Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute onset of severe dyspnea, syncope, and hemodynamic instability. Symptoms include substernal chest pain, profound diaphoresis, and altered mental status. Patient is hypotensive (SBP <90 mmHg or requiring vasopressors) with evidence of right ventricular strain. No history of recent trauma, though risk factors include recent surgery, prolonged immobilization, or known hypercoagulable state.
Clinical Examination Findings
General: Patient appears acutely ill, cyanotic, and in severe respiratory distress. Vitals: Tachycardic, tachypneic, hypotensive, and hypoxic on room air. Cardiovascular: Distended jugular veins (JVD), loud P2, right-sided heave, and signs of cardiogenic shock. Pulmonary: Clear to auscultation bilaterally, but with significant tachypnea. Extremities: Possible unilateral lower extremity swelling and tenderness consistent with DVT.
Treatment Protocol
Immediate stabilization: ABCs, supplemental oxygen/mechanical ventilation, and aggressive fluid resuscitation. Pharmacologic: Initiate systemic thrombolysis (e.g., tPA) or surgical embolectomy/catheter-directed thrombolysis if thrombolysis is contraindicated. Anticoagulation: Start IV unfractionated heparin (UFH) drip. Vasopressors: Norepinephrine or dobutamine as indicated for hemodynamic support. Monitor: Continuous telemetry, serial echocardiography, and arterial blood gases.