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Acute Care Echo

Breathless, hypotensive and hypoxic on the acute take, and not responding to oxygen. You put the probe on. What is driving the shock?

Make your call before you reveal the answer.

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

The right ventricle is dilated, with septal flattening that leaves the left ventricle D-shaped in systole. The left ventricle looks normal but is underfilled, the victim of the obstructed right heart, not a failing pump.

Pearls

  • Read the right ventricle, the septum and the left ventricular cavity together, not in isolation.
  • The left ventricle looks normal but is underfilled, the victim of the obstructed right heart, not a failing pump. Do not reach for inotropes for a ventricle that is simply not filling.
  • 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.
A dilated right ventricle with septal flattening and a normal-looking but underfilled, D-shaped left ventricle is obstructive shock until proven otherwise. In the right context, suspect pulmonary embolism, support the right heart, and escalate urgently.

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.

This is one call from the Acute Echo Trainer. Module 03 works the full differential, obstructive versus cardiogenic versus hypovolaemic shock, with the decision and the single discriminator that separates them.

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Dr Mansour

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This content is for educational purposes for healthcare professionals and does not replace supervised clinical training or local governance.