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Massive pulmonary embolism with obstructive shock — SCE Acute Medicine MCQ

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HardAcute Respiratory PresentationsMassive pulmonary embolism with obstructive shockSCE Acute Medicine

A 42-year-old woman presents six days after knee arthroscopy with pleuritic chest pain and syncope. BP is 82/48 mmHg, HR 132, SpO2 88% on 15 L oxygen, and JVP is elevated. ECG shows sinus tachycardia with right heart strain and bedside echocardiography shows a dilated right ventricle with septal flattening. CT pulmonary angiography is delayed because she is too unstable to leave resus. What is the most important immediate action?

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Correct answer: B — Give systemic thrombolysis for suspected massive pulmonary embolism

This is a high-risk pulmonary embolism with shock and echocardiographic right ventricular strain, so immediate reperfusion with systemic thrombolysis is appropriate when imaging is unsafe to obtain. Apixaban is unsuitable in haemodynamic collapse and D-dimer is not useful in a high-probability unstable presentation. Diuretics may worsen preload-dependent right ventricular output. The acute medicine pearl is that shock from suspected PE is a treatment decision, not a D-dimer decision.

Reference: NICE NG158, ESC PE guideline, BNF