Ultrasound to guide critical decisions: What you need to know

Hypotension in the intensive care unit (ICU) demands rapid diagnosis and intervention, as delays in identifying the etiology of shock directly impact patient outcomes. Point-of-care ultrasound (POCUS) has become an indispensable tool for intensivists and acute care surgeons, enabling bedside classification of shock physiology and guiding targeted resuscitation.

This review synthesizes current evidence and expert consensus regarding the application of POCUS in hypotensive ICU patients. Literature from emergency medicine, critical care, and trauma surgery was evaluated to outline standardized protocols (rapid ultrasound in shock, abdominal and cardiac evaluation with sonography in shock, sonography in hypotension and cardiac arrest algorithm), organ-specific applications (cardiac, pulmonary, abdominal, and vascular), training requirements, limitations, and future directions.

Point-of-care ultrasound reliably distinguishes shock states (hypovolemic, cardiogenic, obstructive, distributive) within minutes. Studies demonstrate that structured ultrasound protocols increase diagnostic accuracy from approximately 60% with clinical examination alone to approximately 85% and alter management in up to 50% of patients. Emerging technologies such as artificial intelligence integration, advanced venous congestion assessment (venous excess ultrasound score), and critical care transesophageal echocardiography are expanding the scope of bedside imaging. Despite its utility, ultrasound remains operator dependent, requiring structured training and continuous competency assessment.

Bedside ultrasound has evolved into an extension of the clinician's physical examination and is now a core competency in critical care. For the hypotensive ICU patient, POCUS accelerates diagnosis, reduces diagnostic uncertainty, and enables lifesaving targeted therapy. As technology advances and training expands, ultrasound will continue to shape the standard of care for critically ill patients with shock. ( J Trauma Acute Care Surg . 2026;100: 692-699. Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.).