A 58 year old man is brought in by ambulance moribund with barely palpable pulse and a sinus tachycardia.
(c) A large pulmonary embolus is confirmed. What management will you institute?
{c) At last a diagnosis. Management at this stage would depend on his clinical state and include supportive measures (02, inotropes, ulcer prophylaxis) and specific (heparin, IVC filter). Dobutamine (lesser forms of haemodynamic disturbance) and noradrenaline (severe RV failure) are the only inotropic agents supported by evidence in this setting.-Adrenaline·may be the only ··
agent immediately available on the arrest trolley though.
NB. Excessive fluid may distend the RV and worsen the situation.
(i) If resuscitated adequately and haemodynamically stable, IV heparin would be the mainstay. Venous .duplex scans may help to gauge further thrombus load. The history of DU and a large mobile DVT may be an indication for insertion of a caval filter but lysis appears contraindicated if the history is confirmed.
(ii) If the patient is haemodynamically unstable and on large doses of vasopressor (preferably noradrenaline at this stage).embolectomy on bypass is indicated. Fibrinolysis is contraindicated by recent surgery and DU.
A question like this would benefit from a systematic answer.