Hypotension & shock
Pump, tank, pipes: find the obstructive cause first, then phenotype and measure flow.
Echo approach, step by step
The ESICM consensus recommends echocardiography to evaluate the type of shock when the clinical examination is not conclusive [153]. Work from the most treatable, most lethal causes towards phenotype and monitoring [152].
- PericardiumEffusion with tamponade → drain [149].
- RVAcute dilatation with dysfunction → PE (or RV infarction) [124].
- LungsAbsent sliding → pneumothorax; B-lines → cardiogenic oedema [199].
- LVLVEF, regional wall motion (ACS), dynamic LVOT obstruction (SAM) [13,138].
- Valves and mechanical lesionsAcute MR, AR, VSD, prosthetic obstruction [138,167].
- AortaFlap, abdominal aortic aneurysm [9,174].
- FlowLVOT VTI, SV, CO, cardiac power [114,170,171].
- VolumeFluid responsiveness (PLR, IVC in ventilated patients) and fluid tolerance (B-lines, E/e′, venous congestion) [121,122].
- StageSCAI stage in cardiogenic shock [154].
- Tamponade
- Acute RV failure
- Pneumothorax
- LV function, LVOTO
- Acute valve lesion / VSD
- Aorta
- LVOT VTI, CO, CPO
- Fluid responsiveness and tolerance
Causes & echo clues
| Shock type | Echo pattern | Action |
|---|---|---|
| Hypovolaemic / haemorrhagic | Small hyperdynamic LV, collapsing IVC | Volume or blood; find the bleeding [153] |
| Distributive (sepsis, anaphylaxis) | Hyperdynamic LV (or septic cardiomyopathy) | Antibiotics, fluid, vasopressors [155] |
| Cardiogenic — LV | Low EF, low VTI, high E/e′ | Revascularisation, inotropes, mechanical support [138,154] |
| Cardiogenic — mechanical | Acute MR, VSD, free-wall rupture | Surgery [138] |
| Obstructive — tamponade | Effusion, collapse, plethoric IVC | Pericardiocentesis [149] |
| Obstructive — PE | Dilated RV, D-shaped LV | Reperfusion [124] |
| Obstructive — dynamic LVOTO | SAM, late-peaking gradient | Stop inotropes; fluid, beta-blocker, vasopressor [13,134] |
| Aortic dissection / rupture | Flap, AR, effusion; AAA | Surgery [9] |
Clinical pathway to the diagnosis
- RecogniseHypotension plus hypoperfusion (lactate, urine output, skin, mental state) [153].
- ImmediateAirway and oxygen, IV access, arterial line, and vasopressor if MAP <65 mmHg despite initial fluid [155].
- ECG, lactate, troponin, blood gas, haemoglobin, cultures.
- Echo and lung ultrasound within minutes[152,153].
- Targeted therapyby phenotype, reassessing with repeated echo.
- Pulmonary artery catheterIn refractory or mixed shock [153,154].
Clinical pearls & pitfalls
PitfallDo not intubate a patient in tamponade or massive PE without preparation. Positive pressure reduces venous return and can cause arrest [124,149].
- Hyperdynamic LV with SAM in a shocked patient: inotropes worsen it [13].
- Mixed shock is common: septic patients may have cardiomyopathy and hypovolaemia at once [152].
- See the Shock disorder page for flow indices, PLR technique and prognosis.
Red flags
- Lactate >2 mmol/L, oliguria, mottling, altered mental state → shock [153]
- Raised JVP + hypotension → tamponade, PE, RV infarction, tension pneumothorax
- New murmur → acute MR, VSD, AR [138]
- Chest or back pain → dissection or ACS [9,138]