There’s a moment every ICU/ED clinician recognises.

The blood pressure is falling. Lactate is climbing. The ventilator is being dialled up. Everyone is working — yet the patient is still sliding.

And then someone says the most dangerous sentence in critical care:

“We think it’s septic shock.”

Maybe it is.
Or maybe it’s tamponade, massive PE, acute RV failure, or catastrophic acute valve disease hiding behind a “sepsis label.”

This is where Critical Care Echocardiography earns its keep — not as a “nice add-on,” but as a decision tool that can stop confident wrong moves and accelerate the right ones.

But only if you understand the one thing that matters more than skill:

"Scope"

Because a modest skillset used inside clear boundaries saves lives.
Advanced skills used without boundaries create misdiagnosis, delay, and litigation.

This first blog is the governance and mindset module. Get this right — and everything that follows becomes safer, sharper, and easier to scale.

1) What Critical Care Echo Is

Critical Care Echocardiography (CCE) is a time-critical, problem-focused echocardiogram performed in environments like ICU, ED, theatre, HDU, cath lab, or ward — for an acutely unstable or high-risk patient.

It is designed to answer a small number of high-impact questions, fast:

• What shock phenotype am I dealing with? (cardiogenic, obstructive, hypovolaemic, distributive)

• Is there tamponade physiology?

• Is the RV failing — or about to fail?

• Is this patient safe for fluids / intubation / surgery / thrombolysis?

• Is there an obvious catastrophic valve lesion? (acute severe MR/AR, flail leaflet, large vegetation)

CCE is:

• Rapid — minutes, not 45 minutes

• Pragmatic — “good enough to guide a life-or-death decision,” not perfection

• Serial — repeated to monitor response to treatment

• Decision-linked — it must change what you do next, or it’s just a scan

And it sits on a spectrum:

• FoCUS / FUSIC / BSE-1/ basic CCE: protocolised scan by trained non-imagers to rule in/out big threats

• Advanced CCE / echo-expert ICU practice: near-comprehensive haemodynamic echo integrated with complex ventilation and support decisions

• Comprehensive echo: guideline-level dataset, often departmental, longer and broader in scope

2) What Critical Care Echo Is Not (Read This Like a Safety Checklist)

CCE is not:

❌ A full comprehensive TTE/TOE

You are not doing full chamber quantification, detailed valve grading, cardiomyopathy work-up, or pre-interventional planning.
You are not replacing the echo lab.

❌ A toy, a hobby, or a “cool image” generator

Done properly, CCE is decision-changing and outcome-changing.
Done badly, it becomes misdiagnosis + false reassurance + medicolegal risk.

❌ A reason to delay essential treatment

CCE should accelerate decisions, not paralyse the team chasing perfection.

You do not delay:

• CPR

• shock

• antibiotics

• intubation
  …because someone wants a pristine parasternal window.

❌ An unlimited licence to pronounce “normal”

“Limited views, looks ok-ish” is a trap.

If the scan is limited, the documentation must be honest:

“Limited/non-diagnostic for X due to poor windows. Cannot exclude Y. Recommend formal echo if clinically indicated.”

That sentence can protect a patient and protect you.

3) The Three Levels of CCE — and the Key Question Each Level Must Answer

CCE competence isn’t one thing. It’s tiered. And confusion here is a governance failure.

3.1 Foundation Level

The question: “Can I safely miss something big?”

This is the FUSIC/BSE Level 1 aligned clinician/sonographer in acute care.

Key questions:

• Is LV grossly normal, severely impaired, or hyperdynamic?

• Is the RV acutely dilated or failing?

• Is there a large pericardial effusion with possible tamponade?

• Is the IVC grossly plethoric vs small and collapsible?

• Is there an obvious catastrophic valve issue (massive MR, flail leaflet, torrential AR pattern, huge vegetation)?

Decision endpoints (foundation):

• Do I escalate immediately to cardiology/anaesthetics/ICU?

• Does this patient need theatre, cath lab, CT for PE, urgent pericardiocentesis?

• Is it dangerous to give fluid / dangerous not to give fluid?

• Is it safe or risky to intubate right now?

If you can answer these consistently with a small protocol, you’re functioning safely at foundation level.

3.2 Intermediate Level

The question: “What haemodynamic pattern am I dealing with?”

This is where you move from pattern spotting to reasoning.

You can:

• Distinguish cardiogenic vs distributive vs obstructive vs hypovolaemic shock by echo patterns

• Trend output surrogates (e.g., LVOT VTI) with fluids/inotropes

• Recognise when ventilator settings are injuring the RV

• Identify subtle but crucial pathology:

  • early septic cardiomyopathy

  • acute RV pressure overload

  • pre-tamponade states

  • acute severe valve lesions before remodelling occurs

Decision endpoints (intermediate):

• Fluid vs vasopressor vs inotrope vs afterload reduction vs mechanical support — and combinations

• Ventilator strategy changes (PEEP, tidal volume, recruitment) to protect RV/LV output

• Need for invasive haemodynamic monitoring or escalation

3.3 Mastery Level

The question: “Can I lead, teach, govern — and defend this practice?”

Mastery is not about fancy views. It’s about systems, calibration, and safety.

You can:

• Set realistic scope for non-imagers and prevent over-reach

• Design local protocols that are concise, decision-focused, auditable, aligned with standards (FUSIC/BSE/EACVI/ASE)

• Lead QA, image review, escalation pathways, and teaching

• Demonstrate defensible practice in court/coroner review:

  • clear indication

  • logical conclusions

  • transparent limitations

  • appropriate escalation

This is where CCE becomes a service, not just a personal skill.

4) Scope and Boundaries — The Non-Negotiables

4.1 The Top Indications (the cases where CCE earns its value)

If you remember nothing else, remember these:

• Undifferentiated shock or hypotension

• Peri-arrest / post-ROSC assessment

• Suspected tamponade

• Suspected massive PE / acute RV failure

• Acute respiratory failure — cardiogenic vs non-cardiogenic unclear

• Pre-intubation risk assessment in unstable patients

• Persistent lactate / unexplained organ dysfunction in ICU

• Oliguria with uncertain volume status and LV function

• Post-operative haemodynamic instability (cardiac or non-cardiac)

• Weaning vasopressors/inotropes/ECMO where haemodynamics are borderline

These are “high-leverage” moments — where echo changes trajectory.

4.2 When CCE Alone Is Not Enough (Mandatory Escalation)

CCE is a screen and guide — not an end-point — in scenarios like:

• Suspected infective endocarditis with embolic phenomena

• When definitive valve grading will change intervention timing

• Complex prosthetic valves

• Intracardiac masses/thrombi where management hinges on accuracy

• Pre-op planning for high-risk non-cardiac surgery in complex valvular/cardiomyopathy patients

• Serial surveillance cardiomyopathy/chemo/congenital disease

The correct behaviour is explicit:

“CCE suggests X, but a comprehensive departmental study is required for definitive assessment.”

That is high-integrity practice.

5) Training, Competency, Governance — How Safe Services Are Built

Foundation tier: “Safe minimum”

• Limited protocol (e.g., FUSIC Heart / focused acute care dataset)

• Outcomes:

  • acquire core windows adequately in most patients

  • recognise gross LV dysfunction, RV dilation/failure, large effusion, extreme volume states

  • know when to escalate

• Assessment:

  • supervised logbook

  • DOPS/OSCE style sign-off

  • regular expert review

Intermediate tier: “Haemodynamic practitioners”

• Additional skills:

  • LVOT VTI trending

  • Doppler, basic TR velocity (where appropriate)

  • systematic shock classification

• Assessment:

  • larger logbook + case-based discussions

  • evidence that echo changed management

Master tier: “Supervisors”

• Independent advanced CCE + protocol design

• Teaching + mentoring + signing off others

• Governance:

  • regular echo review meetings

  • feedback loops (echo vs CT/TOE/angiogram)

  • auditing decision impact

6) High-Risk Pitfalls (These Are the Traps That Cost Lives)

Pitfall 1: Over-confidence from a small skill set

A few impressive saves → false sense of expertise → pronouncing on subtle valve disease/cardiomyopathy beyond scope.

Governance fix: explicit boundaries, supervision, mandatory escalation pathways.

Pitfall 2: “Normal echo, so the patient is fine”

Septic shock can look “ok” on echo: hyperdynamic LV, vasoplegia, early ARDS — patient still dying.

Teach this mantra:
Normal echo ≠ no shock. Normal echo ≠ no problem.

Pitfall 3: Poor quality scan declared “reassuring”

If views are limited, say so. Full stop.

Use this standard phrasing:

“Non-diagnostic for X due to poor windows. Cannot exclude Y. Recommend formal echo if clinically indicated.”

Pitfall 4: Confusing training levels

An ICU trainee with 20 scans is not equivalent to an echo consultant.

If levels aren’t explicit, you will get drift.
And drift is how services get burned.

Pitfall 5: Using CCE to justify high-stakes decisions without full data

Example: borderline valve pathology + sepsis → “no vegetations” on a limited scan used to withhold antibiotics or delay escalation.

Governance rule: if the stakes are high, the imaging standard must match the stakes.

7) Pro Tips — Expert Behaviours Around Scope

Pro Tip 1 — Start with the clinical question
Say it out loud before scanning:
“I’m scanning to differentiate the cause of shock and to rule out tamponade / obvious RV failure.”

Pro Tip 2 — Declare your level
In the notes:
“This was a focused critical care echo performed by an FUSIC-trained clinician (foundation level).”

This sets expectations and protects you.

Pro Tip 3 — Standardise limitation language
“Image quality suboptimal; cannot reliably assess valve morphology. No large effusion or gross LV/RV dysfunction seen.”

Pro Tip 4 — Link the result to the decision
Finish with:
“Based on these findings, we will…” (fluids, reduce PEEP, start vasopressor, call cardiology, etc.)

Pro Tip 5 — Normal doesn’t mean stop thinking
Echo refines the differential — it doesn’t close it.

Final Take-Home Messages 

• Critical care echo is a decision tool, not a beauty contest. Fast, focused, brutally relevant.

• Scope matters more than skill. Clear limits beat vague confidence.

• The right question is half the scan.

• A poor-quality “normal” echo is more dangerous than no echo. Learn to say “limited/non-diagnostic.”

• Training levels must be explicit. Foundation ≠ Intermediate ≠ Mastery.

• Echo does not replace thinking or MDT discussion. It accelerates and sharpens it.

• You are accountable for interpretation, not images. Documentation of limits and next steps is competence.

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Dr Mohamed Mansour
Consultant Cardiologist | Cardiac Imaging Specialist

Echo Under Pressure — Critical Care Echo That Saves Lives
A practical series for ICU/ED clinicians & cardiac sonographers.
Master Echocardiography. Lead with Confidence.