Journal
CHEST
Volume 121, Issue 3, Pages 877-905Publisher
ELSEVIER
DOI: 10.1378/chest.121.3.877
Keywords
echocardiogram; embolectomy; hemodynamics; pulmonary embolism; shock; thrombolytic therapy
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Major pulmonary embolism (PE) results whenever the combination of embolism size and underlying cardiopulmonary status interact to produce hemodynamic instability. Physical findings and standard data crudely estimate the severity of the embolic event in patients without prior cardiopulmonary disease (CPD) but are unreliable indicators in patients with prior CPD. In either case, the presence of shock defines a threefold to sevenfold increase in mortality, with a majority, of deaths occurring within 1 h of presentation. A rapid integration of historical information and physical findings with readily available laboratory data and a structured physiologic approach to diagnosis and resuscitation are necessary for optimal therapeutics in this golden hour. Echocardiography, is ideal because it is transportable, and is capable of differentiating shock states and recognizing the characteristic features of PE. Spiral CT scanning is evolving to replace angiography, as a confirmatory study, in this population. Thrombolytic therapy, is acknowledged as the treatment of choice, with embolectomy, reserved for those in whom thrombolysis is contraindicated.
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