantial. The FALLS-protocol may locate the critically ill patient between these two extreme issues, by proposing the appropriate amount of fluid resuscitation.

Using a simple approach considering a focused part of cardiac sonography, some venous sonography, and this simple part of lung ultrasound which visualizes a direct parameter of volemia, an alternative decision tree for hemodynamic assessment can be proposed.


Septic Shock Central Venous Pressure Cardiogenic Shock Fluid Overload Fluid Therapy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Clinical volemia 

This part of volemia which determines the beginning of fluid overload at the main vital organ, normally fluid-free.


The instant where B-lines replace A-lines under fluid therapy.


Passive leg raising initiating a fluid therapy.


Applying the probe at anterior lung watching for a change from A-lines to B-lines during fluid therapy.


Protocol analyzing the cause of a shock using simple cardiac sonography and lung ultrasound.


Defined by an A-profile (or equivalents) in a patient without ultrasound signs of obstructive or left cardiogenic shock. Clearance for fluid therapy.


Ultrasound search for a site of sepsis or hypovolemia done during the FALLS-protocol.

Supplementary material

Video 30.1

Standard search for a tension pneumothorax. The probe is quietly applied at anterior BLUE-points, or nearby (it does not matter a lot, since the pneumothorax is supposed to be substantial). Note the Carmen maneuver, searching for B-lines, therefore increasing the sensitivity of the A-line sign (MOV 2878 kb)

Video 30.2

Inferior caval vein. In this patient who had the providence of a good window, the IVC can be seen behind the gallbladder (head of patient on left of image). No respiratory variation, suggesting a reasonable fluid therapy. See the ebb and flow of microparticles within the lumen, with inspiratory changes of direction (backward), using this 1982 technology (MOV 2088 kb)


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Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  • Daniel A. Lichtenstein
    • 1
  1. 1.Hôpital Ambroise Paré Service de Réanimation MédicaleBoulogne (Paris-West University)France

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