2011 Volume 18 Issue 4 Pages 567-574
Massive pulmonary embolism is a life-threatening disorder associated with high mortality and morbidity. The majority of deaths in patients with shock occur within the first few hours after presentation, and rapid diagnosis and treatment are therefore essential to save lives. A percutaneous cardiopulmonary support system can be helpful in critical situations involving cardiac arrest or refractory shock, by providing circulation and oxygenation and thus time for definitive diagnosis. Emergency CT angiography provides diagnostic information for the presence of pulmonary embolism and right ventricular dysfunction. Thrombolysis is generally accepted in unstable patients with massive pulmonary embolism, since it effectively resolves thromboembolic obstruction and promptly reduces pulmonary artery pressure and resistance with a concomitant increase in cardiac output. However, thrombolytic agents cannot be fully administered for cases with a high risk of bleeding. On the other hand, catheter or surgical embolectomy is an optimal treatment for massive pulmonary embolism patients with contraindications for thrombolysis. Catheter therapy can be performed with a minimum dose of thrombolytic agents or without such agents, and can be combined with various procedures including catheter fragmentation or embolectomy in accordance with the extent of the thrombus on a pulmonary angiogram. ICUs should establish diagnostic and therapeutic protocols beforehand and rehearse multidisciplinary management for patients with massive pulmonary embolism. Coordination among a skilled team composed of intensivists, cardiologists, radiologists, cardiac surgeons and clinical engineers is crucial to maximize success.