ICU · cardiovascular

Acute Severe Pulmonary Embolism — Comprehensive ICU Management

Also known as Pulmonary embolism · PE · Massive PE · Submassive PE · Pulmonary embolism with shock · Thrombolysis for PE · Pulmonary embolectomy · PERT

Acute severe pulmonary embolism (PE) — obstruction of the pulmonary arterial tree by thrombus (usually from deep vein thrombosis) causing increased dead space, right ventricular afterload, RV failure, reduced cardiac output, and potentially cardiac arrest. Risk factors: immobility, malignancy, surgery, pregnancy, OCP, inherited thrombophilia (factor V Leiden, prothrombin gene mutation, antithrombin deficiency). Severity classification: massive PE (high-risk — sustained hypotension, cardiogenic shock, or cardiac arrest — registry mortality 25 per cent in shock, 65 per cent with CPR), submassive PE (intermediate-risk — normotensive but RV strain — RV dysfunction on echo + biomarker elevation; death or decompensation 5.6 per cent at 7 days on heparin alone in PEITHO), low-risk PE (sPESI 0 — 30-day mortality 1.0 per cent). ICU management: massive PE → thrombolysis (alteplase 100 mg IV over 2 h, run with heparin as in the landmark trial) OR catheter-directed thrombolysis OR surgical embolectomy; thrombolysis during CPR for PE-arrest (tenecteplase 50 mg IV bolus reported with neurological recovery); submassive PE → anticoagulation + monitor for deterioration (rescue thrombolysis only if decompensates — PEITHO showed routine lysis adds stroke and bleeding without a mortality benefit); low-risk → anticoagulation + consider early discharge. VA-ECMO for refractory collapse (bridge to definitive therapy). PESI/sPESI guide disposition. Chronic thromboembolic pulmonary hypertension develops in 3.8 per cent of survivors by two years.

Checked against its sources on 3 Sept 2026