Echo almost never shows you the clot. It shows you what the clot is doing to the right ventricle — and in the hypotensive patient, that indirect evidence is exactly what changes management.
Every finding on this page is a sign of RV strain, not of PE itself. Hold that thought the whole way down.
Curated from POCUS 101's Right Ventricular Ultrasound: Qualitative and Quantitative Assessments and The D Sign. Their clips of McConnell's and the D-sign are worth ten paragraphs — watch them.
Cardiac preset, indicator on the right of the screen. New to the views? Start with TTE Basics (No. 006).
Parasternal short axis at the papillary muscles for the D-sign; apical 4-chamber for RV:LV, McConnell's, and TAPSE. Add subcostal and IVC.
Left lateral decubitus brings the apex to the probe for the apical views — the ones this exam lives on.
Apical 4-chamber · compare end-diastolic chamber widths
Normal RV is about 60% of the LV (ratio ~0.6:1). When the RV appears equal to or larger than the LV, that's significant enlargement — in the right clinical picture, presumed pressure overload.
Parasternal short axis · papillary muscle level
The LV should be a circle with the septum bowing into the RV. Under RV pressure overload the septum flattens and pushes leftward, turning the LV into a "D."
Apical 4-chamber · watch the RV free wall vs. the apex
RV free wall akinesis or hypokinesis with preserved or hyperdynamic apical contraction — the apex keeps beating because it's tethered to the LV. Reported at roughly 77% sensitivity and 94% specificity for acute PE in the strained-RV population.
Apical 4-chamber · M-mode through the lateral tricuspid annulus
Tricuspid Annular Plane Systolic Excursion quantifies how far the RV base descends in systole — a one-number proxy for RV systolic function. Normal ≥17 mm; below that is RV systolic dysfunction, and lower is worse.
IVC · subcostal · the lucky shot
| Finding | Threshold / look | Means |
|---|---|---|
| RV:LV ratio | ≥ 1:1 | RV enlargement — strain in the right context |
| D-sign (systolic) | flat septum, PSAX | RV pressure overload |
| McConnell's | free wall out, apex working | Most specific bedside pattern for acute PE (~77% sens / ~94% spec) |
| TAPSE | < 17 mm | RV systolic dysfunction; prognostic in PE |
| RV free wall | > 5 mm thick | Hypertrophy — the strain is probably chronic, not this morning's PE |
| Clot in transit | seen | Treat as confirmed PE with the cavalry on the phone |
In the hypotensive patient with clinical suspicion, RV strain moves you toward action. In the well-appearing patient, a normal echo moves you nowhere — order the CTPA you were always going to order.
The most dangerous sentence in this exam. Echo detects RV consequences, not clot. A normal RV is entirely consistent with a PE that still needs anticoagulation.
An off-axis apical view slices the RV obliquely and manufactures a big RV. Get the true apex — maximal LV length, no rocking — before you believe any ratio.
An acutely strained RV is a thin-walled RV. A free wall over ~5 mm has been lifting weights for months — think chronic pulmonary hypertension and interpret "strain" accordingly.
In a suspected PE, a positive compression DVT exam plus RV strain is effectively diagnostic — and the DVT scan takes five minutes. The combination is stronger than either alone.
RV infarct, ARDS, high PEEP, and chronic pulmonary hypertension all strain the RV. The echo finding is real; the attribution to PE is a clinical call.
A massively dilated RV during a pulse check in the right story supports empiric thrombolysis. Keep the look under ten seconds — the compressions matter more than the image.
A starting template for the POCUS note. Text in brackets [ ] and pick-lists in { } are fields to complete. Save it as a SmartPhrase, then edit every field to match the actual study.
POINT-OF-CARE ULTRASOUND: FOCUSED ECHO - RV / PE
Indication: {suspected PE : shock : dyspnea} [***]
Exam type: Focused / limited, bedside
Operator: @ME@ Interpretation: independent, real-time
Probe: phased array
FINDINGS
- RV:LV size: {normal <1 : RV >= LV}
- Septal flattening (D-sign): {absent : present}
- McConnell's sign: {absent : present}
- TAPSE: {>= 17 mm : *** mm (reduced)}
- IVC: {normal collapse : plethoric}
- Pericardial effusion: {none : present}
IMAGE QUALITY: adequate / limited by [***]
Images saved and archived to [PACS / Qpath / ***].
IMPRESSION: {no echo signs of RV strain : echo findings of RV strain
consistent with acute cor pulmonale}. A normal focused echo does not
exclude PE. [***]
I personally performed and interpreted this study.
Electronically signed: @ME@ @TD@ @NOW@
Sample template only — not a validated institutional SmartPhrase. Verify wording, image-archival, and attestation requirements against your department's POCUS credentialing, coding, and compliance policies before clinical use. Documentation supports, but does not replace, the medical record and QA workflow.