Massive pulmonary embolism

A massive pulmonary embolism (PE) represents the most severe manifestation of venous thromboembolic disease when classified on a continuum of hemodynamic derangement. It is usually characterized by an acute pulmonary embolism accompanied by one or more of the following

  • sustained systemic hypotension (systolic blood pressure <90 mm Hg) for at least 15 minutes or which requires inotropic support
  • pulselessness
  • persistent and profound bradycardia
    • defined by the presence of a heart rate < 40 bpm associated with signs of end organ hypoperfusion

Massive pulmonary embolism carries a high mortality rate despite advances in diagnosis and therapy.

Treatment and prognosis

Reversal of the associated hypotension and hypoxia with supplemental oxygen and inotropes/vasopressors should be performed to prevent circulatory collapse. As with other forms of venous thromboembolism, anticoagulation is usually initiated .

Intravenous administration of systemic thrombolytics, such as recombinant tissue type plasminogen activator (rtPA), may be considered. Systemic administration may be preferable to catheter-directed thrombolysis, although this remains controversial. Thrombolytic administration may reduce the clot burden, resulting in an improvement in hemodynamics; however, there is an attendant risk of major arterial bleeding. Absolute contraindications to systemic thrombolytic administration include the following:

  • structural intracranial lesions
  • history of intracranial hemorrhage
  • recent (within 3 months) ischemic stroke
  • active bleeding
  • presence of a bleeding diathesis
  • recent spine or brain surgery
  • recent traumatic brain injury

Failure of systemic thrombolytics to resolve hemodynamic instability may warrant surgical or catheter-assisted embolectomy. These may also be considered when thrombolytic administration is contraindicated due to an unacceptably high risk of bleeding.

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Differential diagnosis