❤️Echocardiography in shock: stop asking only “What is the EF?” In undifferentiated shock, echocardiography is most useful when it answers physiological questions, not when it simply describes cardiac anatomy. Colebourn and Fisher propose a pragmatic 5 question framework for approaching the shocked patient: 1. What are the stroke volume and cardiac output? Start with flow. Importantly, cardiac index is not a binary marker of shock. A patient may maintain cardiac output through tachycardia despite a low stroke volume, while another may have low output because bradycardia prevents compensation. SVI, CI, heart rate and rhythm therefore need to be interpreted together. 2. If output is abnormal, why? LV failure? RV failure? Low preload? Valve disease? Mechanical complication? Obstruction? And do not forget dynamic LVOTO. Critical illness can combine low LV volume with hypercontractility, and escalating vasoactive support without recognising LVOTO may paradoxically worsen shock. This is also where LVEF can mislead us. A “normal” EF does not guarantee adequate forward flow. EF depends on LV volume and afterload and does not distinguish forward from regurgitant stroke volume. Vasoplegia may even make LV systolic function appear reassuring until vascular tone is restored. 3. Is left atrial pressure elevated? E/e′ >14 may support elevated LAP in general ICU populations, but performs less reliably in cardiogenic shock and should not be interpreted alone. A normal LA size does not exclude an acute rise in LAP. 4. Are pulmonary pressure and PVR elevated? Now the assessment moves to the RV pulmonary circulation interaction, where pressure, afterload and RV adaptation matter. 5. How is the situation evolving? Perhaps the most important question. The echo we see is not the patient's fixed cardiovascular phenotype. It is the heart under the current preload, afterload, vasoactive therapy and ventilatory conditions. Noradrenaline can increase BP while decreasing SV in one patient, yet increase both BP and SV in another. This is why critical care echocardiography should increasingly be thought of as: Flow → Mechanism → Filling pressures → RV pulmonary circulation → Response over time Not a photograph. A dynamic physiological assessment. This paper represents pragmatic expert guidance rather than a validated diagnostic algorithm. Reference📚 Colebourn C, Fisher R. A structured 5-question approach for echocardiographic evaluation of undifferentiated shock. Echo Res Pract. 2026;13:30. doi.org/10.1186/s44156-026-0… #CriticalCare #Echocardiography #POCUS #Shock #Hemodynamics #Cardiology #IntensiveCare