Synopsis
Recognise systemic venous congestion and acute RV shock, identify the cause and balance preload, afterload and contractility without reflex fluid or vasodilator harm.
- Right-sided HF causes raised systemic venous pressure: raised JVP, peripheral oedema, ascites, hepatomegaly, early satiety and congestive renal/liver dysfunction.
- Common drivers are left-sided HF, pulmonary hypertension or lung disease, acute PE, RV infarction, tricuspid/pulmonary valve disease, cardiomyopathy and constrictive pericardial disease.
- Acute RV failure can present with shock and clear lungs; do not exclude cardiac shock because crackles are absent.
Key red flags
Hypotension, cool peripheries, oliguria, confusion and raised JVP, sometimes with clear lungs; rising lactate signals worsening output.
Investigation priorities
Identify inferior/RV MI, RV strain, AF or other arrhythmia.
Management branches
Raised JVP with hypoperfusion, hypoxaemia or shock
- Start ABCDE, cardiac monitoring, blood gas/lactate and urgent echo; call cardiology and critical care.
- Treat hypoxia, acidosis and the driver: activate ACS reperfusion for RV infarct or NICE PE diagnosis/reperfusion for suspected high-risk PE.
Key medicines
FurosemideFor chronic oedema a common oral start is 20–40 mg in the morning; acute congestion commonly starts 20–40 mg IV if loop-naive, with higher response-led IV dosing when already exposed.
NoradrenalineThe cited ready-to-use SmPC, licensed for adults weighing over 50 kg, starts noradrenaline base at 0.05–0.15 micrograms/kg/min by central IV infusion pump, titrated in critical care to adequate MAP/perfusion.