Normotensive shock, though sounding contradictory, is subtle; it poses a critical diagnostic challenge, especially in patients with acute pulmonary embolism (PE). This term refers to the vascular and perfusion qualities at the end-organ and tissue level. Despite normal systemic blood pressure, these patients can still experience impaired tissue perfusion and end-organ dysfunction. Though the systemic blood pressure can be in a “normal” range, shock can be present at the tissue level compromising end-organ function. Manifestations include renal insufficiency, metabolic acidosis, shortness of breath and cardiac dysfunction, and other indications of clinical or laboratory dysfunction. Management should be aggressive including timely consideration for intervention in the same manner as if the patient had overt shock with lower blood pressure requiring vasopressor support as traditionally diagnosed. Normotensive shock should remain at the top of mind in PE because, if overlooked, delay in treatment may lead to devastating outcomes.