This is the E.M.K.'s.

Our team of experts and educators bring you clear, concise, and condensed, practice-changing

knowledge on all those EM topics that you may not be totally comfortable with. On this EM quick hits, we have Swami on recess, claimant on addictions, Rosenberg on dental, McDonald on Optho, and Morganstern on literature. On upcoming quick hits, we'll have Aaron Sayall on Ortho, Emily Austin on talks, Natalie May on Peds, Hicks and Brinley on human factors,

Petro on trauma, and special guest David Yerlink on drug interactions. Cases, the latest evidence,

procedural tips and tricks, pitfalls to avoid, and the key take home points and references on

the EM cases website. Quick, let's get on with it. Swami on Massive PE.

We talk about pulmonary embolism all the time, but I want to focus today on massive pulmonary embolism management.

Massive PE is defined as a PE with hemodynamic compromise or signs of end organ malperfusion.

This is the severe end of the PE spectrum where seconds and minutes matter,

and we have to make rapid decisions. So let me start with a case that I saw and used it as a framework.

I'm working, and a 73-year-old guy arrives via EMS from a rehab facility. He was at that facility

after a trimal ankle fracture dislocation, and he had a repair done. He was transferring from his

bed to his walker when he syncopized and then when he came to complained of shortness of breath.

EMS reports that he is hypotensive and tachycardic in the field with a low O2 sat and on arrival

he's got vital signs with a heart rate of 153, a BP of 80 over 43, a sat of 94% on a non-re breather, and a respiratory rate of 32.

He's pale and he's clearly working hard to breathe.

When I take the non-re breather off, he tells me he feels like he's going to die, and his stats dropped to 73%.

Now, both in retrospect and at the time, this case seemed really straightforward.

No real diagnostic dilemma here. Massive PE, that's clearly what's going on, and that means

litigs. But pulling the trigger on litigs without imaging backing you up can sometimes be hard.

It's nice here to do some bedside stuff to further convince yourself

that this is what you're dealing with and then pull that trigger. On exam, the patient's lungs

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