PE, tamponade and aortic emergencies

Acute right ventricular failure

Reviewed Nov 2026·1 references
New· views rounded down, updated weekly

Recognise and support the failing RV: optimise preload, maintain systemic pressure, reduce afterload and add inotropes, and ventilate safely.

Definition
Acute RV failure = rapidly progressive syndrome with systemic congestion from impaired RV filling and/or reduced RV output. Causes: PE, ARDS/high PEEP, RV infarction, pulmonary hypertension decompensation (sepsis, arrhythmia), post-cardiac surgery.

At the bedside

  1. 1

    Confirm on echo

    RV dilated (RV/LV > 1 in apical 4-chamber), TAPSE < 17 mm, septal flattening (D-shaped LV), dilated non-collapsing IVC, tricuspid regurgitation; estimate PASP.

  2. 2

    Treat the cause

    PE: reperfusion; RV infarct: revascularise, avoid nitrates; ARDS: reduce plateau pressure/driving pressure, correct hypercapnia, consider prone; arrhythmia: restore sinus rhythm (atrial kick matters).

  3. 3

    Optimise preload

    If CVP low and no congestion: cautious 250-500 mL bolus. If CVP high (> 12-15 mmHg) or congested: diuretics or ultrafiltration; volume removal often improves RV function.

  4. 4

    Maintain systemic pressure

    Noradrenaline first line to keep MAP ≥ 65 mmHg (preserves RCA perfusion). Vasopressin is an option (less pulmonary vasoconstriction).

  5. 5

    Add inotropy

    Dobutamine 2.5-10 mcg/kg/min, or milrinone/levosimendan (both reduce PVR but cause hypotension; combine with noradrenaline).

  6. 6

    Reduce RV afterload

    Correct hypoxaemia, hypercapnia and acidosis; inhaled nitric oxide or inhaled prostacyclin in specialist centres.

  7. 7

    Ventilate carefully

    Avoid intubation if possible. If needed: induce with haemodynamically stable agents and vasopressor ready; Vt 6 mL/kg, plateau < 27-30 cmH2O, lowest PEEP that maintains oxygenation, avoid hypercapnia. Consider ECMO/mechanical RV support for refractory cases.

Maintain MAP / coronary perfusion

Noradrenaline

IV (central)
Dose
0.05-0.5 mcg/kg/min
Preparation
4 mg in 50 mL = 80 mcg/mL
Target
MAP ≥ 65 mmHg
Worked example
70 kg at 0.1 mcg/kg/min = 5.25 mL/h
Open infusion calculator

Inotrope

Dobutamine

IV
Dose
2.5-10 mcg/kg/min
Preparation
250 mg in 50 mL = 5,000 mcg/mL
Worked example
70 kg at 5 mcg/kg/min = 4.2 mL/h
Open infusion calculator
Red flag · call your senior now
Systemic hypotension in RV failure triggers RV ischaemia and a downward spiral: treat hypotension immediately with vasopressor rather than fluid.
Red flag
Bradycardia or loss of sinus rhythm in RV infarction can cause sudden collapse: pacing/cardioversion.
Pitfall
'The RV is preload dependent so give litres of fluid': true only in early RV infarction with low CVP; over-filling worsens septal shift and output.
Pitfall
Nitrates or diuretics in RV infarction with hypotension.
Pearl
A falling CVP and improving urine output after diuresis is a good sign that the RV is unloading.
Pearl
High PEEP and hypercapnia raise PVR; in ARDS, prone positioning can unload the RV.

Calculators for this topic

Infusion rate from mcg/kg/min

Pump rate in mL/h for drugs dosed in mcg/kg/min (noradrenaline, adrenaline, dobutamine, milrinone, nitroglycerin by weight).

Mean arterial pressure

(SBP + 2 × DBP) ÷ 3 (estimate; use the arterial line value when available).

References

  1. 1

    Harjola VP, Mebazaa A, Celutkiene J, et al. Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and Right Ventricular Function of the ESC. Eur J Heart Fail 2016;18:226-41.

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Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.