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Objective To assess the effects of a cardiopulmonary ultrasound (CPUS) examination on diagnostic accuracy for critically ill patients in a resource limited setting. Methods Approximately half of the emergency medicine resident physicians at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana were trained in a CPUS protocol. Adult patients triaged to the resuscitation area of the emergency department (ED) were enrolled if they exhibited signs or symptoms of shock or respiratory distress. Patients were assigned to the intervention group if their treating physician had completed the CPUS training. The physician's initial diagnostic impression was recorded immediately after the history and physical examination in the control group, and after an added CPUS examination in the intervention group. This was compared to a standardized final diagnosis derived from post-hoc chart review of the patient's care at 24 hours by two blinded, independent reviewers using a clearly defined and systematic process. Secondary outcomes were 24-hour mortality and use of IV fluids, diuretics, vasopressors and bronchodilators. Results Of 890 patients presenting during the study period, 502 were assessed for eligibility, and 180 patients were enrolled. Diagnostic accuracy was higher for patients who received the CPUS examination (71.9% vs. 57.1%, Δ 14.8% [CI 0.5%, 28.4%]). This effect was particularly pronounced for patients with a “cardiac” diagnosis, such as cardiogenic shock, congestive heart failure, or acute valvular disease (94.7% vs. 40.0%, Δ 54.7% [CI 8.9%, 86.4%]). Secondary outcomes were not different between groups. Conclusions In an urban ED in Ghana, a CPUS examination improved the accuracy of the treating physician's initial diagnostic impression. There were no differences in 24-hour mortality and a number of patient care interventions. This article is protected by copyright. All rights reserved.