Massive pulmonary embolism

Diagnosis: The high-risk (the massive) pulmonary embolism — the recent major surgery (the hip replacement, a high-risk provoked VTE), the sudden dyspnoea and the syncope, the hypotension (the systolic 78), the hypoxia, the raised JVP (the right ventricular failure), and the right bundle branch block (the right ventricular strain). This is the emergency, and the reperfusion is the priority.^[1]

Assessment: ABCDE. The airway and the breathing (the high-flow oxygen for the hypoxia), the two large-bore cannulae, the arterial blood gas, the bloods (the troponin and the BNP for the confirmation of the right ventricular strain, the renal function before the contrast, the coagulation, the group and save). The patient is too unstable for the CT.^[1]

The bedside echocardiography: The right ventricular dilatation, the McConnell sign (the free-wall hypokinesis with the apical sparing), the septal flattening, and the elevated right ventricular systolic pressure — in the right clinical context, this confirms the PE, and the reperfusion is begun without waiting for the CT.^[1]

Management:

• Supportive: the oxygen, the cautious fluid (the right ventricle is preload-dependent but the over-load worsens the failure), the vasopressor (the noradrenaline) and the inotrope (the dobutamine for the right ventricular failure).^[1]
• Reperfusion: the systemic thrombolysis (the alteplase) as the first-line, after the check of the contraindications (the active bleeding, the recent surgery, the recent stroke, the intracranial disease). The recent hip surgery (three weeks) is a relative contraindication — weigh the risk; the catheter embolectomy or the surgical embolectomy is the alternative if the thrombolysis is contraindicated.^[1]
• Anticoagulation: begun after the thrombolysis (the low-molecular-weight heparin, transitioned to the apixaban or the rivaroxaban).^[1]

Disposition: The intensive care for the monitoring, the haemodynamic support, and the anticoagulation.^[1]