Management of the High-Risk Pulmonary Embolism in the Acute Phase—Respiratory, Hemodynamic and Mechanical Support

The patient with high-risk Pulmonary Embolism presents with profound hemodynamic and respiratory compromise, sometimes as a survivor of cardiac arrest. While great progress has been made regarding definitive care to reduce the clot burden, it is still necessary to stabilize the patient prior to achieving resolution of the Pulmonary Embolus. While positive pressure ventilation should be approached with great caution, due to fear of hemodynamic collapse, the use of High Flow Nasal Cannula can improve oxygenation significantly without risking deterioration. Maintaining good filling pressures is important, it should be done with care due to interventricular septum shift and further hemodynamic worsening. It is crucial to maintain good systemic arterial pressures in order to maintain good coronary blood flow to the right ventricle, mainly with the use of noradrenaline. If systemic perfusion is still compromised after blood pressure optimization, the use of dobutamine as an inotrope is advised. The use of mechanical circulatory support, at the form of Veno—Arterial Extracorporeal Membrane Oxygenation, surgically or percutaneously inserted Ventricular Assist Devices, is also optional for hemodynamic stabilization. Using Targeted Temperature Management to improve neurologic outcome in survivors of cardiac arrest is recommended. We provide a novel pathway of Targeted Temperature Management and thrombolysis therapy in high-risk and intermediate high-risk patients with acute pulmonary embolism.