Pharmacology of Hemodynamic Support in Acute Pulmonary Embolism

In cases of acute PE, it may be necessary to support right ventricular function pharmacologically while plans are being made for reperfusion therapy. This chapter will discuss right ventricular physiology, obstructive shock, basic vasopressor pharmacology, cardiac inotropy, and agents that lead to pulmonary arterial vasodilatation. This chapter will seek to balance the indications, contraindications, and potential adverse effects of these agents on my encounter in clinical application. Case: A 57-year-old man presented directly from the airport after a syncopal episode at baggage claim. He had only just returned from a flight from Europe. While walking down the Jetway he complained to his wife of chest pressure and was noticeably limping. His symptoms worsened and he fell to the ground while lifting one of his suitcases off the conveyor belt. EMS was called and arrived within minutes. They found the patient alert but incoherent, diaphoretic, and overtly tachypneic. In the ED, his blood pressure was 78/35, heart rate 129, and a bedside echo showed an enlarged right atrium and ventricle. He was admitted to the medical ICU and placed on norepinephrine with stabilization of his blood pressure and the PERT was activated immediately to discuss next steps in his treatment.