Classifying a pulmonary embolism (PE) as high‐risk with an indication for reperfusion therapy is generally based on the presence of hypotension. However, normotensive shock is a common, yet underrecognized, presentation of intermediate‐risk PE and is associated with high risk of decompensation. We describe a case of a 44‐year‐old woman who presented to the emergency department with persistent dyspnea and high pretest probability of PE who was unable to undergo confirmatory testing. In the emergency department, she was tachycardic and normotensive, but lab tests were notable for lactic acidosis and hyperglycemia. Despite empiric anticoagulation for presumed PE, the patient decompensated and suffered a cardiac arrest with return of spontaneous circulation after the administration of tenecteplase. Due to continued hemodynamic instability, the patient was cannulated for venoarterial extracorporeal membrane oxygenation. After subsequent mechanical thrombectomy, the patient was decannulated, extubated, and survived with good neurologic outcome. This case report highlights the management of critically ill patients with presumed PE when confirmatory imaging is not available, the recognition of normotensive shock, the use of systemic thrombolytics and extracorporeal life support, and the relationship between PE and hyperglycemia.
Rouleau et al. (Thu,) studied this question.