Obstructive shock from acute right ventricular pressure overload. In this clinical context, suspect high-risk pulmonary embolism.

The right ventricle is dilated, there is septal flattening with a D-shaped left ventricle in systole, and the left ventricle is small and hyperdynamic, underfilled rather than weak.

Pearls

• Read the right ventricle, the septum and the left ventricular cavity together, not in isolation.
• The small, hyperdynamic left ventricle is the victim of the obstructed right heart, not a strong heart. Do not reach for inotropes for a ventricle that is simply underfilled.
• A plethoric inferior vena cava supports raised right-sided pressure and fits the picture.

Pitfalls

• A normal or hyperdynamic right ventricle points more towards hypovolaemia, though a distributive or septic picture can look similar. Clinical correlation is always mandatory.
• Be cautious with large fluid boluses, which can distend the failing right ventricle and worsen left ventricular filling.
• Echo raises the suspicion of pulmonary embolism, it does not confirm it. Chronic pulmonary hypertension, severe lung disease and ventilation can look similar.

This is a focused emergency study. It raises the suspicion and points to the next step. It does not grade severity or confirm the diagnosis at the bedside.

Dr Mansour